Name
GONOCOCCAL ARTHRITIS
DESCRIPTION
DETAIL
OTHER TESTS : * DIRECT VISUALIZATION IN GRAM STAINING IS HIGHLY SPECIFIC & SENSITIVE IN MALE BUT ONLY 50% IN GONOCOCCAL CERVICITIS. * NUCLEIC ACID PROBE TESTS LIKE ONE EMPLOYING NONISOTOPIC CHEMILUMINESCENT DNA PROBE, IS AS SENSITIVE AS CULTURE TEST * ASPIRATION FROM INVOLVED JOINT FOR CULTURE & DIRECT SMEAR TEST * PCR OF JOINT FLUID - IS HIGHLY SPECIFIC
TYPENOTES
Medical Care: A difficult issue in dealing with septic arthritis is that medical management decisions are often needed prior to the availability of laboratory results required for diagnosis. Antibiotic coverage in healthy hosts should initially include gram-positive organisms, which account for approximately 80% of nongonococcal monoarthritis cases. Staphylococcus aureus accounts for 60%, non-group A Streptococcus species cause 15%, and Streptococcus pneumoniae cause 3%. Gram-negative organisms (which account for another 18%) should be covered in the patients who are immunocompromised or otherwise at risk. " Most patients with suspected acute infectious arthritis should be hospitalized to establish a diagnosis and to monitor for improvement. Daily synovial fluid drainage has also been recommended for purulent effusions associated with gonococcal arthritis. Hospitalization is also recommended for initial therapy of patients with suspected disseminated gonococcal infection (DGI), especially in patients with purulent synovial fluid or suspected poor compliance. Transition to oral antibiotics can usually be made 24-48 hours after improvement begins. " A thorough travel history for the patient and any sexual partners is important in selecting initial therapy for gonococcal infections. Quinolone-resistant N gonorrhoeae (QRNG) is common in the Pacific and parts of Asia and is increasing in the western United States. For this reason, the Centers for Disease Control (CDC) no longer recommends quinolones for the treatment of gonococcal infections in Hawaii or infections that may have been acquired in the Pacific or Asia. Furthermore, quinolone use in California is considered inadvisable. " According to 2002 CDC Guidelines, the initial treatment of choice for gonococcal arthritis or DGI in adults is a third-generation cephalosporin: ceftriaxone 1 g q12h, ceftizoxime 1 g q8h, or cefotaxime 1 g q8h. Alternative agents that can be used in penicillin-allergic patients include ciprofloxacin (400 mg IV q12h), ofloxacin (400 mg IV q12h), levofloxacin (250 mg/d IV) or spectinomycin (2 g IM q12h). " Oral regimens that can be started 24-48 hours after initial improvement include the following: o Cefixime 400 mg bid o Ciprofloxacin 500 mg bid o Ofloxacin 400 mg bid o Levofloxacin 500 mg/d " Patients should continue oral antibiotics for at least 1 week. " Special situations include pregnant and pediatric patients (<8 y). These patients should not be treated with quinolones or tetracyclines. Pregnant patients with gonococcal infections should be treated with a recommended cephalosporin. Spectinomycin is indicated for patients who cannot tolerate a cephalosporin. Pediatric patients can be treated as follows: o Children who weigh more than 45 kg - Appropriate adult regimen o Children who weight less than 45 kg - Ceftriaxone 50 mg/kg/d IV or IM for 7 days " Examine patients with DGI for clinical evidence of endocarditis and meningitis. Patients with endocarditis require much longer courses of antibiotics (4-6 wk) and may require surgical intervention. " Patients with confirmed diagnosis of a localized gonococcal infection probably can be discharged with outpatient medications if they are considered reliable for follow-up care. Synovial effusions may require a longer duration of antibiotics, but open drainage is rarely required. Intraarticular antibiotics have no known benefit. Because 30-50% of patients are co-infected with Chlamydia, test all patients and treat with azithromycin (1 g PO as a single dose) or doxycycline (100 mg PO bid for 7 d). Alternatives for pregnant patients include erythromycin (500 mg PO qid for 7 d) or amoxicillin (500 mg tid for 7 d). Regimens for the treatment of chlamydial infection in children include the following: o Children who weigh less than 45 kg - Erythromycin base or ethylsuccinate 50 mg/kg PO divided qid for 14 days o Children who weigh more than 45 kg but who are younger than 8 years - Azithromycin 1 g PO as a single dose o Children older than 8 years - Azithromycin 1 g PO in a single dose or doxycycline 100 mg PO bid for 7 days " Patients should be advised to refer their sexual partners for evaluation and treatment. Surgical Care: Open drainage or arthroscopy of infected joints is rarely indicated. Even purulent joint effusions rarely result in permanent damage. Activity: Bedrest during inpatient status and brief immobilization of the septic joint aid in decreasing pain, especially when NSAIDs are not advisable
RELATED DISEASE
Not Available Disease
DISEASE
INVESTIGATION
URINE CULTURE TEST, BLOOD CULTURE, COMPLETE BLOOD COUNT, PCR, PUS CULTURE TEST, X-RAY, GRAM STAINING