I n f e c t i o n Af t e r H a n d Surgery Kyle R. Eberlin, MDa,b,*, David Ring, MD, PhDa,c KEYWORDS Perioperative antibiotics Hand infections Prophylactic measures Surgical site infection Postoperative infection
KEY POINTS Prophylactic measures that may reduce the risk of postoperative infection include hand washing, skin preparation, sterile technique, and perioperative antibiotics. Perioperative antibiotics are indicated for operations lasting more than 2 hours, contaminated or dirty wounds, and most open fractures. Local, superficial infections around a suture or pin are treated with removal of the suture or pin alone when removal is appropriate and antibiotics when the suture or pin should be retained. More extensive superficial infections are treated with oral or parenteral antibiotics. Deep infections are treated with operative debridement and parenteral antibiotics.
Deep infection after hand surgery is uncommon, but when present, can contribute to scarring, stiffness, and even amputation.1 The incidence of infection is variable and may depend on the criteria used for diagnosis. For instance, the rate of infection after clean elective procedures such as carpal tunnel release has been reported as between 1%2 and 11%.3–5 In the authors’ experience, deep infection is uncommon. Suture abscesses and small colonized wound separations occur more often but typically resolve without sequelae. Proposed risk factors for infection after hand surgery include diabetes, immunosuppression, severe burns, and malnutrition.6,7 Open fractures,3,8 animal9 or human10 bites, and severely crushed or contaminated wounds11 may also predispose patients to postoperative infection. The most common organism involved in postoperative infection is Staphylococcus aureus.12,13
Some infections are caused by Streptococci or mixed flora.14 Patients with diabetes or a history of intravenous drug abuse are more likely to develop infections with gram-negative organisms, although S aureus remains the most common.13 Methicillin-resistant S aureus (MRSA) has become increasingly prevalent, community-acquired MRSA (caMRSA) in particular.15–18 caMRSA has toxins that cause greater tissue damage than typical S aureus infections. Necrotizing fasciitis can be caused by a wide spectrum of different organisms: polymicrobial infections are most common, but monomicrobial necrotizing infections are typically caused by group A Streptococcus.19 Other less common organisms include enterococci, pseudomonas, vibrio species, nocardia, mycobacteria, and Aeromonas hydrophilia, among others.20 This review addresses prophylaxis, diagnosis, and treatment of postoperative infections in the hand.
a Hand Surgery Service, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; b Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Wang Ambulatory Care Center 435, 15 Parkman Street, Boston, MA 02114, USA; c Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Yawkey 2C, 55 Fruit Street, Boston, MA 02114, USA * Corresponding author. Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Wang Ambulatory Care Center 435, 15 Parkman Street, Boston, MA 02114. E-mail address: [email protected]
Hand Clin 31 (2015) 355–360 http://dx.doi.org/10.1016/j.hcl.2014.12.007 0749-0712/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
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INTRODUCTION
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Eberlin & Ring PREVENTION OF POSTOPERATIVE INFECTIONS Adequate surgeon hand washing can result in lower bacterial counts21,22 and may help to prevent surgical site infections.23 Povidone iodine, chlorhexidine, and alcohol-based products can all be effective for preparation of the surgeon’s hands if used properly. This entails routine cleaning of subungual areas, scrubbing the hands and fingers before the forearm, avoidance of contamination of surgical attire during hand washing, and rinsing in one direction from the fingertips to the elbow.21,24 The duration of washing should last for at least 90 seconds, but one study showed no difference in reduction of bacterial colony forming units between 90 and 180 seconds of surgical hand antisepsis.25 Another study in patients undergoing hip arthroplasty demonstrated that prolonged duration of hand-scrub (10 vs 5 minutes) does not provide additional benefit.26 There is no consensus on the optimal solution and duration for hand washing before surgery. Preoperative surgical hand preparation should last at least 90 seconds and should involve organized, meticulous scrubbing. Preoperative prophylactic antibiotics are ideally administered at least 5 minutes but no more than 60 minutes before insufflation of an extremity tourniquet so they are present at adequate levels in the desired tissue at the time of incision.27,28 In a study of 37 patients undergoing knee replacement, Bannister and colleagues27 found that 61% of patients developed bactericidal levels of antibiotics 30 seconds after administration, 83% at 2 minutes after administration, and 100% at 5 minutes after administration. Antibiotics are more effective if given before bacteria have been present in the tissues longer than 3 hours.29 The use of preoperative prophylactic antibiotics for small elective soft tissue procedures such as trigger finger or carpal tunnel release is debated. In 1997, Kleinert and colleagues4 described more than 2000 patients undergoing elective upperextremity surgery and reported an overall infection rate of 1.4%, with a deep infection rate of 0.3%. Similar results were found by Hanssen and colleagues,2 who retrospectively studied 3620 patients undergoing elective carpal tunnel release and found an overall infection rate less than 1%. These findings were further supported by Harness and colleagues,30 who reported a similarly low rate of infection in a multicenter, retrospective review of elective carpal tunnel surgery. These authors concluded that the routine use of antibiotics in carpal tunnel surgery was not indicated, even for patients with diabetes.
