What should be considered when providing organism-specific therapy to treat septic arthritis of native joints?

Updated: Oct 02, 2020
  • Author: John L Brusch, MD, FACP; Chief Editor: Michael Stuart Bronze, MD  more...
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See the list below:

  • Examination of the joint fluid is the key diagnostic test; it typically shows some marked leukocytosis, often > 50,000/µL; glucose is low with no crystals; the Gram stain is positive in < 50% of cases
  • If the Gram stain is negative and crystals are apparent, one may withhold antibiotics and treat for crystalline arthritis unless there is a significant potential source of bacteremia, such as a urinary tract infection. In such situations, the measurement of serum calcitonin may be helpful to document infection. It should not be used to exclude infection. [12]
  • In patients in whom it is difficult maintain an adequate trough level of vancomycin when treating MSSA or MRSA infection (15-20 mcg/mL), consideration should be given to the use of linezolid or daptomycin.
  • Because of its once-weekly dosing regimen, dalbavancin should be considered in patients receiving prolonged antibiotic therapy for susceptible organisms, including all non-enterococcal streptococci, MSSA, MRSA, vancomycin-intermediate S aureus (VISA), CoNS, and vancomycin-sensitive enterococci. [13]
  • Gonococcal arthritis has 2 major types of presentation: (1) the combination of pustular skin lesions, tenosynovitis, and arthralgias without direct joint space involvement; and (2) a typical septic joint without skin lesions
  • Because of the low recovery rate of gonococci from infected joints (25% of cases), potential exposed sites (pharynx, rectum, cervix, urethra) should be cultured in addition to the joint fluid; urine nucleic acid amplification testing (NAAT) can also be performed
  • Blood cultures should be obtained in all patients with suspected joint infection
  • Plain radiography may detect evidence of underlying osteomyelitis or periarticular osteomyelitis caused by extension of the joint infection
  • If joint fluid reaccumulates after the initial aspiration, repeated aspirations should be performed
  • Intra-articular administration of antibiotics is unnecessary
  • If the joint does not show clinical improvement within 72h (or if cultures remain positive after 5d), surgical drainage should be considered, the joint fluid should be reexamined for crystals, and other diagnoses should be considered (eg, Lyme or reactive arthritis)
  • All sexual contacts of patients with gonococcal arthritis should be treated with a single dose of ceftriaxone 125 mg IM or of cefixime 400 mg PO


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