Septic Arthritis of Prosthetic Joints Organism-Specific Therapy 

Updated: Oct 01, 2020
  • Author: John L Brusch, MD, FACP; Chief Editor: Michael Stuart Bronze, MD  more...
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Specific Organisms and Therapeutic Regimens

Organism-specific therapeutic regimens for septic arthritis of prosthetic joints, or periprosthetic joint infection (PJI), are provided below, including those for methicillin-sensitive Staphylococcus aureus (MSSA), methicillin-resistant S aureus (MRSA), coagulase-negative staphylococci (CoNS), penicillin-sensitive and penicillin-resistant Streptococcus pneumoniae [1] , gram-negative rods, and Pseudomonas aeruginosa, as well as special considerations. [2, 3, 4, 5, 6, 7, 8, 9]

Oral antibiotics should be considered for treating septic arthritis. A recent study of septic arthritis involving native and prosthetic joints found that orally administered antibiotics started within 7 days of instituting IV therapy were noninferior to antibiotics administered intravenously through the entire therapeutic course (13% and 15%, respectively). The primary pathogens included S aureus (38%), coagulase-negative staphylococci (27%), and Streptococcus species (15%) Sixty-one percent had prosthetic-related infections. Rifampin was given to 41% of the IV group and 56% of the PO group. For initial oral treatment, the pathogen must be sensitive to antibiotics that have superior GI absorption, and the patient should have no major suppurative complications that would require surgery. These results need to be confirmed by follow-up studies. At minimum, this study may be useful in justifying switchover to PO antibiotics earlier than has been done in the past. [10]

Methicillin-sensitive Staphylococcus aureus (MSSA)*

See the list below:

Methicillin-resistant S aureus (MRSA)*

See the list below:

Coagulase-negative staphylococci (CoNS)*

See the list below:

  • Vancomycin 15 mg/kg IV q12h  or
  • Linezolid 600 mg IV q12h or
  • Daptomycin 4-6 mg/kg IV q24h
  • Rifampin 300-450 mg PO/IV q12h; must be given if prosthetic material is present
  • In patients in whom it is difficult to maintain adequate trough levels of vancomycin (15-20 mcg/mL), consideration should be given to the use of linezolid or daptomycin [11]

Streptococcus pneumoniae (penicillin sensitive) (minimal inhibitory concentration [MIC] < 4 µg/mL)

See the list below:

S pneumoniae (penicillin resistant) (MIC ≥ 4 µg/mL)

See the list below:

  • Ceftriaxone 1-2 g IV q12h or
  • Vancomycin 15 mg/kg IV q12h or
  • Levofloxacin 750 mg IV or PO q24h

Gram-negative rods (other than Pseudomonas)

See the list below:

  • Ceftriaxone 1-2 g IV q12h or
  • Ciprofloxacin 400 mg IV or 500 mg PO q12h or
  • Levofloxacin 500 mg IV or PO q24h for 3wk

Pseudomonas aeruginosa

See the list below:

  • Cefepime 2 g IV q8h plus * ( gentamicin or tobramycin 5 mg/kg IV q24h) or
  • Piperacillin-tazobactam 3.375-4.5 g IV q6h plus * (gentamicin or tobramycin 5 mg/kg IV q24h) or
  • Aztreonam 1-2 g IV q8h plus* (gentamicin or tobramycin 5 mg/kg IV q24h)
  • * Combination therapy to be considered in serious systemic infection or in immunocompromised patients.

Special considerations

See the list below:

  • The sensitivity of cultures of synovial fluid ranges from 45 to 100%.
  • Culture results of periprosthetic tissues have a sensitivity ranging from 65 to 94%. [12, 13]
  • Blood cultures should be obtained in all patients with suspected PJI. [14]
  • In PJI, plain radiography can detect new subperiosteal bone growth and transcortical sinus tracts—both are signs of active infection.
  • The 2-stage joint-replacement procedure is the preferred surgical procedure; the prosthesis is removed, and an antibiotic-impregnated spacer is placed after thorough debridement of the infected tissue; IV antibiotics are delivered for 6-8wk before the new joint is implanted. [12]
  • The 1-stage joint-replacement procedure consists of simultaneous removal and replacement of the joint, and it is usually employed in patients with highly sensitive organisms; however, the success rate is lower than the 2-stage procedure. [12]
  • Early stages of PJI may respond to simple debridement, followed by 2-6wk of IV antibiotics and orally administrated antibiotics for up to 6mo; this approach may also be taken in patients with very high operative risk.
  • Indefinite suppressive antibiotic therapy is an option if the prosthesis cannot be removed (high operative risk) and there is an appropriate orally administrated antibiotic.
  • For prolonged antibiotic treatment of infections with all non-enterococcal streptococci, MSSA, MRSA, CoNS, and vancomycin-sensitive enterococci, dalbavancin should be considered owing to its weekly administration regimen: 1500 mg IV as loading dose followed by 500 mg IV weekly.{ref15-INVALID REFERENCE}