What is the management of septic arthritis of the sternoclavicular joint in Intravenous Drug Users (IVDU)?

From the Guidelines

Management of sternoclavicular joint septic arthritis in intravenous drug users (IVDU) requires prompt surgical debridement combined with targeted antibiotic therapy, as recommended by the most recent guidelines 1. The initial empiric antibiotic coverage should include vancomycin 15-20 mg/kg IV every 8-12 hours plus cefepime 2g IV every 8 hours or piperacillin-tazobactam 4.5g IV every 6 hours to cover Staphylococcus aureus (including MRSA), Pseudomonas, and other gram-negative organisms common in this population 1. Some key points to consider in the management of sternoclavicular joint septic arthritis in IVDU include:

• Blood cultures and joint aspirate should be obtained before starting antibiotics when possible
• Surgical intervention typically involves incision and drainage, with more extensive debridement or resection for severe cases with abscess formation, osteomyelitis, or mediastinal involvement
• CT or MRI imaging is essential to evaluate the extent of infection and guide surgical planning
• Following culture results, antibiotics should be narrowed appropriately and continued for 4-6 weeks total
• IVDU patients require close monitoring for compliance, consideration of PICC lines rather than central venous catheters to discourage drug use, addiction treatment referrals, and screening for HIV, hepatitis B and C The choice of empiric antibiotic regimens in patients with IAI should be based on the clinical condition of the patients, the individual risk for infection by resistant pathogens, and the local resistance epidemiology 1. In the context of intra-abdominal infections, the main resistance problem is posed by ESBL-producing Enterobacteriaceae, which are prevalent in hospital-acquired infections but observed in CA-IAIs too 1. However, the management of sternoclavicular joint septic arthritis in IVDU is more closely related to the management of skin and soft-tissue infections, as outlined in the 2018 WSES/SIS-E consensus conference recommendations 1. The duration of therapy is typically 4 weeks for septic arthritis and 6 weeks for osteomyelitis, as suggested by previous guidelines 1. Overall, the management of sternoclavicular joint septic arthritis in IVDU requires a comprehensive approach that includes prompt surgical debridement, targeted antibiotic therapy, and close monitoring for complications and compliance.

From the Research

Management of Sternoclavicular Joint Septic Arthritis in IVDU

• The management of sternoclavicular joint septic arthritis in intravenous drug users (IVDU) is a complex process that requires prompt diagnosis and treatment to prevent significant morbidity and mortality 2.
• Surgical management is often necessary, with options ranging from simple incision, debridement, and drainage to extended surgery including reconstructive procedures 3, 4.
• The choice of treatment depends on the stage of infection, with early stages potentially manageable with simple incision, debridement, and drainage, and advanced stages requiring more radical intervention 3.
• In some cases, medical management with antibiotic therapy may be sufficient, especially in patients without underlying medical conditions or complications such as osteomyelitis or abscess 5.
• It is essential to consider the patient's status and the causative pathogen when determining the treatment approach 5.

Risk Factors and Complications

• IVDU is a known risk factor for sternoclavicular joint septic arthritis, along with other conditions such as immunocompromising diseases, diabetes, and fractures of the clavicle or catheterization of the subclavian vein 6, 2.
• Complications of sternoclavicular joint septic arthritis can include mediastinitis, osteomyelitis, and septicaemia, which require prompt and aggressive treatment 4.
• The treatment concept should include local joint and bone resection, as well as management of complications such as mediastinitis 4.

Treatment Outcomes

• Successful treatment of sternoclavicular joint septic arthritis can be achieved with surgical or medical management, depending on the individual case 3, 4, 5.
• The use of reconstructive surgery, such as pedicled pectoralis muscle flap, may be necessary to repair defects in the chest wall after successful treatment of the infection 4.
• Patient outcomes can be favorable, with complete recovery from the disease and well-healed wounds without signs of reinfection 3.