Treatment of Septic Olecranon Bursitis
For septic olecranon bursitis, initiate empiric antibiotics targeting Staphylococcus aureus (including MRSA if risk factors present) combined with bursal drainage, either through repeated aspiration or surgical intervention if conservative management fails.
Initial Assessment and Diagnosis
Obtain bursal fluid aspiration for diagnosis when infection is suspected, analyzing fluid with Gram stain, culture, cell count with differential, glucose measurement, and crystal analysis 1. Blood cultures should be obtained before starting antimicrobials if this does not substantially delay antibiotic initiation 2.
Key clinical features distinguishing septic from non-septic bursitis include:
- Fever, marked tenderness, and peribursal cellulitis 3
- Skin involvement overlying the bursa 3
- Elevated bursal fluid leukocyte count, low bursal-to-serum glucose ratio, and positive Gram stain 3
Empiric Antibiotic Selection
Outpatient Management (Non-Acutely Ill Patients)
For outpatients without systemic toxicity, oral antibiotics effective against S. aureus are appropriate 1. Options include:
- Clindamycin 300-450 mg orally three times daily 2
- Trimethoprim-sulfamethoxazole (TMP-SMX) at standard dosing 2
- Doxycycline or minocycline at standard dosing 2
- Linezolid 600 mg orally twice daily 2
If MRSA risk factors are present (recent hospitalization, healthcare contact, known MRSA colonization, failed beta-lactam therapy), empiric MRSA coverage is essential 2.
If MRSA risk is low, consider:
- Cefazolin 1-2 grams IV/IM every 8 hours, which covers methicillin-sensitive S. aureus and streptococci 4
- Nafcillin 1-2 grams IV every 4-6 hours for penicillinase-resistant coverage 5
Inpatient Management (Acutely Ill Patients)
Hospitalize patients with systemic toxicity, extensive cellulitis, or immunocompromise and initiate IV antibiotics 1. Options include:
- Vancomycin IV (dose adjusted for renal function, targeting trough 15-20 mcg/mL for serious infections) 2
- Linezolid 600 mg IV twice daily 2
- Daptomycin 4-6 mg/kg IV once daily 2
Drainage Procedures
Conservative Approach Without Aspiration
Recent evidence suggests empiric antibiotics without bursal aspiration may be reasonable for select ED patients, with 88% achieving uncomplicated resolution without subsequent aspiration, hospitalization, or surgery 6. This approach avoids the risk of iatrogenic complications from aspiration 1.
However, aspiration should be performed if:
- Diagnosis is uncertain 1
- Patient fails to improve within 48-72 hours of empiric therapy 6
- Systemic signs of infection are present 1
Aspiration Technique
Repeated needle aspiration is preferred over incision and drainage for initial management, as it avoids surgical complications and chronic drainage 7, 3.
Surgical Intervention
Consider percutaneous suction-irrigation system placement for severe cases requiring continuous drainage, using local antibiotic irrigation (1% kanamycin and 0.1% polymyxin solution) combined with IV antibiotics 7. This technique demonstrated no complications or recurrences in published series 7.
Reserve surgical debridement (bursectomy) for:
- Failure to respond to antibiotics and aspiration 1
- Recurrent septic bursitis 1
- Suspected underlying osteomyelitis 8
Antibiotic Duration
Standard treatment duration is 10-14 days for uncomplicated septic bursitis 3. The duration of antibiotic therapy necessary to sterilize bursal fluid is proportional to how long the infection has been present 3.
Longer courses may be appropriate (up to several weeks) when:
- Slow clinical response occurs 2
- Underlying osteomyelitis is suspected 8
- S. aureus bacteremia is documented 2
De-escalation Strategy
Narrow antibiotic therapy once culture results and sensitivities are available 2. If MRSA is isolated, continue MRSA-directed therapy. If methicillin-sensitive S. aureus is identified, transition to nafcillin, cefazolin, or oral cephalexin based on clinical stability 4, 5.
Monitoring and Follow-Up
Reassess within 48-72 hours if symptoms worsen or fail to improve 6. Consider alternative diagnoses or complications including:
- Underlying olecranon osteomyelitis 8
- Atypical organisms (Streptococcus species, Cutibacterium acnes in delayed-growth cultures) 8
- Adjacent joint septic arthritis (sympathetic sterile effusion may occur) 3
Common Pitfalls
Do not routinely perform bursal aspiration for chronic microtraumatic (non-septic) bursitis, as this increases the risk of iatrogenic septic bursitis 1.
Do not dismiss slow-growing organisms as contaminants without clinical correlation; C. acnes may require 21 days of culture incubation and can cause true infection requiring prolonged antibiotic therapy 8.
Do not use rifampin as monotherapy or adjunctive therapy for skin and soft tissue infections including bursitis 2.