Septic bursitis: Difference between revisions

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==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%)
 
==Diagnosis==
*Bursal fluid aspiration
**Both diagnostic and therapeutic


==Differential Diagnosis==
==Differential Diagnosis==
*[[Olecranon bursitis (nonseptic)]]
*[[Olecranon bursitis (nonseptic)]]
*[[Prepatellar bursitis (nonseptic)]]
*[[Prepatellar bursitis (nonseptic)]]
*[[Cellulitis]]
*[[Septic arthritis]]
==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
**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
*Drainage
**[[Incision and Drainage]] vs. serial needle drainage


==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==
==See Also==
*[[Bursitis]]
*[[Bursitis]]


==Source==
==External Links==
*Tintinalli
*Septic Bursitis: ED Presentation, Evaluation, and Management on [http://www.emdocs.net/septic-bursitis-ed-presentation-evaluation-and-management/ emDocs.net]
==References==
<references/>
 


[[Category:Ortho]]
[[Category:Orthopedics]]
[[Category:ID]]

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