Treatment algorithm
Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer
vancomycin plus joint aspiration
Gram-positive organisms are the most common etiological agents and should be suspected if there are no risk factors to suggest an alternative etiology. Empirical treatment is with vancomycin. If allergic, clindamycin or a cephalosporin may be used.
Patients at risk for MRSA include recent inpatients, nursing home residents, or patients with leg ulcers or urinary catheters. For suspected MRSA, an infectious disease specialist should be consulted.
The affected joint or joints should be aspirated to dryness as often as is necessary. Aspiration may be performed either by closed-needle aspiration or arthroscopically. Hip involvement may require aspiration under ultrasound guidance. Orthopedic consultation is advised for hip infection.
How to aspirate synovial fluid from the knee and administer intra-articular medication using a medial approach.
How to aspirate synovial fluid from the shoulder and administer intra-articular medication. Video demonstrates a posterior approach to the glenohumeral joint and a lateral approach to the subacromial space.
For intravenous drug users or patients in the intensive care unit, an infectious disease specialist should be consulted immediately. For prosthetic joints, an orthopedist should be consulted directly.
In patients in whom joint sepsis has been confirmed by positive synovial or blood cultures, antibiotic therapy should be modified in light of the nature and sensitivities of the organisms detected. Standard treatment is 2 weeks of intravenous therapy followed by 4 weeks of oral therapy, guided by sensitivities. There is limited evidence indicating that it may be safe to reduce the duration of intravenous antibiotics and/or the overall duration of antibiotics in carefully selected patients.[34][35] Local guidance and/or expert opinion should always be consulted.
Primary options
vancomycin: 30 mg/kg/day intravenously given in divided doses every 12 hours
clindamycin or cephalosporin plus joint aspiration
Gram-positive organisms are the most common etiological agents and should be suspected if there are no risk factors to suggest an alternative etiology. Empirical treatment is usually with vancomycin. If allergic, clindamycin or a cephalosporin may be used.
Patients at MRSA include recent inpatients, nursing home residents, or patients with leg ulcers or urinary catheters. For suspected MRSA, an infectious disease specialist should be consulted.
The affected joint or joints should be aspirated to dryness as often as is necessary. Aspiration may be performed either by closed-needle aspiration or arthroscopically. Hip involvement may require aspiration under ultrasound guidance. Orthopedic consultation is advised for hip infection.
How to aspirate synovial fluid from the knee and administer intra-articular medication using a medial approach.
How to aspirate synovial fluid from the shoulder and administer intra-articular medication. Video demonstrates a posterior approach to the glenohumeral joint and a lateral approach to the subacromial space.
For intravenous drug users or patients in the intensive care unit, an infectious disease specialist should be consulted immediately. For prosthetic joints, an orthopedist should be consulted directly.
In patients in whom joint sepsis has been confirmed by positive synovial or blood cultures, antibiotic therapy should be modified in light of the nature and sensitivities of the organisms detected. Standard treatment is 2 weeks of intravenous therapy followed by 4 weeks of oral therapy, guided by sensitivities. There is limited evidence indicating that it may be safe to reduce the duration of intravenous antibiotics and/or the overall duration of antibiotics in carefully selected patients.[34][35] Local guidance and/or expert opinion should always be consulted.
Primary options
clindamycin: 450-600 mg intravenously every 6 hours
OR
ceftriaxone: 2 g intravenously every 24 hours
OR
ceftazidime sodium: 1-2 g intravenously every 8 hours
OR
cefotaxime: 2 g intravenously every 8 hours
third-generation cephalosporin plus joint aspiration
Patients with a high risk of gram-negative sepsis include older and frail patients, those with recurrent urinary tract infections, and those who have had recent abdominal surgery. Suggested empirical treatment is with a third-generation cephalosporin. Local policy may be to add gentamicin. In those patients who are cephalosporin-allergic, ciprofloxacin is recommended.
Pseudomonas infection should be suspected in intravenous drug users. If Pseudomonas is suspected, ceftazidime should be used in preference to other cephalosporins.
The affected joint or joints should be aspirated to dryness as often as is necessary. Aspiration may be performed either by closed-needle aspiration or arthroscopically. Hip involvement may require aspiration under ultrasound guidance. Orthopedic consultation is advised for hip infection.
How to aspirate synovial fluid from the knee and administer intra-articular medication using a medial approach.
How to aspirate synovial fluid from the shoulder and administer intra-articular medication. Video demonstrates a posterior approach to the glenohumeral joint and a lateral approach to the subacromial space.
For intravenous drug users or patients in the intensive care unit, an infectious disease specialist should be consulted immediately. For prosthetic joints, an orthopedist should be consulted directly.
In patients in whom joint sepsis has been confirmed by positive synovial or blood cultures, antibiotic therapy should be modified in light of the nature and sensitivities of the organisms detected. Standard treatment is 2 weeks of intravenous therapy followed by 4 weeks of oral therapy, guided by sensitivities. There is limited evidence indicating that it may be safe to reduce the duration of intravenous antibiotics and/or the overall duration of antibiotics in carefully selected patients.[34][35] Local guidance and/or expert opinion should always be consulted.
