eMedicine Specialties > Rheumatology > Infectious Arthritis

Nongonococcal Infectious Arthritis: Treatment & Medication

Author: Edward Dwyer, MD, Department of Medicine, Assistant Professor, Columbia University College of Physicians and Surgeons
Contributor Information and Disclosures

Updated: Oct 7, 2009

Treatment

Medical Care

  • The most important consideration in the treatment of infectious arthritis is the rapid institution of appropriate antimicrobial therapy. Daily joint aspiration must be performed until inflammation subsides.
  • Patients with bacterial arthritis must be hospitalized.
    • Intravenous antibiotic therapy is initiated immediately upon admission. If the results of a Gram stain of synovial fluid identify no organism, initiate empiric therapy based on the clinical characteristics of the host.
    • Healthy adults can be treated with antistaphylococcal penicillin or cephalosporin. Patients who reside in communities with a high prevalence of community-acquired methicillin-resistant S aureus should be initially treated with vancomycin pending culture results.1
    • Elderly debilitated patients or patients with chronic medical conditions require expanded antimicrobial coverage to cover gram-negative bacteria. This usually requires the addition of a third-generation cephalosporin, an aminoglycoside, or a quinolone.
    • Patients with nosocomial infections in whom pseudomonal species are considered may need an extended-spectrum penicillin such as piperacillin or carbenicillin.
    • Cultural sensitivities, when available, may help identify appropriate modifications to subsequent therapy.
    • Depending on the causative organism, most experts recommend 2-4 weeks of parenteral therapy.
    • Institute daily arthrocentesis of the affected joint until synovial fluid culture results are negative or considerable clinical improvement in the joint is apparent.
  • Fungal arthritis is appropriately treated with intravenous amphotericin B plus an oral azole. The recommended duration of therapy is 6-12 weeks, for a total dose of 1-3 g of amphotericin B.9
  • Mycobacterial arthritis treatment varies depending on the infecting agent.
    • Patients with M tuberculosis infection are treated initially with 4 drugs (rifampin, isoniazid, pyrazinamide, ethambutol [RIPE]) for 2 months; then, depending on the sensitivities, isoniazid and rifampin are continued for a total of 9-12 months.9
    • An M marinum infection requires rifampin and ethambutol for 6-12 weeks.

Surgical Care

  • Joints that do not respond to antimicrobial therapy and daily arthrocentesis require drainage and debridement, either with arthroscopy or with an open procedure.
  • A joint with an infected prosthesis requires removal of the prosthesis and reimplantation after an appropriate course of antimicrobial therapy.

Consultations

  • Rheumatologist
  • Orthopedic surgeon

Activity

  • Encourage either passive or active daily range-of-motion exercises.
  • Avoid immobilizing the joint.

Medication

Antimicrobial therapy is dictated by the results of a Gram stain and the clinical characteristics of the host. If the Gram stain result is positive for gram-positive cocci, then S aureus and streptococci are the most likely infecting agents. If the patient is a healthy sexually active adult, gonococci and gram-positive cocci are the most likely infecting agents. If the Gram stain result is negative in an elderly or compromised host, gram-negative rods are likely. S epidermidis and gram-negative rods are more likely in a patient with a prosthetic joint or a patient who has undergone a recent operative procedure.

Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.


Nafcillin (Unipen)

Initial therapy for possible penicillin G–resistant streptococcal or staphylococcal infections.
Use parenteral therapy initially in severe infections. Change to oral therapy as condition warrants.
Due to thrombophlebitis, particularly in elderly patients, administer parenterally only for short term (1-2 d); change to oral route as clinically indicated.

Adult

2 g IV q4h

Pediatric

50 mg/kg IV q6h

Increases effects of warfarin; decreases levels of cyclosporin; associated with warfarin resistance when administered concurrently; effects may decrease with bacteriostatic action of tetracycline derivatives

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

To optimize therapy, determine causative organisms and susceptibility; >10 d treatment to eliminate infection and prevent sequelae (eg, endocarditis, rheumatic fever); obtain cultures after treatment to confirm eradication of infection


Ceftriaxone (Rocephin)

Third-generation cephalosporin with broad-spectrum gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Arrests bacterial growth by binding to one or more penicillin-binding proteins.

Adult

1-2 g IV qd

Pediatric

Not established

Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Adjust dose in renal impairment; caution in breastfeeding and penicillin allergy


Ciprofloxacin (Cipro)

Inhibits bacterial DNA synthesis and, consequently, growth. Active against gram-negative rods; administered with nafcillin

Adult

400 mg IV q12h

Pediatric

Not recommended

Antacids, iron salts, and zinc salts may reduce serum levels; administer antacids 2-4 h before or after taking fluoroquinolones; cimetidine may interfere with metabolism; reduces therapeutic effects of phenytoin; probenecid may increase serum concentrations
May increase toxicity of theophylline, caffeine, cyclosporine, and digoxin (monitor digoxin levels); may increase effects of anticoagulants (monitor PT)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

In prolonged therapy, periodically evaluate organ system functions (eg, renal, hepatic, hematopoietic); adjust dose in renal function impairment; superinfections may occur with prolonged or repeated antibiotic therapy


Vancomycin (Vancocin)

Active against S epidermidis. To avoid toxicity, the current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Dose adjustment possible in renal impairment. Base adjustment on CrCl.

