Antibiotics for Olecranon Bursitis
Antibiotics are indicated for septic olecranon bursitis when clinical features suggest infection—specifically erythema, warmth, tenderness, and systemic signs—and the first-line oral regimen should cover MRSA with trimethoprim-sulfamethoxazole (TMP-SMX) 1–2 double-strength tablets twice daily or doxycycline 100 mg twice daily for 10–14 days. 1
Distinguishing Septic from Non-Septic Bursitis
Clinical indicators of septic bursitis:
- Local erythema, warmth, and tenderness over the bursa 2
- Fever, tachycardia, or other systemic inflammatory response criteria 3
- History of penetrating trauma, prior MRSA infection, or immunocompromise 3
- Approximately one-third of olecranon bursitis cases are septic 2
Diagnostic approach:
- Always aspirate the bursa in all cases to differentiate septic from non-septic causes 2
- Send aspirate for cell count, Gram stain, and culture 2, 4
- Synovial fluid white blood cell count >3000 cells/mm³ suggests infection 4
- Staphylococcus aureus (including MRSA) is the most common pathogen, followed by beta-hemolytic Streptococcus 5, 4
When Antibiotics Are Indicated
Start antibiotics when:
- Bursal aspirate shows bacteria on Gram stain or elevated WBC count 2, 4
- Clinical signs of systemic infection (fever >38.5°C, heart rate >110 bpm, WBC >12,000/µL) 3
- Erythema and induration extending >5 cm from the bursa 3
- Risk factors for MRSA are present: recent hospitalization, prior MRSA infection, nasal colonization, recent antibiotic use within 30 days 3
Do not use antibiotics when:
- Non-septic bursitis confirmed by negative aspirate culture and normal cell count 2, 6
- Simple traumatic bursitis without signs of infection can be managed with aspiration alone 6
First-Line Oral Antibiotic Regimens for MRSA Coverage
Preferred oral agents (choose one):
- Trimethoprim-sulfamethoxazole (TMP-SMX): 1–2 double-strength tablets (160–320/800–1600 mg) orally twice daily 1
- Doxycycline or minocycline: 100 mg orally twice daily 1
- Clindamycin: 300–450 mg orally three times daily, only if local MRSA resistance rates are <10% 1, 3
Duration of therapy:
- 10–14 days for septic olecranon bursitis with adequate drainage 1
- Recovery can take months even with appropriate treatment 2
Additional Management Beyond Antibiotics
Drainage procedures:
- Repeated aspiration is the primary treatment and may need to be performed multiple times 2, 6
- Percutaneous suction-irrigation systems can be placed for continuous drainage in severe cases 5
- Incision and drainage is rarely needed but may be required for refractory cases 6
Indications for hospitalization and IV antibiotics:
- Systemic toxicity, rapidly progressive infection, or failure of outpatient therapy 1
- Vancomycin 15–20 mg/kg IV every 8–12 hours is the standard first-line IV option for severe MRSA infections 1
- Linezolid 600 mg IV twice daily or daptomycin 4–6 mg/kg IV once daily are effective alternatives 1
Common Pitfalls to Avoid
- Do not use beta-lactam antibiotics alone (cephalexin, amoxicillin, dicloxacillin) for suspected MRSA—they lack coverage due to mecA-mediated resistance 1
- Do not skip aspiration—clinical features alone cannot reliably distinguish septic from non-septic bursitis, even when erythema is present 2
- Do not prescribe antibiotics for non-septic bursitis—aspiration, NSAIDs, and compression are sufficient 6, 7
- Reassess at 48–72 hours—if no improvement occurs, consider inadequate drainage, resistant organism, or deeper infection requiring surgical intervention 1, 4