SGEM#358: I Would Do Anything for Septic Olecranon Bursitis But I Won’t Tap That

Date: January 25th, 2022 Reference: Beyde et al. Efficacy of empiric antibiotic management of septic olecranon bursitis without bursal aspiration in emergency department patients. AEM January 2022 Guest Skeptic: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine. Case: You’re working in your busy freestanding emergency department (ED) getting absolutely crushed handing out COVID19 tests like candy and are relieved to see a patient with something different. A 27-year-old male construction worker building a local house presents with a tender, warm, erythematous olecranon and you diagnose him with septic olecranon bursitis. You offer to drain the bursa and get him back to work ASAP, and the patient looks very anxious and asks if you really must. Background: We have covered skin and soft tissue infections multiple times on the SGEM. The most recent time was with guest skeptic and SAEM FOAMed Excellence in Education Award winner Dr. Lauren Westafer (SGEM#348). We reviewed Dr. David Talan and colleagues’ study that was the October 2021 SGEM Hot Off the Press. That study investigated if a single-dose long-acting intravenous antibiotic could reduce hospitalization in patients with skin infections. The SGEM bottom line from that episode was in hospital systems with access to IV dalbavancin and the ability to establish expedited telephone and in-person follow up, this clinical pathway is associated with a decrease in hospitalizations for patients with moderately severe cellulitis. A couple of other SGEM episodes have looked at the management of cellulitis including SGEM#131 and SGEM#209. The treatment of abscesses has been covered four times on the SGEM (SGEM#13, SGEM#156, SGEM#164 and SGEM#311). The latest episode looked at the loop technique to drain uncomplicated abscesses. One topic we have not looked at is infected bursa. It’s estimated that about half of olecranon bursitis cases are septic[1]. Often, diagnostic aspiration is performed, but complications include fistula formation, further infection, and need for bursectomy [2-6]. Often the workup of septic bursitis is based upon anecdotal evidence [7]. This is likely due to the lack of high-quality evidence to direct our care. One area with limited information is the efficacy of empiric antibiotics without bursal aspiration. Clinical Question: What is the efficacy and outcomes associated with empiric antibiotic therapy, without aspiration, for septic olecranon bursitis? Reference: Beyde et al. Efficacy of empiric antibiotic management of septic olecranon bursitis without bursal aspiration in emergency department patients. AEM January 2022 Population: Adults >18 years old with olecranon bursitis Excluded: Declined authorization, underlying fracture, or surgery on the joint within 3 months Exposures: Antibiotics, aspiration, surgery or admission to hospital Comparison: None Outcome: Primary Outcome: Complicated versus uncomplicated bursitis resolution (Uncomplicated was defined as bursitis resolution without the need for bursal aspiration, surgery, or hospitalization) Secondary Outcome: Descriptive statistics of the cohort Study Design: Retrospective observational cohort study Dr. Ronna Campbell This is an SGEMHOP episode which means we have the senior author on the show. Dr. Ronna Campbell is an emergency physician practicing since 2007 in Rochester, MN. She enjoys mentoring medical students, residents and others in research. Authors’ Conclusions: “Eighty-eight percent of ED patients with suspected septic olecranon bursitis treated with empiric antibiotics without aspiration had resolution without need for subsequent bursal aspiration, hospitalization, or surgery. Our findings suggest that empiric antibiotics without bursal aspiration may be a reasonable initial approach to ED management of select patients with suspected septic olecranon bursitis.” Quality Checklist for Observational Study: Did the study address a clearly focused issue? Yes Did the authors use an appropriate method to answer their question? Yes Was the cohort recruited in an acceptable way? Yes Was the exposure accurately measured to minimize bias? Yes Was the outcome accurately measured to minimize bias? Yes Have the authors identified all-important confounding factors? Unsure Was the follow up of subjects complete enough? Yes How precise are the results? Fairly wide 95% CI around some of the point estimates Do you believe the results? Yes Can the results be applied to the local population? Unsure Do the results of this study fit with other available evidence? Yes Funding of the Study? NCATS/NIH grant Results: 264 patients included in the study, 229 with three months of follow up, 220 with six months. The age ranged from 42-69 years with 