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Infectious arthritis

details about infectitious arthritis by dr manoj kandoi , leading orthopedic and arthritis expert from Thane district

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Infectious arthritis

  1. 1. About The AuthorDr Manoj R. kandoi is the founder president of “Institute of Arthritis Care & Prevention”an NGO involved in the field of patient education regarding arthritis. Besides providingliterature to patient & conducting symposiums, the institute is also engaged in creatingpatients “Self Help Group” at every district level. The institute also conducts a certificatecourse for healthcare professionals & provide fellowship to experts in the field ofarthritis.The author has many publications to his credit in various journals. He has also written a book “ The Basics Of Arthritis” for healthcare professionals.The author can be contacted at:Dr manoj R. kandoiC-202/203 Navare ArcadeShiv Mandir Road, Opposite Dena BankShiv mandir Road, Opposite Dena bankShivaji Chawk, Ambarnath(E) Dist: Thane Pin:421501State: Maharashtra Ph: (0251)2602404 Country: IndiaMembership Application forms of the IACR for patients & healthcare professionalscan be obtained from.Institute of Arthritis Care & PreventionC/o Ashirwad HospitalAlmas mension, SVP Road, New Colony,Ambarnath(W) Pin:421501 Dist: ThaneState: Maharashtra Country: IndiaPh: (0251) 2681457 Fax: (0251)2680020Mobile ;9822031683Email: have shown that people who are well informed & participate actively intheir own care experience less pain & make fewer visits to the doctor than do other people with arthritis. Unfortunately in India & many third world countries we do nothave patient education & arthritis self management programs as well as support groups.This is an attempt to give a brief account of various arthritis, their prevention & selfmanagement methods which can serve as useful guide to the patients of arthritis.It would be gratifying if the sufferers of the disease knew most of what is given in thebook.AcknowledgementI am thankful to Dr (Mrs) Sangita Kandoi for her immense help in proofreading & for herinvaluable suggestions. The help rendered by Nisha Jaiswal is probably unrivalled.Thanks also to vidya, praveen, rizwana and parvati for their continous supportthroughout the making of the book. The author is grateful to his family for the constantinspiration they offered. The author alone is responsible for the shortcoming in this pieceof work. He welcomes suggestions for improvement from the readers.
  2. 2. Infectious Arthritis:Septic Arthritis: This is an arthritis caused by pyogenic organisms. It may be acute,subacute or chronic depending upon duration.Aetio-Pathogenesis:Etiological Agents: These include in decreasing order of frequency  Staphylococcus aureus  Streptococci  Staphylococcus epidermidis  Pheumococci  Pseudomonos aeruginosa  Haemophilus influenzae (commonest cause of arthritis in children below 2 years of age)  Polymicrobial infection.Predisposing conditions:-Underlying chronic joint disease -Malignancy-Trauma -Immunosuppresive drug therapy-Joint involvement in RA -Parenteral drug abuse-Diabetes mellitus -Recent joint infection-Steroid administration -Injection or Aspiration-Renal failure -Vascular insufficiency Commonest joint involved: In decreasing order of frequency these are:I) Knee II) Hip III) Elbow IV) Shoulder V) Wrist VI) AnkleMethods of spread: The organisms reach the joint by one of the following routes: a) Haematogenous: This is the commonest route. There may be a primary focus of infection such as Septicemia, Skin infection, URTI etc. b) Secondary to Osteomyelitis: In joints of Hip, Shoulder etc. with intraarticular metaphysis spread to joints may occur from osteomyelitis. c) Penetrating wounds : e.g. Superficial joint injuries like knee joint. d) Latrogenic: This includes I. Intraarticular steroid injections II. Femoral artery punctures for blood collectionPathologyDepending upon the evidence of organisms and individual body resistance, three types ofexudation of fluid in the joint may occur:The serous type:Join is distended with clear serous fluid and is associated with mild inflammatoryhyperaemia of vessels of synovial membrane and capsule
