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The treatment for septic arthritis requires an adequate drainage of purulent joint fluid and appropriate antimicrobial therapy. Empiric therapy should be started after the collection joint fluid and blood sample, and these should be send for culture.

Empiric Therapy Adapted from

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▸  Pediatric   ▸  Newborns (< 1 week)   ▸  Newborns (1 -4 week)   ▸  Infants (1 - 3 months)   ▸  Children (3 mo - 14 yr)   ▸  Adults   ▸  Acute Monoarticular   ▸  Chronic Monoarticular   ▸  Polyarticular

Newborn (< 1 week) High suspicion of MRSA ▸ Vancomycin 18 mg/kg q12h PLUS ▸ Cephalosporin 3gen Low suspicion of MRSA ▸ Nafcillin 25 mg/kg q8h OR ▸ Oxacillin 25 mg/kg q8h OR ▸ Clindamycin 5mg/kg q8h Newborn (1 - 4 weeks) High suspicion of MRSA ▸ Vancomycin 22 mg/kg q12h PLUS ▸ Cephalosporin 3gen Low suspicion of MRSA ▸ Nafcillin 37 mg/kg q6h OR ▸ Oxacillin 37 mg/kg q6h OR ▸ Clindamycin 5mg/kg q6h|- Infants (1- 3 months) High suspicion of MRSA ▸ Vancomycin 40 mg/kg/day q6-8h Low suspicion of MRSA ▸ Nafcillin 37 mg/kg q6h (max 8-12 g/day) OR ▸ Oxacillin 37 mg/kg q6h (max 8-12 g/day) OR ▸ Clindamycin 7.5 mg/kg q6h Children (3 mo - 14 yr) Preferred Regimen ▸ Vancomycin 40 mg/kg/day IV q6-8h PLUS ▸ Cephalosporin 3gen Acute Monoarticular At risk for Gonococcal infection ▸ Ceftriaxone 1 gm IV q24h OR ▸ Cefotaxime 1 gm IV q8h OR ▸ Ceftizoxime 1 gm IV q8h Not at risk for Gonococcal infection ▸ Vancomycin 1g IV q12h PLUS ▸ Cephalosporin 3gen Chronic Monoarticular Brucella ▸ Doxycycline PLUS ▸ Gentamycin OR ▸ Streptomycin Nocardia ▸ TMP-SMX Mycobacteria ▸ ▸ Fungi ▸ Polyarticular Preferred Regimen ▸ Ceftriaxone 1 gm IV q24h

CSF Gram Stain-Based Therapy Adapted from

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Gram-Positive   ▸  Gram-Positive Cocci Gram-Negative   ▸  Gram-Negative Cocci   ▸  Gram-Negative Rods   ▸  Negative Gram Stain

Gram-Positive Cocci Preferred Regimen ▸ Vancomycin 15-20 mg/kg IV q8—12h (trough 15—20 μg/mL) Alternative Regimen (For patients allergic to vancomycin) ▸ Linezolid OR ▸ Daptomycin Gram-Negative Cocci Preferred Regimen ▸ Ceftriaxone 1 g IV q24h Gram-Negative Rods Preferred Regimen ▸ Ceftazidime 2 g IV q8h OR ▸ Cefepime 2g IV q12h OR ▸ Piperacillin-Tazobactam 4.5 g q6h OR ▸ Imipenem 500 mg IV q6h OR ▸ Meropenem 1 g IV q8h Alternative Regimen (For patients allergic to cephalosporins) ▸ Aztreonam 2 g q8h OR ▸ Ciprofloxacin 400 mg IV q12h OR ▸ Levofloxacin 750 mg IV q24h Negative Gram Stain Preferred Regimen ▸ Vancomycin 15-20 mg/kg IV q8—12h PLUS ▸ Ceftazidime 2 g IV q8h Alternative Regimen ▸ Ciprofloxacin 750 mg IV q12h OR ▸ Levofloxacin 750 mg IV q24h OR ▸ Tobramycin OR ▸ Gentamycin 5-7 mg/kg once daily or 5 mg/kg divided in 3 doses/day

Pathogen-Based Therapy — Bacteria Adapted from

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Bacteria   ▸  Staphylococcus aureus   ▸  Staphylococcus epidermidis   ▸  Methicillin-resistant S. aureus   ▸  Streptococcus groups A, B, C, G   ▸  Enterococcus feacalis   ▸  Pseudomonas aeruginosa   ▸  Neisseria gonorrhoeae

