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Flamin’ Hot Elbows – Should We Aspirate Olecranon Bursitis?

January 31, 2022

Written by Clay Smith

Spoon Feed
Empiric antibiotics, without aspiration, is safe and effective for most cases of suspected septic olecranon bursitis.

Why does this matter?
Some guidelines recommend aspiration of suspected septic olecranon bursitis prior to treatment. About half of cases are infectious. However, aspiration of olecranon bursitis may be complicated by a chronic draining fistula. On the other hand, without aspiration, the causative organism may remain a mystery. But do we really need a positive ID? Could we just treat for “the usual suspects,” staphylococci and streptococci, and do just fine?

Flamin’ hot elbows
This was an eight year retrospective, single center study that found 266 cases of olecranon bursitis. Four had aspiration; 39 were admitted; 76 did not get antibiotics and were not considered “septic” olecranon bursitis. None of the 4 aspirations led to chronic draining fistula or had subsequent bursectomy. Cultures grew MSSA, MRSA, group C strep, and no growth. That leaves 147 patients who were discharged on antibiotics, of which only 134 had follow data available. Of these, 88% (118/134) did just fine with empiric antibiotics; 8 had later aspiration; 9 were later admitted. Even if all patients lost to follow up were considered to have complicated resolution, this still means 80% of them did fine. Regarding antibiotic choice, over half were discharged on a beta-lactam, like cephalexin, with no MRSA coverage, which is interesting. What this tells me is that emergency physicians are already not aspirating most elbows, and empiric treatment works in the majority of cases. Use your judgment. In cases with a red hot olecranon but no significant systemic symptoms or comorbidities, an antibiotic prescription is probably all they need. More severe cases may benefit from hospitalization and orthopedic consultation. But I will not change my current practice and don’t plan to start aspirating these flamin’ hot elbows.

By the way, congrats to Vandy people Alexa and Kristi! I didn’t notice this until I dug into the full text. You two are amazing!

Efficacy of empiric antibiotic management of septic olecranon bursitis without bursal aspiration in emergency department patients. Acad Emerg Med. 2022 Jan;29(1):6-14. doi: 10.1111/acem.14406. Epub 2021 Nov 9.

What are your thoughts?