J Med Cases

Journal of Medical Cases, ISSN 1923-4155 print, 1923-4163 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Med Cases and Elmer Press Inc

Journal website http://www.journalmc.org

Case Report

Volume 3, Number 2, April 2012, pages 100-105

Inadvisable Treatment of Recalcitrant Septic Olecranon Bursitis: An Unusual Case of Extremely Prolonged Treatment With Oral Antibiotics After Bursectomy

Figure 1. Lateral (A, B) and axial (C) MRI views of the patient’s right elbow. Signal changes are seen in the posterior portion of the olecranon (O) process (arrow) and adjacent periosteal and subcutaneous tissue. Additionally, the open wound is seen on the posterior aspect of the elbow (arrow head). T: trochlea of humerus; Ant.: anterior in images A and B.

**Table 1.** Antibiotics, Cultures, and Blood Test Results
Day	Antibiotics	Cultures	Surgical I and D* (in hospital)	Erythrocyte Sedimentation Rate (ESR)	C-Reactive Protein (CRP)	White Blood Cell Count (WBC)
*I and D: irrigation and debridement; ED: emergency department; †: abnormal laboratory values.
Admittance to Las Vegas ED*	Cefazolin (iv)	No growth				15,000/µL ^†
Time between discharge from Las Vegas to Salt Lake City Hospital	Cephalexin, Moxifloxacin (both oral)	Methicillin sensitive S. aureus negative mecA gene
Initial I and D (7 days after sting)	Amoxicillin Clavulanate, iv Ertapenem Sodium		Yes	42 mm/hr ^†		8,800/µL
15 days following initial I and D	Amoxicillin Clavulanate, levofloxacin, (iv Ertapenem Sodium for 48 hours after surgery)		Yes	10 mm/hr	0.3 mg/dL
39 days following initial I and D	Amoxicillin Clavulanate, Levofloxacin	No growth		4mm/hr	0.2 mg/dL
64 days following initial I and D	Levofloxacin (iv Ceftriaxone for first week after surgery)	No growth	Yes
82 days following initial I and D	Trimethoprim and Sulfamethoxazole double strength, Rifampin (both oral)					6,000/µL
103 days following initial I and D	↓	No growth
105 days following initial I and D	↓			1 mm/hr	0.4 mg/dL	4,900/µL
151 days following initial I and D	↓			6 mm/hr	0.3 mg/dL	5,400/µL
213 days following initial I and D	↓
236 days following initial I and D	Patient deemed at maximum medical improvement

Table 1. Antibiotics, Cultures, and Blood Test Results

Day

Antibiotics

Cultures

Surgical I and D* (in hospital)

Erythrocyte Sedimentation Rate (ESR)

C-Reactive Protein (CRP)

White Blood Cell Count (WBC)

*I and D: irrigation and debridement; ED: emergency department; †: abnormal laboratory values.

Admittance to Las Vegas ED*

Cefazolin (iv)

No growth

15,000/µL ^†

Time between discharge from Las Vegas to Salt Lake City Hospital

Cephalexin, Moxifloxacin (both oral)

Methicillin sensitive S. aureus negative mecA gene

Initial I and D (7 days after sting)

Amoxicillin Clavulanate, iv Ertapenem Sodium

Yes

42 mm/hr ^†

8,800/µL

15 days following initial I and D

Amoxicillin Clavulanate, levofloxacin, (iv Ertapenem Sodium for 48 hours after surgery)

Yes

10 mm/hr

0.3 mg/dL

39 days following initial I and D

Amoxicillin Clavulanate, Levofloxacin

No growth

4mm/hr

0.2 mg/dL

64 days following initial I and D

Levofloxacin (iv Ceftriaxone for first week after surgery)

No growth

Yes

82 days following initial I and D

Trimethoprim and Sulfamethoxazole double strength, Rifampin (both oral)

