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Ahead of the days of antibiotics, septic bursitis was apotentially life-threatening problem.Nowadays, because of higher index ofsuspicion as well as the presence of , it should be, in most case,readily treatable. This article discusses this problem.

 

A bursa (plural=bursae) is a sack containing a minor amountof fluid that serves as a protective cushion between bones and overlyingmuscles or between bones and tendons. Bursitis is inflammation of a bursacaused by repetitive use, trauma, infection, or a systemic inflammatorydisease.

 

These sacks are lined with the synovium - the same tissuethat lines the inside of joints. Humans have approximately 160 bursae.Bursitismost frequently affects the shoulder, elbow, hip, and knee. Symptoms ofbursitis may include contained tenderness, edema, redness, heat, and limitedability to move the affected area.

 

When a bursa becomes infected, the condition is referred toas septic bursitis. In septic bursitis, trauma is the usual culprit. Traumacauses inoculation of bacteria into the bursa, which triggers an inflammatoryresponse.The two most commonly infected bursae are the olecrenon bursa at theelbow and the prepatellar bursa in the knee. The reason these two bursae getinfected more easily is because of their position.

 

The olecranon bursa lies at the tip of the elbow. Because ofits superficial location, it is easily traumatized from acute trauma orrepetitive stress.

 

Trauma to the skin makes the olecranon a frequent locationfor infectious bursitis. The risk of septic bursitis increases in those whohave a history of another chronic disease.

 

Chronic repetitive stress from burden on the elbows is seenin hemodialysis patients, pc users, and chronic lung disease patients.Wheninflamed, the olecrenon bursa at the tip of the elbow becomes swollen, red, andpainful. Bending the elbow makes the pain worse. Low grade fever and chills mayalso be present.

 

The prepatellar bursa lies in front of the knee between thepatella (kneecap) and the skin.

Infection can develop due to either trauma or constantfriction between the skin and the patella, most commonly when frequent kneelingis involved. It can be seen in carpet-layers, coal miners, roofers, gardeners,electricians, and plumbers. In fact any activity involving a lot of kneelingand friction can lead to septic prepatellar bursitis.

 

The superficial location of the prepatellar bursa allows forrather easy introduction of bacteria. This is similar to the circumstancesinvolving the olecrenon bursa.

 

Prepatellar bursitis presents with swelling, redness, heat,and pain involving the front of the knee. Bending the knee causes increasedpressure over the bursa and increases pain.

 

(A quick note: there is also another bursa called theinfrapatellar bursa. It is located below the knee cap and may be confused withthe prepatellar bursa).

 

As mentioned before, septic bursitis occurs from theintroduction of bacteria through trauma. It can also occur from the spread ofinfection from the skin adjacent to a bursa. Skin infection is calledcellulitis.

 

It is less likely for deeper bursae to become infectedbecause of their location. This can occur as a result of spread from septicarthritis (an infected joint) or from bacteria carried to the bursa from theblood.

 

Predisposing factors include diabetes, alcoholism, steroidtherapy, kidney disease, trauma, and skin disease. A history of noninfectiousinflammation of the bursa (as seen in rheumatoid arthritis, gout, andpseudogout) also increases the risk of septic bursitis.

 

Signs that favor the diagnosis of septic over simpleinflammatory bursitis include: severe tenderness, extreme redness, heat, fever,and chills.

 

Laboratory tests may show an increase in white blood cellcount and erythrocyte sedimentation rate. Blood cultures should be obtained ifdeep bursal infection is suspected.

 

Aspiration and analysis of bursal fluid from a suspectedinfected bursa should be performed when possible. Certainly, the mostfrequently infected bursae, such as the olecranon and prepatellar bursae shouldundergo this procedure. The use of ultrasound makes aspiration much moreaccurate.Bursal fluid culture is the most foremost test for diagnosis.

 

Fluid should also be examined for crystals. Monosodium uratecrystals can be seen in gout and calcium pyrophosphate crystals can be seen inpseudogout; however, the presence of crystals does not exclude concomitantinfection.

 

All fluid should be civilized.Patients with suspected septicbursitis should be treated with while awaiting cultureresults. Superficial septic bursitis can be treated with oral antibiotics.

 

Deep bursal infection will generally require intravenousantibiotics.

 

Staph aureus is the most common bacteria, causing more than80% of cases. Streptococcal species account for 5-20% of cases. Other organismsare less familiar.

 

An appropriate antistaph antibiotic should be started. Thisshould be a penicillinase-resistant penicillin, such as oxacillin sodium(Bactosill), or a first-generation cephalosporin, such as (Ceclor). Penicillin allergic patients can be treated with erythromycin.

 

The length of antibiotic treatment varies with the patientand the clinical situation. Uncomplicated septic bursitis presenting within aweek of infection should be treated with a 10-14 day course. Aspiration shouldbe repeated every 1-3 days while are being administered.Antibiotics should be continued for 5 days past sterilization of bursal fluidas seen by aspiration. Again, the use of ultrasound can help with fluiddetection since aspiration of a bursa without fluid may yield very littleexpensive material.

 

Patients who are immuno suppressed require a longer courseof treatment of at least 15 days.Deep bursal infections require prolonged   therapy and surgery is oftenessential.Surgical intervention, such as incision and drainage is needed incomplicated cases