What is the empirical treatment for olecranon (elbow) bursitis infection?

From the Guidelines

Empirical treatment for olecranon bursitis infection should begin with broad-spectrum antibiotics, such as amoxicillin-clavulanate 875/125 mg twice daily, to cover common pathogens including Staphylococcus aureus, streptococci, and anaerobes 1.

Key Considerations

• The choice of antibiotic should be guided by the likelihood of methicillin-resistant Staphylococcus aureus (MRSA) and the presence of anaerobes, with amoxicillin-clavulanate being a suitable option for initial empirical treatment 1.
• For patients with a history of hypersensitivity to β-lactams, a fluoroquinolone such as ciprofloxacin or levofloxacin plus metronidazole, or moxifloxacin as a single agent, may be considered 1.
• Bursal aspiration is crucial to relieve pressure, obtain fluid for culture, and improve antibiotic penetration, and the affected elbow should be immobilized, elevated, and ice applied intermittently to reduce inflammation.

Treatment Approach

• First-line therapy: amoxicillin-clavulanate 875/125 mg twice daily for 7-10 days 1.
• Alternative options:
  • Ampicillin-sulbactam for broader coverage 1.
  • Fluoroquinolones (ciprofloxacin or levofloxacin) plus metronidazole for patients with β-lactam hypersensitivity 1.
  • Moxifloxacin as a single agent for its broad-spectrum activity including anaerobes 1.
• Monitoring and adjustment: patients should be monitored for improvement within 48-72 hours, with consideration for changing antibiotics if no response occurs, and antibiotics should be adjusted based on culture results when available.

From the Research

Empirical Treatment for Olecranon (Elbow) Bursitis Infection

• The empirical treatment for olecranon bursitis infection involves the use of antibiotics, with or without aspiration of the bursa 2, 3.
• A study published in 1986 found that percutaneous suction-irrigation with antibiotics was an effective treatment for septic olecranon bursitis, with no complications or recurrences reported 4.
• More recent studies have suggested that empirical management without aspiration may be a reasonable initial approach for uncomplicated septic olecranon bursitis, with high success rates and low complication rates 2, 3.
• The use of antibiotics without aspiration has been shown to be effective in resolving the infection, with one study finding that 88% of patients had an uncomplicated resolution 3.
• Another study found that empirical management without aspiration resulted in fewer chronic draining sinuses and less progression to bursectomy compared to traditional bursal aspiration 2.

Comparison of Treatment Approaches

• A systematic review of 29 studies found that nonsurgical management of olecranon bursitis was significantly more effective and safer than surgical management 5.
• The review also found that corticosteroid injection for aseptic bursitis was associated with increased overall complications and skin atrophy, and that aspiration did not increase the risk of bursal infection for aseptic bursitis 5.
• A study published in 2012 found that conservative treatment, including ice, rest, anti-inflammatory and analgesic drugs, and occasional bursal fluid aspiration, was the first line of treatment for olecranon bursitis, with arthroscopy being considered as a suitable new modality of management for unresponsive patients 6.

Treatment Outcomes

• The outcomes of empirical treatment for olecranon bursitis infection are generally favorable, with high success rates and low complication rates 2, 3.
• However, some studies have reported complications, such as chronic draining sinuses and progression to bursectomy, particularly with traditional bursal aspiration 2.
• The choice of treatment approach should be individualized based on the patient's specific condition and medical history, with careful consideration of the potential risks and benefits of each approach 2, 3, 5.