What's the next step for a patient with persistent bursitis symptoms, including swelling and erythema, despite initial treatment with a steroid pack and doxycycline (doxycycline) 100 mg twice daily for 10 days?

Management of Persistent Bursitis After Initial Treatment

For persistent swelling and erythema after a steroid pack and 10 days of doxycycline, you must first rule out septic bursitis through aspiration with fluid analysis and culture, then proceed based on whether infection is present or absent. 1, 2

Immediate Next Steps: Rule Out Septic Bursitis

Perform bursal aspiration immediately to obtain fluid for:

• Gram stain and bacterial culture (including mycobacterial culture if immunocompromised or prior steroid injection) 3, 2
• Cell count with differential 1, 2
• Crystal analysis to exclude gout/pseudogout 1

Critical pitfall: Never inject steroids into a potentially infected bursa—this can worsen infection and delay appropriate treatment. 1, 3

If Septic Bursitis is Confirmed

Continue or restart antibiotics based on culture sensitivities for a minimum of 14 days after achieving sterile bursal fluid (typically requires 4 weeks total treatment). 2

• Perform serial aspirations every 2-3 days until fluid is sterile (typically takes 4 days with appropriate antibiotics, but longer if symptoms were present >2 weeks before initial treatment) 2
• Duration of symptoms before diagnosis directly correlates with time to achieve sterile fluid (r=0.68, p<0.001) 2
• Continue antibiotics for 5 additional days after documented culture sterility 2
• If culture grows atypical organisms (e.g., Mycobacterium goodii), adjust to appropriate antimicrobials such as doxycycline plus ciprofloxacin 3

If Non-Septic (Aseptic) Bursitis is Confirmed

Your treatment approach depends on the degree of improvement:

For Partial Response (Mild Residual Swelling)

Option 1 (Preferred for safety): Compression bandaging with NSAIDs for 4 weeks 4

• Apply compression wrap continuously
• NSAIDs for anti-inflammatory effect
• Expected resolution time: 3.2 weeks (range 2-4 weeks) 4

Option 2: Aspiration with corticosteroid injection 4

• Provides fastest resolution (2.3 weeks vs 3.2 weeks with compression alone, p=0.015) 4
• However, carries risk of complications including infection and recurrence 4
• Use only after infection definitively ruled out 1

For No Response or Worsening (Moderate to Severe Persistent Swelling)

Aspiration with corticosteroid injection is indicated after confirming negative cultures 4, 1

• Provides earliest symptom resolution 4
• May require repeat injection if fluid reaccumulates 4

Monitor weekly for 4 weeks and repeat the same treatment if bursitis recurs with substantial fluid collection 4

Key Prognostic Factor

Longer duration of symptoms before treatment is the only factor associated with treatment failure (failed cases: 6 weeks symptom duration vs successful cases: 4 weeks, p=0.008). 4 This explains why your patient with one week of symptoms before initial treatment may still be responding.

When to Consider Surgery

Refer for surgical bursectomy if:

• Persistent symptoms despite 4 weeks of appropriate conservative management 1
• Recurrent episodes despite multiple treatment courses 1
• Significant functional limitation 1

What NOT to Do

• Do not inject steroids without first ruling out infection through aspiration and culture 1, 3
• Do not use intra-articular corticosteroids during active infection 5
• Do not assume the initial 10-day doxycycline course was adequate if infection is present—septic bursitis requires treatment until sterile fluid is documented plus 5 additional days 2