What is the role of pharmacologic therapy in the treatment of gonococcal arthritis?

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

Because of 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 Neisseria 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]

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.,


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