Septic Bursitis and
Laura Patel, M.D.
Septic Bursitis: Defined
Small fluid-filled sac located at the point
where a muscle or tendon slides across bone.
Bursae serve to reduce friction between the
two moving surfaces. There are >150 bursae in
Superficial: subcutaneous and separate skin
from deeper tissues
Deep: reduce friction between fibrous
structures such as tendons from adjacent bone.
Common locations for Septic
Superficial bursa: predisposed to infection from skin
trauma. Direct inoculation vs spread from cellulitus
Olecranon bursitis: often from repetitive trauma.
Plumbers, carpenters, COPD, chronic HD via access
Prepatellar bursitis: often seen in people who kneel a
lot- housemaids, gardners, clergy.
Ischiogluteal bursitis: often in spinal cord injured
Deep Bursa: more often associated with septic
arthritis from hematogenous seeding
RA or gout: increase bursal fluid
Loss of skin integrity
Impaired response to infection: e.g DM, etoh
History and Physical
pain and peribursal
Majority have fever
Joint motion is relatively
preserved vs septic joint
where motion is usually
Labs: Elevated wbc with
Usually are not bacteremic.
Aspiration of bursal fluid:
cell count usually >2000 wbc
Gram stain and culture
Send for crystals
Micro: Usually staph aureus
>80% or Beta hemolytic strep.
Subacute bursitis more often
brucella, mycobacteria or fungal.
Plain film to evaluate for foreign
body if trauma
If septic bursitis of deep bursa is
suspected then ultrasound, CT or
Crystal induced bursitus
Drain infected bursa either by serial needle aspiration,
I&D, or in extreme cases bursectomy
Mild inflammation and not immunosuppressed:
dicloxicillin or clindamycin, +/- bactrim if high rates of
MRSA (multiple contacts with hospital, long term care,
IVDA, community with prevalence >15%)
Severe inflammation: Vancomycin
Immunosuppressed: broad spectrum including
Duration of Therapy
Based on clinical response, culture results and
health of host
Most treated 2-3 weeks
Community Acquired MRSA
MRSA- initially described in the 1960s in association
with nosocomial infections
CA-MRSA- first reported in 1980s. Increasing in
incidence and prevalence
NEJM 2006 Prospective study: examined adults with skin
and soft tissue infections who presented to 1 of 11
university affiliated ED in US. S. Aureus isolated from 320
of 422 (76%). Of these, 59% were MRSA and 98% of
these were CaMRSA
Some closed communities thought to have higher
prevalence, up to 40%: Native Americans, daycare, MSM,
prison inmates, competitive athletes.
So what’s the difference between
HA-MRSA and CA-MRSA?
Strain SCCmec Antibiotic PFGE Toxins PVL Infection
gene resistance type genes spectrum
HA-MRSA Types I, II, Multidrug USA 100 Fewer Rare Bloodstream,
III resistant respiratory
CA-MRSA Types IV, V Resistance USA 300 More Common Commonly:
limited to skin and soft
Clinical Characteristics of CA-
Diagnosis made in outpatient setting
No medical history of MRSA infection or
No recent history of hospitalization, surgery, dialysis
No permanent indwelling catheter
Often associated with skin and soft tissue infections
CA-MRSA often sensitive to clindamycin, bactrim,
CA-MRSA is crossing borders
More CA-MRSA strains found in hospitalized
2003 metaanalysis: found to account for 37% of
MRSA isolates in hospitalized patients. But
majority of these patients had >1 healthcare
Migration of resistant strains from community into
hospitals may lead to failure of traditional control
Septic bursitis- more common in superficial bursa
Associated with erythema, edema and pain, but joint
Confirm diagnosis with aspiration and culture of fluid
Majority caused by S.Aureus
CA-MRSA is on the rise- think about this when
Treatment involves debridement and antibiotics
File, TM. Impact of community-acquired methicillin-resistant Staphylococcus
aureus in the hospital setting. Cleveland Clinic Journal of Medicine. Vol 74,
Supplement 4. Aug 2007 S6-11.
Kluytmans-Vandenberg MF. Community-acquired methicillin-resistant
Staphylococcus aureus: current perspectives. Clinical Microbiology and Infection,
Vol 12. Supplement 1, 2006, 9-15.
Salgado CD, Farr BM, Clafee DP. Community-acquired methicillin-resistant
Staphylococcus aureus: a meta-analysis of prevalence and risk factors. Clin Infect
Dis 2003; 36: 131-139.
Shorr, AF. Epidemiology and Economic Impact of Meticillin-Resistant
Staphylococcus Aureus. Pharmacoeconomics 2007: 25 (9) 751-768.
Uptodate: septic bursitis
Uptodate: Epidemiology and clinical manifestations of methicillin-resistant
Staphylococcus aureus infection in adults.