6,000/µL

103 days following initial I and D

↓

No growth

105 days following initial I and D

↓

1 mm/hr

0.4 mg/dL

4,900/µL

151 days following initial I and D

↓

6 mm/hr

0.3 mg/dL

5,400/µL

213 days following initial I and D

↓

236 days following initial I and D

Patient deemed at maximum medical improvement

**Table 2.** Antibiotic Treatment of Septic Bursitis; Summary of Selected Studies
Reference (year)	Microorganism	Bursa (% of cases)	Osteomyelitis	Treatments	Antibiotics	Maximum Duration
^‡: Raddatz et al. and Garcia-Porrua et al. did not report specifically on the duration of antibiotics for their few cases of osteomyelitis; †: 76-78% of cases were penicillin resistant; *: 86% of cases were penicillin resistant.
Ho et al. (1978)	Staphylococcus aureus ^†	Olecranon (80%) Prepatellar (20%)	No	Parenteral and oral antibiotics, drainage	Dicloxacillin 500 mg q6h	25 Days
Ho et al. (1979)	Staphylococcus aureus	Olecranon Prepatellar	No	Parenteral and oral antibiotics, drainage	IV – oxacillin 2g q6h; Oral – oxacillin 500mg qid, erythromycin 500mg qid	15 Days
Ho and Su (1981)	Staphylococcus aureus ^†	Olecranon (84%) Prepatellar (12%) Infrapatellar (4%)	No	Parenteral and oral antibiotics	IV – oxacillin 2g q6h; Oral – oxacillin 500mg qid, erythromycin 2g daily	21 Days
Söderquist and Hedström (1986)	Staphylococcus aureus (63%)*	Olecranon (31%) Prepatellar (69%)	No	Parenteral and oral antibiotics	Isoxazolylpenicillin, benzylpenicillin, cloxacillin, cefuroxime, dlindamycin	12 Days
Knight et al. (1986)	Staphylococcus aureus (75%)	Olecranon (83%) Prepatellar (17%)	No	Parenteral and oral antibiotics, drainage	Given, but not named. IV and Oral	19 Days
Raddatz et al. (1987)	Staphylococcus aureus (78%)	Olecranon (63%) Prepatellar (27%)	Yes^‡	Parenteral and oral antibiotics, drainage	Cephalosporin	135 Days
Pien et al. (1991)	Staphylococcus aureus (70%)	Olecranon (72%) Prepatellar (28%)	No	Parenteral and oral antibiotics, drainage	Dicloxacillin 4g, probenecid 2g daily	30 Days
Garcia-Porrua et al. (1999)	Staphylococcus aureus (84%)	Olecranon (47%) Prepatellar (44%)	Yes^‡	Parenteral and oral antibiotics, drainage	IV – cloxacillin 2g q6h, Oral – cloxacillin 500-1000mg q6h	∼ 42 Days
Laupland and Davies (2001)	Staphylococcus aureus (88%)	Olecranon	No	Parenteral and oral antibiotics, drainage	IV- cefazolin, Oral - clindamycin	35 Days

Table 2. Antibiotic Treatment of Septic Bursitis; Summary of Selected Studies

Reference (year)

Microorganism

Bursa (% of cases)

Osteomyelitis

Treatments

Antibiotics

Maximum Duration

^‡: Raddatz et al. and Garcia-Porrua et al. did not report specifically on the duration of antibiotics for their few cases of osteomyelitis; †: 76-78% of cases were penicillin resistant; *: 86% of cases were penicillin resistant.

Ho et al. (1978)

Staphylococcus aureus ^†

Olecranon (80%)
Prepatellar (20%)

Parenteral and oral antibiotics, drainage

Dicloxacillin 500 mg q6h

25 Days

Ho et al. (1979)

Staphylococcus aureus

Olecranon
Prepatellar

Parenteral and oral antibiotics, drainage

IV – oxacillin 2g q6h; Oral – oxacillin 500mg qid, erythromycin 500mg qid

15 Days

Ho and Su (1981)

Staphylococcus aureus ^†

Olecranon (84%)
Prepatellar (12%)
Infrapatellar (4%)

Parenteral and oral antibiotics

IV – oxacillin 2g q6h; Oral – oxacillin 500mg qid, erythromycin 2g daily

21 Days

Söderquist and Hedström (1986)

Staphylococcus aureus (63%)*

Olecranon (31%)
Prepatellar (69%)

Parenteral and oral antibiotics

Isoxazolylpenicillin, benzylpenicillin, cloxacillin, cefuroxime, dlindamycin

12 Days

Knight et al. (1986)

Staphylococcus aureus (75%)

Olecranon (83%)
Prepatellar (17%)

Parenteral and oral antibiotics, drainage

Given, but not named.
IV and Oral

19 Days

Raddatz et al. (1987)

Staphylococcus aureus (78%)

Olecranon (63%)
Prepatellar (27%)

Yes^‡

Parenteral and oral antibiotics, drainage

Cephalosporin

135 Days

Pien et al. (1991)

Staphylococcus aureus (70%)

Olecranon (72%)
Prepatellar (28%)

Parenteral and oral antibiotics, drainage

Dicloxacillin 4g, probenecid 2g daily

30 Days

Garcia-Porrua et al. (1999)

Staphylococcus aureus (84%)

Olecranon (47%)
Prepatellar (44%)

Yes^‡

Parenteral and oral antibiotics, drainage

IV – cloxacillin 2g q6h, Oral – cloxacillin 500-1000mg q6h

∼ 42 Days

Laupland and Davies (2001)

Staphylococcus aureus (88%)

Olecranon

Parenteral and oral antibiotics, drainage

IV- cefazolin, Oral - clindamycin

35 Days