Written by Graham Van Schaik
Empiric antibiotic therapy – without aspiration – is a reasonable approach for the management of suspected prepatellar septic bursitis in non-toxic patients with close outpatient follow up.
Why does this matter?
Rapid triage, assessment, and treatment of prepatellar bursitis enables a safe and (potentially) quick disposition for patients. While guidelines recommend aspiration and antibiotic therapy, aspiration is not without its own risks (fistulous tracts, seeding a joint, patient discomfort). If there is a way to safely spare patients these risks and save time, it would benefit everyone.
Something you “kneed” to know
This was a retrospective cohort study based on chart review of patients presenting to an emergency department over 8 years between 2011 and 2019. The study identified 380 patients during that period with “prepatellar” or “unspecified” bursitis. Of these, 157 patients with prepatellar bursitis were evaluated for an uncomplicated resolution (defined as “the absence of need for subsequent bursal aspiration, hospitalization or bursal surgery”).
Of the 157 patients, only 6 (4%) underwent a bursal aspiration in the ED (1 underwent subsequent bursectomy). Of those who did not undergo ED aspiration, 26 were admitted and treated with empiric antibiotics. Sixty-one patients did not undergo ED bursal aspiration and were discharged home with antibiotics. Among them, Fifty-one with available follow up data had an uncomplicated resolution (88%, 95% CI 76–95%); 3 were lost to follow up.
Sixty-four patients did not undergo aspiration in the ED and were discharged home without antibiotics. Of those with follow up data, 56 (88%, 95% CI 79%–96%) had an uncomplicated resolution and 8 (13%) improved after initiation of empiric antibiotic therapy. Of note, those admitted or prescribed antibiotics had elevated inflammatory markers when compared to those not receiving antibiotics. Bottom Line: For me, these data do not necessarily inform my decision to admit or discharge a patient, but it does make me feel better about giving antibiotics without aspiration.
Editor’s note: Great work, Alexa Thomas! ~Clay Smith
Efficacy of empiric antibiotic therapy without aspiration for septic prepatellar bursitis in emergency department patients. Acad Emerg Med. 2022 Aug;29(8):1027-1032. doi: 10.1111/acem.14499. Epub 2022 Apr 25.