What is the preferred antibiotic regimen for septic arthritis due to Neisseria (N.) gonorrhea?

Preferred Antibiotic for Septic Arthritis Due to Gonorrhea

Ceftriaxone 250 mg IM in a single dose plus azithromycin 1 g orally in a single dose is the preferred antibiotic regimen for septic arthritis due to Neisseria gonorrhoeae. 1

First-Line Treatment

• Ceftriaxone is the most effective agent against N. gonorrhoeae, providing sustained, high bactericidal levels in the blood with cure rates of 98.9% for uncomplicated gonococcal infections 1
• The recommended dose is 250 mg IM in a single dose, which is higher than the previously recommended 125 mg dose in older guidelines 1
• Combination therapy with azithromycin 1 g orally in a single dose should be added to delay emergence and spread of resistance to cephalosporins 1

Rationale for Ceftriaxone

• Ceftriaxone is highly effective for treating gonococcal infections at all anatomic sites, including joint infections 1
• It provides higher and more sustained bactericidal levels than oral cephalosporins 1
• Ceftriaxone has been successfully used in cases of gonococcal septic arthritis with good outcomes 2, 3

Alternative Regimens

• If ceftriaxone is unavailable, cefixime 400 mg orally in a single dose plus azithromycin 1 g orally can be used, but a test-of-cure should be performed in 1 week 1
• For patients with severe cephalosporin allergy, azithromycin 2 g orally in a single dose can be considered, with test-of-cure in 1 week 1
• Spectinomycin 2 g IM in a single dose is useful for patients who cannot tolerate cephalosporins and quinolones 1

Important Considerations

• Quinolones (ciprofloxacin, ofloxacin, levofloxacin) are no longer universally effective against N. gonorrhoeae due to increasing resistance, though they may be used if susceptibility is confirmed 1, 4
• Other single-dose cephalosporin regimens that can be effective include ceftizoxime 500 mg IM, cefoxitin 2 g IM with probenecid 1 g orally, and cefotaxime 500 mg IM 1, 5
• For gonococcal septic arthritis, treatment duration may need to be extended beyond the single dose recommended for uncomplicated gonorrhea 3

Monitoring and Follow-up

• Joint aspiration may be necessary in addition to antibiotic therapy for gonococcal septic arthritis 3
• Patients with persistent symptoms after treatment should be evaluated by culture for N. gonorrhoeae, and any isolates should be tested for antimicrobial susceptibility 1
• Sexual partners should be evaluated and treated for N. gonorrhoeae and C. trachomatis infections if their last sexual contact with the patient was within 60 days 1

Special Populations

• Pregnant women should not be treated with quinolones or tetracyclines; cephalosporins are the preferred treatment 1
• For patients with penicillin allergy, spectinomycin is a safe alternative 1

The evidence strongly supports ceftriaxone as the cornerstone of treatment for gonococcal septic arthritis due to its excellent efficacy, safety profile, and ability to achieve high concentrations in joint fluid 6, 3.