In another large, retrospective review of almost 9000 patients undergoing small elective soft tissue procedures in the hand, Bykowski and colleagues31 found that the administration of prophylactic antibiotics did not reduce the overall 1% incidence of postoperative infections. These findings were corroborated in a study by Tosti and colleagues,32 who demonstrated an infection rate of 0.66% in 600 patients undergoing elective hand surgery procedures, with no difference between those who did and did not receive preoperative antibiotics. In one prospective, randomized trial of 160 patients with skin, tendon, and nerve injuries without debris or devitalized tissue in the wound, there was no significant difference in the rate of infection between patients who received and did not receive antibiotics.33 It is important to note that the overall infection rate of 10% in this study is higher than other studies, perhaps because of prospective evaluation and stringent criteria for diagnosis of infection with inclusion of suture abscesses. Prophylactic antibiotics are routine in patients having soft tissue surgeries lasting longer than 2 hours, surgeries involving bone or implants, and patients with debris or devitalized tissue in the wound,11,34 as well as animal or human bites.3,9,35–37 This routine use of prophylactic antibiotics is mostly based on wisdom and rationale. There are clinical trials that address the use of antibiotics for open fractures of the distal phalanx with conflicting evidence. One study of 85 patients found an infection rate of 30% in patients who did not receive antibiotics and less than 3% in patients treated with antibiotics.8 However, another double-blind, randomized placebo-controlled trial of 193 patients presenting to the emergency room with open fractures of the distal phalanx demonstrated similar rates of infection in patients treated with and without antibiotics (3% in the group receiving antibiotics and 4% in the group without antibiotics).38 Both prospective and retrospective studies have identified that operations lasting longer than 2 hours have a higher risk of postoperative infection.37,39,40 Other factors such as the American Society of Anesthesiologists’ assessment and the level of contamination may also play a role; composite risk indices incorporating such information can help in the stratification of risk for postoperative infections.41 Although it is often difficult to predict the precise duration of an operation, those that may take longer than 2 hours may benefit from prophylactic antibiotics given the higher risk of postoperative infection (Table 1).
Postoperative Hand Infections
Table 1 Recommendations for prophylactic antibiotic use in hand surgery Patient Group
Recommendations
Clean, elective procedures with an operative duration less than 2 h Clean, elective procedures longer than 2 h in duration
Use of prophylactic antibiotics is not necessary
Elective procedures in the setting of clean, isolated hand injuries with simple lacerations Traumatic contaminated or dirty wounds including human and animal bites
Open fractures of the phalanges or metacarpals
Patients with diabetes and other systemic diseases such as rheumatoid arthritis
Preoperative and perioperative prophylactic use of antibiotics are recommended, not to exceed 24 h in duration Prophylactic antibiotics are optional but not necessary
Targeted antibiotic use preoperatively and perioperatively based on type and degree of contamination, typically given for 1–2 wk Prophylactic antibiotics targeting grampositive bacteria are recommended until at least 24 h after wound closure; gramnegative coverage recommended for high-grade injuries Routine use of prophylactic antibiotics for elective, clean procedures less than 2 h in duration is not necessary
DIAGNOSIS OF INFECTION AFTER HAND SURGERY A consensus is needed for diagnostic criteria for infection after hand surgery that are reliable. It will be difficult to test the accuracy of diagnostic criteria because there is no reference standard (eg, cultures are often negative). Peel and Taylor42 diagnosed postoperative infection based on the simultaneous presence of erythema, tenderness, edema, wound separation, and the presence of purulence—criteria most
appropriate for deep infections. Some erythema and swelling can be normal postoperatively, particularly around sutures. A small wound separation may be colonized, but not necessarily infected. According to the criteria set by the Centers for Disease Control and Prevention (CDC), a surgical site infection can be superficial or deep.30 Superficial infections occur within 30 days after the procedure and involve only the skin and subcutaneous tissue of the incision, in the presence of other cardinal signs of infection. Deep infections occur within 30 days after the operation (or 1 year if an implant has been placed) and involves the deep soft tissues, such as fascial and muscle layers.32 Both categories require objective criteria to meet the diagnosis, or diagnosis by a surgeon or other attending physician. Given the stringency of the criteria provided by the CDC, consistent application of these definitions within the hand surgery community may contribute to more impactful and meaningful data within the literature.
