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
Antimicrobial therapy is not easy. No single regimen covers all possibilities. Start antimicrobial treatment empirically with wide-spectrum coverage, and tailor the regimen, as needed, based on microbiology results.
In clean surgical procedures, S aureus is the most common pathogen. It is acceptable to start empirical treatment with an antistaphylococcal penicillin, first-generation cephalosporin, or clindamycin. In contaminated wounds, gram-negative bacteria, anaerobes, fungal organisms, and mixed infections are more commonly seen.35-37
First-generation cephalosporin provides good coverage for gram-positive and gram-negative bacteria in clean wounds. However, in contaminated wounds with devitalized tissue, a more aggressive scheme is recommended: start with a penicillin and aminoglycoside.35-37 In some cases, monotherapy with either ampicillin/sulbactam, imipenem, meropenem, piperacillin/tazobactam, or tigecylline may be sufficient until culture results are available; at that point, antibiotic coverage can be narrowed as indicated (TABLE 27).35,36
CORRESPONDENCE
Carlos A. Arango, MD, 8399 Bayberry Road, Jacksonville, FL 32256; carlos.arango@jax.ufl.edu.
