Septic Arthritis of Prosthetic Joints Empiric Therapy 

Updated: Oct 06, 2020
  • Author: John L Brusch, MD, FACP; Chief Editor: Michael Stuart Bronze, MD  more...
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Empiric Therapy Regimens

General recommendations and empiric therapeutic regimens for septic arthritis of prosthetic joints, or periprosthetic joint infection (PJI), are provided below, based on Gram stain results. [1, 2, 3, 4, 5, 6, 7]

It is difficult to differentiate aseptic loosening of prosthetic joints from low-grade-chronic periprosthetic joint infections. Measurement of circulating biomarkers code hold promise in making these determinations. The specificity of procalcitonin measurements is low in these situations (27.8%). The combination of a C-reactive protein (CRP) level [8] greater than 0.3 mg/dL and IL-6 level greater than 5.12 pg/mL is superior, with a sensitivity of 75% and specificity of 98.2% in high-risk patients. [9, 10]

General recommendations

Unless the clinical situation demands (ie, clinical sepsis), a culture should be obtained before initiating antibiotic therapy for PJI. [11]

Duration of antibiotic therapy is at least 6wk; some patients require indefinite antibiotic treatment.

Rifampin 600 mg PO q24h should be added for staphylococcal infections if the hardware is retained. To prevent the development of resistance, rifampin should be started 2 days following initiation of antibiotic therapy. [1, 2, 3, 4, 5]

Negative or unavailable Gram stain

Vancomycin 15 mg/kg IV q12h plus ceftriaxone 1 g IV q24h

Gram-positive cocci in clusters

Usual pathogens: methicillin-susceptible Staphylococcus aureus (MSSA), methicillin-resistant S aureus (MRSA), coagulase-negative staphylococci (CoNS)

Vancomycin 15 mg/kg q12h

If nasal swab negative for MRSA: Cefazolin 1 g q8h

Gram-positive cocci in chains

Cefazolin 1 g IV q8h

Patients with severe penicillin allergy:

Vancomycin 15 mg/kg IV q12h

Gram-negative rods

Ceftriaxone 1 g IV q12h or

Cefepime 2 g IV q8h or

Piperacillin-tazobactam 3.375-4.5 g IV q6-8h

Patients with severe penicillin allergy:

Aztreonam 2 g IV q8h