What is the recommended antibiotic treatment for bursitis?

Antibiotic Treatment for Bursitis

For septic bursitis, antibiotics effective against Staphylococcus aureus are the first-line treatment, with intravenous cloxacillin 2g every 4 hours until improvement, followed by oral cloxacillin 1g every 6 hours until resolution. 1

Diagnosis of Septic vs. Non-Septic Bursitis

Proper diagnosis is crucial before initiating antibiotic therapy:

• Septic bursitis should be distinguished from non-infectious causes (traumatic, microtraumatic, inflammatory) 2
• Key physical findings suggestive of septic bursitis include:
  • Tenderness (present in 88% of septic cases vs 36% of aseptic cases) 3
  • Erythema/cellulitis (83% septic vs 27% aseptic) 3
  • Warmth (84% septic vs 56% aseptic) 3
  • Evidence of trauma or skin lesion (50% septic vs 25% aseptic) 3
  • Fever (38% septic vs 0% aseptic) 3
• Bursal aspiration with fluid analysis is essential when infection is suspected 2
  • Fluid should be examined with Gram stain, crystal analysis, glucose measurement, cell count, and culture 2

Antibiotic Treatment Algorithm for Septic Bursitis

First-Line Treatment:

• Staphylococcus aureus is the most common pathogen (94.4% of culture-positive cases) 1
• Cloxacillin/flucloxacillin is the recommended first-line treatment: 4, 1
  • Intravenous: 2g every 4 hours until clinical improvement
  • Then oral: 1g every 6 hours until resolution
  • Total duration: 2-3 weeks 4

For Severe Cases (extensive cellulitis or systemic symptoms):

• Cloxacillin plus gentamicin (240mg/day IV for 5-7 days) 1
• Alternative regimen: cloxacillin plus rifampicin (600mg/day orally) 1

For Penicillin-Allergic Patients:

• Vancomycin (15mg/kg every 12 hours IV) 4
• Clindamycin (600-900mg every 8 hours IV) 4

For MRSA Coverage:

• Vancomycin (15mg/kg every 12 hours IV) 4
• Linezolid, quinupristin/dalfopristin, or daptomycin for resistant strains 4

Management Principles

• Outpatient oral antibiotics may be considered for patients who are not acutely ill 2
• Hospitalization with IV antibiotics is indicated for patients who are acutely ill 2
• Antibiotics should be administered intravenously initially, then switched to oral once clinical improvement occurs 4
• Repeat imaging (MRI preferred) should be performed in patients with persistent bacteremia to identify undrained foci of infection 4

Surgical Considerations

• Early drainage of purulent material should be performed 4
• Surgical intervention is typically reserved for cases not responsive to antibiotics or for recurrent cases 2
• Endoscopic bursectomy may be considered for patients requiring surgical debridement to decrease morbidity 5

Special Considerations

• For immunocompromised patients or those with open trauma to the area, add an agent active against enteric gram-negative bacilli 4
• For polymicrobial infections (less common), broader coverage may be needed:
  • Ampicillin-sulbactam, piperacillin-tazobactam, or a carbapenem 4
  • Ceftriaxone plus metronidazole 4
  • Ciprofloxacin plus metronidazole 4

Non-Infectious Bursitis

• Acute traumatic/hemorrhagic bursitis: conservative treatment with ice, elevation, rest, and analgesics 2
• Chronic microtraumatic bursitis: address underlying cause; bursal aspiration generally not recommended due to risk of iatrogenic infection 2
• Inflammatory bursitis (e.g., gout, rheumatoid arthritis): treat underlying condition 2