Management of Septic Bursitis
The management of septic bursitis requires prompt antibiotic therapy, drainage procedures, and close monitoring, with empiric broad-spectrum antibiotics started within 1 hour of recognition followed by targeted therapy based on culture results. 1
Initial Assessment and Diagnosis
- Evaluate for signs of systemic infection: fever, chills, erythema extending beyond the bursa, and regional lymphadenopathy
- Assess risk factors: immunocompromised status, diabetes, recent trauma or skin breakdown
- Obtain bursal fluid for:
- Gram stain and culture (before starting antibiotics if possible)
- Cell count (WBC >2000/mm³ with neutrophil predominance suggests infection)
- Crystal analysis to rule out gout/pseudogout
Antimicrobial Therapy
Initial Empiric Treatment
- Start empiric antibiotics within 1 hour of recognizing septic bursitis 1
- Target Staphylococcus aureus and streptococci as they account for >80% of cases 2
- First-line options:
- Outpatient (mild cases): Oral anti-staphylococcal antibiotics (cephalexin, dicloxacillin)
- Inpatient (severe cases): IV vancomycin or IV cefazolin
Duration and Adjustment
- Standard duration: 7-10 days for uncomplicated cases 1
- Reassess antibiotic regimen daily for de-escalation opportunities 1
- Adjust therapy based on culture results (typically available within 48-72 hours)
- Consider longer courses (14+ days) for:
- Slow clinical response
- Immunocompromised patients
- Complicated infections with systemic symptoms 1
Drainage Procedures
Aspiration vs. Empiric Management
- Recent evidence suggests empiric antibiotic management without aspiration may be effective for uncomplicated cases:
Drainage Options
Needle aspiration:
- Indicated for moderate cases with significant fluid collection
- May need to be repeated every 1-3 days until fluid accumulation resolves
- Consider if empiric antibiotic therapy fails to show improvement within 48-72 hours
Percutaneous suction-irrigation system:
- Effective for severe cases requiring continuous drainage
- Allows for local antibiotic irrigation
- Associated with fewer complications and recurrences compared to simple aspiration 5
Surgical intervention (bursectomy):
- Reserved for cases that fail to respond to antibiotics and aspiration
- Consider when there is:
- Persistent infection despite adequate medical therapy
- Formation of loculations or abscesses
- Necrotic tissue requiring debridement
Hospitalization Criteria
Indications for inpatient management include:
- Presence of fulminant local infection
- Evidence of systemic toxicity (fever >38.5°C, hypotension)
- Significant comorbidities
- Immunocompromised status
- Failed outpatient management 2
Monitoring and Follow-up
- Clinical improvement should be evident within 48-72 hours of initiating treatment
- Monitor for:
- Decreasing erythema, warmth, and swelling
- Improved range of motion
- Resolution of systemic symptoms
- Consider repeat aspiration if clinical improvement stalls
Special Considerations
- For diabetic or immunocompromised patients, consider broader antimicrobial coverage and lower threshold for hospitalization
- Early, appropriate antimicrobial therapy and adequate source control are the cornerstones of successful treatment 1
- The duration of symptoms prior to diagnosis correlates with time to achieve culture sterility (r = 0.68, P < 0.001) 6, emphasizing the importance of early treatment
Prevention of Recurrence
- Address underlying risk factors (e.g., occupational kneeling, pressure on elbows)
- Consider protective padding for at-risk areas during activities
- Prompt treatment of skin infections near bursal areas
By following this structured approach to septic bursitis management, clinicians can effectively treat the infection while minimizing complications and recurrence.