- 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.
- Observe for allergic reactions
- Significant possible interactions:
- Broad-spectrum antibiotics: May reduce effectiveness of oral contraceptives; barrier method recommended
Fluoroquinolones (e.g., ciprofloxacin)
Issue for Referral
- 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.
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.
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