Primary options
ceftriaxone: 2 g intravenously every 24 hours
OR
ceftazidime sodium: 1-2 g intravenously every 8 hours
OR
cefotaxime: 2 g intravenously every 8 hours
intravenous ciprofloxacin plus joint aspiration
Patients with a high risk of gram-negative infection include older and frail patients, those with recurrent urinary tract infections, and those who have had recent abdominal surgery. In patients who are allergic to cephalosporins, empirical treatment with clindamycin may be used. Local policy may be to add gentamicin.
The affected joint or joints should be aspirated to dryness as often as is necessary. Aspiration may be performed either by closed-needle aspiration or arthroscopically. Hip involvement may require aspiration under ultrasound guidance. Orthopedic consultation is advised for hip infection.
How to aspirate synovial fluid from the knee and administer intra-articular medication using a medial approach.
How to aspirate synovial fluid from the shoulder and administer intra-articular medication. Video demonstrates a posterior approach to the glenohumeral joint and a lateral approach to the subacromial space.
For intravenous drug users or patients in the intensive care unit, an infectious disease attending should be consulted immediately. For prosthetic joints, an orthopedist should be consulted directly.
In patients in whom joint sepsis has been confirmed by positive synovial or blood cultures, antibiotic therapy should be modified in light of the nature and sensitivities of the organisms detected. Standard treatment is 2 weeks of intravenous therapy followed by 4 weeks of oral therapy, guided by sensitivities. There is limited evidence indicating that it may be safe to reduce the duration of intravenous antibiotics and/or the overall duration of antibiotics in carefully selected patients.[34][35] Local guidance and/or expert opinion should always be consulted.
Primary options
ciprofloxacin: 400 mg intravenously every 8-12 hours
intravenous antibiotics plus joint aspiration
Risk factors for MRSA include recent inpatients, nursing home residents, or patients with leg ulcers or urinary catheters. Patients with confirmed MRSA infection should receive intravenous antibiotic therapy for 2 weeks, vancomycin being the treatment of choice. This is followed by oral antibiotics for a further 4 weeks. There is limited evidence indicating that it may be safe to reduce the duration of intravenous antibiotics and/or the overall duration of antibiotics in carefully selected patients.[34][35] Local guidance and/or expert opinion should always be consulted.
The affected joint or joints should be aspirated to dryness as often as is necessary. Aspiration may be performed either by closed-needle aspiration or arthroscopically. Hip involvement may require aspiration under ultrasound guidance. Orthopedic consultation is advised for hip infection.
How to aspirate synovial fluid from the knee and administer intra-articular medication using a medial approach.
How to aspirate synovial fluid from the shoulder and administer intra-articular medication. Video demonstrates a posterior approach to the glenohumeral joint and a lateral approach to the subacromial space.
Primary options
vancomycin: 1 to 1.5 g intravenously every 12 hours
intravenous antibiotics plus joint aspiration
Patients with confirmed infection with gram-negative rods should receive intravenous antibiotic therapy for 2 weeks, followed by oral antibiotics for 4 further weeks. A third-generation cephalosporin is the treatment of choice. There is limited evidence indicating that it may be safe to reduce the duration of intravenous antibiotics and/or the overall duration of antibiotics in carefully selected patients.[34][35] Local guidance and/or expert opinion should always be consulted.
The affected joint or joints should be aspirated to dryness as often as is necessary. Aspiration may be performed either by closed-needle aspiration or arthroscopically. Hip involvement may require aspiration under ultrasound guidance. Orthopedic consultation is advised for hip infection. For intravenous drug users or patients in the intensive care unit, an infectious disease specialist should be consulted immediately. For prosthetic joints, an orthopedist should be consulted directly.
How to aspirate synovial fluid from the knee and administer intra-articular medication using a medial approach.
How to aspirate synovial fluid from the shoulder and administer intra-articular medication. Video demonstrates a posterior approach to the glenohumeral joint and a lateral approach to the subacromial space.
Primary options
ceftriaxone: 2 g intravenously every 24 hours
OR
ceftazidime sodium: 1-2 g intravenously every 8 hours
OR
cefotaxime: 2 g intravenously every 8 hours
intravenous antibiotics plus joint aspiration
Suggested empirical treatment is with a third-generation cephalosporin for 2 weeks, followed by 4 weeks of oral antibiotic therapy. There is limited evidence indicating that it may be safe to reduce the duration of intravenous antibiotics and/or the overall duration of antibiotics in carefully selected patients.[34][35] Local guidance and/or expert opinion should always be consulted.
The affected joint or joints should be aspirated to dryness as often as is necessary. Aspiration may be performed either by closed-needle aspiration or arthroscopically.
How to aspirate synovial fluid from the knee and administer intra-articular medication using a medial approach.
How to aspirate synovial fluid from the shoulder and administer intra-articular medication. Video demonstrates a posterior approach to the glenohumeral joint and a lateral approach to the subacromial space.
Primary options
ceftriaxone: 2 g intravenously every 24 hours for 2 weeks
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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer
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