Septic Bursitis


Article Author:
Justina Truong


Article Editor:
John Ashurst


Editors In Chief:
Amie Kim
Todd May
Matthew Varacallo


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
2/14/2019 8:07:40 AM

Introduction

Bursae are fluid-filled sac-like structures located between mobile structures of the musculoskeletal system, between skin and bone, or between the joints. There are upward of 150 superficial and deep bursae located in between bone, muscle, tendons, and skin. Small amounts of synovial fluid are produced within the bursa and reduce friction by lubrication. Inflammation of the bursa causes excess fluid production and leads to swelling and irritation, known as bursitis. This inflammation can be caused by prolonged pressure, overuse, inflammatory and crystalloid arthritis, and direct injury or trauma. Common locations of bursitis include prepatellar, olecranon, and trochanteric.[1][2][3][4]

Septic (or infectious) bursitis occurs when infection from either direct inoculation (usually superficial bursa) or hematogenous or direct spread from other sites (deep bursa involvement) causes inflammatory bursitis. Septic bursitis can be acute, subacute, or recurrent/chronic. The clinical features of septic bursitis are sometimes indistinguishable from non-infectious bursitis; therefore, bursa aspiration and fluid analysis must be completed to make an accurate diagnosis.

Etiology

Inoculating the bursa with infections bacteria causes septic bursitis. This happens most often from micro-trauma or direct puncture of the overlying skin causing subsequent infection. Contiguous spread of overlying cellulitis of the skin is also a common cause of superficial septic bursitis. In 80% to 90% of cases, Staphylococcus aureus is the most common organism in acute septic bursitis and Streptococcus species being the next. Other organisms include Escherichia coli, Enterococcus, Pseudomonas aeruginosa, and coagulase-negative staphylococci. Chronic, infectious bursitis is likely due to atypical mycobacteria and fungi and should warrant prompt evaluation for systemic infection.[5][6][7]

Epidemiology

Septic bursitis happens more commonly in males with the mean age at onset approximately 50 years. Some studies suggest increases in the incidence of septic bursitis in relation to people with comorbid disease conditions, but most cases are due to repetitive trauma related to occupational behaviors. Plumbers, carpenters, roofers, clergy, and athletes are commonly affected. Septic bursitis can also be caused by joint steroid injections meant to relieve the symptoms of non-infectious bursitis. Patients with underlying crystal-induced arthropathy like Gout have an increased amount of bursal fluid and can have higher incidences of septic bursitis. People with inflammatory arthritis, for example, rheumatoid arthritis, are also at an increased risk.

Pathophysiology

Bursitis is the result of inflammation that leads to increased fluid production from the synovial cells that line the bursa. Increased fluid production leads to increasing pressure of the bursa and in the result, increased pain. Trauma or puncture of skin at the site of a bursa can lead to the direct introduction of bacteria and subsequent inflammation and infection. Overlying skin and soft tissue infections such as cellulitis can also lead to secondary infectious bursitis. In deep bursa, an infectious spread is more likely related to spread from blood or joint infections such as septic arthritis.

History and Physical

History may allude to the recent trauma of the affected area or an occupation suspicious for a high likelihood of septic bursitis. Therefore, it is important to ask relevant questions. Clinical findings may be indistinguishable from non-infectious bursitis and sometimes even a septic joint. Patients with septic bursitis are more likely to present with pain or tenderness overlying the bursa, edema, erythema, and warmth. Patients may also have signs of trauma or wounds and lesions with or without symptoms of cellulitis. Fever may or may not be present but is more likely to be present when bursitis is infectious versus when it is non-infectious. Joint motion is usually unaffected in septic bursitis and likely limited with septic arthritis. The findings discussed above are not completely reliable in distinguishing between infectious and non-infectious bursitis, and therefore, additional diagnostic testing must be done.