Adult

500 mg IV q6h

Pediatric

Not established

Erythema, histaminelike flushing, and anaphylactic reactions may occur when administered with anesthetic agents; taken concurrently with aminoglycosides, risk of nephrotoxicity may increase above that with aminoglycoside monotherapy; effects in neuromuscular blockade may be enhanced when coadministered with nondepolarizing muscle relaxants

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Caution in renal failure or neutropenia; red man syndrome is caused by IV infusion that is too rapid (dose given over a few min) but rarely occurs when dose given as 2-h administration or PO or IP; red man syndrome is not an allergic reaction

Antitubercular agents

These agents are used when therapy for tuberculous arthritis is indicated.


Isoniazid (NIH, Laniazid)

Best combination of effectiveness, low cost, and minor adverse effects. Coadministration of pyridoxine is recommended if peripheral neuropathies develop secondary to isoniazid therapy. Prophylactic doses of 6-50 mg/d of pyridoxine are recommended.

Adult

300 mg PO qd

Pediatric

Not established

Higher incidence of isoniazid-related hepatitis can occur with daily alcohol ingestion; aluminum salts may decrease serum levels (administer 1-2 h before taking aluminum salts); may increase effects of anticoagulants with coadministration; may inhibit metabolic clearance of benzodiazepines
Carbamazepine toxicity or isoniazid hepatotoxicity may result from concurrent use (monitor carbamazepine concentrations and liver function); coadministration with cycloserine may increase adverse CNS effects (eg, dizziness); acute behavioral and coordination changes may occur with coadministration of disulfiram
Coadministration with rifampin after halothane anesthesia may result in hepatotoxicity and hepatic encephalopathy; may inhibit hepatic microsomal enzymes and increase toxicity of hydantoin

Documented hypersensitivity; previous isoniazid-associated hepatic injury or other severe adverse reactions

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Ingestion of alcohol increases risk of liver toxicity; monitor patients with active chronic liver disease or severe renal dysfunction; periodic ophthalmologic examinations are recommended during therapy, even in the absence of visual symptoms


Rifampin (Rifadin, Rimactane)

For use in combination with at least one other antituberculous drug, such as isoniazid; inhibits DNA-dependent bacterial but not mammalian RNA polymerase. Cross-resistance may occur. Treat for 6-9 mo or until 6 mo have elapsed since conversion to negative sputum culture result.

Adult

600 mg PO qd

Pediatric

Not established

Induces microsomal enzymes, which may decrease effects of acetaminophen, oral anticoagulants, barbiturates, benzodiazepines, beta-blockers, chloramphenicol, oral contraceptives, corticosteroids, mexiletine, cyclosporine, digitoxin, disopyramide, estrogens, hydantoins, methadone, clofibrate, quinidine, dapsone, tazobactam, sulfonylureas, theophyllines, tocainide, and digoxin; blood pressure may increase with coadministration of enalapril; coadministration with isoniazid may result in higher rate of hepatotoxicity than with either agent alone (discontinue one or both agents if alterations in LFTs occur)

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Obtain CBC counts and baseline clinical chemistry values prior to and throughout therapy; in liver disease, weigh benefits against risk of further liver damage; interruption of therapy and high-dose intermittent therapy are associated with thrombocytopenia that is reversible if therapy is discontinued as soon as purpura occurs; if treatment is continued or resumed after appearance of purpura, cerebral hemorrhage or death may occur

Antifungals

These agents are used when fungal arthritis, such as candidal arthritis, is documented.


Amphotericin B lipid complex (Abelcet)

Produced from a strain of Streptomyces nodosus; can be fungistatic or fungicidal. Binds to sterols, such as ergosterol, in the fungal cell membrane, causing intracellular components to leak, with subsequent fungal cell death.

