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Clinical Reference

Septic arthritis, SA

Notes

## Basic introduction

  • This is the infection of joints that is often preceded by septicemia
  • Delays in the treatment of SA could lead to the destruction of bones and jointsc

## Causative agentsa,b

  • Staphylococcus aureus (the most common cause)
  • Neisseria meningitidis
  • Escherichia coli
  • Streptococcus pyogenes
  • Streptococcus pneumoniae
  • Mycobacteria
  • Some viruses and fungus

## Risk factors for SA

  • Infections in other parts of the body such as STDs and skin infections
  • Physical injury (especially that of the joints)
  • Joint surgery
  • Joint investigations
  • Rheumatoid arthritis
  • Systemic lupus erythematosus
  • Joint prosthesis
  • Immunocompromised status e.g. HIV, chemotherapy, and corticosteroid therapy
  • Osteomyelitis (especially near the joints)
  • Advancing age
  • Bacteremia
  • Alcoholism
  • Injection drug use
  • Sickle cell disease

## Statistics

  • 50% of cases of SA occur in the knee-joint while 20% of them occur in the hip-joint
  • 20% of all cases of SA involve at least two joints
Symptoms
  • Pain in the affected joint(s) that worsen(s) on movement (it also develops quickly)
  • Tender swelling of the joint(s)
  • Warm joint
  • Redness of joint(s)
  • Fever
  • Malaise
  • Restricted motion
  • Dermatitis-polyarthritis-tenosynovitis syndrome in case of gonococcal arthritis
Diagnosis
  • Clinical review
  • Arthrocentesis with synovial fluid examination
  • Culture and sensitivity
  • Ultrasound scan or X-ray or CT scan or MRI scan
  • FBC
  • ESR or C-reactive protein
Differential
  • Bursitis
  • Cellulitis
  • Extrapulmonary tuberculosis
  • Gout or pseudo-gout
  • Lyme disease
  • Osteoarthritis
  • Psoriatic arthritis
  • Rheumatoid arthritis
  • Trauma
Prevention
  • Prevention of underlying cause
Reference
  1. Cuéllar ML, Silveira LH, Espinoza LR (May 1992). "Fungal arthritis". Ann. Rheum. Dis. 51 (5): 690–7
  2. Ytterberg SR (July 1999). "Viral arthritis". Current Opinion in Rheumatology. 11 (4): 275–80.
  3. Kenyan Ministry of Health. Clinical guidelines for management and referral of common conditions at levels 4-6. Hospitals. 2009; 3:259-261.http://apps.who.int/medicinedocs/documents/s21000en/s21000en.pdf
  4. Ministry of Health, Kenya. Kenya Essential Medicine List (2016). http://publications.universalhealth2030.org/uploads/KEML-2016Final-1.pdf
  5. World Health Organization. (2001). WHO model prescribing information: drugs used in bacterial infections. World Health Organization.
Management

Management

  • Analgesics
  • Draining the joint fluid
  • Splinting
  • Physiotherapy
  • Sometimes, it may be necessary to remove/replace prosthetic joints

## Antibiotic regimes within the Essential Drug List (EDL);  2-4wks

_Empirical treatment before culture and sensitivity results:

  • IV or IM Penicillin PLUS gentamycin

_SA due to Staphylococcus aureus:

  • IV or IM Cloxacillin 2g QID x 2/52 then Caps Cloxacillin 1g QID

OR

  • IV or IM Cefazolin 1-2 g TID x  2/52 then Caps Cephalexin 1-2 g QID

OR

  • IV Clindamycin 600mg TID initially and continue with Caps Clindamycin 300 - 450mg QID

_SA due to β-haemolytic streptococci: 

  • IV or IM Benzyl penicillin 2 million IU (1.2 g) every 4 - 6 hrs initially and continue with Caps Amoxicillin 1gm QID or TID for a total duration of 2 - 4 wks

_SA due to Salmonella spp:

  • Tabs Ciprofloxacin 750gm BD x 6/52

_SA in children aged > 5 yrs (mainly caused by S. aureus)

  • IV or IM Cloxacillin 25 - 50mg/kg (maximum 2g) every 4 - 6 hours for 4 - 6 days, followed by Caps Cloxacillin 25mg/kg (maximum 500mg) QID for 3 - 4 weeks

OR

  • IV or IM Ceftriaxone 50 - 75mg/kg (maximum 1g) daily for 4 - 6 days, followed by Caps Cloxacillin 25mg/kg (maximum 500mg) or Caps Cephalexin 25mg/kg (maximum 500mg) QID

