Medication Summary
The goals of pharmacotherapy are to reduce morbidity and to prevent complications.
Topical Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Diclofenac topical (Voltaren Gel, Flector Transdermal Patch, Pennsaid topical solution)
Since prepatellar bursitis is quite superficial, topical NSAIDs such as diclofenac topical gel (Voltaren Gel) can be very effective, with minimal systemic side effects.
Nonsteroidal Anti-inflammatory Drugs (NSAIDs)
Class Summary
NSAIDs are the drugs of choice for mild to moderate pain. They work by decreasing prostaglandin synthesis, thereby reducing inflammation. Ibuprofen commonly is used; however, alternatives are available, such as naproxen and ketoprofen. Use of a particular NSAID usually is secondary to physician and patient experience.
Ibuprofen (Advil, Nuprin, Motrin, Midol)
Drug of choice for patients with mild to moderate pain. Inhibits inflammatory reactions and pain by decreasing prostaglandin synthesis.
Antibiotics
Class Summary
Antibiotics should be started if septic prepatellar bursitis is suspected or documented after aspiration of bursal fluid for Gram stain and culture. An initial antibiotic can be selected based on a common pathogen (Staphylococcus aureus) and Gram stain results. In some cases of severe inflammation and in immunocompromised individuals, intravenous (IV) antibiotics may be required.
Patients with high risk for methicillin-resistant S aureus (MRSA) infection should receive empiric therapy with an antimicrobial agent that has activity against MRSA, such as IV vancomycin or daptomycin (in cases of severe inflammation) or oral clindamycin, doxycycline, or trimethoprim-sulfamethoxazole (in mild cases). [31]
In a retrospective study of 82 patients treated for severe septic bursitis (in most cases, prepatellar bursitis), Martinez-Taboada et al investigated the effectiveness of antibiotic therapy using cloxacillin, either alone or in combination with another antibiotic. [32] The authors concluded that if extensive cellulites are not present, cloxacillin may by itself be sufficient to treat severe septic bursitis. In particularly severe cases, however, they found that cloxacillin administered in combination with gentamicin appears to be a better treatment choice.
Cephalexin (Keflex, Biocef)
First-generation cephalosporin arrests bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal activity against rapidly growing organisms. Primary activity against skin flora; used for skin infections or prophylaxis in minor procedures.
Corticosteroids
Class Summary
Corticosteroids have anti-inflammatory properties and cause profound and varied metabolic effects. In addition, these agents modify the body's immune response to diverse stimuli. Many injectable corticosteroids are available. Selection usually is physician directed.
Hydrocortisone (Solu-Cortef, Westcort)
Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
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Prepatellar bursa in normal (left) and inflamed (right) state; trilaminar form.
Tables
Characteristic |
Septic bursitis (SB) |
Nonseptic bursitis (NSB) |
Appearance |
Purulent |
Serosanguineous, straw colored, or bloody |
White blood cell count per µL |
1500-300,000; mean 75,000 |
50-10,000; usually < 3000 |
Differential count |
Polymorphonuclear (PMN) cells |
Predominantly mononuclear cells |
Bursal fluid–to–serum glucose ratio |
< 50% |
>50% |
Gram stain |
Positive in 70% |
Negative |
Culture |
Positive |
Negative |
