What is the treatment for an infected bursa (bursal infection) of the elbow?

Treatment for Infected Bursa Elbow (Septic Olecranon Bursitis)

The treatment for an infected bursa of the elbow (septic olecranon bursitis) should include aspiration of the bursa, empiric antibiotic therapy targeting Staphylococcus aureus, and possible repeated aspirations, with surgical intervention reserved for refractory cases.

Diagnosis and Initial Assessment

• Look for:

  • Swelling over the olecranon process
  • Erythema and warmth
  • Pain with movement
  • Possible fever
  • History of trauma, skin breakage, or occupational risk factors
  • Cellulitis adjacent to the bursa (present in 89% of cases) 1

• Diagnostic approach:

  • Aspiration of bursal fluid is essential for all suspected cases
  • Send fluid for cell count, Gram stain, and culture
  • Bursal fluid white blood cell counts can vary widely (350-392,500 WBC/mm³) 1
  • Obtain culture before starting antibiotics if purulent drainage is present

Antimicrobial Therapy

First-line Treatment:

• Empiric antibiotic therapy targeting Staphylococcus aureus (most common pathogen in 78% of cases) 1
• Options include:
  • First-generation cephalosporins (e.g., cephalexin)
  • Anti-staphylococcal penicillins (e.g., dicloxacillin)

For suspected MRSA:

• Consider MRSA coverage if:
  • Local MRSA prevalence is high
  • Patient has risk factors for MRSA
  • No response to initial therapy 2
• Options include:
  • Trimethoprim-sulfamethoxazole DS twice daily
  • Doxycycline 100mg twice daily
  • Vancomycin, linezolid, daptomycin, or ceftaroline for complicated cases

Duration of Therapy:

• 10-14 days for uncomplicated infections
• Longer courses may be needed as clinical resolution can be slow (mean >5 weeks, up to 20 weeks in some cases) 1

Bursa Drainage Approach

1. Initial management:

   • Aspiration of the bursa is essential for both diagnosis and treatment 3
   • Thoroughly clean the area with sterile normal saline before aspiration
   • May need repeated aspirations for adequate drainage

2. Follow-up:

   • Reassess after 48-72 hours of treatment
   • Monitor for signs of improvement vs. deterioration
   • Repeat aspiration if reaccumulation occurs

3. Surgical intervention:

   • Reserved for refractory cases that fail to respond to aspiration and antibiotics
   • Indications include:
     • Failure to respond to empiric antibiotics within 48-72 hours
     • Severe systemic symptoms
     • Recurrent or complicated infections
     • Presence of a foreign body
   • Options include percutaneous suction-irrigation systems or surgical bursectomy 2
   • Note: Surgical management has been associated with higher rates of overall complications, persistent drainage, and bursal infection compared to nonsurgical management 4

Adjunctive Measures

• Ice application to reduce inflammation
• Activity modification and protection of the affected area
• NSAIDs for pain and inflammation control
• Avoid corticosteroid injections in septic bursitis as they may worsen infection

Important Considerations and Pitfalls

• Do not use corticosteroid injections in suspected or confirmed septic bursitis as they can worsen infection 4

• Avoid inadequate drainage, as this can lead to persistent infection

• Be aware that clinical resolution can be slow, taking several weeks 1

• Consider hospitalization for patients with:

  • Systemic symptoms
  • Immunocompromised status
  • Extensive cellulitis or profound edema (occurs in 11% of affected limbs) 1
  • Failed outpatient management

• A significant number of patients may fail to respond to initial oral antibiotics and may require IV antibiotics 1

• Outpatient parenteral antimicrobial therapy (OPAT) is an option for patients requiring IV antibiotics but who are otherwise stable 5

By following this approach, most cases of septic olecranon bursitis can be successfully managed without the need for surgical intervention, though patients should be monitored closely due to the potentially prolonged recovery period.