What is the treatment for knee gonorrhea (septic arthritis caused by Neisseria gonorrhoeae)?

Treatment of Knee Gonorrhea (Gonococcal Septic Arthritis)

For gonococcal septic arthritis of the knee, the recommended treatment is ceftriaxone 1 gram IV or IM every 24 hours, continued for 24-48 hours after improvement begins, followed by oral therapy to complete at least one week of antimicrobial treatment. 1

Initial Management

Hospitalization and Diagnostic Approach

• Hospitalization is recommended for initial therapy of disseminated gonococcal infection (DGI), especially for patients who:
  • Might not comply with treatment
  • Have uncertain diagnosis
  • Have purulent synovial effusions or other complications 1
• Obtain synovial fluid for:
  • Gram stain (look for intracellular gram-negative diplococci)
  • Culture on chocolate agar
  • PCR testing if available (can improve diagnostic yield) 2
• Additional cultures from:
  • Blood
  • Genital sites
  • Pharynx
  • Rectum 3

Initial Antibiotic Regimen

Recommended Regimen:

• Ceftriaxone 1 g IV or IM every 24 hours 1, 4

Alternative Regimens (if ceftriaxone unavailable):

• Cefotaxime 1 g IV every 8 hours, OR
• Ceftizoxime 1 g IV every 8 hours, OR
• Spectinomycin 2 g IM every 12 hours (for patients with severe beta-lactam allergy) 1, 4

CAUTION: Quinolones (ciprofloxacin, ofloxacin, levofloxacin) are no longer recommended due to widespread resistance 4

Continuation Therapy

After 24-48 hours of improvement on IV/IM therapy, switch to one of the following oral regimens to complete at least 1 week of total antimicrobial therapy:

• Cefixime 400 mg orally twice daily 1

Special Considerations

Joint Management

• Aspirate joint effusions until resolution 3
• Purulent effusions may require longer antibiotic treatment 3

Concurrent Testing and Treatment

• Test for concurrent Chlamydia trachomatis infection 1
• Presumptively treat for chlamydia unless appropriate testing excludes this infection 1
• Test for syphilis and HIV 3

Management of Sex Partners

• All sex partners from the previous 60 days should be evaluated and treated 1, 4
• Patients should avoid sexual activity until therapy is completed and both they and their partners no longer have symptoms 4

Common Pitfalls and Caveats

1. Diagnostic challenges: N. gonorrhoeae is a fragile organism that is difficult to culture, especially if antibiotics have already been started 3

   • PCR of synovial fluid can improve diagnostic yield when cultures are negative 2

2. Resistance patterns: Penicillin resistance has developed worldwide, making third-generation cephalosporins the drugs of choice 5

3. Presentation variability: Gonococcal arthritis may present as:

   • Monoarticular arthritis (as in knee involvement)
   • Part of disseminated gonococcal infection with skin lesions and polyarthralgias 6
   • Can affect patients of any age, not just young adults 7

4. Treatment duration: Complete at least one week of total antimicrobial therapy, even if rapid improvement occurs 1

5. Follow-up: Monitor for clinical improvement; persistent symptoms warrant repeat cultures with antimicrobial susceptibility testing 4

By following this treatment algorithm, most patients with gonococcal arthritis of the knee will experience rapid improvement and complete resolution without long-term joint damage.