You have made the diagnosis of disseminated gonococcal infection in your patient presenting with history and physical exam findings suggestive of purulent arthritis, now what? Treatment for gonococcal arthritis goes beyond the one-time "shot and a pill" given for uncomplicataed gonococcal infections. A quick review of disseminated gonococcal infection:

• Disseminated gonococcal infection occurs in up to 3% of all cases of uncomplicated infection with N.gonorrhoeae
• Risk factors: IVDA, HIV, SLE, complement deficiency, pregnancy
• While many cases occur in sexually active patients under 40 years old, the increasing incidence of STI in older populations should terminate the perpetuation of medical dogma that this syndrome is restricted to certain age groups.
• Patients can present with triad of "arthritis-dermatitis" syndrome of tenosynovitis, dermatitis, polyarthralgias without purulent arthritis or with purulent arthritis. Presence of purulent arthritis with some or all of the "triad" symptoms is also possible.
• Cultures should be taken from synovial fluid, mucosal sites (pharynx, urethra, cervix, rectum), and blood. Culture skin lesions when appropriate.
• The diagnosis is made with positive non-mucosal cultures. In the setting of negative non-mucosal cultures, diagnosis is made with high clinical suspicion and positive mucosal cultures. Since culture results are not available in the Emergency Department, the diagnosis of DCI will be based on clinical presentation and treatment will be started empirically.

Treatment:

• Initial therapy: IV/IM ceftriaxone 1 g every 24 hours. PO azithromycin 1 g is also recommended to empirically treat for concomitant infection with C.trachomatis
• Admission to hospital for parenteral therapy, evaluation by infectious disease specialist, and culture sensitivities is recommended
• Duration of parenteral therapy with ceftriaxone is dictated by clinical response to therapy. Patients can be "downgraded" to outpatient regimens after clinical response has been established.
• Purulent arthritis should be drained by aspiration(s), arthroscopic drainage, or open surgical drainage.

References:
1. Tintinalli, J. "Acute Disorders of the Joint and Bursae." Tintinalli's Emergency Medicine: A Comprehensive Study Guide 7th Edition. New York. McGraw-Hill 2011. Section 23, Chapter 281. Pp 1926-1933.
2. Goldenberg, D. "Disseminated Gonococcal Infection." UpToDate. September 2016.