Management of septic bursitis

Plasma Microbial Cell-free DNA Next-generation Sequencing Can Be a Useful Diagnostic Tool in Patients With Osteoarticular Infections

Background

Recent advances in shotgun metagenomic sequencing (sMGS) for detecting microbial cell-free DNA (mcfDNA) in peripheral blood have shown promise across various patient populations. This study evaluates the application of sMGS for diagnosing osteoarticular infections (OAIs), a condition with significant diagnostic challenges.

Methods

We conducted a retrospective analysis on 73 patients suspected of OAIs at the Mayo Clinic from 2019 to 2023, incorporating mcfDNA sMGS (Karius test [KT]) into their diagnostic evaluation. We categorized the clinical impact of KT on OAI diagnoses and management into 4 distinct outcomes. (1) KT was able to confirm an established diagnosis, (2) KT supported noninfectious diseases diagnosis, (3) KT established an unsuspected diagnosis, (4) KT did not add relevant information.

Results

In our cohort, KT was performed in 73 patients. Among the infected individuals, KT yielded positive results in 22 of 43 (51.2%) cases. Of these 22 cases, 11 (50%) showed agreement with conventional diagnostic workup, whereas in 5 (22.7%) cases, the KT established an unsuspected diagnosis. Native vertebral osteomyelitis diagnosis (P < .001) or OAIs with concomitant presence of endocarditis or endovascular infection (P = .005) were statistically associated with a definite, probable, or possible diagnostic certainty of KT result.

Conclusions

In complex OAIs, KT enhanced diagnostic accuracy by 11.6%, proving especially beneficial in diagnosing native vertebral osteomyelitis and infections with concurrent endocarditis or endovascular complications. Our findings underscore the utility of KT in the diagnostic workflow for challenging OAI cases, potentially altering clinical management for a significant subset of patients.

Orthopedic Articular and Periarticular Joint Infections

Acute nontraumatic joint pain has an extensive differential. Emergency physicians must be adept at identifying limb and potentially life-threatening infection. Chief among these is septic arthritis. In addition to knowing how these joint infections typically present, clinicians need to be aware of host and pathogen factors that can lead to more insidious presentations and how these factors impact the interpretation of diagnostic tests.

Optimal antibiotics duration following surgical management of septic olecranon bursitis: a 12-year retrospective analysis

Introduction: The absence of a standardized postoperative antibiotic treatment approach for patients with surgically treated septic bursitis results in disparate practices. Methods: We retrospectively reviewed charts of adult patients with surgically treated septic olecranon bursitis at Mayo Clinic sites between 1 January 2000 and 20 August 2022, focusing on their clinical presentation, diagnostics, management, postoperative antibiotic use, and outcomes. Results: A total of 91 surgically treated patients were identified during the study period. Staphylococcus aureus was the most common pathogen (64 %). Following surgery, 92 % (84 of 91 patients) received systemic antibiotics. Excluding initial presentations of bacteremia or osteomyelitis (n = 5 ), the median duration of postoperative antibiotics was 21 d (interquartile range, IQR: 14-29). Postoperative complications were observed in 23 % (21 of 91) of patients, while cure was achieved in 87 % (79 of 91). Active smokers had 4.53 times greater odds of clinical failure compared with nonsmokers (95 % confidence interval, 95 % CI: 1.04-20.50; p = 0.026 ). The highest odds of clinical failure were noted in cases without postoperative antibiotic administration (odds ratio, OR: 7.4). Conversely, each additional day of antibiotic treatment, up to 21 d, was associated with a progressive decrease in the odds of clinical failure (OR: 1 at 21 d). Conclusion: The optimal duration of antibiotics postoperatively in this study was 21 d, which was associated with a 7.4-fold reduction in the odds clinical failure compared with cases without postoperative antibiotics. Further validation through a randomized controlled trial is needed.

