What are is the role of antibiotic therapy in the treatment of bursitis?

Updated: Dec 11, 2020
  • Author: Kristine M Lohr, MD, MS; Chief Editor: Herbert S Diamond, MD  more...
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In cases in which septic bursitis is suspected, the bursa should be aspirated. The skin over the bursa is sterilized, and the area is anesthetized with lidocaine via a 27-gauge needle. A 20- or 22-gauge needle is then introduced sterilely into the bursa. Fluid is aspirated and sent for analysis to identify any infectious organisms or crystals present.

Staphylococcus aureus is the most common pathogen in septic bursitis, accounting for more than 80% of cases. Streptococcal species (mostly group A hemolytic streptococci) account for 5-20% of cases. Other gram-positive, gram-negative, and anaerobic infections are rare. Mycobacterial, fungal, algal, and spirochetal infections are even rarer and tend to occur in unusual clinical settings (especially in those who are predisposed to infection).

If bursitis is found to be secondary to infection after aspiration and fluid analysis, treatment should be initiated with antibiotics. [45] An appropriate antistaphylococcal antibiotic should be started empirically. This should be a penicillinase-resistant penicillin, such as oxacillin, or a first-generation cephalosporin, such as cefazolin. In penicillin-allergic patients or in carriers of methicillin-resistant S aureus (MRSA), vancomycin is an appropriate alternative treatment.

In a study involving 82 patients with severe septic bursitis, Martinez-Taboada et al concluded that in patients with severe septic bursitis but without extensive cellulitis, aspiration plus IV cloxacillin may be sufficient treatment, whereas in patients with more severe cases of septic bursitis, aspiration along with cloxacillin plus gentamicin may be appropriate in the majority. [11]

The duration of antibiotic treatment varies with the patient and the clinical situation. Uncomplicated septic bursitis presenting within 7 days of infection should be treated with a minimum 10-day course. [46] Outpatient treatment is effective in 40-50% of patients with mild to moderate infections. A 4-week course is advisable using high doses of sensitivity-directed antibiotics.

Aspiration should be repeated every 1-3 days while antibiotics are being administered. Antibiotics should be continued for 5 days past sterilization of bursal fluid as seen by aspiration. Aspiration also helps to decrease the bacterial load and to promote comfort.

Immunocompromised patients require a longer course of treatment, at least 15 days. Deep bursae infections have higher associations with bacteremia and call for more aggressive and prolonged antibiotic therapy. In particularly severe cases, hospitalization is required, with 1 week of parenteral antibiotics followed by 30 days of oral antibiotics. Surgical drainage or debridement is often necessary.

Treatment of tuberculous bursitis involves full excision of the bursae and surrounding affected tissue with concomitant antituberculous therapy for 6-12 months. Atypical mycobacteria occasionally may be successfully treated with conservative drainage and appropriate antibiotics. Brucella bursitis is treated with excision of bursae and administration of tetracycline with or without rifampin.

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