  3. 3. PrognosisComplete recovery Recovery Seropurulent Purulent followed by arthritis arthritis recurrenceSerofibrinous Arthritis:Here the synovial membrane is hyperaemic and inflamed with serofibrinous exudatecovering the joint aspect. The cavity is filled with cloudy fluid containing a large numberof polymorphs and a few large mononuclear cells. Since there is associated periarticularinflammation adhesions may occur. In early stages organisms may be demonstrated.Purulent Arthritis:The joint cavity is filled with pus containing large numbers of polymorphs, bacteria,RBCs and fibrin. The capsule and synovial membrane are infilterated with leucocytes andengorged and there may be small areas of focal necrosis or fatty degeneration.Pathology Radiographic CorelationFibrous or bony ankylosis Bony ankylosisPannus with cartilage destruction Joint space lossIncreased blood flow OsteopeniaArthritic advanced destruction Joint deformityPannus with bony destruction ErosionsFluid accumulation and synovial Periarticular soft tissuesEdema swellingClinical Feature:Symptoms: 1. Continuous severe throbbing pain disturbing sleep 2. Swelling and redness of joint 3. Inability to use the joint 4. Fever is present in 50% of cases 5. Patient may present with pseudoparalysis 6. In subacute form, limp may be the presenting complaint. NORMAL FIBROUS BONY JOINT ANKYLOSIS ANKYLOSISSigns: 1. Child is generally severely toxic with a high temperature and tachycardia 2. Joint is swollen and held in the position of ease
  4. 4. 3. Palpation: local warmth, effusion and tenderness can be elicited 4. ROM: severely restricted and painful.Septic arthritis in animal bite:May occur due to bite by dogs, cats and rodents. Commonest organisms are pasturellamultocida, staphylococcus aureus and streptococcus sp. etc. Treatment of p. multocidainfection should include penicillin G.Polyarticular septic arthritis:Uncommon with an incidence of around 10%. Usually seen in immunosuppressed,immunodeficient, immunocompromised patients, rheumatoid arthritis, multiplearthroplasties. The mortality rate isapproximately 25%.Investigations: A. Radiological examination: Early stage: Soft tissue shadows of joint swelling can be seen. Late stage: Joint space is narrowed with irregularity of joint margins. Ocassionally there may be a subluxation or dislocation of the joint. B. Haematological investigation:  Neurophilic leucocytosis and raised ESR can be seen  HIV if polyarticular or adult patient  Blood culture may be positive in some cases. C. Joint aspiration: Synovial fluid examination Points Normal Non-Inflammatory Inflammatory Septic Gross examination Volume (Ml) Often < 3.5ml Often> 3.5ml Often> 3.5ml > 3.5ml Viscosity High High Low Variable Colour Colourless Straw Yellow VariableExamination in Lab Yellow Clarity Transparent Transparent Translucent Opaque Examination in Lab WBC count < 200 200-2000 2000- 7500 > 10000 PMN < 25% < 25% >50% > 75% Leucocytes Culture - - - + Mucin clot Firm Firm Friable FriableCrystal examination may be done in suspected pseudogout.< 25 mg% of Glucose Equal to Nearly equal > 25 mg% Level blood glucose to blood glucose blood glucose of blood glucose
  5. 5. Role of specialized radiographic studies in septic arthritis:1. Bone scan: a. Technetium bone scan: is often positive in 1-2 days but lacks specificity. b. Gallium scan: It is more specific but lacks sensitivity, gallium scan is more useful in children with growth plate abnormalities. c. WBC lebelled indium scan: It is more specific as it relies on migration of WBC to the site of infection. It is the preferred modality in joint replacement surgeries.2. CT scan: It may be useful in S1 joint or sternoclavicular joint infection.3. MRI: It provides early detection of soft tissue changes such as edema and effusion. Italso demonstrates osteomyelitis.Acute monoarticular Chronic monoarticular PolyarticularDifferential Diagnosis of Arthritis Syndromes:Arthritis arthritis arthritisStaphylococcus Mycobacterium Neisseria meningitisaureus tuberculosisStreptococcus