Difference between revisions of "Septic bursitis"

(Treatment)
 
(22 intermediate revisions by 8 users not shown)
Line 1: Line 1:
 
==Background==
 
==Background==
 
*Most common sites are prepatellar bursa and olecranon bursa
 
*Most common sites are prepatellar bursa and olecranon bursa
 +
 
==Clinical Features==
 
==Clinical Features==
 
*Acute pain, tenderness, warmth, and erythema of affected bursa
 
*Acute pain, tenderness, warmth, and erythema of affected bursa
 
**None of which is seen in aseptic bursitis
 
**None of which is seen in aseptic bursitis
*Fever (<50%)
+
*[[Fever]] (<50%)
 +
 
 +
==Differential Diagnosis==
 +
*[[Olecranon bursitis (nonseptic)]]
 +
*[[Prepatellar bursitis (nonseptic)]]
 +
*[[Cellulitis]]
 +
*[[Septic arthritis]]
  
==Diagnosis==
+
==Evaluation<ref>Lohr KM et al. Bursitis workup. eMedicine. NOV 2017. https://emedicine.medscape.com/article/2145588-workup#c8</ref>==
 +
*Plain radiograph, CT, MRI usually not helpful
 +
*[[Musculoskeletal ultrasound|US]] may help guide procedures or help with diagnostic uncertainty
 
*Bursal fluid aspiration
 
*Bursal fluid aspiration
 
**Both diagnostic and therapeutic
 
**Both diagnostic and therapeutic
 +
**Do not perform if there is evidence overlying cellulitis
 +
*Procedure
 +
**Placed in flexed position, elbow and forearm rested on surface
 +
**Prep and drap
 +
**Plus/minus local anesthesia skin wheal
 +
**Approach with 18-22 ga needle from posterior aspect of bursa, aspirate until bursa is flat
 +
**Compressing bursa to help with aspiration
 +
**[[Arthrocentesis]] should be performed if joint involvement suspected
 +
*Septic workup
 +
**Cell counts > 5000 - 20,000/µL depending on source
 +
***Predominance of PMNs
 +
***Cell counts < 2000/µL, with predominant mononuclear cells highly suggestive of nonseptic bursitis
 +
**Gram stain and culture
 +
***Gram stain with variable levels of sensitivities
 +
***Thus, high WBC count with negative gram stain should not exclude diagnosis
 +
**Elevated protein
 +
**Reduced glucose
 +
**Crystal analysis
  
==Treatment==
+
==Management==
*[[Antibiotics]]
+
===[[Antibiotics]]===
**Cover staph/strep (including [[MRSA]])
+
{{Septic Bursitis Antibiotics}}
**[[Clindamycin]] 300mg TID x10d OR dicloxacillin 500mg q6hr x10d
 
  
 
==Disposition==
 
==Disposition==
 
*Consider admission for:
 
*Consider admission for:
 
**Extensive purulent bursitis
 
**Extensive purulent bursitis
**Extensive surrounding cellulitis
+
**Extensive surrounding [[cellulitis]]
**Suspected joint involvement
+
**Suspected [[septic arthritis|joint involvement]]
**Immunocompromise
+
**Immunocompromised
**Failure to resopnd to course of PO abx
+
**Failure to respond to course of PO antibiotics
 +
 
 +
==See Also==
 +
*[[Bursitis]]
 +
 
 +
==External Links==
 +
*Septic Bursitis: ED Presentation, Evaluation, and Management on [http://www.emdocs.net/septic-bursitis-ed-presentation-evaluation-and-management/ emDocs.net]
 +
==References==
 +
<references/>
  
==Source==
 
*Tintinalli
 
  
[[Category:Ortho]]
+
[[Category:Orthopedics]]
 +
[[Category:ID]]

Latest revision as of 09:28, 26 June 2020

Background

  • Most common sites are prepatellar bursa and olecranon bursa

Clinical Features

  • Acute pain, tenderness, warmth, and erythema of affected bursa
    • None of which is seen in aseptic bursitis
  • Fever (<50%)

Differential Diagnosis

Evaluation[1]

  • Plain radiograph, CT, MRI usually not helpful
  • US may help guide procedures or help with diagnostic uncertainty
  • Bursal fluid aspiration
    • Both diagnostic and therapeutic
    • Do not perform if there is evidence overlying cellulitis
  • Procedure
    • Placed in flexed position, elbow and forearm rested on surface
    • Prep and drap
    • Plus/minus local anesthesia skin wheal
    • Approach with 18-22 ga needle from posterior aspect of bursa, aspirate until bursa is flat
    • Compressing bursa to help with aspiration
    • Arthrocentesis should be performed if joint involvement suspected
  • Septic workup
    • Cell counts > 5000 - 20,000/µL depending on source
      • Predominance of PMNs
      • Cell counts < 2000/µL, with predominant mononuclear cells highly suggestive of nonseptic bursitis
    • Gram stain and culture
      • Gram stain with variable levels of sensitivities
      • Thus, high WBC count with negative gram stain should not exclude diagnosis
    • Elevated protein
    • Reduced glucose
    • Crystal analysis

Management

Antibiotics

Cover Staphylococcus aureus (80-90%) and Streptococcus

Outpatient Options

Treatment followup with primary physician is important since the regimen may need extension to 3 weeks.

Inpatient Options

  • Vancomycin 25-30 mg/kg IV loading then 15-20 mg/kg IV OR
  • Clindamycin 600 mg (10/mg/kg) IV three times daily
  • Linezolid 600 mg IV BID (10mg/kg Q8hrs for pediatrics)

Disposition

  • Consider admission for:
    • Extensive purulent bursitis
    • Extensive surrounding cellulitis
    • Suspected joint involvement
    • Immunocompromised
    • Failure to respond to course of PO antibiotics

See Also

External Links

  • Septic Bursitis: ED Presentation, Evaluation, and Management on emDocs.net

References

  1. Lohr KM et al. Bursitis workup. eMedicine. NOV 2017. https://emedicine.medscape.com/article/2145588-workup#c8