Is antibiotic therapy indicated for a swollen elbow bursa in an adult patient with no significant past medical history, 3 months post-trauma, without signs of acute infection, and who appears generally well?

Antibiotics Are NOT Indicated Post-Aspiration for This Non-Infected Elbow Bursa

For a swollen elbow bursa 3 months post-trauma without signs of infection (no heat, patient appears well), antibiotics are not indicated after aspiration. The absence of fever, erythema, warmth, and systemic signs indicates this is likely aseptic (non-septic) bursitis, which does not require antimicrobial therapy 1.

Key Clinical Distinction: Septic vs. Aseptic Bursitis

The clinical presentation strongly suggests aseptic bursitis based on:

• Absence of infection markers: No heat/warmth (present in 84% of septic cases), no erythema/cellulitis (present in 83% of septic cases), patient appears well with no fever (present in 38% of septic cases) 2
• Chronic timeline: 3 months post-trauma suggests chronic aseptic bursitis rather than acute septic process 3, 2
• Physical examination findings: Tenderness occurs in only 36% of aseptic cases versus 88% of septic cases; warmth in 56% aseptic versus 84% septic 2

When Antibiotics ARE Indicated

Antibiotics would only be necessary if the patient demonstrates 1:

• Temperature >38.5°C
• Heart rate >110 beats/minute
• Erythema extending >5 cm beyond the bursa margins
• Purulent drainage on aspiration
• Positive Gram stain or culture results
• Evidence of systemic toxicity or immunocompromise 3

Management Approach for This Patient

Aspiration alone is appropriate 1:

• Perform diagnostic aspiration to confirm aseptic nature (send fluid for cell count, Gram stain, culture)
• Expected findings in aseptic bursitis: normal bursal-to-serum glucose ratio, low leukocyte count, negative Gram stain 4
• If fluid analysis confirms aseptic bursitis, no antibiotics are needed

Symptomatic management only 1:

• Cold compresses for local swelling
• Oral NSAIDs or analgesics for discomfort
• Compression and elevation as needed
• Avoid corticosteroid injection until infection definitively ruled out

Critical Pitfall to Avoid

Do not prescribe antibiotics empirically without evidence of infection 1:

• Studies of subcutaneous abscesses and surgical site infections found no benefit for antibiotics when combined with drainage alone in the absence of systemic signs 1
• Unnecessary antibiotic use contributes to resistance without clinical benefit 1
• The swelling and inflammation are caused by mediator release from trauma, not infection 1

If Infection Is Subsequently Confirmed

Should culture results return positive or clinical deterioration occur 3, 4, 5:

• Staphylococcus aureus causes >80% of septic bursitis cases 3, 4
• First-line antibiotic: Anti-staphylococcal agent (e.g., cephalexin, dicloxacillin) for penicillin-resistant S. aureus 4
• Duration: Average 12-19 days of therapy, proportional to duration of infection 4, 5
• Consider percutaneous suction-drainage with local antibiotic irrigation for severe cases 5
• Indications for hospitalization: fulminant local infection, systemic toxicity, or immunocompromised state 3