Empirical therapy for suspected staphylococcal septic arthritis of a native joint

The regimens below are recommended for the empirical treatment of native joint septic arthritis when gram-positive cocci in clusters (consistent with Staphylococcus species) have been identified on Gram stain of a joint aspirate.

For patients with sepsis or septic shock, treat as for Sepsis or septic shock associated with a bone or joint source.

For patients suspected to have concurrent Staphylococcus aureus bacteraemia, consider the recommendations in this topic and the recommendations in Staphylococcus aureus bacteraemia, including sepsis and septic shock.

For patients without sepsis or septic shock at low risk of methicillin-resistant Staphylococcus aureus (MRSA) infection (for risk factors, see Risk factors for infection with methicillin-resistant Staphylococcus aureus), use:

1cefazolin 2 g (child: 50 mg/kg up to 2 g) intravenously, 8-hourly. For dosage adjustment in adults with kidney impairment, see cefazolin dosage adjustment. See advice in Intravenous to oral switch and duration of therapy for native joint septic arthritis cefazolin cefazolin cefazolin

1flucloxacillin 2 g (child: 50 mg/kg up to 2 g) intravenously, 6-hourly. For dosage adjustment in adults with kidney impairment, see flucloxacillin intravenous dosage adjustment. See advice in Intravenous to oral switch and duration of therapy for native joint septic arthritis. flucloxacillin flucloxacillin flucloxacillin

If the patient is at increased risk of MRSA infection, add vancomycin to either flucloxacillin or cefazolin. Add:

vancomycin intravenously; for initial dosing, see Intermittent vancomycin dosing for noncritically ill adults or Intermittent vancomycin dosing for young infants and children. See advice in Intravenous to oral switch and duration of therapy for native joint septic arthritis. vancomycin vancomycin vancomycin

In some regions, based on local MRSA susceptibility patterns, clindamycin is a suitable alternative to vancomycin; use:

clindamycin 600 mg (child: 15 mg/kg up to 600 mg) intravenously, 8-hourly¹; see advice in Intravenous to oral switch and duration of therapy for native joint septic arthritis. clindamycin clindamycin clindamycin

For patients who have had a nonsevere (immediate or delayed) hypersensitivity reaction to a penicillin who are at low risk of MRSA infection, use cefazolin (see dosage above).

For patients who have had a severe immediate² hypersensitivity reaction to a penicillin who are at low risk of MRSA infection, cefazolin (at the dosage above) can be considered if a beta-lactam antibiotic is strongly preferred (for considerations, see Severe immediate hypersensitivity: Implications of cross-reactivity between penicillins and cephalosporins).

For patients who have had a severe immediate² hypersensitivity reaction to a penicillin in whom cefazolin is not used, or for patients who have had a severe delayed³ hypersensitivity reaction to a penicillin, use vancomycin as monotherapy (see dosage above).

Modify therapy according to the results of culture and susceptibility testing. For suggested regimens, see:

¹ There are more clinical and microbiological data to support the use of clindamycin than lincomycin. Intravenous lincomycin can be used at the same dosage if clindamycin is unavailable or if a local protocol recommends its use.Return

² Severe immediate hypersensitivity reactions include anaphylaxis, compromised airway, airway angioedema, hypotension and collapse.Return

³ Severe delayed hypersensitivity reactions include cutaneous adverse drug reactions (eg drug rash with eosinophilia and systemic symptoms [DRESS], Stevens–Johnson syndrome/toxic epidermal necrolysis [SJS/TEN], severe blistering or desquamative rash), and significant internal organ involvement (eg acute interstitial nephritis).Return