What is the first-line antibiotic (abx) treatment for bursitis without aspiration?

First-Line Antibiotic Treatment for Bursitis Without Aspiration

For uncomplicated septic bursitis without aspiration, empirical antibiotic therapy with oral antibiotics targeting Staphylococcus aureus is the first-line treatment, with amoxicillin-clavulanate being the preferred choice. 1, 2, 3

Epidemiology and Microbiology

• Septic bursitis is commonly caused by Staphylococcus aureus (approximately 85% of cases), with beta-hemolytic Streptococcus and Staphylococcus epidermidis being less common causative organisms 4
• The most common types of bursitis include prepatellar, olecranon, trochanteric, and retrocalcaneal 5

Empirical Antibiotic Selection

First-line options:

• Amoxicillin-clavulanate is the preferred first-line antibiotic due to its coverage against S. aureus, including many community-acquired methicillin-resistant strains 1
• Alternative options include:
  • Cefuroxime-axetil (second-generation cephalosporin) 1
  • Cefpodoxime-proxetil (third-generation cephalosporin) 1

For patients with beta-lactam allergies:

• Pristinamycin (where available) 1
• Clindamycin (for gram-positive coverage) 1

Treatment Duration and Monitoring

• Standard duration of antibiotic therapy is 7-10 days 1, 4
• Recent evidence suggests that shorter courses (≤7 days) may be as effective as longer courses (>7 days) in non-immunocompromised patients 4
• Clinical improvement should be expected within 48-72 hours of initiating antibiotics 3
• If no improvement is observed after 72 hours, consider:
  • Changing antibiotic therapy
  • Obtaining imaging (ultrasound) to assess for fluid collection
  • Possible aspiration or surgical intervention 1

Special Considerations

• Immunocompromised patients have a higher risk of recurrence and may require longer treatment courses 4
• Severe cases with systemic symptoms (high fever, extensive cellulitis) may require:
  • Initial intravenous antibiotics
  • Hospitalization
  • Possible surgical intervention 4

Evidence for Non-Aspiration Approach

• Recent studies show that empirical antibiotic therapy without aspiration results in successful resolution in approximately 88% of cases of suspected septic olecranon bursitis 3
• Empirical management without aspiration has been associated with fewer complications and lower rates of progression to surgical bursectomy compared to traditional bursal aspiration 2
• The number needed to harm when aspiration was performed was 1.46, suggesting potential risks with routine aspiration 2

When to Consider Alternative Management

• Failure to respond to initial antibiotic therapy after 72 hours 1
• Presence of systemic symptoms suggesting severe infection 4
• Immunocompromised status 4
• Recurrent episodes of bursitis 5
• Suspicion of crystal-induced bursitis rather than infectious etiology 5