Evaluation

Routine blood work is somewhat unhelpful in the diagnosis and distinguishing septic bursitis versus non-infectious bursitis. The peripheral white blood count (WBC) may not differ between infectious and non-infectious bursitis and may not even be elevated above the normal range. However, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) usually are elevated in septic bursitis. A uric blood acid level should also be checked if suspicion of underlying crystal arthropathy exists. Antinuclear antibody and rheumatoid factor can be ordered in chronic cases or when the underlying autoimmune disease is suspected. Plain film radiography is usually performed, but it is unnecessary and unhelpful in most cases of septic bursitis. Spurs may be seen in chronic cases of bursitis, but joint effusions are not normally present. Computed tomography (CT) and magnetic resonance imagining (MRI) are not needed unless suspicion for osteomyelitis or septic arthritis exists, or if the physician is evaluating a severe case of septic bursitis in which surgical management may be necessary.[8][9][10]

Aspiration and analysis of bursal fluid is the gold standard of diagnostic criteria. A bursal fluid analysis should always be performed in any case of bursitis to rule out septic or crystal-induced bursitis. Fluid should be evaluated for cell count with differential, gram stain, culture, and crystals. In recent literature summaries, the average bursal WBC was found to be around 63,000/mm; although, other studies show leukocytosis of more than 2000/mm was 94% sensitive and 79% specific for septic bursitis. Septic bursitis usually has a predominance of polymorphonuclear leukocytes while non-infectious has a predominance of mononuclear cells. Gram staining can vary between 15% and 100% sensitive and may only be positive in half of septic bursitis cases. However, a negative gram stain with WBC more than 50,000/hpf and clinical signs and suspicion for septic bursitis should be treated accordingly. The culture of bursal fluid should always be done in order to evaluate for any bacterial growth in order to help guide treatment.

Treatment / Management

Although non-infectious bursitis can be managed with conservative measures aimed at reducing inflammation, treatment for septic bursitis is always antibiotic therapy. Treatment can be done on an outpatient basis; although, inpatient treatment with intravenous antibiotic therapy may be needed in patients who are immunocompromised, show systemic signs and symptoms, or have joint involvement. In chronic or severe cases, incision and drainage or bursectomy may be warranted. An orthopedic surgeon should be consulted for all cases of septic bursitis.

Antibiotic therapy should initially be aimed at the most likely organisms and tailored as needed to gram-stain and culture results. Methicillin-resistant Staphylococcus aureus coverage with oral clindamycin, doxycycline, and trimethoprim-sulfamethoxazole is recommended for empiric therapy until culture results are finalized. If there is a severe local infection or in an immunocompromised patient, admission for intravenous vancomycin is most appropriate. For those patients with a penicillin allergy, the recommended treatment is ciprofloxacin and rifampin. 

Duration and type of therapy are debated. Recommendations include a minimum of 10 days of treatment in mild cases, and repeat aspirations and continuation of antibiotics until bursal fluid is clear of infectious signs in severe cases. Treatment can usually be guided by clinical response and culture results.

Pearls and Other Issues

Although debate over the duration of treatment exists, the fact of the matter is septic bursitis requires antibiotic treatment. Chronic septic bursitis can develop if initially not treated appropriately. Complications such as osteomyelitis and continual pain can occur. Overlying ligaments and tendons can become weak and may rupture due to chronic infection. Therefore, tendinitis must be a consideration when diagnosing septic bursitis.

Enhancing Healthcare Team Outcomes

The management of septic bursitis is multidisciplinary. The majority of patients are first seen by the emergency department, primary provider or nurse practitioner. Once the condition has been diagnosed, some patients may be referred to the orthopedic surgeon for more definitive treatment. Most patients are managed as outpatients but the duration of therapy remains unknown. Because there is a potential of developing osteomyelitis, these patients must be closely monitored. Duration and type of therapy are debated. Recommendations include a minimum of 10 days of treatment in mild cases, and repeat aspirations and continuation of antibiotics until bursal fluid is clear of infectious signs in severe cases. Treatment can usually be guided by clinical response and culture results. The outcomes in most patients with septic bursitis are good. [7][11]


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Septic Bursitis - Questions

Take a quiz of the questions on this article.