OR

  • IV or IM Cefazolin 15mg/kg (maximum 1g) TID for 4 - 6 days followed by Caps Cephalexin 25mg/kg (maximum 500mg) QID

 OR

  • IV Clindamycin 10mg/kg (maximum 450mg) QID for 4 - 6 days followed by Caps clindamycin 10mg/kg (maximum 450mg) QID

_SA in children aged up to 5 yrs (mainly due to Haemophilus influenzae)

  • IV or IM Cloxacillin 25 - 50mg/kg (maximum 2g) every 4 - 6 hrs PLUS IV or IM Ceftriaxone 50 - 75mg/kg (maximum 1g) daily until clinical improvement occurs followed by Syrup Amoxicillin 15mg/kg + Clavulanic acid (maximum 500mg) TID

_SA for neonates (mainly due to Haemophilus influenzae)

  • IV /IM Cloxacillin 25 - 50mg/kg (maximum 2g) every 4 - 6 hours PLUS IV Cefotaxime 50 - 75mg/kg (maximum 2g) TID until clinical improvement occurs, followed by Suspension Amoxicillin 15mg/kg + Clavulanic acid  (maximum 500mg) TID

 

_SA due to S. aureus in Children aged 2 months to 5 years

  • IV/IM Cloxacillin 25 - 50mg/kg (maximum 2g) every 4 - 6 hours PLUS IV/IM Ceftriaxone 50 - 75mg/kg (maximum 1g) daily until clinical improvement occurs, followed by Suspension Cloxacillin 12.5mg/kg (maximum 500mg)

_SA due to S. aureus in neonates

  • IV/IM Cloxacillin 25 - 50mg/kg (maximum 2g) every 4 - 6 hours PLUS IV Cefotaxime 50 - 75mg/kg (maximum 2g) TID until clinical improvement occurs, followed by Suspension Cloxacillin 12.5mg/kg (maximum 500mg) QID

_SA due to Salmonella spp in Children aged 2 months to 5 years

  • IV/IM Cloxacillin 25 - 50mg/kg (maximum 2g) every 4 - 6 hours PLUS IV/IM Ceftriaxone 50 - 75mg/kg (maximum 1g) daily until clinical improvement occurs, followed by either Suspension Sulfamethoxazole 20mg/kg + Trimethoprim 4mg/kg (maximum 800mg + 160 mg) BID or  Suspension Amoxicillin 7.5 - 15mg/kg (maximum 1g) TID or  Suspension Ciprofloxacin 10 - 15mg/kg (maximum 500mg) BD

## Antibiotic regimes outside the Essential Drug List (EDL)

Acute hematogenous SA

  • IV Vancomycin 1gm BD when MRSA is prevalent in a community

OR

  • IV Ceftazidime 2gm TID

OR

  • IV Cefepime 2gm BD

Chronic SA arising from a contiguous soft-tissue focus (e.g. diabetes)

  • Treatment needs to be effective against anaerobic organisms in addition to gram-positive and gram-negative aerobes
  • IV Ampicillin/sulbactam 3gm QID

OR

  • IV Piperacillin/tazobactam 3.375gm QID

 OR

  • Add Vancomycin 1gm BD is when infection is severe or MRSA is prevalent.

SA from contiguous spread of infection

  • IV Piperacillin-tazobactam 3.375gm IV QID

OR

  • IV Ampicillin-sulbactam 3gm QID

OR

  • IV Ticarcillin-clavulanate 3.1gm QID in Patients with penicillin allergy

OR

  • IV Clindamycin 600mg QID

OR

  • IV Metronidazole 500 mg IV TID PLUS Ciprofloxacin 750 mg daily orally or 400 mg IV BD or Levofloxacin 750 mg orally daily or moxifloxacin 400 mg orally daily

If MRSA is suspected add;

  • IV Vancomycin 15 mg/kg BD

If Vancomycin is contraindicated in MRSA use;

  • Linezolid Orally or IV

 

Oral therapy after IV treatment for patients with SA from contiguous spread of infection:

  • Tabs Amoxicillin-clavulanate 875 mg/125 mg BD OR
  • Tabs Ciprofloxacin 750 mg BD PLUS Clindamycin 300-450 mg QID OR
  • Tabs Levofloxacin 750 mg daily PLUS caps Clindamycin 300-450 mg PO QID or
  • Tabs Moxifloxacin 400 mg daily.

Prevention

  • Prevention of underlying cause
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