Septic Olecranon Bursitis With Osteomyelitis Attributed to Cutibacterium acnes: Case Report and Literature Overview of the Dilemma of Potential Contaminants and False-Positives

Abstract

We report an unusual case of acute septic olecranon bursitis, with probable olecranon osteomyelitis, where the only organism isolated in culture was initially considered a contaminant, Cutibacterium acnes. However, we ultimately considered it the likely causal organism when treatment for most of the other more likely organisms failed. This typically indolent organism is prevalent in pilosebaceous glands, which are scarce in the posterior elbow region. This case illustrates the often challenging empirical management of a musculoskeletal infection when the only organism isolated might be a contaminant, but successful eradication requires continued treatment as if it is the causal organism. The patient is a Caucasian 53-yearold male who presented to our clinic with a second episode of septic bursitis at the same location. Four years prior, he had septic olecranon bursitis from methicillin-sensitive Staphylococcus aureus that was treated uneventfully with one surgical debridement and a one-week course of antibiotics. In the current episode reported here, he sustained a minor abrasion. Cultures were obtained five separate times because of no growth and difficulty eradicating the infection. One culture grew C. acnes on day 21 of incubation; this long duration has been reported. The first several weeks of antibiotic treatment failed to eradicate the infection, which we ultimately attributed to inadequate treatment of C. acnes osteomyelitis. Although C. acnes has a well-known propensity for false-positive cultures as typically reported in post-operative shoulder infections, treatment for our patient's olecranon bursitis/osteomyelitis was successful only after several surgical debridements and a prolonged course of intravenous and oral antibiotics that targeted it as the presumptive causal organism. However, it was possible that C. acnes was a contaminant/superinfection, and another organism was the culprit, such as a Streptococcus or Mycobacterium species that was eradicated by the treatment regime targeted for C. acnes.

Optimal antibiotics duration following surgical management of septic olecranon bursitis: a 12-year retrospective analysis

“…Moreover, compared with patients who never smoked, active but not former smokers were at increased odds of clinical failure following bursectomy. This association may be partly due to the bursa's watershed midline blood supply (Blackwell et al, 2014), which, when combined with the temporary effects of smoking that decrease tissue oxygenation and disrupt the inflammatory healing response, leads to delayed wound healing and an elevated risk of postoperative infectious complications (Sørensen, 2012;Skedros et al, 2023). Notably, smoking cessation for 4 weeks or more appears to partially reverse these effects (Sørensen, 2012), highlighting the importance of patient counseling and the implementation of effective strategies to facilitate and maintain smoking cessation in the perioperative period.…”

“…Despite the variability in treatment practices between institutions, the surgical indications for septic olecranon bursitis have not significantly changed over the last 2 decades. Surgery is typically reserved for select cases such as those involving refractory or relapsing infection, critically ill patients, presence of extensive peribursal soft tissue involvement requiring debridement, presence of a bursal abscess that fails needle aspiration, or for patients with chronic draining sinus (Baumbach et al, 2014;Small and Ross, 2005;Zimmermann et al, 1995). The ideal surgical approach (incision and drainage vs. bursectomy) remains debated (Lormeau et al, 2019;Baumbach et al, 2013a).…”