Septic Arthritis of Prosthetic Joints Organism-Specific Therapy 

Updated: Nov 07, 2018
  • Author: John L Brusch, MD, FACP; Chief Editor: Michael Stuart Bronze, MD  more...
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Specific Organisms and Therapeutic Regimens

Organism-specific therapeutic regimens for septic arthritis of prosthetic joints, or periprosthetic joint infection (PJI), are provided below, including those for methicillin-sensitive Staphylococcus aureus (MSSA), methicillin-resistant S aureus (MRSA), coagulase-negative staphylococci (CoNS), penicillin-sensitive and penicillin-resistant Streptococcus pneumoniae [1] , gram-negative rods, and Pseudomonas aeruginosa, as well as special considerations. [2, 3, 4, 5, 6, 7, 8, 9]

Methicillin-sensitive Staphylococcus aureus (MSSA)*

See the list below:

Methicillin-resistant S aureus (MRSA)*

See the list below:

Coagulase-negative staphylococci (CoNS)*

See the list below:

  • Vancomycin 15 mg/kg IV q12h^ or

  • Linezolid 600 mg IV q12h or

  • Daptomycin 4-6 mg/kg IV q24h

  • Rifampin 300-450 mg PO/IV q12h; must be given if prosthetic material is present

  • In patients in whom it is difficult to maintain adequate trough levels of vancomycin (15-20 mcg/mL), consideration should be given to the use of linezolid or daptomycin [10]

Streptococcus pneumoniae (penicillin sensitive) (minimal inhibitory concentration [MIC] < 4 µg/mL)

See the list below:

S pneumoniae (penicillin resistant) (MIC ≥ 4 µg/mL)

See the list below:

  • Ceftriaxone 1-2 g IV q12h or

  • Vancomycin 15 mg/kg IV q12h or

  • Levofloxacin 750 mg IV or PO q24h

Gram-negative rods (other than Pseudomonas)

See the list below:

  • Ceftriaxone 1-2 g IV q12h or

  • Ciprofloxacin 400 mg IV or 500 mg PO q12h or

  • Levofloxacin 500 mg IV or PO q24h for 3wk

Pseudomonas aeruginosa

See the list below:

Special considerations

See the list below:

  • The sensitivity of cultures of synovial fluid ranges from 45 to 100%

  • Culture results of periprosthetic tissues have a sensitivity ranging from 65 to 94% [11, 12]

  • Blood cultures should be obtained in all patients with suspected PJI [13]

  • In PJI, plain radiography can detect new subperiosteal bone growth and transcortical sinus tracts—both are signs of active infection

  • The 2-stage joint-replacement procedure is the preferred surgical procedure; the prosthesis is removed, and an antibiotic-impregnated spacer is placed after thorough debridement of the infected tissue; IV antibiotics are delivered for 6-8wk before the new joint is implanted [11]

  • The 1-stage joint-replacement procedure consists of simultaneous removal and replacement of the joint, and it is usually employed in patients with highly sensitive organisms; however, the success rate is lower than the 2-stage procedure [11]

  • Early stages of PJI may respond to simple debridement, followed by 2-6wk of IV antibiotics and orally administrated antibiotics for up to 6mo; this approach may also be taken in patients with very high operative risk

  • Indefinite suppressive antibiotic therapy is an option if the prosthesis cannot be removed (high operative risk) and there is an appropriate orally administrated antibiotic