2023 French recommendations for diagnosing and managing prepatellar and olecranon septic bursitis

Septic bursitis (SB) is a common condition accounting for one third of all cases of inflammatory bursitis. It is often related to professional activities. Management is heterogeneous and either ambulatory or hospital-based, with no recommendations available. This article presents recommendations for managing patients with septic bursitis gathered by 18 rheumatologists from the French Society for Rheumatology work group on bone and joint infections, 1 infectious diseases specialist, 2 orthopedic surgeons, 1 general practitioner and 1 emergency physician. This group used a literature review and expert opinions to establish 3 general principles and 11 recommendations for managing olecranon and prepatellar SB. The French Health authority (Haute Autorité de santé [HAS]) methodology was used for these recommendations. Designed for rheumatologists, general practitioners, emergency physicians and orthopedic surgeons, they focus on the use of biological tests and imaging in both outpatient and inpatient management. Antibiotic treatment options (drugs and duration) are proposed for both treatment modalities. Finally, surgical indications, non-drug treatments and prevention are covered by specific recommendations.

Clinical Outcomes Following Open Olecranon Bursa Excision for Septic and Aseptic Olecranon Bursitis: An Observational Study

Background and objective Olecranon bursitis (aseptic or septic) is caused by inflammation in the bursal tissue. While it is typically managed with conservative measures, refractory cases may indicate surgical intervention. There is currently limited research about outcomes following bursal excision for both septic and aseptic etiologies. In light of this, the purpose of this study was to determine if patients experienced improvement following surgical olecranon bursa excision and to compare outcomes between septic and aseptic forms. Materials and methods A retrospective review was performed involving patients who underwent olecranon bursa excision from 2014 to 2021. Demographic data, patient characteristics, surgical data, and outcome-related data were collected from the medical records. Patients were classified into subgroups based on the type of olecranon bursitis (septic or aseptic). Preoperative and one-year postoperative 12-item short-form survey (SF-12) results and range of motion (ROM) outcomes were evaluated for the entire cohort as well as the subgroups. Results We included 61 patients in our study and found significant improvement in the Physical Component Scale 12 (PCS-12) score for all patients (42.0 vs. 45.5, p=0.010) following surgery. However, based on subgroup analysis, the aseptic group improved in PCS-12 following surgery (41.5 vs. 46.8, p<0.001), but the septic group did not (43.6 vs. 40.5, p=0.277). No improvements were found in the Mental Component Scale 12 (MCS-12) scores following surgery in either group. Eighteen of the 61 patients experienced postoperative complications (29.5%), but only 6.5% required a second surgical procedure. Specifically, 14 of the 18 complications occurred in the aseptic group while two septic and two aseptic patients required additional surgeries. Elbow ROM did not change significantly after surgery but more patients were found to have full ROM postoperatively (83.0% to 91.8%, p=0.228). Conclusion Our findings suggest that patients with refractory olecranon bursitis, particularly if aseptic, tend to gain significant physical health benefits from open bursectomy.

[Evidence-Based Treatment and Differential Diagnoses of Olecranon Bursitis]

Evidence-Based Treatment and Differential Diagnoses of Olecranon Bursitis Abstract. Bursitis olecrani is a common clinical diagnosis that can have systemic, infectious and traumatic causes. In this article we want to present the diagnostics, possible differential diagnoses, complications and the current therapy recommendations as a practical guide.

Olecranon Bursitis Secondary to Trauma

The authors present a case of traumatic olecranon bursitis, initially presumed to be cellulitis. The clinical presentation, diagnosis, and management are discussed. 

Hot off the press: SGEM #358-I would do anything for septic olecranon bursitis but I won't tap that

Suspected septic olecranon bursitis is a common complaint in emergency medicine. Limited evidence exists as to the safety and necessity of bursal aspiration compared to empiric antibiotic therapy without aspiration. In this article, we summarize a study by Beyde et al. investigating these strategies, as well as the podcast and discussion, along with social media commentary.

