Gonococcal Arthritis Treatment & Management

Updated: Jan 12, 2019
  • Author: Victoria Fernandes Sullivan, MD; Chief Editor: Herbert S Diamond, MD  more...
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Treatment

Approach Considerations

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.

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Pharmacologic Therapy

Neisseria gonorrhoeae can develop resistance to antibiotics because it can mutate rapidly and acquire new genes.  Selection pressures allow antimicrobials to kill susceptible strains and resistant strains to survive; resistance genes then spread to other strains of gonococcus.  In the early 1990’s, fluoroquinolone resistance was noted in some strains of N gonorrhoeae.{ref 22}  By 2007, cephalosporins became the antimicrobials of choice to treat gonorrhea, but 2 years later, gonococcus began showing reduced susceptibility to them. 

Resistance to antimicrobials persists even after the antimicrobial is no longer used to treat gonorrhea.  Because of the resistance to oral cephalosporins in the United States, there is only one first-line regimen, which is dual treatment with ceftriaxone and azithromycin.

In addition, persons infected with N gonorrhoeae frequently are coinfected with Chlamydia trachomatis; this finding has led to the longstanding recommendation that persons treated for gonococcal infection also be treated with a regimen that is effective against uncomplicated genital C trachomatis infection, further supporting the use of dual therapy that includes azithromycin. [17]  

Unfortunately, cases of ‘super-resistant gonorrhea’ strains (eg, H041) with resistance to ceftriaxone, and multi-drug–resistant strains have been identified around the world.{ref 24}  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.

Disseminated gonococcal infection (DGI) frequently results in petechial or pustular acral skin lesions, asymmetric polyarthralgia, tenosynovitis, or oligoarticular septic arthritis. Hospitalization and consultation with an infectious-disease specialist are recommended for initial therapy, especially for persons who might not comply with treatment, have an uncertain diagnosis, or have purulent synovial effusions or other complications. Examination for clinical evidence of endocarditis and meningitis should be performed. [17]

The 2015 CDC recommendations for disseminated gonococcal infection are:

  • Ceftriaxone 1 g IM/IV every 24 h plus a single dose of azithromycin 1 g PO
  • Alternative regimen - Cefotaxime 1 g IV every 8 h plus a single dose of azithromycin 1 g PO

When treating for the arthritis-dermatitis syndrome, the clinician can switch to an oral agent, with the choice guided by antimicrobial susceptibility testing, 24-48 h after substantial clinical improvement. The total treatment course should be at least 7 days.

Spectinomycin was once recommended in this setting but is no longer available in the United States. [18]

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  in patients  gonorrhea, so those who have been treated for gonorrhea should be retested 3 months later.

 

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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.

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Prevention

Measures that may help prevent gonococcal arthritis include the following:

  • Patient education

  • Identification of high-risk sexual practices

  • Promoting use of protective barrier contraceptives (ie, condom)

  • Contacting the patient’s sexual partners for education, examination, and possible treatment

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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).

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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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