Sandbox septic arthritis: Difference between revisions
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Revision as of 18:23, 1 May 2015
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Septic arthritis Microchapters |
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Diagnosis |
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Treatment |
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Case Studies |
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Sandbox septic arthritis On the Web |
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American Roentgen Ray Society Images of Sandbox septic arthritis |
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Risk calculators and risk factors for Sandbox septic arthritis |
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 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
Methicillin-resistant Staphylococcus aureus (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 hours in adults or 15 mg/kg/dose IV every 6 hours in children), daptomycin (6 mg/kg/day IV every 24 hours in adults or 6–10 mg/kg/dose IV every 24 hours in children), linezolid (600 mg PO/IV twice daily in adults or 10 mg/kg/dose PO/IV every 8 hours in children), clindamycin (600 mg PO/IV every 8 hours in adults or 10–13 mg/kg/dose PO/IV every 6–8 hours in children), and trimethoprim-sulfamethoxazole (3.5–4.0 mg/kg/dose PO/IV every 8–12 hours 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 according to the causative organisms and the surgical intervention performed. Empiric or pathogen-directed antibiotic therapy should be instituted following the procedure.
Antimicrobial Regimen – Empiric Therapy (Native Joint)
Newborn (< 1 week)
High Risk for MRSA
- Vancomycin 18 mg/kg/day IV q12h AND
- Cefotaxime 50 mg/kg IV q12h
Low Risk for MRSA
- Cefotaxime 50 mg/kg IV q12h AND
- Nafcillin 25 mg/kg IV q8h OR Oxacillin 25 mg/kg IV q8h
- Clindamycin 5 mg/kg IV q8h
Newborn (1–4 week)
High Risk for MRSA
- Vancomycin 22 mg/kg/day IV q12h AND
- Cefotaxime 50 mg/kg IV q8h
Low Risk for MRSA
- Cefotaxime 50 mg/kg IV q8h AND
- Nafcillin 37 mg/kg IV q6h OR Oxacillin 37 mg/kg IV q6h
- Clindamycin 5 mg/kg IV q6h