Noninfectious bursitis care
›Conservative measures
›Activity modification
›Avoid kneeling or leaning on elbows
›Ergonomic changes at work
›Compression and padding
›Elbow pad
›Knee pad
›Ice therapy
›10 to 15 minutes per session
›Several sessions daily during flare
›Elevation when feasible
›Reduce dependent edema
›Reduce throbbing pain
›Analgesia and antiinflammatory options
›Acetaminophen
›650 mg PO every 6 hours as needed
›Maximum 3000 mg per day in older adults or liver disease risk
›Ibuprofen
›400 mg PO every 6 to 8 hours as needed
›Avoid in advanced CKD or active GI bleed risk
›Naproxen
›250 to 500 mg PO twice daily as needed
›Avoid with anticoagulation high bleed risk
›Topical NSAID option
›Diclofenac gel local application
›Lower systemic adverse effects than oral NSAID
›Aspiration strategy
›Diagnostic aspiration indications
›Suspected septic bursitis
›Suspected gout or CPPD
›Therapeutic aspiration considerations
›Very large tense bursa with pain
›Functional limitation
›Aspiration precautions
›Avoid if overlying cellulitis without suspected bursal infection
›Strict sterile technique
›Corticosteroid injection constraints
›Avoid when infection not excluded
›No injection with purulent aspirate
›No injection with systemic infection signs
›Selective use in recurrent nonseptic bursitis
›Persistent symptoms despite compression and NSAIDs
›Clear counseling on infection risk
Septic bursitis antibiotics
›Empiric coverage targets
›Staphylococcus aureus coverage
›MSSA coverage option
›MRSA coverage option based on risk
›Streptococcus pyogenes coverage
›Beta lactam option
›Alternative if beta lactam allergy
›Outpatient oral regimens
›MSSA predominant risk
›Cephalexin 500 mg PO four times daily
›Duration 10 to 14 days
›Adjust for renal function
›Dicloxacillin 500 mg PO four times daily
›Duration 10 to 14 days
›Avoid if penicillin anaphylaxis history
›MRSA risk or high local prevalence
›Doxycycline 100 mg PO twice daily
›Duration 10 to 14 days
›Add beta lactam if streptococcal coverage needed
›Trimethoprim sulfamethoxazole DS 1 tablet PO twice daily
›Duration 10 to 14 days
›Hyperkalemia risk monitoring in high risk patients
›Clindamycin 300 to 450 mg PO three times daily
›Duration 10 to 14 days
›C difficile diarrhea risk counseling
›Inpatient IV regimens
›Severe infection or immunocompromise
›Vancomycin IV 15 to 20 mg per kg every 8 to 12 hours
›Titrate to local AUC monitoring protocol
›Renal function monitoring
›Cefazolin IV 2 g every 8 hours for MSSA when MRSA unlikely
›Renal adjustment
›Step down to oral when improving
›Drainage escalation
›Repeat aspiration strategy
›Persistent large reaccumulation
›Ongoing purulence despite antibiotics
›Incision and drainage indications
›Loculated bursa not aspiratable
›Failure of repeated aspiration
Evidence and recommendation labels
›Evidence notes
›No ACEP clinical policy specific to bursitis
›Evidence labeling uses source guideline strength and expert consensus
›Apply local antimicrobial stewardship pathways
›Class I expert consensus
›Antibiotics plus drainage strategy for confirmed septic bursitis
›Culture directed narrowing when available
›Class IIb expert consensus
›Steroid injection for recurrent nonseptic bursitis after infection exclusion
›Avoid routine injection in initial presentation