Sandbox septic arthritis

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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 (e.g., ceftazidime, cefepime) 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 septic 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)

Risk factors for septic arthritis caused by methicillin-resistant Staphylococcus aureus (MRSA) include:

• Known MRSA colonization or infection
• Recent hospitalization
• Nursing-home resident
• Presence of leg ulcers
• Indwelling catheters

Drainage or debridement of the joint space should always be performed in septic arthritis caused by MRSA. A 3- or 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 4 to 6 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 weeks)

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

Infants (1–3 months)

High Risk for MRSA

• Vancomycin 40 mg/kg/day IV q6–8h 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 7.5 mg/kg IV q6h

Children (3 months–14 years)

• Vancomycin 40 mg/kg/day IV q6–8h AND
• Cefotaxime 50 mg/kg IV q8h

Adults (Monoarticular)

At risk for sexually-transmitted disease

• Ceftriaxone 1 g IV q24h OR Cefotaxime 1 g IV q8h OR Ceftizoxime 1 g IV q8h

• Vancomycin 1 g IV q12h

Not at risk for sexually-transmitted disease

• Vancomycin 1 g IV q12h AND
• Ceftriaxone 1 g IV q24h OR Cefotaxime 1 g IV q8h OR Ceftizoxime 1 g IV q8h

• Vancomycin 1 g IV q12h AND
• Ciprofloxacin 400 mg IV q12h OR Levofloxacin 750 mg IV q 24 h

Adults (Polyarticular)

• Ceftriaxone 1 g IV q24h

Antimicrobial Regimen – Synovial Fluid Gram Stain-Based Therapy (Native Joint)

Negative Gram stain

• Vancomycin 15–20 mg/kg q8–12h AND
• Ceftazidime 2 g IV q8h OR Cefepime 2 g IV q8–12h

• Daptomycin 6-8 mg/kg IV q24h OR Linezolid 600 mg IV/PO q12h AND
• Piperacillin-Tazobactam 4.5 g IV q6h OR Aztreonam 2 g IV q8h OR Imipenem 500 mg IV q6h OR Meropenem 1 g IV q8h OR Doripenem 500 mg IV q8h OR Carbapenems

Gram-positive cocci

• Vancomycin 15–20 mg/kg q8–12h

• Daptomycin 6-8 mg/kg IV q24h OR Linezolid 600 mg IV/PO q12h

Gram-negative cocci

• Ceftriaxone 1 g IV q24h OR Cefotaxime 1 g IV q8h

Gram-negative bacilli

• Ceftazidime 2 g IV q8h OR Cefepime 2 g IV q8–12h OR Piperacillin-Tazobactam 4.5 g IV q6h

• Aztreonam 2 g IV q8h OR Imipenem 500 mg IV q6h OR Meropenem 1 g IV q8h OR Doripenem 500 mg IV q8h OR Carbapenems