Suggested empiric parenteral regimens for acute bacterial arthritis in children age 3 months and older

Hemodynamically unstable children ≥3 months of age
Coverage for S. aureus (MSSA and MRSA) and Neisseria meningitidis	Antimicrobial regimen*	Comment
	Three drug combination therapy: Vancomycin plus Ceftriaxone plus One of the following: Cefazolin Nafcillin Oxacillin	Cefazolin, nafcillin, or oxacillin is superior to vancomycin for MSSA Ceftriaxone provides coverage for N. meningitidis
	or
	Two drug combination therapy: Vancomycin plus Cefepime	Cefepime provides activity against MSSA and N. meningitidis
Hemodynamically stable children ≥3 months of age
Coverage for S. aureus	Antibiotic agent*	Comment
	*<10% of community S. aureus* isolates are MRSA**^¶
	One of the following: Cefazolin Nafcillin Oxacillin	Cefazolin also provides coverage for Kingella kingae (eg, for children 6 to 36 months of age who attend day care or had oral ulcers before onset of musculoskeletal symptoms)
	*≥10% of community S. aureus* isolates are MRSA**^¶
	Clindamycin or vancomycin	Vancomycin is preferred: For life-threatening infections (in combination with nafcillin/oxacillin pending susceptibility results) If ≥10% of community S. aureus isolates are clindamycin-resistant^¶ For children with prosthetic joints (CoNS)
plus
Additional coverage as clinically indicated	Indication	Antibiotic agent(s)*
	Gram-negative organisms on Gram stain	Cefotaxime, ceftriaxone, or cefuroxime
	Penetrating trauma or history of penetrating trauma (polymicrobial, including P. aeruginosa)	Cefepime monotherapy,^Δ or Combination therapy^◊ with: Either cefepime or ceftazidime plus Either clindamycin or vancomycin
	Age 6 to 36 months and day care attendance or history of oral ulcers before onset of musculoskeletal symptoms (K. kingae)	Use cefazolin for antistaphylococcal coverage, if possible^§
	Incomplete Hib immunization in child <2 years of age in area with low rates of Hib immunization (Hib)	Cefotaxime or ceftriaxone
	Incomplete pneumococcal immunization in a child <2 years of age, or high-risk condition for invasive pneumococcal disease^¥, or antibiotic therapy within 4 weeks of diagnosis of bacterial arthritis (penicillin-nonsusceptible Streptococcus pneumoniae)
	Sickle cell disease or related hemoglobinopathies (Salmonella)
	Recent GI surgery or complex urinary tract anatomy (enteric gram-negative organism)	One of the following: Cefotaxime Ceftriaxone Cefepime (if P. aeruginosa is a concern)
	Sexually active adolescent (N. gonorrhoeae)^‡	Ceftriaxone plus presumptive treatment for chlamydia
	Injection drug user (P. aeruginosa)	Ceftazidime

MSSA: methicillin-susceptible S. aureus; MRSA: methicillin-resistant S. aureus; CoNS: coagulase-negative S. aureus; Hib: Haemophilus influenzae type b; GI: gastrointestinal.

* Refer to UpToDate topic on treatment of bacterial arthritis in children for dosing.

¶ Other experts may use different thresholds for methicillin or clindamycin resistance.

Δ Provides coverage for P. aeruginosa and MSSA.

◊ Provides coverage for P. aeruginosa and MRSA.

§ We do not generally provide initial empiric coverage for K. kingae in young children if K. kingae coverage requires two drugs; we add coverage for K. kingae if the child does not improve.*

¥ Refer to UpToDate topic on pneumococcal vaccination in children for details.

‡ Refer to UpToDate topic on disseminated gonococcal infection for details.

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Suggested empiric parenteral regimens for acute bacterial arthritis in children age 3 months and older