Approach Considerations
When septic arthritis is suspected, empiric antibiotics directed against likely pathogens should be used until confirmatory laboratory data are available. Antibiotic coverage in healthy hosts should initially include gram-positive organisms, which account for approximately 80% of nongonococcal monoarthritis cases (Staphylococcus aureus, 60%; non–group A Streptococcus species, 15%; S pneumoniae, 3%). Gram-negative organisms (18%) should be covered in patients who are immunocompromised, elderly, or otherwise at risk.
Most patients with suspected acute infectious arthritis, including gonococcal arthritis, should be hospitalized to establish a diagnosis and to monitor for improvement or complications. Daily synovial fluid drainage is recommended for purulent effusions associated with gonococcal arthritis. Surgical drainage is needed when arthrocentesis is ineffective. The transition to oral antibiotics can usually be made 24-48 hours after clinical improvement.
Bed rest during hospitalization and brief immobilization of the septic joint aid in decreasing pain, especially when nonsteroidal anti-inflammatory drugs (NSAIDs) are not used.
Antimicrobial Therapy
Neisseria gonorrhoeae can develop resistance to antibiotics because it can mutate rapidly and acquire new genes, which then spread to other strains of gonococcus. In the early 1990s, fluoroquinolone resistance was noted in some strains of N gonorrhoeae, and by 2006, fluoroquinolones were no longer recommended for treatment of gonococcal infection. [19] By 2007, cephalosporins became the antimicrobials of choice to treat gonorrhea but 2 years later, gonococcus began showing reduced susceptibility to them, and by 2010, oral cephalosporins were no longer recommended for this indication. [20] Similarly, azithromycin was previously used as part of first-line treatment for gonorrhea but is no longer recommended, because of rising resistance. [21]
Current recommendations from the US Centers for Disease Control and Prevention for treatment of gonococcal-related arthritis and arthritis-dermatitis syndrome are as follows [22] :
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Ceftriaxone 1 g IM/IV every 24 h
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Alternative regimen - Cefotaxime 1 g IV every 8 h
In addition, persons infected with N gonorrhoeae frequently are coinfected with Chlamydia trachomatis; this finding has led to the longstanding recommendation that if chlamydial infection has not been excluded, patients treated for gonococcal infection also be treated with a regimen that is effective against uncomplicated genital C trachomatis infection. Currently this consists of doxycycline, 100 mg twice a day for 7 days. [22]
Treatment can be switched to an oral agent, with the choice guided by antimicrobial susceptibility testing, 24-48 h after substantial clinical improvement, for a total treatment course of at least 7 days. [22]
Unfortunately, cases of ‘super-resistant gonorrhea’ strains (eg, H041) with resistance to ceftriaxone, and multi-drug–resistant strains have been identified around the world. [23] This development highlights the importance of monitoring cases of antibiotic resistance in N gonorrhoeae with programs such as the CDC’s Gonococcal Isolate Surveillance Project (GISP) and developing new treatments.
Patients should be advised to refer their sexual partners for evaluation and treatment, as partners of patients with DGI often have asymptomatic infections.
Patients with confirmed diagnosis of a localized gonococcal infection can probably be discharged with outpatient medications if they are considered reliable for follow-up care. Synovial effusions may require a longer duration of antibiotic therapy, but open drainage is rarely required. Intra-articular antibiotics have no known benefit.
Follow-up is important for patients who have been treated for gonorrhea, as they have a high incidence of reinfection. They should be retested 3 months later.
Arthrocentesis, Arthroscopy, and Surgical Drainage
Daily aspiration with synovial fluid drainage has been recommended for purulent effusions associated with gonococcal arthritis. Open drainage or arthroscopy of infected joints is needed when arthrocentesis is insufficient.
Although patients with persistent joint effusion despite early antibiotic therapy may require frequent joint aspiration, joint effusions in gonococcal arthritis rarely result in permanent damage. Arthroscopic evaluation or surgical drainage that requires an orthopedic surgeon is rarely needed.
Patients with acute endocarditis secondary to gonococcal infection may require cardiothoracic surgery.
Prevention
Measures that may help prevent gonococcal arthritis include the following:
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Patient education
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Identification and reduction of high-risk sexual practices
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Promoting use of protective barrier contraceptives (ie, condoms)
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Contacting the patient’s sexual partners for education, examination, and possible treatment
Consultations
Consider consulting a rheumatologist for assistance in the evaluation and management of septic joints.
Consider consulting an infectious disease specialist for management of DGI cases and determination of optimal antibiotic therapy later in the course of the disease or if there is concern for treatment failure.
Consider consulting a cardiologist if acute endocarditis is suspected.
An orthopedic consultation may be required for arthroscopic or surgical drainage of an inaccessible joint (eg, the hip) or for failure of nonsurgical management (ie, daily aspiration).
Long-Term Monitoring
Reevaluate patients to ensure resolution of illness. Reculture all known infected sites at least 5-7 days after the last dose of antibiotics. Due to high risk of reinfection, repeat testing for N gonorrhoeae 3 months after treatment. Patients screened for syphilis and HIV should be screened again in 4-6 weeks.
Contact, examine, and treat the patient’s sexual partners, especially those with whom the patient has had sexual contact within the past 60 days. Encourage the patient to abstain from sexual activity for 7 days after treatment completion.{ref 23}
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Synovial joint.
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The lesion on this patient's heel was due to the systemic dissemination of the N gonorrhoeae bacteria.
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The foot of this patient is swollen due to gonococcal arthritis.
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This patient presented with cutaneous foot lesions that were diagnosed as a disseminated gonococcal infection.
