Etiotropic therapy: elimination of the trigger
Antibacterial therapy tactics depend on the pathogen that triggered the arthritis. A critical requirement for a drug in intracellular infections is the ability to penetrate host cells.
In chlamydial infection (urogenital trigger) Chlamydiae (Chlamydia trachomatis) are intracellular pathogens. Macrolides are the drugs of choice in pediatrics because they accumulate well within cells and are safe for children.
- Azithromycin: 10 mg/kg on the first day, then 5 mg/kg. Course: 7–10 days.
- Roxithromycin: 5–8 mg/kg/day in 2 doses for 10 days.
- Josamycin: 30–50 mg/kg/day in 3 doses for 10 days.
- Spiramycin: dose depends on weight, 10-day course.
The tetracycline group (e.g., doxycycline) can only be used in children over 8 years old due to its effects on bone growth and tooth enamel. Fluoroquinolones are also strictly age-restricted.
In enteric infections (Campylobacter jejuni, Yersinia enterocolitica) Antibiotic prescription requires laboratory confirmation (stool culture or antibodies).
- First line: aminoglycosides (gentamicin, amikacin intravenously).
- Alternative: fluoroquinolones, but their use is approved only for children over 12 years old.
Symptomatic and anti-inflammatory treatment
A two-component approach is used to relieve acute joint syndrome:
- Locally: intra-articular administration of glucocorticoids.
- Systemically: nonsteroidal anti-inflammatory drugs (NSAIDs) in age-appropriate dosages.
Disease-modifying antirheumatic drugs (e.g., methotrexate) are not indicated during the acute flare-up stage of typical post-enterocolitic reactive arthritis.
Therapy for protracted and chronic course
If arthritis takes on a protracted course (especially against the background of persistent chlamydial infection), antibiotic therapy alone is insufficient.
In such cases, immunomodulators (glucosaminylmuramyl dipeptide, thymus extract, azoximer bromide) are added. However, they are strictly contraindicated in high immunological activity or the appearance of signs of juvenile spondyloarthritis.
Immunosuppressive therapy is prescribed for an unfavorable course:
- Chronification of the process;
- Appearance of signs of spondyloarthritis;
- Presence of the HLA-B27 antigen;
- Persistent elevation of inflammatory markers (ESR, CRP, IgG).
The drug of choice is sulfasalazine (30–40 mg/kg/day in 2 doses). Methotrexate is used less frequently.
Prevention and epidemiological control
One of the main problems of chlamydial reactive arthritis is the high risk of reinfection.
For successful recovery of the child, simultaneous diagnostics and treatment of all family members are mandatory. In case of confirmed reinfection, the course of anti-chlamydial therapy must be repeated.
Classic triad of Reiter's syndrome (urogenital reactive arthritis): Urethritis → Arthritis → Conjunctivitis. Mnemonic: "Can't see, can't pee, can't climb a tree."
Class and exam questions
Why are tetracyclines not first-line drugs for chlamydial arthritis in children?
Due to specific side effects: they negatively affect bone growth, cartilage tissue, and tooth enamel development, which is why they are only approved starting from 8 years of age.
In what case is sulfasalazine indicated for reactive arthritis?
It is prescribed for an unfavorable course: chronic arthritis, carriage of HLA-B27, signs of spondyloarthritis, and persistently high inflammatory markers.
What is the main reason for antibiotic failure in chlamydial reactive arthritis?
Most often, this is reinfection of the child within the family. Without simultaneous examination and treatment of all family members, therapy may be ineffective.
What else to study on this topic
- Clinical presentation of the post-enterocolitic form of ReA
- Classic triad of symptoms in Reiter's syndrome
- Pathogens of respiratory, enteric, and urogenital infections as triggers of ReA
- Differential diagnosis of ReA with other juvenile arthritides
- Prognostic significance of the HLA-B27 antigen
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Other topics of «Chapter 9. Rheumatic Diseases»
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