Antibiotic Treatment for Infective Bursitis
For infective bursitis, cloxacillin or flucloxacillin (12 g/day IV in 4-6 doses) is the first-line antibiotic, with vancomycin (15 mg/kg IV every 12 hours) reserved for penicillin-allergic patients or suspected MRSA. 1
Initial Empiric Therapy
- Start with cloxacillin/flucloxacillin as first-line treatment since Staphylococcus aureus causes >80% of septic bursitis cases 2, 3, 4
- Administer 12 g/day IV in 4-6 divided doses initially 5
- For penicillin-allergic patients, use vancomycin 15 mg/kg IV every 12 hours or clindamycin 600-900 mg IV every 8 hours 1, 5
Treatment Duration and Route
- Begin with IV antibiotics, then switch to oral once clinical improvement occurs 1
- Total duration should be 2-3 weeks 1
- Evidence supports that adjuvant antibiotic therapy can be limited to ≤7 days in non-immunosuppressed patients when combined with surgical drainage, as longer courses (8-14 days or >14 days) showed no additional benefit 6
- The oral continuation after IV therapy typically uses cloxacillin 1 g every 6 hours 4
Special Populations Requiring Broader Coverage
- For immunocompromised patients or those with open trauma, add coverage for enteric gram-negative bacilli with ampicillin-sulbactam, piperacillin-tazobactam, or a carbapenem 1
- For polymicrobial infections, use broader regimens such as ceftriaxone plus metronidazole, or ciprofloxacin plus metronidazole 1
- Patients with extensive cellulitis or systemic toxicity may benefit from adding gentamicin 240 mg/day IV for 5-7 days to cloxacillin 4
MRSA Considerations
- If MRSA is suspected or confirmed, vancomycin remains the standard choice 5
- Alternative options for MRSA include linezolid 600 mg IV/PO twice daily or daptomycin 4 mg/kg/dose IV daily 5
- Clindamycin 600-900 mg IV every 8 hours is acceptable if the isolate is susceptible 5, 1
Common Pitfalls to Avoid
- Do not use rifampin as monotherapy or routine adjunctive therapy for bursitis, as it is not recommended for skin and soft tissue infections 5
- Avoid unnecessarily prolonged antibiotic courses in non-immunosuppressed patients who undergo adequate drainage, as this does not reduce recurrence risk 6
- Immunosuppression is the primary risk factor for recurrence (OR 5.6), not antibiotic duration 6