How best to approach these acute hand infections
Antimicrobial therapy is not straightforward with the 4 infectious conditions reviewed here. Combination therapy at the start must usually be tailored once an organism is known.
PRACTICE RECOMMENDATIONS
› Obtain a sample of pus for Gram stain and for cultures of aerobic and anaerobic organisms, acid-fast bacilli, and fungi. A
› Use antibiotics as an adjunct to elevation and splinting in flexor tenosynovitis to improve range-of-motion outcomes. A
› Notify your microbiology lab to enrich cultures with 10% CO2 to isolate Eikenella corrodens. A
› Consider prescribing acyclovir, famciclovir, or valacyclovir for herpetic whitlow. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
HSV-1 and HSV-2, as well as hepatitis B and C and human immunodeficiency virus (HIV) can be isolated in saliva of infected individuals and can be transmitted when contaminated blood is exposed to an open wound. Still, the presence of HIV in saliva is unlikely to result in disease transmission, due to salivary inhibitors rendering the virus non-infective in most cases.25 Obtain HIV and hepatitis B and C serology at baseline and at 3 and 6 months.25 If HIV infection is known or suspected, or if there was exposure to blood in the wound, the Centers for Disease Control and Prevention recommends postexposure prophylaxis with a 28-day course of anti-retroviral medication (SOR: A).24,31
Hepatitis B virus has an infectivity 100-fold greater than HIV.27 If possible, the 2 people involved in the altercation should be tested for hepatitis B surface antigen. If the result is positive, the individual with the skin wound should receive hepatitis B immune globulin (0.06 mL/kg/dose),32 and the vaccination schedule started if not done previously (SOR: A).33
Most experts recommend early antibiotic therapy given over 3 to 5 days for fresh, superficial wounds and specifically for wounds affecting hands, feet, joint, and genital area.11 For treatment of cellulitis or abscess, 10 to 14 days is sufficient; tenosynovitis requires 2 to 3 weeks; osteomyelitis requires 4 to 6 weeks.24 Wound care associated with daily dressing changes and antimicrobial therapy was superior to wound care alone (0% vs 47%).30 Assess tetanus status in all cases (SOR: A).17,33,34
Antimicrobial therapy for contamination with oral secretion is not straightforward. No one medication covers all possible pathogens. Use a combination therapy initially and then narrow coverage once the microorganism has been identified and susceptibilities are known. Empirical oral therapy with amoxicillin-clavulanate would be reasonable.
If IV therapy is needed, consider using ampicillin-sulbactam, cefazolin, or clindamycin. These antibiotics usually cover S aureus, Streptococcus sp, E corrodens and some anaerobes. Dicloxacillin will cover S aureus but provides poor coverage for E corrodens. First-generation cephalosporins cover S aureus, but E corrodens resistance is common. For penicillin-allergic individuals, use trimethoprim-sulfamethoxazole to cover E corrodens. Doxycycline can be used in children older than 8 years and in adults; avoid it in pregnant women.
Continue to: General principles guiding wound care, microbiology, and antibiotic management