85% male. The most common presenting symptoms were swelling (94%), erythema (77%), and pain (85%). Key Results: Most patients with suspected septic olecranon bursitis had an uncomplicated resolution of their bursitis. Primary Outcome: Complicated vs uncomplicated resolution 88.1% were uncomplicated (95% CI: 81.1%–92.8%) 6.0% had subsequent bursal aspiration (95% CI: 2.8%–11.8%) 6.7% were subsequently admitted to hospital for antibiotics (95% CI: 3.3%–12.7%) Secondary Outcomes: 1.5% (4) had ED aspiration with no known complications (one lost to follow-up) 15% (39) were admitted to hospital on the initial visit 56% (147) were discharged from the ED with antibiotics 8.8% (13) lost to follow up, 17.2% (27) 95% CI 11.4%-25.9% had subsequent bursitis-related visit, 88.1% (118) 95% CI 81.1-92.8% uncomplicated resolution and 8 (6.0%, 95% CI 2.8%-11.8%) underwent subsequent bursal aspiration 29% (76) were discharged from the ED without Antibiotics 12% (9) lost to follow up, 97% (65) 95% CI 89-99% resolved without antibiotics, 91% (61) 95% CI 81.96% had an uncomplicated resolution and 3% (2) 95% CI 1-11% received inpatient antibiotics in a subsequent hospitalization Listen to the SGEM podcast to hear Ronna answer our five nerdy questions about her study. 1. Study Design: You decided to perform a retrospective observational study. This really limits the strength of conclusions that can be made from the data. Can you comment on the decision not to perform a prospective observational study or a randomized control trial (CEBM)? 2. STROBE – You mentioned the STROBE guidelines (Strengthening the Reporting of Observational Studies in Epidemiology). Some of the SGEM listeners may not be familiar with these guidelines. Can you tell us a little about these guidelines and why it is important to follow them? 3. Lack of Blinding – The abstractors were not blinded to the study objectives. Do you think that could have impacted the results and what did you do to mitigate this potential bias? 4. Gold Standard - Was there any gold standard for the diagnosis of septic olecranon bursitis other than provider impression? 5. External Validity – This study was conducted at a single centre. In addition, it was the Mayo Clinic which is a quaternary care ED. Practice patterns of clinical staff (MD/DO/NP/PA) and management may be different here than at other quaternary EDs or community and rural EDs. Do you think your study has external validity to other practice environments? Comment on Authors’ Conclusion Compared to SGEM Conclusion: We generally agree with their conclusions SGEM Bottom Line: Antibiotics without aspiration seems safe and may be an effective method of treatment for suspected septic olecranon bursitis. Case Resolution: You discuss the options with the patient and using shared decision making, decide on an empiric antibiotic approach, without aspiration. The patient has a full and uncomplicated resolution. Clinical Application: The evidence base is weak and does not provide a clear answer. When deciding on a treatment plan, it is reasonable to not perform an aspiration for suspected septic olecranon bursitis. Dr. Corey Heitz What Do I Tell My Patient? You have what appears to be an infected elbow bursa. A bursa is a fluid-filled pad around our joints. We can either stick a needle in the bursa (aspirate) and try to get some fluid. This fluid can be tested for infection. Aspiration of a bursa can have complications such as bleeding, causing an infection or hitting a nerve. Another option is to not do the aspiration and treat you with antibiotics. If this does not work or you are getting worse, you can always return to the ED. Would you prefer aspiration plus antibiotics or no aspiration plus antibiotics? Keener Kontest: Last weeks’ winner was Ravin Debie. They knew budesonide was patented in 1973. Listen to the SGEM podcast for this weeks’ question.  If you know, then send an email to thesgem@gmail.com with “keener” in the subject line. The first correct answer will receive a cool skeptical prize. SGEMHOP: Now it is your turn SGEMers. What do you think of this episode on septic olecranon bursitis? Tweet your comments using #SGEMHOP.  What questions do you have for Ronna and her team? Ask them on the SGEM blog. The best social media feedback will be published in AEM. Don’t forget those of you who are subscribers to Academic Emergency Medicine can head over to the AEM home page to get CME credit for this podcast and article. Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine. References: Stell IM. Management of acute bursitis: outcome study of a structured approach. J R Soc Med. 1999;92:516-521. Lormeau C, Cormier G, Sigaux J, Arvieux C, Semerano L. Management of septic bursitis. Joint Bone Spine. 2019;86:583-588. Deal JB Jr, Vaslow AS, Bickley RJ, Verwiebe EG,