What antibiotics are recommended to treat a female patient with gonococcal arthritis, indicated by synovial fluid with a high white blood cell count and gram-negative diplococci on gram stain?

Treatment of Gonococcal Septic Arthritis

Initiate treatment immediately with ceftriaxone 1 g IV or IM every 24 hours PLUS azithromycin 1 g orally as a single dose to cover concurrent chlamydial infection, which is present in a substantial proportion of patients with gonococcal infections. 1

Initial Parenteral Therapy

Hospitalization is strongly recommended for initial therapy, especially given the purulent synovial effusion (WBC 70,000) and need for reliable treatment compliance. 1

First-Line Regimen

• Ceftriaxone 1 g IM or IV every 24 hours is the recommended initial treatment for disseminated gonococcal infection (DGI) with septic arthritis. 1
• Continue parenteral therapy for 24-48 hours after clinical improvement begins (defervescence, reduced joint pain/swelling). 1

Alternative Parenteral Regimens (if ceftriaxone unavailable)

• Cefotaxime 1 g IV every 8 hours 1
• Ceftizoxime 1 g IV every 8 hours 1
• For β-lactam allergy: Spectinomycin 2 g IM every 12 hours (though availability is limited in the United States) 1

Concurrent Chlamydia Treatment

Critical: Patients with gonococcal infection must be treated presumptively for concurrent Chlamydia trachomatis infection because coinfection rates are substantial and ceftriaxone has no activity against chlamydia. 1, 2

• Azithromycin 1 g orally as a single dose (preferred for directly observed therapy and compliance) 1, 3, 4
• Alternative: Doxycycline 100 mg orally twice daily for 7 days 1, 3, 4

Transition to Oral Therapy

After 24-48 hours of clinical improvement with parenteral therapy, switch to oral therapy to complete a full 7 days of total antimicrobial treatment. 1

Oral Continuation Options

• Cefixime 400 mg orally twice daily 1
• Ciprofloxacin 500 mg orally twice daily (contraindicated if patient has history of recent foreign travel, infection acquired in areas with high quinolone resistance, or if patient is pregnant/lactating) 1

Joint Management

• Aspirate purulent synovial effusions repeatedly until resolution. 5, 6
• Patients with purulent effusions (like this case with WBC 70,000) improve more slowly than those with non-purulent effusions, but respond well to antibiotics plus drainage by arthrocentesis without requiring surgical drainage. 6, 7
• Most patients show subjective improvement and defervescence within 2 days of appropriate treatment. 7

Partner Management and Additional Testing

Both sexual partners must be evaluated, tested, and treated empirically to prevent reinfection and further transmission. 1, 5

• Test patient for syphilis and HIV at initial visit. 3
• Instruct patient to abstain from sexual intercourse for 7 days after completing treatment and until all partners are treated. 3, 4
• Failing to treat sex partners leads to reinfection in up to 20% of cases. 3

Critical Pitfalls to Avoid

• Do not use quinolones empirically without knowing travel history or local resistance patterns, as quinolone-resistant N. gonorrhoeae (QRNG) prevalence has increased. 1
• Do not omit chlamydia treatment—coinfection is common and ceftriaxone alone will not treat chlamydia. 1, 2
• Do not use penicillin or ampicillin empirically—penicillin resistance has developed worldwide and these are no longer recommended as initial therapy. 5
• Do not delay treatment while awaiting culture results in a patient with classic presentation (gram-negative diplococci on Gram stain, high synovial fluid WBC, sexual exposure history). 5, 8

Expected Clinical Response

• Expect defervescence and subjective improvement within 48 hours of appropriate antibiotic therapy. 7
• Complete clinical and bacteriologic cure should be achieved with the recommended regimen. 7
• Prompt response to antimicrobial treatment supports the diagnosis when cultures are negative. 5, 8