Sandbox septic arthritis: Difference between revisions
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==Overview== | ==Overview== | ||
Acute non-[[gonococcal]] septic arthritis is a medical emergency requiring prompt drainage followed by empiric antimicrobial therapy according to patient's history, clinical presentation, and [[synovial fluid]] analysis. [[Vancomycin]] is recommended as empirical therapy for patients with [[Gram-positive cocci]] on a [[synovial fluid]] [[Gram stain]] or as a component of regimen for those with a negative [[Gram stain]] if [[MRSA|methicillin-resistant ''Staphylococcus aureus'' (MRSA)]] is prevalent. If [[Gram-negative bacilli]] are observed, an anti-[[pseudomonal]] [[cephalosporin]] should be administered. Carbapenems should be considered in conditions such as colonization or infection by extended-spectrum β-lactamase–producing pathogens. Antibiotic regimen may be deescalated as culture results and susceptibility tests permit. The optimal duration of therapy for septic arthritis remains uncertain. A minimum 3- to 4-week course is suggested for arthritis caused by ''S. aureus'' or Gram-negative bacteria. The use of corticosteroids or intraarticular antibiotics is not advisable. | Acute non-[[gonococcal]] septic arthritis is a medical emergency requiring prompt drainage followed by empiric antimicrobial therapy according to patient's history, clinical presentation, and [[synovial fluid]] analysis. [[Vancomycin]] is recommended as empirical therapy for patients with [[Gram-positive cocci]] on a [[synovial fluid]] [[Gram stain]] or as a component of regimen for those with a negative [[Gram stain]] if [[MRSA|methicillin-resistant ''Staphylococcus aureus'' (MRSA)]] is prevalent. If [[Gram-negative bacilli]] are observed, an anti-[[pseudomonal]] [[cephalosporin]] should be administered. [[Carbapenems]] should be considered in conditions such as colonization or infection by extended-spectrum β-lactamase–producing pathogens. Antibiotic regimen may be deescalated as culture results and susceptibility tests permit. The optimal duration of therapy for septic arthritis remains uncertain. A minimum 3- to 4-week course is suggested for arthritis caused by ''S. aureus'' or Gram-negative bacteria. The use of corticosteroids or intraarticular antibiotics is not advisable. | ||
==Medical Therapy== | ==Medical Therapy== | ||
Revision as of 17:39, 1 May 2015
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Acute non-gonococcal septic arthritis is a medical emergency requiring prompt drainage followed by empiric antimicrobial therapy according to patient's history, clinical presentation, and synovial fluid analysis. Vancomycin is recommended as empirical therapy for patients with Gram-positive cocci on a synovial fluid Gram stain or as a component of regimen for those with a negative Gram stain if methicillin-resistant Staphylococcus aureus (MRSA) is prevalent. If Gram-negative bacilli are observed, an anti-pseudomonal cephalosporin should be administered. Carbapenems should be considered in conditions such as colonization or infection by extended-spectrum β-lactamase–producing pathogens. Antibiotic regimen may be deescalated as culture results and susceptibility tests permit. The optimal duration of therapy for septic arthritis remains uncertain. A minimum 3- to 4-week course is suggested for arthritis caused by S. aureus or Gram-negative bacteria. The use of corticosteroids or intraarticular antibiotics is not advisable.
Medical Therapy
Empiric treatment should be commenced as soon as possible after culture samples have been obtained. The choice of empiric antibiotics should be determined on the basis of:
- Gram stain results of synovial fluid analysis
- Local prevalence of organisms and resistance patterns
- Predisposing factors including intravenous drug use, hospitalization, or colonization of certain infectious pathogens, and risk for methicillin-resistant Staphylococcus aureus (MRSA)
If the patient fails to respond to initial treatment, consider:
- Misidentification of causative pathogen
- Infection with atypical pathogen
- Concurrent osteomyelitis
- Occult nidus of infection
Specific Considerations
MRSA
Drainage or debridement of the joint space should always be performed in septic arthritis caused by MRSA. A 3–4-week course of therapy with vancomycin (15–20 mg/kg/dose IV every 8–12 h in adults or 15 mg/kg/dose IV every 6 h in children), daptomycin (6 mg/kg/day IV QD in adults or 6–10 mg/kg/dose IV QD in children), linezolid (600 mg PO/IV BID in adults or 10 mg/kg/dose PO/IV every 8 h in children), clindamycin (600 mg PO/IV TID in adults or 10–13 mg/kg/dose PO/IV every 6–8 h in children), and trimethoprim-sulfamethoxazole (3.5–4.0 mg/kg/dose PO/IV every 8–12 h in adults) have been used with success. A prolonged treatment of four to six weeks may be required if the condition is complicated by osteomyelitis.
Prosthetic joint infection
Management of prosthetic joint infection typically requires both surgical intervention and extended courses of antimicrobial therapy. Options of surgical approach include debridement with retention of prosthesis, two-stage procedure (removal of prosthesis and cement with debridement of infected tissue and placement of a joint spacer, followed by prolonged antibiotics and replacement of prosthesis), one-stage procedure (removal of prosthesis, debridement, and replacement of prosthesis in a single procedure), permanent resection arthroplasty, and amputation. The surgical decision should be made by orthopedic surgeon with specialty consultation, such as infectious disease or plastic surgery as necessary. Antibiotic selection and duration are determined on the causative organisms and the surgical intervention performed. Empiric or pathogen-directed antibiotic therapy should be instituted following the procedure.