From the Research
The treatment of infected tophi in gout requires a dual approach addressing both the infection and underlying gout, with the most recent evidence suggesting that pegloticase is probably beneficial for resolution of tophi in gout, as shown in a 2021 study 1.
Key Considerations
- Initially, empiric broad-spectrum antibiotics such as vancomycin plus piperacillin-tazobactam should be started, with adjustment based on culture results and continued for 2-4 weeks depending on severity.
- Surgical debridement is often necessary to remove infected and necrotic tissue, drain abscesses, and obtain specimens for culture.
- Once the infection is controlled, gout management should be optimized with urate-lowering therapy such as allopurinol (starting at 100mg daily and titrating up) or febuxostat (40-80mg daily) to achieve serum urate levels below 6 mg/dL.
- During acute phases, colchicine (0.6mg once or twice daily), NSAIDs, or corticosteroids may be used for symptom control, though these should be used cautiously in the setting of infection.
Rationale
The comprehensive approach is necessary because infected tophi represent a serious complication where uric acid crystals create an environment conducive to bacterial growth, while the surrounding inflammation and poor blood supply complicate antibiotic delivery, necessitating both antimicrobial therapy and surgical intervention for effective treatment, as supported by a 2016 study 2 and a 2020 review 3.
Additional Considerations
- Lesinurad 400 mg plus febuxostat may be beneficial for tophi resolution compared with lesinurad 200 mg plus febuxostat, as shown in the 2021 study 1.
- The lack of trial data on interventions for managing tophi in gout is surprising, given that allopurinol is a well-established treatment for gout, highlighting the need for more research in this area, as noted in the 2021 study 1.