First Line

• Neisserial (7)[A]:
  • Ceftriaxone 1 g IM or IV every day for 14 days (and at least 7 days after symptoms resolve)
  • Fluoroquinolone for 14 days; caveat resistance
  • Concomitant treatment for Chlamydia
• Nonneisserial (7)[A]:
  • Gram-positive cocci in clusters: Empiric therapy: Vancomycin or linezolid IV. If methicillin-sensitive Staphylococcus aureus (MSSA), nafcillin or cefazolin IV
  • Gram-positive cocci in chains: Ceftriaxone
  • Gram-negative bacilli: Neonates: Cefotaxime, and gentamicin; ages 6 months to 4 years: 3rd-generation cephalosporin; adult: 3rd-generation cephalosporin plus gentamicin. No bacteria seen on smear: Vancomycin or linezolid plus 3rd-generation cephalosporin.
• Precautions:
  • Observe for allergic reactions
• Significant possible interactions:
  • Broad-spectrum antibiotics: May reduce effectiveness of oral contraceptives; barrier method recommended

Second Line Fluoroquinolones (e.g., ciprofloxacin)

General Measures

• Hospitalization for parenteral therapy
• Outpatient treatment rarely possible for extremely compliant patient with known organism.
• Repeat (once) arthrocentesis if fluid reaccumulates. Next step is arthroscopic debridement and irrigation.
• Avoid anti-inflammatory therapy to allow assessment of therapeutic response to antibiotic.
• If joint prosthesis is present in an infection, orthopedic surgery, to include possible removal of the prosthesis, must be considered.
• Continue treatment for 1–2 weeks after total resolution of all signs of inflammation, for a total of 4–6 weeks for most organisms, except neisserial (2–3 weeks).
• Intra-articular antibiotics are not required.

Issue for Referral Infectious disease and orthopedic consults strongly advised to supplement rheumatologist.

• Arthroscopy indicated if fluid accumulated is loculated and/or not amenable to needle drainage.
• Surgical drainage typically is required for shoulder or hip involvement.