Figure 68.1 Empiric antibiotic coverage for nontraumatic, acute monoarticular arthritis. RA = rheumatoid arthritis; DM = diabetes mellitus.
|Staphylococcus aureus||Penicillinase-resistant penicillins,a first-generation cephalosporin,b or cefuroxime, 1.5 g q8h||3–4 wk|
|Methicillin-resistant S. aureus or patient allergic to penicillin||Vancomycin, 1 g q12h daptomycin 4–6 mg/kg/d, or linezolid 600 mg q12h||3–4 wk|
|Streptococci||Penicillin G, 4 million units q6h, or first-generation cephalosporinb or clindamycin, 300 mg q8h||2 wk|
|Gram-negative bacilli||Antipseudomonal cephalosporins,c carbapenem,d quinolonee||3–4 wk|
|Disseminated gonococcal infection||Ceftriaxone, 1 g q24h until response, then cefixime, 400 mg PO BID||7–10 d|
|Septic gonococcal arthritis||Ceftriaxone, 1 g q24h||3 wk|
|Lyme arthritis||Doxycycline, 100 mg PO BID, or ceftriaxone, 2 g q24h IV||4 wk, 2 wk|
|Mycobacterium tuberculosis||Isoniazid, 300 mg/d, plus rifampin, 600 mg/d, with ethambutol, 15 mg/kg/d, and pyrazinamide, 1500 mg/day for the first 2 mo||1 y|
|Fungal arthritis||Amphotericin B, 0.5–0.7 mg/kg/d for a total of 2 g, then itraconazole, 200–400 mg/d PO, or fluconazole, 200–400 mg/d PO||1 y|
a Nafcillin, 2 g q6h IV.
b Cefazolin, 1 g q8h IV, or cephalothin, 1–2 g q6h IV.
c Ceftazidime, 2 g q8h IV, or cefepime, 1 g q12h IV.
d Imipenem–cilastatin, 500 mg q6h IV, or meropenem, 500 mg q8h IV.
e Ciprofloxacin, 400 mg q12h IV, or levofloxacin, 500 mg q24h IV.
Abbreviations: PO = orally; BID = twice a day; IV = intravenously.
Infected joint effusions require repeated needle aspirations of recurrent joint effusions during the first 5 to 7 days of antimicrobial therapy. Most patients respond to needle aspiration. If the volume of fluid and number and percentage of PMLs decrease with each aspiration, no drainage is required. However, if the effusion persists for more than 7 days or the cell count does not decrease, surgical drainage is indicated. Surgical drainage is also indicated when effective decompression with needle aspiration is unlikely (hip joint) or when the joint is not accessible for aspiration (sternoclavicular and sacroiliac joints); if the joint space has become loculated as a result of formation of adhesions; or if thick, purulent material resisting aspiration is encountered. Arthroscopic drainage is an alternative to open drainage for the knee, shoulder, and ankle joints.
Bacterial arthritis is associated with a mortality of 10% to 15%. Up to 25% to 50% of surviving patients are left with residual loss of joint function. Poor outcomes are commonly seen in the elderly and those with severe underlying joint disease, hip infections, or infections caused by mycobacterial or fungal agents.
Prosthetic joint infections
Prosthetic joint surgery has been used with increasing frequency over the past 4 decades. About 1 000 000 arthroplasties are performed in the United States each year. Although most procedures involve the hip and knee joints, arthroplasties of the elbow, shoulder, and wrist are also being performed. Primary indications for surgery generally include rheumatoid arthritis, degenerative joint disease, fractures, and septic arthritis.