TREATMENT OF INFECTION AFTER HAND SURGERY Cellulitis (infection of the skin and subcutaneous tissues) around a wound typically occurs approximately 1 week after surgery. Patients often present with an edematous, painful hand with erythema at the incision site. This erythema may involve a small area around the suture penetration site (so-called suture abscess).43,44 Most superficial infections resolve with suture removal with or without empiric oral antibiotics. Worsening infection or lymphangitic spread usually merits intravenous antibiotics and close monitoring, often with hospital admission. Kirschner wires and external fixation pins protruding from the skin can become infected. In one review of 422 pins used in hand surgery, there was a 7% infection rate and a 4% rate of pin loosening without infection.45 Stahl and Swartz46 studied 236 patients undergoing K-wire fixation in the hand, 13 of whom (5.5%) developed pin site infection between 2 and 8 weeks after surgery. In another study of percutaneous pinning of proximal phalanx fractures, 2 of 50 patients (4%) developed pin-tract infections.47 Factors associated with pin-tract infections may include motion at the bony interface, necrotic bone or soft tissue adjacent to the pin, and/or motion or tension on the skin. Pin infections usually resolve without antibiotics after pin removal. Oral antibiotics are used when it is too early to remove the pin, when the pin is loose or there is deep purulence, or when the pin crosses a joint. Infections with extensive cellulitis
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Eberlin & Ring might benefit from intravenous antibiotics initially. Operative treatment is considered for pin infection associated with substantial radiolucency around the pin (so-called ring sequestrum).1 Patients undergoing hand or finger replantation or reconstructive flap coverage of wounds are at risk of infection because of contamination from the initial injury, leech therapy, and relative ischemia and/or vascular congestion in the tissues. If medicinal leeches are used, infection with A hydrophila can occur within the first day or even weeks after initiation of leech therapy.48 A common prophylactic antibiotic choice is a fluoroquinolone such as ciprofloxacin,49 and established infections can be treated with third-generation cephalosporins, aminoglycosides, fluoroquinolones, tetracycline, trimethoprim/sulfamethoxazole, or a combination of agents.50 It is important to provide prophylaxis during therapy with medicinal leeches and to know the local characteristics of Aeromonas resistance.51 Surgery for debridement of necrotic tissue and irrigation of involved tissues are recommended when there is deep purulence. Deep space infections following hand surgery are uncommon. There are 4 confined spaces in the hand in which infection can develop; these include the thenar space, hypothenar space, midpalmar space, and web space.52 For thenar and hypothenar space abscesses, a volar incision is made over the thenar or hypothenar eminence, respectively. Postoperative deep space infections in the midpalmar space are often decompressed through a direct incision; most commonly, an existing surgical incision is used for access. Web space infections typically require both a volar and a dorsal approach; longitudinal incisions are preferred to prevent contracture. Deep space infections following hand surgery are rare but most require surgical drainage. There are no established guidelines for duration of antibiotic therapy in postoperative hand infections. In a recent article by Osterman and colleagues,20 recommendations were made for antibiotic duration in suture abscesses (7–10 days); deep space infection (7–10 days); cat, dog, or human bites (7–14 days); tenosynovitis (2–3 weeks); septic arthritis (3–4 weeks); and osteomyelitis (6–8 weeks). In the absence of prospective data comparing multiple different regimens, these guidelines are reasonable and consistent with current practice.
DIRECTIONS FOR FUTURE RESEARCH The study of a large, multicenter prospective cohort of patients having hand surgery would help determine risk factors for superficial and
deep infection. There may be subsets of patients who benefit from specific prophylactic measures such as perioperative antibiotics, particularly those with significant systemic disease, such as diabetes and rheumatoid arthritis, among others. Given the infrequency of deep infection after hand surgery, prospective randomized trials comparing the advantages and disadvantages of various prophylactic measures (eg, skin preparation, preoperative antibiotics) would need to be very large to detect a difference. If an acceptable rate of deep infection after hand surgery can be agreed on in terms of resource utilization, lost time from work, and the risk of permanent impairment from the infection and operative treatment, the difference in infection rate that would be meaningful can be determined. Prospective studies would then be powered to detect this difference. It is possible that we are already within the acceptable rate of infection with current practices. In the authors’ opinion, it is likely that a combination of factors, including the patient’s age, nature of injury, comorbidities, type of procedure or procedures, and operative duration will provide a composite measure of risk of infection after surgery. Such a probability score might help guide perioperative patient care and inform patient and surgeon decision-making. Because the acceptable rate of infection after surgery is a balance of the risks of harm (eg, allergic reaction or colitis from prophylactic antibiotics) as well as a matter of values and preferences, a probability score would help patients and surgeons make an informed, shared decision.
