What is the best course of action for a patient with a history of rheumatoid arthritis (RA) who has olecranon bursitis with possible infection, showed improvement with a 10-day course of Keflex (Cephalexin) but is now worsening after stopping the medication?

Management of Olecranon Bursitis in a Patient with Rheumatoid Arthritis

For a patient with rheumatoid arthritis who has olecranon bursitis with possible infection that initially improved with a 10-day course of Keflex (cephalexin) but is now worsening after stopping the medication, a longer course of antibiotics (2-4 weeks) is needed, followed by consideration of surgical bursectomy if symptoms persist.

Assessment and Immediate Management

• The worsening of symptoms after completion of the initial antibiotic course suggests either inadequate treatment duration or antibiotic resistance, requiring prompt intervention 1
• Patients with rheumatoid arthritis are at increased risk for both septic and inflammatory bursitis, making proper diagnosis and management crucial 2
• Aspiration of the bursa should be performed to:
  • Obtain fluid for culture and sensitivity testing
  • Assess white blood cell count and differential
  • Rule out crystal arthropathies through crystal analysis 1

Antibiotic Therapy

• Resume cephalexin at an appropriate dose (typically 500mg four times daily) for a longer course of 2-4 weeks, as the initial improvement suggests some susceptibility 3
• If no improvement is seen within 7 days of restarting antibiotics, consider changing to a different antibiotic based on culture results 4
• Be vigilant for potential superinfection with resistant organisms or fungi, which can occur with prolonged antibiotic use, especially in immunocompromised patients with rheumatoid arthritis 2
• Monitor for side effects of prolonged cephalexin use, including gastrointestinal symptoms and potential development of C. difficile colitis 3

Management Algorithm

1. Immediate intervention:

   • Resume cephalexin for a longer course (2-4 weeks)
   • Perform bursal aspiration for diagnostic testing 1

2. If improvement occurs with extended antibiotics:

   • Complete the full antibiotic course
   • Implement conservative measures (ice, rest, NSAIDs if not contraindicated)
   • Consider protective padding to prevent recurrence 5

3. If minimal or no improvement after 7 days of resumed antibiotics:

   • Review culture results and adjust antibiotics accordingly
   • Consider unusual pathogens including fungal organisms 2
   • Consult infectious disease specialist if cultures are negative but infection is still suspected 1

4. For persistent or recurrent bursitis after completing antibiotics:

   • Consider surgical bursectomy, especially if this is a recurrent episode 6
   • Note that surgical outcomes may be less favorable in rheumatoid arthritis patients (only 40% success rate compared to 94% in non-rheumatoid patients) 6

Special Considerations for Rheumatoid Arthritis

• The underlying rheumatoid arthritis may contribute to inflammation of the bursa, requiring optimization of disease-modifying antirheumatic drug (DMARD) therapy 4
• For isolated joint/bursa inflammation in rheumatoid arthritis, consider local intra-articular glucocorticoid injection after infection has been ruled out or adequately treated 4
• Avoid intrabursal corticosteroid injections if infection is suspected or not fully resolved 4
• Assess current DMARD therapy and consider adjustments if disease activity is not well-controlled 4

Pitfalls to Avoid

• Failure to distinguish between infectious and inflammatory bursitis can lead to inappropriate treatment 1
• Premature cessation of antibiotics may result in recurrence of infection 3
• Intrabursal corticosteroid injections should be avoided if infection is suspected, as they can worsen the infection 4
• Surgical intervention in rheumatoid arthritis patients has a lower success rate and should be considered only after failed conservative and medical management 6

Long-term Management

• After resolution of the acute episode, address prevention of recurrence through:
  • Optimizing rheumatoid arthritis treatment to reduce overall inflammation 4
  • Using protective padding over the olecranon to prevent trauma 5
  • Regular monitoring for early signs of recurrence 7
  • Patient education regarding early reporting of symptoms 1