Atypical mycobacteria Neisseria gonorrhoeapneumoniae hemolytic Lyme disease Nongonococcalstreptococci bacterial arthritisGram-negative Treponema pallidum Bacterial endocarditisbacillaeNeisserra gonorrhoea Candida species Candida speciesFracture Nocardia species Poncets diseaseHaemarthrosis Brucella speciesOsteoarthritis Legg calve perthes Viral lesions diseaseMonoarticular RA Osteoarthritis Reactive arthritisCrystal induced Serum sicknessarthritisIschaemic necrosis Acute rheumatic fever Inflammatory bowel disease SLE RA/Stills disease Other vasculitides sarcoidosisOrganisms commonly found in different age groups of childhood septic arthritis:Neonates: - Staphylococcus Aureus (Hospital acquired) - Streptococci - Gram-negative bacilliAge < 2 year - Hemophilus influenzae - Staphylococcus aureusAge 2-15 years - Staphylocossus aureus - Streptococcus pyogenes
  6. 6. Differentiating features between gonococcal and nongonococcal septic arthritis: Gonococcal Nongonococcal Personality of Young, healthy adults Infants, elderly, immuno-compromised. Pattern Migratory polyarthlgias/ single joint arthritis Tenosynovitis ++ Rare Skin Lesions ++ Rare Joint culture Rarely positive +++ Blood culture Rarely positive ++ (40-50%) Prognosis good in > 95% Poor in half of the patientsPseudoseptic arthritis:This term is used when synovial fluid WBC count is more than > 100,000 cells/mm3,with cultures and staining negative, Commonest type is poorly controlled rheumatoidarthritis which responds toincreased carticosteroids dosage (not to antibiotics). Other DID include crystal inducedarthrides and seronegative spondyloarthropathies,Diagnostic clues for septic arthritis coexisting with hemarthrosis:  Failure of joint to resolve with factor replacement  Raised WBC count  HIV infection and other predisposing factors point towards septic arthritis  Previous joint aspiration, surgery  Underlying joint damage (chronic arthropathy).Treatment protocol: Septic arthritis Antibiotics based on Aspiration and Supporting therapy-Age intra articular Immobilization antibiotics Passive ROM-Source of (multiple after 48 hoursinfection aspirations Active ROM-Clinical several times exercises oncepresentation a day) pain resolves-Gram Analgesicstaining-Culture Failuresensitivity Surgical drainage (In indicated cases)
  7. 7. Absolute indications for drainage in a septic joint: 1. Infected hip joints and probably shoulder joints 2. Prosthetic joints. 3. Inability to remove purulent fluid by needle drainage because fluid is too thick or laculated. 4. Vertebral osteomyelitis with cord compression. 5. Anatomically difficult to drain joints e.g. sternoclavicular joint. 6. Arthritis associated with foreign body. 7. Delayed onset of therapy (more than 7 days) or failure to respond to therapy. 8. Associated osteomyelitis requiring surgical drainage.Initial antibiotic therapy based on gram staining report: Gram stain findings Antibiotic of choice Alternatives Gram positive cocci Nafcillin Vancomycin Gram negative cocci Ceftriaxone or cefotaxime Ciprofloxacin Gram negative bacilli Gentamicin Ceftazidime Septic picture but Ampicillin plus Vancomycin plus No organism seen. Gentamicin CeftizoximeAntibiotic treatment following culture report: Organism Antibiotic of choice Alternatives Staphylococcus aureus Nafcillin Vancomycin Methicillin resistant vancomycin S. aureus Streptococci Penicillin Cefazoline Vancomycin Enterococcus Ampicillin plus Vancomycin Gentamicin Plus aminoglycoside Enterobacteriaceae Third generation Aminoglycoside Cephalosporine ciprofloxacine Haemophilus Ampicillin Third generation Influenza cephalosporin Chloramphenicol Cefuroxime Pseudomonus Aminoglycoside CeftazidimeRole of serial joint aspiration in septic arthritis:Principle: 1. Mechanical debridement by saline lavage 2. To decrease intraarticuJar pressure
