From the Guidelines
The recommended empiric treatment for suspected septic arthritis is immediate joint drainage combined with broad-spectrum antibiotics, such as vancomycin and ceftriaxone or cefepime, to cover common causative organisms including Staphylococcus aureus, streptococci, and gram-negative bacteria. This approach is supported by the Surviving Sepsis Campaign guidelines, which recommend empiric broad-spectrum therapy with one or more antimicrobials for patients presenting with sepsis or septic shock to cover all likely pathogens 1. The initial antibiotic therapy should include vancomycin 15-20 mg/kg IV every 8-12 hours plus either ceftriaxone 2g IV daily or cefepime 2g IV every 8 hours. For patients with penicillin allergy, fluoroquinolones like levofloxacin 750mg IV daily can replace the cephalosporin.
Key Considerations
- Treatment should begin immediately after obtaining synovial fluid and blood cultures, without waiting for results.
- Joint drainage should be performed either by arthrocentesis (repeated as needed), arthroscopy, or open surgical drainage depending on the affected joint and severity.
- The initial IV antibiotics are typically continued for 2-4 weeks, followed by oral antibiotics to complete a total 4-6 week course, guided by culture results and clinical response.
- Prompt treatment is crucial as delayed therapy can lead to irreversible joint damage, with S. aureus being particularly destructive to cartilage within 24-48 hours of infection.
Rationale
The initiation of appropriate antimicrobial therapy is one of the most important facets of effective management of life-threatening infections causing sepsis and septic shock. Failure to initiate appropriate empiric therapy in patients with sepsis and septic shock is associated with a substantial increase in morbidity and mortality 1. The choice of empiric antimicrobial therapy depends on complex issues related to the patient’s history, clinical status, and local epidemiologic factors. Key patient factors include the nature of the clinical syndrome/site of infection.
Antimicrobial Therapy
- The Surviving Sepsis Campaign guidelines recommend that administration of IV antimicrobials should be initiated as soon as possible after recognition and within one hour for both sepsis and septic shock 1.
- Empiric antimicrobial therapy should be narrowed once pathogen identification and sensitivities are established and/or adequate clinical improvement is noted 1.
- The guidelines also recommend against sustained systemic antimicrobial prophylaxis in patients with severe inflammatory states of noninfectious origin 1.
From the Research
Empiric Treatment for Suspected Septic Arthritis
The recommended empiric treatment for suspected septic arthritis involves several key considerations:
- Initiation of empiric antibiotic therapy as soon as possible after synovial fluid has been obtained, if there is clinical concern for septic arthritis 2
- Coverage for Staphylococcus aureus and common respiratory pathogens, as well as consideration for other potential pathogens such as Neisseria gonorrhoeae, Borrelia burgdorferi, and fungal infections 2, 3
- Use of oral antibiotics in most cases, as they are not inferior to intravenous therapy 2, 3
- Total duration of therapy ranging from two to six weeks, although certain infections may require longer courses 2
Key Principles of Treatment
Some key principles of treatment for septic arthritis include:
- Prompt and effective treatment to avoid irreversible joint destruction or death 4, 5
- Combination of antibiotics and prompt removal of purulent material from the affected joint 4
- Identification of causative bacteria to administer the correct antibiotic 5
- Consideration of the patient's age, medical history, and other factors to guide treatment decisions 2, 3
Special Considerations
Special considerations in the treatment of septic arthritis include: