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septic bursitis and community acquired mrsa

Septic Bursitis: Defined. Small fluid-filled sac located at the point where a muscle or tendon slides across bone. Bursae serve to reduce friction between the two moving surfaces. There are >150 bursae in the body. Superficial: subcutaneous and separate skin from deeper tissuesDeep: reduce friction between fibrous structures such as tendons from adjacent bone. .

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septic bursitis and community acquired mrsa

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    1. Septic Bursitis and Community Acquired MRSA AM Report 9/21/07 Laura Patel, M.D.

    2. Septic Bursitis: Defined Small fluid-filled sac located at the point where a muscle or tendon slides across bone. Bursae serve to reduce friction between the two moving surfaces. There are >150 bursae in the body. Superficial: subcutaneous and separate skin from deeper tissues Deep: reduce friction between fibrous structures such as tendons from adjacent bone.

    3. Common locations for Septic bursitis Superficial bursa: predisposed to infection from skin trauma. Direct inoculation vs spread from cellulitus Olecranon bursitis: often from repetitive trauma. Plumbers, carpenters, COPD, chronic HD via access in arm. Prepatellar bursitis: often seen in people who kneel a lot- housemaids, gardners, clergy. Ischiogluteal bursitis: often in spinal cord injured patients. Deep Bursa: more often associated with septic arthritis from hematogenous seeding

    4. Anatomy

    5. Host Factors RA or gout: increase bursal fluid Loss of skin integrity Impaired response to infection: e.g DM, etoh

    6. Clinical Presentation: History and Physical pain and peribursal erythema, edema Majority have fever Joint motion is relatively preserved vs septic joint where motion is usually severely limited.

    7. Diagnosis: Labs: Elevated wbc with neutrophilic predominance. Usually are not bacteremic. Aspiration of bursal fluid: cell count usually >2000 wbc Gram stain and culture Send for crystals Micro: Usually staph aureus >80% or Beta hemolytic strep. Subacute bursitis more often brucella, mycobacteria or fungal. Plain film to evaluate for foreign body if trauma If septic bursitis of deep bursa is suspected then ultrasound, CT or MRI.

    8. Differential diagnosis Cellulitus Crystal induced bursitus Acute monoarthritis Hemobursa Nonseptic bursitis

    9. Treatment Drain infected bursa either by serial needle aspiration, I&D, or in extreme cases bursectomy Antibiotics: Mild inflammation and not immunosuppressed: dicloxicillin or clindamycin, +/- bactrim if high rates of MRSA (multiple contacts with hospital, long term care, IVDA, community with prevalence >15%) Severe inflammation: Vancomycin Immunosuppressed: broad spectrum including pseudomonal coverage

    10. Duration of Therapy Based on clinical response, culture results and health of host Most treated 2-3 weeks

    11. Community Acquired MRSA MRSA- initially described in the 1960s in association with nosocomial infections CA-MRSA- first reported in 1980s. Increasing in incidence and prevalence NEJM 2006 Prospective study: examined adults with skin and soft tissue infections who presented to 1 of 11 university affiliated ED in US. S. Aureus isolated from 320 of 422 (76%). Of these, 59% were MRSA and 98% of these were CaMRSA Some closed communities thought to have higher prevalence, up to 40%: Native Americans, daycare, MSM, prison inmates, competitive athletes.

    12. So what’s the difference between HA-MRSA and CA-MRSA?

    13. Clinical Characteristics of CA-MRSA Diagnosis made in outpatient setting No medical history of MRSA infection or colonization No recent history of hospitalization, surgery, dialysis or SNF No permanent indwelling catheter Often associated with skin and soft tissue infections CA-MRSA often sensitive to clindamycin, bactrim, doxycycline etc.

    14. CA-MRSA is crossing borders More CA-MRSA strains found in hospitalized patients 2003 metaanalysis: found to account for 37% of MRSA isolates in hospitalized patients. But majority of these patients had >1 healthcare associated risk Migration of resistant strains from community into hospitals may lead to failure of traditional control measures

    15. Conclusion Septic bursitis- more common in superficial bursa Associated with erythema, edema and pain, but joint motion preserved Confirm diagnosis with aspiration and culture of fluid Majority caused by S.Aureus CA-MRSA is on the rise- think about this when choosing antibiotics Treatment involves debridement and antibiotics

    16. References: File, TM. Impact of community-acquired methicillin-resistant Staphylococcus aureus in the hospital setting. Cleveland Clinic Journal of Medicine. Vol 74, Supplement 4. Aug 2007 S6-11. Kluytmans-Vandenberg MF. Community-acquired methicillin-resistant Staphylococcus aureus: current perspectives. Clinical Microbiology and Infection, Vol 12. Supplement 1, 2006, 9-15. Salgado CD, Farr BM, Clafee DP. Community-acquired methicillin-resistant Staphylococcus aureus: a meta-analysis of prevalence and risk factors. Clin Infect Dis 2003; 36: 131-139. Shorr, AF. Epidemiology and Economic Impact of Meticillin-Resistant Staphylococcus Aureus. Pharmacoeconomics 2007: 25 (9) 751-768. Uptodate: septic bursitis Uptodate: Epidemiology and clinical manifestations of methicillin-resistant Staphylococcus aureus infection in adults.

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