  8. 8. 3. To reduce leukocyte enzyme activity 4. To instill antibiotics in the joint if required 5. To monitor response to medicationMethod:Preferable once daily as reaccumulation of fluid is very promptProgression of disease and response to therapy can be monitored by serial synovial fluidWBC count which should reduce by atleast 50% by one wk. of therapy.Arthritis of tuberculosis:Tuberculous arthritis accounts for about 1 % of all cases of tuberculosis and for 10% ofextrapulmonary cases.Types: 2 major groupsMonoarticular tuberculous arthritis Atypical group Poncets disease Polyarthalgias of Atypical mycobacterial Akt drugs arthritisUnusual forms of arthritis in tuberculosis:Poncets disease: It is a reactive symmetrical form of polyarthritis that affects personswith visceral or disseminated tuberculosis. No organisms can be seen in the joints andsymptoms tend to resolve with AKT drugs.Polyarthralgias of AKT therapy: Polyarthlgias are known to occur with pyrazinamidetherapy and tend to regress with the withdrawal of drug.These are less common with other AKT drugs.Atypical mycobacterial arthritis: Atypical mycobacteria found in water and soil maycause arthritis of digits, wrists and knees by direct inoculation during farming, gardeningetc. Commonest etiological agents includeM. marinum, M. avium intracellular, M. terrae etc. Haematogenous spread may occur inimunocompromised patients leading to involvement of joints by organisms such asM.kansasii, M. haemophilum etc. Diagnosisshould be confirmed by biopsy and culture and treatment is based on sensitivity patterns.SYPHILIS OF JOINT:Types of syphilitic of joints:A) Joint lesions in congental syphilis: 1. Parots syphilic osteochondritis 2. Cluttons joint: symmetrical hydrarthrosisB) Joint lesions in acquired (early) syphillis: 1. Arthralgia 2. Hydrarthrosis SYPHILITIC OSTEOPERIOSTITIS
  9. 9. 3. Plastic arthritis (very uncommon)C) Joint lesions in acquired (late) syphilis: Gummatous arthritis: 1. The synovial form. 2. The oseous form 3. Charcots anthropathy.A. Joint lesions in congenital syphilis:Parots syphilitic osteochondritis: It is a juxtaepiphyseal inflammation involving growingends of bone of more commonly upper limb. Occuring during the first few months of lifethe child presents with large and tender epiphyses and sometimes pseudoparalysis.Features similar to scuvry may be seen including seperation of epiphysis. Diagnosis is bystrongly positive treponema immobilization reaction. Early and prompt treatment withantisyphilic therapy may produce complete resolution unless damage to growth cartilagehas occured.Cluttons joint: Symmetrical hydrarthrosis: Children (between 8 to 16 years of age) maypresent with painless symmetrical hydrarthrosis of knee with ability to walk unaffected.Associated features such as eye changes & other stigmata congenital syphilis are present.It is a gradually progressive disease (with spontaneous recovery in few cases) respondingslowly to treatment.B. Joint lesion in early acquired syphilisArthralgia: Mild nocturnal arthlgia may occur in secondary stage before or afterappearance of early rashes. Usually affecting one or more of larger joints there is goodprognosis with respect of joint deformity or motion.Hydrarthrosis: Changes similar to clutton joint may be seen in later stages of secondarysyphilis with abundant fluid & synovial membrane edema. Pain is moderate & gentlepassive movements are painless.C. Joint lesions in acquired (late) syphilis (Tertiary syphililic arthritis):The gummatous arthritis occurs usually in insidous (rarely acute) form consisting offollowing variants: 1. Synovial form: The outer layer of capsule of joint becomes thickened with perivascular infiltration with abundant synovial effusion. Pain may or may not be present. Joints involved: Knee, ankle, elbow, shoulder & rarely IP joints. 2. Osseous form: Only knee joint in involved with feature of osteoarthritis & chronic synovitis present. Spine sometimes if affected resembles that of tuberculous spine. Diagnosis is by serological tests & should be preferably done in all cases of OA knee not responding to routine medication. . 3. Charcots joints: It usually occurs in acquired syphilis but may sometimes be seen in congenital syphilis. The features are similar to charcots joint, diagnosis is mainly base on presence of locomotor ataxia (tabes dorsalis), associated neurotrophic features such as perferating ulcers may be seen.
