How Long Should Patients Take Antibiotics after Operative Treatment for Native Joint Bacterial Arthritis?

In a prospective, randomized trial published in Annals of the Rheumatic Diseases, researchers compared two lengths of postoperative antibiotic therapy in patients who underwent surgical drainage for native joint bacterial arthritis. Challenging traditional guidelines, they found that a two-week course of treatment was not inferior to four weeks of treatment.

“For almost 40 years, the recommended total duration of postsurgical systemic antibiotic therapy has been 3–6 weeks, with most clinicians prescribing 4 weeks for adults,” the study authors wrote. “Unfortunately, this recommendation is based on expert opinion and individual experience, rather than on research studies. Furthermore, clinicians often treat bacterial arthritis at all anatomic sites in the same way, with no distinction between small and large joints.”

The single-center study was conducted from March 1, 2015, through March 10, 2018. Inclusion criteria were native joint bacterial arthritis patients aged ≥ 18 years who underwent at least one articular lavage (by arthrotomy or arthroscopy; with or without synovectomy), and who received systemic antibiotic therapy treatment. Exclusion criteria included recurrent bacterial arthritis, non-bacterial arthritis, history of allergies to multiple antibiotics, long-term prophylaxis use due to immune-suppression, left-side endocarditis, incomplete joint lavage or > 4 surgical lavages, plans to undergo repetitive arthrocentesis therapy, concomitant spondylodiscitis or osteomyelitis, plans for arthrodesis or amputation, foot arthritis in a diabetes mellitus patient, necrotiing fasciitis, intravertebral arthritis, presence of or plan for a Girdlestone procedure, prior bone marrow transplantation, active oncological chemotherapy, or presence of foreign material in close vicinity to the infected joint. Infection with mycobacteria, actinomycetes, gonococci, meningococci, fungi, brucellosis, mycoplasma, or nocardia were also excluded because current guidelines recommend either an unusually long or short course of antibiotics.

Treatment Successful in Both Patient Groups

Final analysis included 154 cases; 77 each received two weeks and four weeks of antibiotic treatment. Median intravenous antibiotic treatment length was 1 day in the four-week cohort and 2 days in the two-week group. Three patients presented recurrent infection: one in the two-week group (99% cure rate) and two in the four-week group (97% cure rate). There were no between-group differences in the number of adverse events or sequelae.

The researchers conducted a subgroup analysis of hand and wrist cases (n = 99) because they made up the majority of the total cohort. There were three recurrences in this group—one in the two-week arm (97% cure rate) and two in the four-week arm (96% cure rate). They observed sequelae in half of the two-week cohort and 55% of the four-week group; five and six patients, respectively, required further interventions.

The study authors concluded, “As there are many clinical and economic advantages, and apparently no disadvantages, to shorter courses of antibiotic therapy, patients with hand bacterial arthritis might benefit from shorter treatment courses. Similarly, our data support an earlier switch from parenteral to oral antibiotic therapy for these patients, which could help reduce financial costs, length of hospital stay and potentially intravenous line-related complications.”