Septic bursitis: Difference between revisions
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*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== | ==Differential Diagnosis== | ||
*[[Olecranon bursitis (nonseptic)]] | *[[Olecranon bursitis (nonseptic)]] | ||
*[[Prepatellar bursitis (nonseptic)]] | *[[Prepatellar bursitis (nonseptic)]] | ||
*[[Cellulitis]] | |||
*[[Septic arthritis]] | |||
==Evaluation== | ==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 | |||
==Management== | ==Management== | ||
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*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]] | ||
** | **Immunocompromised | ||
**Failure to | **Failure to respond to course of PO antibiotics | ||
==See Also== | ==See Also== | ||
*[[Bursitis]] | *[[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== | ||
<references/> | <references/> | ||
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[[Category:Orthopedics]] | [[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
- Cell counts > 5000 - 20,000/µL depending on source
Management
Antibiotics
Cover Staphylococcus aureus (80-90%) and Streptococcus
Outpatient Options
- Clindamycin 300 mg PO three times daily x 14 days OR
- TMP/SMX 2 DS tabs PO two times daily x 14 days OR
- Dicloxacillin 500mg PO q6hr x10 days
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
- ↑ Lohr KM et al. Bursitis workup. eMedicine. NOV 2017. https://emedicine.medscape.com/article/2145588-workup#c8