Treatment of Bursitis with Fever
Bursitis accompanied by fever should be treated as septic bursitis with immediate diagnostic aspiration for Gram stain and culture, followed by empiric antibiotics targeting Staphylococcus aureus including MRSA coverage, with vancomycin or daptomycin as first-line therapy. 1
Immediate Diagnostic Evaluation
The presence of fever fundamentally changes the management approach, as it strongly suggests septic rather than aseptic bursitis. 1 Key clinical indicators that support septic bursitis include:
- Fever, severe erythema, warmth, and systemic symptoms are the primary distinguishing features 1
- Diagnostic aspiration must be performed immediately for Gram stain, culture, and cell count 1
- Septic bursal fluid typically shows elevated white blood cell count (>3,000 cells/mm³), low bursal-to-serum glucose ratio, and positive Gram stain 2
- Blood cultures should be obtained from at least two sets to evaluate for bacteremia 3
Empiric Antibiotic Therapy
Empiric coverage must target Staphylococcus aureus, which accounts for the majority of septic bursitis cases (75-90%). 2 The recommended regimen is:
- Vancomycin IV or daptomycin 6 mg/kg IV once daily for empiric MRSA coverage 1
- Treatment duration is at least 2 weeks, with the duration proportional to how long the infection has been present 1, 2
- Culture-directed therapy should follow, adjusting antibiotics based on aspirate culture results 1
- In one study, the average duration of successful antibiotic therapy was 12 days when treated prospectively 2
Drainage and Source Control
Therapeutic aspiration should be performed initially, with consideration for more aggressive drainage if needed. 1 Options include:
- Percutaneous suction-irrigation systems have shown excellent results with no recurrences in published series, controlling infection with an average of 19 days of treatment 4
- This approach combines local suction-drainage with antibiotic irrigation (historically 1% kanamycin and 0.1% polymyxin) 4
- Surgical wash-out may be required for cases that fail to improve with initial aspiration and antibiotics 5
Hospitalization Criteria
Hospitalization is recommended for patients meeting any of these criteria: 1
- Concern for deeper or necrotizing infection
- Severe immunocompromise
- Systemic toxicity or sepsis
- Failed outpatient management
Critical Pitfalls to Avoid
Delaying antibiotics in septic patients increases mortality, and empiric antimicrobial therapy should be initiated when clinical distinction is unclear. 3 Additional considerations:
- Do NOT inject corticosteroids when infection is suspected, as this can worsen septic bursitis 6
- Consider atypical organisms in immunocompromised patients, including mycobacterial bursitis requiring prolonged multi-drug therapy 1
- Streptococcus pyogenes accounts for approximately 17% of cases and can progress to osteomyelitis if untreated 2, 7
- Monitor for sympathetic sterile effusion in neighboring joints or adjacent fascial spaces 2
Follow-up and Treatment Adjustment
Close monitoring is essential, with return evaluation in 2-3 days if treated as outpatient. 5 Signs of treatment failure include:
- Interval worsening of symptoms despite antibiotics
- Persistent fever after 48-72 hours
- Progression of erythema or systemic symptoms
- These findings mandate hospitalization and surgical intervention 5