AIIMS Guidance on Septic arthritis, Prosthetic joint infections

All India Institute of Medical Sciences, Delhi has released AIIMS Antibiotics Policy which has been prepared by the Department of Medicine with Multidisciplinary collaboration. The guidance for Orthopaedic Infections includes Septic arthritis, Prosthetic joint infections the salient features of which are hereunder.

When to suspect

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  Pain, swelling, tenderness, increased the warmth of affected joint, restricted range of movement of one or more joint

  
  

How to confirm

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  ESR, CRP, WBC count

  
  


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  Blood culture

  
  


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  Synovial fluid cell count- >50,000/mm3

  
  


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  Synovial fluid gram stain, crystals and C/S +/- PCR

  
  


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  Uterine cervical swab/urethral swab C/S (if the history of high-risk behaviour present)

  
  


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  Imaging- X-ray, USG, MRI (if required)

  
  

Treatment:

A) Empiric (No risk factor for MDR GNB): N.gonorrheae, Staphylococcus aureus, Streptococcus spp.

Preferred: Inj Cefazolin 2g IV TDS or Inj Ceftriaxone 2g IV OD Plus Inj Vancomycin 1-2g IV BD or Teicoplanin 400 mg IV 12th hourly for 3 doses followed by 400mg IV 24th hourly

Linezolid can be used instead of vancomycin

Alternative: Inj Cefuroxime 1.5 g TDS Plus Inj Daptomycin 6mg/kg OD

B) Empiric (Risk factors for MDR-GNB)- trauma/severe immunosuppression/ Prior hospitalization:

Preferred: Inj Vancomycin 1-2g IV BD or Inj Teicoplanin 400 mg IV 12th hourly for 3 doses followed by 400mg IV 24th hourly PLUS Inj Piperacillin-tazobactam 4.5 g QID or Inj Cefoperazone sulbactam 2-3 g IV BD

Alternative: Inj Daptomycin 6mg/kg OD Plus Inj Imipenem 500 mg QID or Inj Meropenem 1g TDS

Special Remarks:

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  Septic arthritis is a surgical emergency. Early arthrotomy and debridement is recommended to prevent permanent cartilage damage.

  
  


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  Joint aspiration is recommended for diagnostic purposes and it should be ideally performed before administration of the first dose of antibiotic.

  
  


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  Total duration is 4-6 weeks. Parenteral therapy for 2-4week – then shifts to oral on the basis of sensitivity.

  
  


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  If risk factor for STI- suspect gonococcal arthritis- Synovial fluid may show gram-negative diplococci- send PCR/culture for confirmation- may require at least 7 to 14 days of therapy with Ceftriaxone/Doxycycline.

  
  


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  Suspect Tubercular or Brucella arthritis in long-standing cases.

  
  


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  CPK monitoring for patients on Daptomycin

  
  

Prosthetic joint Infection :

When to suspect

Persistent wound drainage, sinus tract, acute onset painful prosthesis, chronic painful prosthesis

How to confirm

Investigation

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  ESR, CRP, Arthrocentesis and fluid for the total count, differential count, culture for an aerobic and anaerobic organism and Mycobacteria

  
  


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  Arthrocentesis and culture are the gold standard investigation for diagnosis (procedure may be repeated if the first aspiration did not identify an organism and the index of suspicion is high)

  
  


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  Bone scan (low specificity), MRI, PET-scan

  
  

During surgery

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  Intraoperative inspection, Histopathology, cultures, ultra-sonicate of prosthesis

  
  

Treatment:

A) Empiric (CONS, Staphylococcus aureus, Streptococci) :

Preferred: Imipenem 500mg QID Or Meropenem 1 g TDS Plus Vancomycin IV 15mg/kg BD Plus Rifampicin 300mg BD for 2-6 weeks

Alternative: Cefepime 2g IV BD Plus Daptomycin 10-12 mg/kg (high dose) OD or Teicoplanin 10 mg/kg iv 12 hourly 3 doses fb 24th hourly Plus Rifampicin 300mg BD for 2-6 weeks

Oral therapy following IV therapy: Ciprofloxacin 750 mg BD or Levofloxacin 750 mg OD plus Rifampicin 300 mg BD for 3-6 months (3- hip, 6- knee)

B) Viridans Streptococci:

Preferred: Ampicillin 2gm IV six times daily for 6 weeks

Alternative: Ceftriaxone 2g IV OD for 6 weeks

C) MSSA:

Preferred: Cefazolin 2gm iv TDS Plus Rifampicin 300mg BD for 2-6 weeks

Alternative: Ceftriaxone 2g OD Plus Rifampicin 300mg BD for 2-6 weeks

Oral therapy following IV therapy: Ciprofloxacin 750 mg BD or levofloxacin 750 mg OD plus rifampicin 300 mg BD for 3-6 months (3- hip, 6- knee)

D) MRSA:

Preferred: Vancomycin 1-2 g IV BD Plus Rifampicin 300mg BD for 2-6 weeks

Alternative: Daptomycin 10-12 mg/kg (high dose) OD OR Teicoplanin 10 mg/kg iv 12 hrly in 3 dose f/b OD Plus Rifampicin 300mg BD for 2-6 weeks

Oral therapy following IV therapy: Ciprofloxacin 750 mg BD or levofloxacin 750 mg OD or linezolid 600 mg BD plus rifampicin 300 mg BD for 3-6 months (3- hip, 6- knee)