Staphylococcus aureus Preferred Regimen ▸ Nafcillin 1.5-2 g IV q4h OR ▸ Oxacillin 1.5-2 g IV q4h OR ▸ Cefazolin 1 g IV q8h Alternative Regimen ▸ Vancomycin 15 mg/kg IV q12h (do not exceed 2g/day) Staphylococcus epidermidis Preferred Regimen ▸ Vancomycin 15 mg/kg IV q12h Alternative Regimen ▸ TMP-SMX OR Methicillin-resistant S. aureus Preferred Regimen ▸ Vancomycin 15 mg/kg IV q12h Alternative Regimen ▸ Linezolid 600 mg IV/PO q12h Streptococcus groups A, B, C, G Preferred Regimen ▸ Penicillin G 20 MU IV q24h or divided in 6 doses/day OR ▸ Ceftriaxone 2 g IV or IM q24h OR ▸ Cefazolin 1 g IV q8h Alternative Regimen ▸ Vancomycin 15mg/kg IV q12h Enterococcus faecalis Preferred Regimen ▸ Penicillin G 20 MU IV q24h or divided in 6 doses/day PLUS ▸ Ampicillin 2 g IV q6h OR ▸ Gentamicin 1 mg/kg IV or IM q8h Alternative Regimen Vancomycin PLUS ▸ Gentamicin 1 mg/kg IV or IM q8h Pseudomonas aeruginosa Preferred Regimen ▸ Ciprofloxacin 750 mg PO q12h Alternative Regimen ▸ Levofloxacin 500 mg PO q24h PLUS ▸ Gentamicin 1.7 mg/kg IV q8h Neisseria gonorrhoeae Preferred Regimen ▸ Ceftrixone 1 g IV q24h for 1-2 days after clinical improvement' FOLLOWED BY ▸ Cefixime 400 mg po q12h for 1 week OR ▸ Ciprofloxacin 500 mg po q12h for 1 week OR ▸ Ofloxacin 400 mg PO q12h for 1 week Alternative Regimen ▸ Ciprofloxacin 400 mg IV q12h for 1-2 days after clinical improvement OR ▸ Ofloxacin 400 mg iv q12h for 1-2 days after clinical improvement OR ▸ Spectinomycin 2 g IM q12h for 1-2 days after clinical improvement FOLLOWED BY ▸ Ciprofloxacin 500 mg po q12h for 1 week' OR ▸ Ofloxacin 400 mg po q12h for 1 week

Pathogen-Based Therapy — Fungi

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Fungi   ▸  Candida   ▸  Coccidioides   ▸  Blastomyces   ▸  Histoplasma   ▸  Sporothrix   ▸  Aspergillus

Candida Preferred Regimen ▸ Amphotericin B deoxycholate 0.5-1 mg/kg/day for 2-3 weeks FOLLOWED BY ▸ Fluconazole to complete a total duration of therapy of 6-12 months. Preferred Regimen ▸ Itraconazole 400 mg/day for at least 12 months Aspergillus Preferred Regimen ▸ Voriconazole

Pathogen-Based Therapy in Patients with Prosthetic Joint — Bacteria Adapted from Diagnosis and Management of Prosthetic Joint Infection CID 2013:56

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Bacteria   ▸  Staphylococci, oxacillin-susceptible   ▸  Staphylococci, oxacillin-resistant   ▸  Enterococcus spp, penicillin-susceptible   ▸  Enterococcus spp, penicillin-resistant   ▸  Pseudomonas aeruginosa   ▸  Enterobacter spp   ▸  Enterobacteriaceae

Staphylococci, oxacillin-susceptible Preferred Regimen ▸ Nafcillin 1.5-2 g IV q4-6h OR ▸ Cefazolin 1–2 g IV q8 h OR ▸ Ceftriaxone 1–2 g IV q24h Alternative Regimen ▸ Vancomycin IV 15 mg/kg q12h OR ▸ Daptomycin 6 mg/kg IV q24h OR ▸ Linezolid 600 mg PO/IV q12h Staphylococci, oxacillin-resistant Preferred Regimen ▸ Vancomycin 15 mg/kg IV q12h Alternative Regimen ▸ Daptomycin 6 mg/kg IV q24h OR ▸ Linezolid 600 mg PO/IV q12h Enterococcus spp, penicillin-susceptible Preferred Regimen ▸ Penicillin G 20-40 MU IV q24h continuously or divided in 6 doses Alternative Regimen ▸ Vancomycin IV 15 mg/kg q12h OR ▸ Daptomycin 6 mg/kg IV q24h OR ▸ Linezolid 600 mg PO/IV q12h Enterococcus spp, penicillin-resistant Preferred Regimen ▸ Vancomycin IV 15 mg/kg q12h Alternative Regimen ▸ Daptomycin 6 mg/kg IV q24h OR ▸ Linezolid 600 mg PO/IV q12h Pseudomonas aeruginosa Preferred Regimen ▸ Cefepime 2 g IV q12 h OR ▸ Meropenem 1 g IV q8 h Alternative Regimen ▸ Ciprofloxacin 750 mg PO q12h or 400 mg IV q12h OR ▸ Ceftazidime 2 g IV q8h Enterobacter spp Preferred Regimen ▸ Cefepime 2 g IV q12h OR ▸ Ertapenem 1 g IV q24 h Alternative Regimen ▸ Ciprofloxacin 750 mg PO q12h or 400 mg IV q12h Pseudomonas aeruginosa Preferred Regimen ▸ Ceftazidime 2 g IV q8h OR ▸ Cefepime 2 g IV q8h PLUS ▸ Gentamicin 1.7 mg/kg IV q8h Alternative Regimen ▸ Aztreonam 2 g IV q6—8h OR ▸ Meropenem 2 g IV q8h OR ▸ Ciprofloxacin 400 mg IV q8—12h PLUS Expand▸ Gentamicin 1.7 mg/kg IV q8h Staphylococcus aureus, Methicillin sensitive Preferred Regimen ▸ Nafcillin 1.5—2 g IV q4h OR ▸ Oxacillin 1.5—2 g IV q4h Alternative Regimen Expand▸ Vancomycin 15 mg/kg IV q6h (trough 15—20 μg/mL) OR ▸ Linezolid 600 mg IV q12h OR ▸ Daptomycin 6 mg/kg IV q24h