  10. 10. Signs suggestive of syphilis are: 1. Joint disease without heat, pain or tenderness 2. Bilateral painless hydrops of knees 3. Pupillary changes or absent knee jerks 4. Rheumatic fever type picture not responding to salicylates 5. Positive VDRL test of BloodDiagnostic tests for syphilis:A. Nonspecific tests: Venereal Diseases Research laboratory (VDRL) test is widely used flocculation test as it is easy to perform False positive: Viral pneumonia, malaria, leptospirosis & following inoculation, certain chronic disorders such as Tuberculosis, collagen, vascular disorder.B. Specific tests: a) Fluorescent Treponemal Antibody (FTA) test b) Treponemal Hemagglutination test (TPHA) c) Treponemal immobilization test (TPI)Treatment: a. Benzathin penicillin > 6-9 mega units in divided doses b. P.A.M: 2-4 mega units stat then every 3rd day for 6-10 injections c. Erythromycin 500 mg qds for one month d. Tetracyclin 3 to 4 gm over 10-15 days.GONOCOCCAL ARTHRITISIt is an uncommon sequalae of gonorrhoea occurying in less than 1% of case. Usually itdevelops during the third week of infection but may also occur some months after theinfection.Pathology:  It is more common in young adult males.  Mono articular involvement of large joints occur in 40% of cases, including knee, ankle, shoulder, wrist etc.  Small joints of hands & feet may also be involved in polyarticular case.Clinical Types:Acute cases: there are 4 types of presentation: 1. Arthralgia: One or more joints are painful with no detectable physical signs. 2. An acute infection with effusion in one or more of the larger joint. 3. Acute infection with effusion & erosion of cartilage. 4. Acute infection with purulent exudate with severe unceration & erosion of all cartilaginous surfaces.Subacute & chronic case: 2 types: 1. Synovial type: Features suggestive of chronic synovitis mainly involving knee joint
  11. 11. 2. Mixed type: Polyarticular involving smaller joints, associated with fibroblastic & serofibrinous exudate. Proliferative fibroblastic changes in the periarticular region is noticeable.Patterns of arthritis with gonorrheaMigratory polyarthralgia 70%Tenosynovitis 67%Purulent arthritis 42%Monoarthritis 32%Polyarthritis 10% .Clinical Picture:Acute cases have presentation similar to acute pyogenic arthritis with associated pyrexia& chills or rigors.Chronic cases resemble that of chronic synovitis with associated inflammatory changes intendons, tendonsheaths, bursae & the periosteum.More commonly tendons of wrist & ankle & retrocalcaneal bursae are involved. Mostimportant diagnostic due for Gonorrhoea is tenosynovitis.Laboratory diagnosis: 1. Examination of urethral Dischange: a. Gram staining b. Cultural tests c. Sugar formentation d. Oxidase reactionDifferential diagnosis: I. Acute Rheumatism II. Arthritis following pneumonia, dysentary, cerebrospinal infection, typhoid or scarlet fevers, acute tonsillitis & tuberculosis III. Reiters SyndromeDifferentiating features between Reiters syndrome & gonococcal arthritis Features Reiters Gonococcal Migratory polyarthlgia - + Enthesitis + - Spondylitis + -Differential diagnosis between acute rheumatism and gonococcal arthritis: - Uveitis + Oral ulcers + - Skin lesions Keratoderma, balanitis Pustules Culture Negative May be positive HLA B27 positive > 80% < 10% Arthritis Lower limbs Knees, Upper limb Response to penicillin - +
  12. 12. Acute Rheumatism Gonococcal Arthritis- No evidence of genitourinary -Mild to moderate signs and disease symptoms may be present- Marked pyrexia & constitutional -Except in purulent case, very symptoms moderate pyrexia and constitutional symptoms- Pain intense & increased by the -Pain less intense slightest touch- Sweating very profuse with -Very little sweating except in acid odour purulent cases- Fleeting joint pain +ve -Absent- Tendon sheaths & periarticular -Very frequent tissues rarely involvedIMP-TIPS:- Cardiac involvement with an -Very rareGonorrhoea must always be excluded if there is an acute, subacute or chronic affection of active focus of tonsilitis- Responds well painful, persistent & associated periarticular changes.a joint which is to salicylates -Little effect on pain & swellingPrognosis: Prognosis Acute Subacute or chronic Arthraligia Exudation Exudation Severe erosion Recurrences Complete With mild with suppurationrecovery erosion Adequate treatment Fibrous ankylosis Good prognosisTreatment: a. Rest b. Physiotherapy c. Penicillin compounds d. Aspiration and injection of antibiotics in purulent type e. Rarely surgical debridement f. Patient should also be tested for syphilis and HIVAntimicrobial therapy:
  13. 13. 1. Cefriaxone 1-2 gm im or IV per day till symptoms resolve followed by outpatient therapy for 7 days with cefuroxime (500 mg 1-1) or amoxicillin calvulanate (500 mg 1-1-1) 2. Alternatively ciprofloxacin or norfloxacin may be used 3. Doxycyclin (100 mg 1-1 x (7) days) must also be given for coexistent chlamydial infection.Parasitic arthritis:Guinea warm (Dracunculus medinesis): May sometimes cause destructive lesions in thelower extremities as migrating gravid female worms invade joint or may cause ulcer inthe surrounding soft tissue which may become secondarily infected.Hydatid cyst (1 to 2% bone involvement caused by E granulosus): May sometime burstinto joint from neighbouring bone involvement eg. Hip joint.Lymphatic filariasis: It may be associated with monoarticular arthritis in children andresponds well to diethylcarbamizine treatment.Reactive arthritis: It may occur due to  Hookwarm  Strongyloides  Cryptosporidium  Giardia infestationsFungal arthritisEtiological agents:  Candida species  Aspergillus species  Cryptococcus neoformans  Blastomyces dermatitidis etcMethods of spread:  Direct inoculation  Disseminated hematogenous infection in immunocompromised patient.Differentiating Features:The synovial fluid usually contains 10,000 to 40,000 cells with about 70% neutrophilis.Stained specimen and cultures of synovial tissue should be done in cases of disseminatedfungal infections to confirm diagnosis.Treatment:  Drainage and lavage of joint  Intra-articular installation of amphotericin - B  Systemic therapy with antifungals (including amphotericin -B, flucanazole or itracanozole etc).Spirochaetal arthritis (Lyme disease):The disease caused by borrelia burgderferi may lead to arthritis in 70% of cases if leftuntreated.
  14. 14. Clinical presentation: 1. Monoarthritis or oligoarthritis : Commonest, involving knee and/or other large joints. The symptoms may wax or wane over period of months or years and spontaneous remission may also occur without treatment. 2. Waxing and waning arthralgias 3. Chronic inflammatory synovitis with erosion or destruction of the jointTreatment:  Oral doxycyclin  Oral amoxycillin plus probenecid, over a period of 3 to 4 weeks  Parenteral cefriaxoneViral arthritis:Common viral disorder that may be accompanied by arthritis Hepatitis B Mumps Parvovirus B19 (fifth disease) Chickenpox Rubella Human immunodificiency virus (HIV)Arthritis of brucellosis:Clinical types include: 1. Arthralgias and ostealgias 2. Fibrositis 3. Hydrarthrosis 4. Acute arthritis 5. Chronic arthritis 6. Osteitis, osteomyelitis and osteoperiostitisCommonest presentation:Spondylitis resembling potts spine is one of the commonest presentation and brucellosisshould be kept in mind in those cases of potts spine not responding to AKT.Etiopathogenesis: Arthritis of brucellosis Acute type Chronic type Invasion by microbes Usually due to an allergic inside the joint inflammatory response of mesenchymal tissue Inflammatory arthritisAssociated conditions:  Psychic asthenia
  15. 15.  Autonomous nervous system disturbances  Fever (mayor may not be present)  Changes of the eight cranial nerveLaboratory findings:Salient features are: 1. Positive intradermal reaction of bund 2. Anaemia with anisocytosis, leucopenia with neutropenia and lymphocytosis 3. Normal ESR 4. Positive agglutination titre to brucella of (SAT) > 80 5. Estimation of serum anti-brucella immunoglobulin (lgA, IgG, IgM) by radioimmunoessay or ELISATreatment:  Streptomycin 19m intramuscular daily and Chlortetracyclin 2gm daily x 3 wks.  Steroids may be used to reduce inflammation  Some authors reserve use of streptomycin (1 gm/day 1M) or gentamicin (6 mg/day IV /1M) for first 3 weeks of a 6 week course of chlortetracyclin in case of failure of response or relapse.Lymphogranuloma venereum  Chronic process with acute flare-up & a tendency to relapse  Usually polyarticular involvement including knees, ankles & wrists  Swelling usually confined to periarticular tissuesAssociated conditions: a. Inguinal bubo b. Multiple discharging sinus in the inguinal region c. Rectal strictures in females d. Elephentiasis of genitaliaDiagnosis: 1. Smear to identify HP inclusion bodies 2. PREI intradermal testTreatment: 1. Sulfonamides 1 gm qds for 7-14 days 2. Tetracyclin 250-500 mg 4 times daily for 15 days