Adult

1.5 mg/kg IV qd

Pediatric

Not established

Antineoplastic agents may enhance potential for renal toxicity, bronchospasm, and hypotension; corticosteroids, digitalis, and thiazides may potentiate hypokalemia; risk of renal toxicity is increased with cyclosporine

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Monitor renal function, serum electrolytes (eg, magnesium, potassium), liver function, CBC count, and hemoglobin concentrations; resume therapy at lowest level (eg, 0.25 mg/kg) when therapy is interrupted for more than 7 d; hypoxemia, acute dyspnea, and interstitial infiltrates may occur in neutropenic patients receiving leukocyte transfusions (separate time of amphotericin infusion from time of leukocyte transfusion)


Fluconazole (Diflucan)

Synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alpha-demethylation. Suggested for use with amphotericin administration

Adult

200 mg PO/IV qd

Pediatric

Not established

Levels may increase with hydrochlorothiazides; levels may decrease with long-term coadministration of rifampin; coadministration may decrease phenytoin concentrations; may increase concentrations of theophylline, tolbutamide, glyburide, and glipizide; effects of anticoagulants may increase with coadministration; increases in cyclosporine concentrations may occur when administered concurrently

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Monitor closely if rashes develop and discontinue drug if lesions progress; caution in renal failure; may cause clinical hepatitis, cholestasis, and fulminant hepatic failure (including death) with underlying medical conditions such as AIDS or a malignancy and while taking multiple concomitant medications; not recommended for nursing mothers

More on Nongonococcal Infectious Arthritis

Overview: Nongonococcal Infectious Arthritis
Differential Diagnoses & Workup: Nongonococcal Infectious Arthritis
Treatment & Medication: Nongonococcal Infectious Arthritis
Follow-up: Nongonococcal Infectious Arthritis
References
[ CLOSE WINDOW ]

References

  1. Chambers HF. Community-associated MRSA--resistance and virulence converge. N Engl J Med. Apr 7 2005;352(14):1485-7. [Medline].

  2. [Best Evidence] Mathews CJ, Kingsley G, Field M, Jones A, Weston VC, Phillips M, et al. Management of septic arthritis: a systematic review. Ann Rheum Dis. Apr 2007;66(4):440-5. [Medline].

  3. Shirtliff ME, Mader JT. Acute septic arthritis. Clin Microbiol Rev. Oct 2002;15(4):527-44. [Medline].

  4. von Essen R. Culture of joint specimens in bacterial arthritis. Impact of blood culture bottle utilization. Scand J Rheumatol. 1997;26(4):293-300. [Medline].

  5. Kaandorp CJ, Krijnen P, Moens HJ, Habbema JD, van Schaardenburg D. The outcome of bacterial arthritis: a prospective community-based study. Arthritis Rheum. May 1997;40(5):884-92. [Medline].

  6. Goldenberg DL, Reed JI. Bacterial arthritis. N Engl J Med. Mar 21 1985;312(12):764-71. [Medline].

  7. Smith JW, Chalupa P, Shabaz Hasan M. Infectious arthritis: clinical features, laboratory findings and treatment. Clin Microbiol Infect. Apr 2006;12(4):309-14. [Medline].

  8. Gupta MN, Sturrock RD, Field M. A prospective 2-year study of 75 patients with adult-onset septic arthritis. Rheumatology (Oxford). Jan 2001;40(1):24-30. [Medline].

  9. Harrington JT. Mycobacterial and fungal arthritis. Curr Opin Rheumatol. Jul 1998;10(4):335-8. [Medline].

[ CLOSE WINDOW ]

Further Reading

[ CLOSE WINDOW ]

Keywords

bacterial arthritis, fungal arthritis, candidal arthritis, mycobacterial arthritis, septic arthritis, infectious arthritis, non-gonococcal arthritis, nongonococcal infectious arthritis, non-gonococcal infectious arthritis, infected joint prosthesis, joint prosthesis infection, staphylococcal arthritis

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Edward Dwyer, MD, Department of Medicine, Assistant Professor, Columbia University College of Physicians and Surgeons
Edward Dwyer, MD is a member of the following medical societies: Alpha Omega Alpha and American College of Rheumatology
Disclosure: Nothing to disclose.

Medical Editor

Robert E Wolf, MD, PhD, Professor Emeritus, Department of Medicine, Louisiana State University Health Sciences Center at Shreveport; Chief, Rheumatology Section, Medical Service, Overton Brooks Veterans Administration Medical Center of Shreveport
Robert E Wolf, MD, PhD is a member of the following medical societies: American College of Rheumatology, Arthritis Foundation, and Society for Leukocyte Biology
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Elliot Goldberg, MD, Dean of the Western Pennsylvania Clinical Campus, Professor, Department of Medicine, Temple University School of Medicine
Elliot Goldberg, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, and American College of Rheumatology
Disclosure: Nothing to disclose.

CME Editor

Alex J Mechaber, MD, FACP, Associate Dean for Undergraduate Medical Education, Associate Professor of Medicine, University of Miami Miller School of Medicine
Alex J Mechaber, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, and Society of General Internal Medicine
Disclosure: Nothing to disclose.

Chief Editor

Herbert S Diamond, MD, Professor of Medicine, Temple University School of Medicine; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital
Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, and Phi Beta Kappa
Disclosure: medifocus Honoraria Review panel membership; health dialogs Honoraria Consulting; West Penn Allegheny Health System None Board membership

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.