›Mean resolution 2.3 weeks with injection versus 3.2 weeks without
›Risks of corticosteroid injection
›Iatrogenic septic bursitis
›Skin atrophy and depigmentation
›Recurrence risk increased with repeated injections
›ACEP Level C — injection acceptable in refractory aseptic cases
Septic bursitis — outpatient antibiotics
›Empiric antibiotic selection targeting Staphylococcus aureus
›Mild to moderate disease — outpatient oral therapy
›Cephalexin 500 mg orally four times daily
›Duration minimum 14 days
›Treatment less than 14 days associated with higher failure rates
›TMP-SMX DS (800 mg trimethoprim 160 mg) orally twice daily
›Preferred when MRSA concern
›Duration minimum 14 days
›Doxycycline 100 mg orally twice daily
›MRSA-active alternative
›Avoid in pregnancy and children under 8 years
›Clindamycin 300 to 450 mg orally every 6 to 8 hours
›Alternative for penicillin-allergic patients
›Counsel on C difficile risk
›Close follow-up within 48 to 72 hours mandatory
›Reassess clinical response to antibiotics
›Repeat aspiration if worsening
Septic bursitis — inpatient IV antibiotics
›IV antibiotic regimens for moderate to severe disease
›Vancomycin IV — preferred when MRSA risk or severe disease
›15 to 20 mg per kg IV every 8 to 12 hours
›Target AUC/MIC 400 to 600 per institutional protocol
›Trough monitoring per protocol
›Renal function monitoring
›Nafcillin or oxacillin IV — MSSA when susceptibility confirmed
›Nafcillin 1 to 2 g IV every 4 to 6 hours
›Hepatic metabolism — monitor LFTs
›Cefazolin IV — MSSA alternative with better tolerability
›1 to 2 g IV every 8 hours
›Step down to oral cephalexin when clinically improved
›Antibiotic duration
›Minimum 14 days total course for septic bursitis
›Extend to 21 days in immunocompromised or delayed response
›IV to oral transition when afebrile and improving
Drainage and surgical management
›Bursal aspiration for septic bursitis
›Diagnostic aspiration — cell count, culture, crystal analysis
›Serial aspirations if fluid re-accumulates
›Repeat every 1 to 3 days until collection resolved
›Ultrasound guidance improves accuracy
›Empiric antibiotics without aspiration
›88% uncomplicated resolution in ED cohort study
›Acceptable for non-toxic, immunocompetent patients
›Surgical bursectomy indications
›Refractory septic bursitis failing medical management
›26% of septic cases require surgical drainage in series
›Chronic recurrent nonseptic bursitis unresponsive to conservative care
›Draining sinus tract formation
›Osteomyelitis complication
›Orthopedic consultation for surgical planning
›Crystal-induced bursitis management
›Acute flare treatment
›NSAIDs — first-line for non-contraindicated patients
›Colchicine 1.2 mg orally then 0.6 mg one hour later
›Maximum 1.8 mg in acute flare
›Renal dose reduction required with GFR <30 mL per min
›Corticosteroids when NSAIDs and colchicine contraindicated
›Prednisone 0.5 mg per kg per day for 5 to 10 days
›Urate-lowering therapy
›Not initiated during acute flare
›Allopurinol or febuxostat for chronic gout prevention
›Rheumatology referral for long-term management