Sandbox/AL

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 ▸ Penicillin G 2 MU IV q4h OR ▸ Ampicillin 2 g IV q6h PLUS ▸ Gentamicin 1 mg/kg IV or IM q8h Alternative Regimen Vancomycin PLUS ▸ Gentamicin 1 mg/kg IV or IM q8h N. meningitidis, Penicillin MIC ≥0.1 μg/mL Preferred Regimen ▸ Cefotaxime 2 g IV q4—6h OR ▸ Ceftriaxone 2 g IV q12h Alternative Regimen ▸ Cefepime 2 g IV q8h OR ▸ Chloramphenicol 1—1.5 g IV q6h OR ▸ Moxifloxacin 400 mg IV q24h OR ▸ Meropenem 2 g IV q8h

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

Staphylococcus aureus Preferred Regimen ▸ Nafcillin 2 g IV q6h Alternative Regimen ▸ Vancomycin OR ▸ Cefazolin OR ▸ Clindamycin 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 ▸ TMP-SMX OR ▸ Doxycycline OR ▸ Linezolid Streptococcus groups A, B, C, G Preferred Regimen ▸ Penicillin G 2 MU IV q4h Alternative Regimen ▸ Vancomycin OR ▸ Cefazolin OR ▸ Erythromycin Enterococcus faecalis Preferred Regimen ▸ Penicillin G 2 MU IV q4h OR ▸ Ampicillin 2 g IV q6h PLUS ▸ Gentamicin 1 mg/kg IV or IM q8h Alternative Regimen Vancomycin PLUS ▸ Gentamicin 1 mg/kg IV or IM q8h N. meningitidis, Penicillin MIC ≥0.1 μg/mL Preferred Regimen ▸ Cefotaxime 2 g IV q4—6h OR ▸ Ceftriaxone 2 g IV q12h Alternative Regimen ▸ Cefepime 2 g IV q8h OR ▸ Chloramphenicol 1—1.5 g IV q6h OR ▸ Moxifloxacin 400 mg IV q24h OR ▸ Meropenem 2 g IV q8h 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

Pathogen-Based Therapy in Patients with Prosthetic Joint — Bacteria Adapted from

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

Staphylococcus aureus Preferred Regimen ▸ Nafcillin 2 g IV q6h Alternative Regimen ▸ Vancomycin OR ▸ Cefazolin OR ▸ Clindamycin 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 ▸ TMP-SMX OR ▸ Doxycycline OR ▸ Linezolid Streptococcus groups A, B, C, G Preferred Regimen ▸ Penicillin G 2 MU IV q4h Alternative Regimen ▸ Vancomycin OR ▸ Cefazolin OR ▸ Erythromycin Enterococcus faecalis Preferred Regimen ▸ Penicillin G 2 MU IV q4h OR ▸ Ampicillin 2 g IV q6h PLUS ▸ Gentamicin 1 mg/kg IV or IM q8h Alternative Regimen Vancomycin PLUS ▸ Gentamicin 1 mg/kg IV or IM q8h N. meningitidis, Penicillin MIC ≥0.1 μg/mL Preferred Regimen ▸ Cefotaxime 2 g IV q4—6h OR ▸ Ceftriaxone 2 g IV q12h Alternative Regimen ▸ Cefepime 2 g IV q8h OR ▸ Chloramphenicol 1—1.5 g IV q6h OR ▸ Moxifloxacin 400 mg IV q24h OR ▸ Meropenem 2 g IV q8h 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

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