The Utility of Routine Cultures, Cell Count, and Crystal Evaluation of Aspirate from Aseptic Olecranon Bursitis

Background

Aspiration of the olecranon bursa is a treatment option for acute olecranon bursitis (OB). Typically, the aspirate is sent for microbiologic analysis, cell count, and crystal analysis. This study investigates the utility of fluid aspirate analysis from patients with clinically diagnosed aseptic OB.

Methods

In this prospective study (IRB #i20-00986), patients presenting with acute aseptic OB were treated with aspiration as standard of care. Patients consented to participate in this study via phone. Patients with suspected infectious bursitis, open draining wound, and chronic OB were excluded. The aspirate was sent out for routine microbiologic analysis (aerobic and anaerobic cultures and Gram staining) and fluid analyses, including cell count with differential and crystal analysis. Nucleated and differential cell count was reported as absolute numbers per cubic millimeter and percentage, respectively. Compression wrap was applied after OB aspiration, and patients were asked to ice and take anti-inflammatory medications. Clinical follow-up was done after 6 weeks and at 3 months for resolution vs. recurrence of symptoms, and the mean time to resolution was reported.

Results

A total of 26 patients (28 cases) with aseptic OB were enrolled in this study. Two patients had bilateral OB. The mean time to aspiration after the onset of symptoms was 26.4 days. One patient had recurrence of swelling after the first aspiration and underwent repeat bursa aspiration. No organisms were isolated or reported on Gram staining on any of the aspirate samples. Two aspirates were reported positive for calcium pyrophosphate dihydrate crystals. No patient had monosodium urate crystals. All patients had resolution of swelling and symptoms without the development of postaspiration infection.

Conclusions

This study demonstrates limited clinical utility of routine microbiologic analysis (cell count, microbiologic, and crystal evaluation) of fluid aspirate from clinically diagnosed aseptic OB. Although 7% of fluid aspirates were positive for calcium pyrophosphate dihydrate crystals, it did not change the overall treatment.

Efficacy of empiric antibiotic management of septic olecranon bursitis without bursal aspiration in emergency department patients

OBJECTIVES

Many guidelines for septic olecranon bursitis recommend aspiration of the bursa prior to initiation of antimicrobial therapy despite the absence of robust clinical data to support this practice and known risk of aspiration complications. Our objective was to describe outcomes associated with empiric antibiotic therapy without bursal aspiration among emergency department (ED) patients with suspected septic olecranon bursitis.

METHODS

We conducted a retrospective observational cohort study of patients presenting to an academic ED from January 1, 2011, to December 31, 2018, with olecranon bursitis. The health record was reviewed to assess patient characteristics and outcomes within 6 months of the ED visit. Olecranon bursitis was considered "suspected septic" if the patient was treated with antibiotics. The primary outcome of interest was complicated versus uncomplicated bursitis resolution. Uncomplicated resolution was defined as bursitis resolution without subsequent bursal aspiration, surgery, or hospitalization.

RESULTS

During the study period, 264 ED patients were evaluated for 266 cases of olecranon bursitis. The median age was 57 years and 85% were men. Four (1.5%) patients had bursal aspiration during their ED visit, 39 (14.7%) were admitted to the hospital, 76 (28.6%) were dismissed without antibiotic therapy, and 147 (55.3%) were dismissed with empiric antibiotic therapy for suspected septic olecranon bursitis. Among these 147 patients, 134 had follow-up available including 118 (88.1%, 95% confidence interval [CI] = 81.1%-92.8%) with an uncomplicated resolution, eight (6.0%, 95% CI = 2.8%-11.8%) who underwent subsequent bursal aspiration, and nine (6.7%, 95% CI = 3.3%-12.7%) who were subsequently admitted for inpatient antibiotics.

