What is the treatment for an infected olecranon bursa?

Treatment of Infected Olecranon Bursa

The optimal treatment for infected olecranon bursitis includes empiric antibiotic therapy targeting Staphylococcus aureus without the need for routine bursal aspiration, as this approach results in successful resolution in approximately 88% of cases. 1

Diagnosis and Initial Assessment

• Look for:
  • Erythema, warmth, tenderness over the olecranon
  • Fluctuant swelling of the bursa
  • Systemic symptoms (fever, chills)
  • Risk factors (trauma, previous bursal inflammation, immunocompromise)

Treatment Algorithm

First-Line Management

1. Empiric Antibiotic Therapy

   • Oral antibiotics targeting Staphylococcus aureus (most common pathogen in 75-90% of cases) 2, 1
   • First-line options:
     • Cephalexin 500mg four times daily for 7-10 days
     • Anti-staphylococcal penicillin (e.g., dicloxacillin 500mg four times daily) for 7-10 days 3
   • For penicillin allergy:
     • Clindamycin 300-450mg three times daily for 7-10 days 3
   • For suspected MRSA (based on local prevalence or risk factors):
     • Trimethoprim-sulfamethoxazole DS twice daily
     • Doxycycline 100mg twice daily 4

2. Supportive Measures

   • Rest, elevation of the affected limb
   • Application of cold compresses
   • Avoidance of pressure on the affected area
   • NSAIDs for pain and inflammation

When to Consider Aspiration or Surgical Intervention

Contrary to traditional practice, recent evidence suggests that empirical antibiotic management without aspiration may be superior to routine aspiration for uncomplicated cases 1, 5. Consider aspiration or surgical intervention only in the following scenarios:

• Failure to respond to empiric antibiotics within 48-72 hours
• Severe systemic symptoms
• Immunocompromised patients
• Recurrent or complicated infections
• Presence of a foreign body

Surgical Options (if needed)

If conservative management fails, surgical options include:

1. Percutaneous Suction-Irrigation System

   • Placement of a catheter for drainage and local antibiotic irrigation
   • Effective for severe cases requiring continuous drainage 6
   • Lower complication and recurrence rates compared to simple incision and drainage

2. Surgical Bursectomy

   • Reserved for recurrent or refractory cases
   • Consider when multiple courses of antibiotics have failed

Evidence-Based Rationale

Recent studies strongly support empirical antibiotic treatment without aspiration as the initial approach:

• A 2022 study showed 88.1% of patients with suspected septic olecranon bursitis treated with empiric antibiotics without aspiration had uncomplicated resolution 1
• A 2020 study demonstrated that empirical management without aspiration resulted in fewer chronic draining sinuses and less progression to bursectomy compared to traditional bursal aspiration 5
• The number needed to harm when aspiration was performed was 1.46, indicating potential risks of the procedure 5

Monitoring and Follow-up

• Reassess after 48-72 hours of antibiotic therapy
• If improvement is seen, complete the full course of antibiotics
• If no improvement or worsening occurs, consider:
  • Diagnostic aspiration for culture and sensitivity
  • Changing antibiotic regimen
  • Surgical consultation

Common Pitfalls to Avoid

1. Routine aspiration of all infected olecranon bursae (increases risk of chronic draining sinuses and need for surgical intervention)
2. Inadequate duration of antibiotic therapy
3. Failure to consider MRSA in high-prevalence areas or non-responsive cases
4. Delayed surgical referral for cases failing conservative management

By following this evidence-based approach prioritizing empiric antibiotic therapy without routine aspiration, most cases of infected olecranon bursitis can be successfully treated with minimal complications and reduced need for surgical intervention.