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Septic Bursitis

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Septic Bursitis, Septic Olecranon Bursitis, Septic Prepatellar Bursitis, Olecranon Bursa Infection, Prepatellar Bursa Infection

  • Mechanism
  1. Often follows acute Trauma
  • Causes
  1. Staphylococcus aureus (80-85% of cases)
  2. Streptococcus Pyogenes and other species
  3. Staphylococcus Epidermidis
  4. Enterococcus (rare)
  5. Escherichia coli (rare)
  6. Pseudomonas aeruginosa (rare)
  7. Candida (rare)
  • Risk Factors
  1. Common Predisposing Factors (present in 50% of cases)
    1. Diabetes Mellitus
    2. Chronic Kidney Disease
    3. Rheumatic disorders
    4. Alcoholism
    5. Immunocompromised state (e.g. HIV Infection, Chronic Corticosteroids)
  2. Other Risk Factors
    1. Male gender
    2. Trauma or recent procedures
    3. Gouty Arthritis
    4. Dermatologic conditions (e.g. Psoriasis, Eczema)
  • Symptoms
  1. Fever (variably present)
  2. Bursal pain, redness and swelling
  • Signs
  1. Inflammation of skin overlying bursa
    1. Bursa erythema, warmth, and effusion
  2. Normal range of motion
    1. Range of motion will however increase pain when bursa is compressed (esp. flexion)
    2. Contrast with Septic Arthritis
      1. Restricted joint range of motion is a red flag for deep infection or Septic Arthritis
  • Labs
  1. Complete Blood Count with differential
    1. May show Leukocytosis with Left Shift
  2. Bursa Aspiration for Gram Stain and culture
    1. See Bursa Aspiration
    2. Indications
      1. Historically has been recommended in all cases of Septic Bursitis
      2. However, empiric antibiotic management without aspiration may be a safe and effective strategy
        1. Beyde (2022) Acad Emerg Med 29:6-14 [PubMed]
    3. Findings
      1. Bursal fluid PMNs >1000/mm3 (typically >2000/mm3) suggests Septic Bursitis
      2. Rising MRSA rate dictates culture-directed therapy
      3. Culture Test Sensitivity >67% (lower with prior antibiotics)
  • Imaging
  1. Ultrasound indications
    1. Deep infection suspected
    2. Guidance for Bursa Aspiration
  2. Joint Xray
    1. Consider in evaluation of differential diagnosis (e.g. Fracture, foreign body, crystal Arthritis)
  • Complications
  1. Contiguous spread to surrounding tissue (including Septic Arthritis)
  2. Abscess
  3. Cutaneous fistula
  4. Aseptic sympathetic joint effusion
    1. Diagnosis of exclusion
    2. Differentiate from Septic Arthritis with Arthrocentesis
  • Management
  1. General measures
    1. Moist heat
    2. Splinting
    3. Repeated aspiration or incision, drainage as needed
  2. Antibiotics
    1. Cover Staphylococcus and Streptococcus
    2. Modify antibiotics based on culture of aspirate
    3. Duration of therapy: 14-21 days
      1. Shorter courses may be effective, and are not a risk for recurrent infection
      2. Perez (2010) J Antimicrob Chemother 65(5): 1008-14 +PMID:20197288 [PubMed]
    4. Mild infection
      1. First-line antibiotics for MSSA
        1. Oral: Dicloxacillin or Cephalexin
        2. IV: Cefazolin, Oxacillin or Nafcillin
      2. Consider MRSA coverage
        1. Trimethoprim-sulfamethoxazole
        2. Doxycycline
        3. Clindamycin (high rates of MRSA resistance, and induced resistance risk)
    5. Severe infection (treat as presumed MRSA)
      1. Start with Vancomycin IV
      2. Alternatives: Linezolid, Daptomycin
      3. Transition to oral agents based on culture results
  • References
  1. (2016) Sanford Guide, accessed on IOS 2/16/2017
  2. (2006) UpToDate, accessed 12/19/06
  3. Funk and Hurely (2022) Crit Dec Emerg Med 36(1): 18-9
  4. Koutouzis (2006) Marx: Rosen's Emergency Med
  5. Small (2005) Infect Dis Clin North Am 19:991-1005 [PubMed]
  6. Lopez (2006) Infect Dis Clin North Am 20:759-72 [PubMed]
  7. Khodaee (2017) Am Fam Physician 95(4): 224-31 [PubMed]