CONCLUSIONS

Eighty-eight percent of ED patients with suspected septic olecranon bursitis treated with empiric antibiotics without aspiration had resolution without need for subsequent bursal aspiration, hospitalization, or surgery. Our findings suggest that empiric antibiotics without bursal aspiration may be a reasonable initial approach to ED management of select patients with suspected septic olecranon bursitis.

Clinical characteristics and management of olecranon and prepatellar septic bursitis in a multicentre study

BACKGROUND

No current guidelines are available for managing septic bursitis (SB).

OBJECTIVES

To describe the clinical characteristics and management of olecranon and prepatellar SB in five French tertiary care centres.

METHODS

This is a retrospective observational multicentre study. SB was diagnosed on the basis of positive cultures of bursal aspirate. In the absence of positive bursal fluid, the diagnosis came from typical clinical presentation, exclusion of other causes of bursitis and favourable response to antibiotic therapy.

RESULTS

We included 272 patients (median age of 53 years, 85.3% male and 22.8% with at least one comorbidity). A microorganism was identified in 184 patients (67.6%), from bursal fluids in all but 4. We identified staphylococci in 135 samples (73.4%), streptococci in 35 (19%) and 10 (5.5%) were polymicrobial, while 43/223 bursal samples remained sterile (19.3%). Forty-nine patients (18%) were managed without bursal fluid analysis. Antibiotic treatment was initially administered IV in 41% and this route was preferred in case of fever (P = 0.003) or extensive cellulitis (P = 0.002). Seventy-one (26%) patients were treated surgically. A low failure rate was observed (n = 16/272, 5.9%) and failures were more frequent when the antibiotic therapy lasted <14 days (P = 0.02) in both surgically and medically treated patients.

CONCLUSIONS

Despite variable treatments, SB resolved in the majority of cases even when the treatment was exclusively medical. The success rate was equivalent in the non-surgical and the surgical management groups. However, a treatment duration of <14 days may require special attention in both groups.

Septic Malleolar Bursitis in a Patient with an Ankle Electronic Monitoring Device: A Case Report

Introduction

Septic malleolar bursitis is a rare cause of ankle pain and swelling. It has been described in certain occupational and recreational activities that involve tight-fitting boots, such as figure skating. Court-ordered electronic monitoring devices are often worn on the ankle. It is not known whether these devices are a risk factor for the development of malleolar bursitis.

Case Report

We describe a 41-year-old male under house arrest with an electronic monitoring device on his right ankle who presented to our emergency department with several days of progressive pain and swelling over the medial malleolus. Point-of-care ultrasound revealed a thick-walled cystic structure consistent with medial malleolar bursitis. Bursal aspiration was performed. Fluid culture yielded Staphylococcus aureus.

Discussion

Emergency physicians regularly see patients with ankle pain and swelling and must consider a comprehensive differential diagnosis. Septic malleolar bursitis is an uncommon but important cause of ankle pain and swelling that requires prompt diagnosis and intervention. Point-of-care ultrasonography may aid in the diagnosis. Additionally, emergency physicians should be aware of potential complications related to electronic monitoring devices.

Brucellosis as a rare cause of olecranon bursitis: case-based review

A 51-year-old man shepherd presented with mild pain and swelling of the right posterior aspect of his right elbow. In ultrasonography, the affected bursal space had swelling and effusion. Moreover, the aspiration of the affected bursa revealed an inflammatory profile. Brucella melitensis was detected in aspirated fluid and blood cultures. The serum agglutination test (SAT) and 2-mercaptoethanol test for brucellosis were also positive. Therefore, the diagnosis of brucellar olecranon was confirmed. Treatment was initiated using gentamicin for the first 7 days and doxycycline plus rifampicin for 2 months. After treatment, all clinical signs and symptoms were resolved. No relapse was seen after 1 year of the completion of treatment. Clinicians should pay attention to the symptoms of olecranon brucellar bursitis that is similar to that of pyogenic bursitis.