What is the treatment for gonorrhea arthritis?

Treatment for Gonorrhea Arthritis (Disseminated Gonococcal Infection)

For gonorrhea arthritis, initiate treatment with ceftriaxone 1 g IV or IM every 24 hours PLUS azithromycin 1 g orally as a single dose, continuing parenteral therapy until clinical improvement (typically 24-48 hours), then transition to oral cefixime 400 mg twice daily to complete 7 days of total therapy. 1, 2

Initial Parenteral Therapy

• Begin with ceftriaxone 1 g IV or IM every 24 hours as the cornerstone of treatment for disseminated gonococcal infection with arthritis 3
• Add azithromycin 1 g orally as a single dose on day 1 to address potential chlamydial coinfection (present in 40-50% of cases) and provide dual antimicrobial coverage to combat resistance 1, 2
• Continue parenteral ceftriaxone until 24-48 hours after clinical improvement begins, which typically includes reduction in fever, joint pain, and swelling 3

Transition to Oral Therapy

• Once clinical improvement is documented, switch to cefixime 400 mg orally twice daily to complete a total of 7 days of antimicrobial therapy 4, 3
• The total duration (parenteral plus oral) should be 7 days for uncomplicated gonococcal arthritis, or 10-14 days if meningitis is documented 4

Joint Drainage Considerations

• Perform repeated arthrocentesis (needle aspiration) for purulent joint effusions, particularly in large joints like the knee or hip 5
• Gonococcal arthritis responds well to antibiotics plus needle drainage, unlike other bacterial arthritides that often require surgical drainage 5
• Open surgical drainage is not typically necessary for gonococcal hip infections, which differ from other bacterial hip infections in their excellent response to antibiotics and arthrocentesis 5

Diagnostic Confirmation

• Obtain cultures from synovial fluid (44% positive), urogenital sites (86% positive), blood (12% positive), rectum (39% positive), and pharynx (7% positive) before initiating antibiotics 6
• Synovial fluid with gonococcal infection typically shows white blood cell counts >20.0 × 10⁹/L 6
• The diagnosis is secure if mucosal gonococcal infection is documented alongside typical clinical syndrome (migratory arthralgias, tenosynovitis, dermatitis) that responds promptly to therapy 3

Clinical Presentation to Recognize

• Look for migratory arthralgias (66% of cases), urogenital symptoms (63%), fever (51%), and characteristic skin lesions (39%) - typically painless pustular or vesiculopustular lesions on extremities 6
• The knee is the most commonly affected joint, followed by wrists, ankles, and elbows 6
• Patients are typically young (mean age 22-23 years), female (83%), and sexually active 6

Critical Antimicrobial Resistance Considerations

• Never use fluoroquinolones (ciprofloxacin, ofloxacin) due to widespread resistance in the United States, despite their historical effectiveness 1, 2
• Never use penicillin as initial therapy - at least 5% of gonococcal arthritis cases involve penicillin-resistant organisms, and resistance rates have increased substantially since the 1980s 6
• Third-generation cephalosporins (ceftriaxone) remain highly effective and are the only recommended initial therapy until susceptibilities are known 6, 3

Alternative Regimens (Severe Cephalosporin Allergy)

• If severe cephalosporin allergy exists, use azithromycin 2 g orally as a single dose with mandatory test-of-cure at 1 week, though this has lower efficacy (93%) and high gastrointestinal side effects 1, 2
• Consider gentamicin 240 mg IM single dose PLUS azithromycin 2 g orally as an alternative, though gentamicin has poor efficacy for pharyngeal infections (only 20% cure rate) 2
• Consult infectious disease specialist for cephalosporin-allergic patients 2

Hospitalization Criteria

• Hospitalize all patients with suppurative arthritis or when the diagnosis is uncertain 3
• Mean hospitalization duration is approximately 6 days, with longer stays for patients with elevated erythrocyte sedimentation rate, positive synovial fluid cultures, or comorbid conditions (IV drug use, systemic lupus erythematosus, HIV) 6

Partner Management and Follow-Up

• Evaluate and treat all sexual partners from the preceding 60 days with the same dual therapy regimen (ceftriaxone 250 mg IM plus azithromycin 1 g orally for uncomplicated infection) 1, 2
• Instruct patients to avoid sexual intercourse until therapy is completed and both patient and partners are asymptomatic 1
• Test for HIV and syphilis at the time of gonorrhea diagnosis, as gonorrhea facilitates HIV transmission 2
• Retest at 3 months due to high reinfection rates (most post-treatment infections are reinfections, not treatment failures) 1, 2

Treatment Failure Management

• If symptoms persist after 48-72 hours of appropriate therapy, obtain culture with antimicrobial susceptibility testing immediately 2
• Report suspected treatment failure to local public health officials within 24 hours 2
• Salvage regimens for ceftriaxone failure include gentamicin 240 mg IM PLUS azithromycin 2 g orally or ertapenem 1 g IM for 3 days 2

Special Populations

• Pregnant women: Use ceftriaxone 1 g IV/IM daily plus azithromycin 1 g orally; never use doxycycline or fluoroquinolones in pregnancy 2
• Neonates with disseminated gonococcal infection: Use ceftriaxone 25-50 mg/kg/day IV or IM for 7 days (10-14 days if meningitis documented) 4

Expected Clinical Response

• Response to appropriate cephalosporin therapy is typically prompt, with improvement within 24-48 hours 6, 3
• Complete recovery of joint function without residual deficit is expected with timely treatment and adequate drainage 5
• Eventual outcome remains excellent despite increasing antimicrobial resistance patterns 6