Take Quiz
A 42-year-old white male presents complaining of left elbow swelling that has been present for one week. He thinks that his symptoms initially began when he hurt himself while playing baseball. He is able to move his elbow but states the swelling is bothering him. He denies fever and chills. On examination, full ROM is possible at the elbow, however, there is some erythema and swelling present over the olecranon. Aspiration of fluid shows 2000 WBC/microL and extracellular negatively birefringent crystals. Gram stain is pending. What is the best step for management of this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year-old male presents with right elbow pain after falling onto it several days ago. Examination reveals a tender joint with no limitations in range of motion. Swelling and erythema are noted along the posterior aspect of the olecranon along the area of the bursa. Radiograph of the joint is normal. A bursa aspirate reveals 52,000 white blood cells/HPF. Which of the following antibiotics would be the most appropriate first-line therapy for this patient's diagnosis?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 17-year-old male presents with left knee pain that occurred several days after a fall. An abrasion is noted in the pre-patellar region with surrounding erythema and swelling but no decrease in range of motion. Which of the following is considered the gold standard for diagnosing the patient's condition?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 51-year-old male presents with fever, productive cough, and worsening of his chronic right shoulder pain. The patient has a history of interstitial lung disease and dermatomyositis. He notes he was undergoing immunosuppressive therapies until 5 months ago and was admitted one month ago for pneumonia. The patient denies any trauma or recent steroid injections to the shoulder. On exam, his right shoulder is limited in all planes of motion with a fluctuant mass on the superior and posterior aspect of the joint. His lungs are clear to auscultation. Bedside ultrasound reveals a large subacromial bursal fluid collection and a radiograph of the chest shows interstitial infiltrates. What would be the most appropriate treatment for this patient?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Septic Bursitis - References

References

Glass M,Everist B,Nelson D,Spencer J, Methicillin-resistant {i}Staphylococcal aureus{/i} patellar tendon abscess and septic prepatellar bursitis in an injection drug user. Radiology case reports. 2019 Feb;     [PubMed]
DeRogatis MJ,Parameswaran L,Lee P,Mayer TG,Issack PS, Septic Shoulder Joint After Pneumococcal Vaccination Requiring Surgical Debridement. HSS journal : the musculoskeletal journal of Hospital for Special Surgery. 2018 Oct;     [PubMed]
Herring K,Mathern S,Khodaee M, Septic Infrapatellar Bursitis in an Immunocompromised Female. Case reports in orthopedics. 2018;     [PubMed]
Parker CH,Leggit JC, Novel Treatment of Prepatellar Bursitis. Military medicine. 2018 Nov 1;     [PubMed]
Blumberg G,Long B,Koyfman A, Clinical Mimics: An Emergency Medicine-Focused Review of Cellulitis Mimics. The Journal of emergency medicine. 2017 Oct;     [PubMed]
Oda R,Sekikawa Y,Hongo I, Meningococcal Bursitis. Internal medicine (Tokyo, Japan). 2017 Dec 15;     [PubMed]
Lieber SB,Fowler ML,Zhu C,Moore A,Shmerling RH,Paz Z, Clinical characteristics and outcomes of septic bursitis. Infection. 2017 Dec;     [PubMed]
Hanrahan JA, Recent developments in septic bursitis. Current infectious disease reports. 2013 Oct;     [PubMed]
Reed MJ,Carachi A, Management of the nontraumatic hot swollen joint. European journal of emergency medicine : official journal of the European Society for Emergency Medicine. 2012 Apr;     [PubMed]
Wasserman AR,Melville LD,Birkhahn RH, Septic bursitis: a case report and primer for the emergency clinician. The Journal of emergency medicine. 2009 Oct;     [PubMed]
Sayegh ET,Strauch RJ, Treatment of olecranon bursitis: a systematic review. Archives of orthopaedic and trauma surgery. 2014 Nov;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Sports Medicine. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Sports Medicine, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Sports Medicine, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Sports Medicine. When it is time for the Sports Medicine board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Sports Medicine.