Septic Arthritis (Emergency Referral)

Intravenous. Where a loading dose is used the formulary gives 25 to 30 mg/kg, then 15 to 20 mg/kg every 8 to 12 hours at normal renal function, adjusted afterwards on measured blood levels. - About 2 weeks intravenously, then 1 to 2 weeks orally - 3 to 4 weeks in total, and 4 to 6 weeks where Pseudomonas is grown

10-15 mg/kg/dose

(The formulary prints no ordinary paediatric dose for vancomycin. It appears only as the stated baseline of the renal-adjustment table: those adjustments are based on intravenous doses of 10 mg/kg every 6 hours or 15 mg/kg every 8 hours. Both are per dose, not per day, and each figure is locked to its own interval: 10 mg/kg goes six-hourly and 15 mg/kg goes eight-hourly, which come to 40 and 45 mg/kg a day. They are not a range to pick from freely: pairing the higher amount with the shorter interval gives a daily total the formulary states nowhere. No paediatric ceiling is printed because the formulary states none - the dose is set by measured blood levels, not by a cap.)

WATCH group - carries resistance cost. Egyptian EML 2025.

Egyptian National Drug Formulary - Antimicrobial 2023 (vancomycin monograph, p333)

The card's article states that empirical antibiotic coverage includes antistaphylococcal coverage - nafcillin, oxacillin or vancomycin - for all age and risk categories, and that empirical treatment of non-gonococcal septic arthritis usually involves intravenous vancomycin against gram-positive organisms, especially where MRSA is suspected on local data. It states no amount. The amounts here are the Egyptian formulary's, and the formulary states them only inside its renal-adjustment table: the first row of that table is normal renal function.

1 to 2 g intravenously or intramuscularly once daily, or the same total divided into two doses. Maximum 4 g daily. - Added to the antistaphylococcal cover for the same course; in gonococcal arthritis it is continued for 24 to 48 hours after improvement, then oral treatment for the rest

100 mg/kg/day [child max 2000 mg]

(The formulary gives two paediatric figures by severity, and the one printed is the severe-infection figure, because a joint that needs draining is not a mild infection: 100 mg/kg/day divided every 12 to 24 hours. Its mild-to-moderate figure is lower - 50 to 75 mg/kg once daily, maximum 1,000 mg/day. The formulary states three ceilings and they do not agree. The severe-infection dose line itself carries a maximum of 4,000 mg a day. Its Prescribing Limits section separately caps a child at 2 g daily for most infections and at 4 g daily for endocarditis or meningitis. The 2 g figure is the one applied above, because septic arthritis is neither endocarditis nor meningitis - which means the calculator stops rising at 20 kg, and a 30 kg child is shown 2,000 mg where 100 mg/kg would be 3,000 mg. The formulary supports the higher figure on its own dose line; the lower one is used here, and both are written out so the choice is visible rather than silent. A premature or term neonate is dosed separately at 50 mg/kg every 24 hours.)

WATCH group - carries resistance cost. Egyptian EML 2025.

Egyptian National Drug Formulary - Antimicrobial 2023 (ceftriaxone monograph, p255)

The card's article states that where the patient is immunocompromised, injects drugs, or the Gram stain is negative, a third-generation cephalosporin such as ceftriaxone, ceftazidime or cefotaxime should be added for gram-negative cover, and that gonococcal arthritis responds well to intravenous ceftriaxone. It states no amount. The amount is the Egyptian formulary's, whose ceftriaxone monograph names septic arthritis in its own indication list.

Same-day referral to a hospital specialist who can aspirate the joint. Do NOT start an antibiotic in the clinic first. - Immediate same-day referral

The BSR guideline covers adults only; a separate BSR guideline for the hot, swollen or stiff joint in children and young people is still in development. Refer any child with a hot, swollen, painful joint, or a limp with fever, the same day. Do not start an antibiotic first.

No dose - emergency referral pathway, no medicine given in primary care

BSR 2006 grade B: the synovial fluid must be aspirated, Gram-stained and cultured prior to starting antibiotics. An antibiotic given before aspiration can sterilise the sample, so the organism is never identified and the six-week course cannot be targeted. BSR 2006 grade C: GPs should refer to a specialist within the hospital who has the expertise to aspirate the joint. Untreated or delayed, the joint is destroyed; the 2006 guideline reports a case fatality of 11%.