REFERENCES 1. Shapiro DB. Postoperative infection in hand surgery. Cause, prevention, and treatment. Hand Clin 1998; 14:669–81, x. 2. Hanssen AD, Amadio PC, DeSilva SP, et al. Deep postoperative wound infection after carpal tunnel release. J Hand Surg Am 1989;14:869–73. 3. Platt AJ, Page RE. Post-operative infection following hand surgery. Guidelines for antibiotic use. J Hand Surg Br 1995;20:685–90. 4. Kleinert JM, Hoffmann J, Miller Crain G, et al. Postoperative infection in a double-occupancy operating room. A prospective study of two thousand four hundred and fifty-eight procedures on the extremities. J Bone Joint Surg Am 1997;79:503–13. 5. Ariyan S, Watson HK. The palmar approach for the visualization and release of the carpal tunnel. An analysis of 429 cases. Plast Reconstr Surg 1977; 60:539–47. 6. Gunther SF, Gunther SB. Diabetic hand infections. Hand Clin 1998;14:647–56.
Postoperative Hand Infections 7. Deitch EA. Infection in the compromised host. Surg Clin North Am 1988;68:181–97. 8. Sloan JP, Dove AF, Maheson M, et al. Antibiotics in open fractures of the distal phalanx? J Hand Surg Br 1987;12:123–4. 9. Cummings P. Antibiotics to prevent infection in patients with dog bite wounds: a meta-analysis of randomized trials. Ann Emerg Med 1994;23:535–40. 10. Zubowicz VN, Gravier M. Management of early human bites of the hand: a prospective randomized study. Plast Reconstr Surg 1991;88:111–4. 11. Hoffman RD, Adams BD. The role of antibiotics in the management of elective and post-traumatic hand surgery. Hand Clin 1998;14:657–66. 12. Hausman MR, Lisser SP. Hand infections. Orthop Clin North Am 1992;23:171–85. 13. Houshian S, Seyedipour S, Wedderkopp N. Epidemiology of bacterial hand infections. Int J Infect Dis 2006;10:315–9. 14. Tosti R, Ilyas AM. Empiric antibiotics for acute infections of the hand. J Hand Surg Am 2010;35: 125–8. 15. O’Malley M, Fowler J, Ilyas AM. Communityacquired methicillin-resistant Staphylococcus aureus infections of the hand: prevalence and timeliness of treatment. J Hand Surg Am 2009;34:504–8. 16. Kiran RV, McCampbell B, Angeles AP, et al. Increased prevalence of community-acquired methicillin-resistant Staphylococcus aureus in hand infections at an urban medical center. Plast Reconstr Surg 2006;118:161–6 [discussion: 167–9]. 17. Bach HG, Steffin B, Chhadia AM, et al. Communityassociated methicillin-resistant Staphylococcus aureus hand infections in an urban setting. J Hand Surg Am 2007;32:380–3. 18. LeBlanc DM, Reece EM, Horton JB, et al. Increasing incidence of methicillin-resistant Staphylococcus aureus in hand infections: a 3-year county hospital experience. Plast Reconstr Surg 2007;119:935–40. 19. Wong CH, Chang HC, Pasupathy S, et al. Necrotizing fasciitis: clinical presentation, microbiology, and determinants of mortality. J Bone Joint Surg Am 2003;85A:1454–60. 20. Osterman M, Draeger R, Stern P. Acute hand infections. J Hand Surg Am 2014;39:1628–35. 21. Widmer AF. Surgical hand hygiene: scrub or rub? J Hosp Infect 2013;83(Suppl 1):S35–9. 22. Widmer AF, Rotter M, Voss A, et al. Surgical hand preparation: state-of-the-art. J Hosp Infect 2010; 74:112–22. 23. Awad SS, Palacio CH, Subramanian A, et al. Implementation of a methicillin-resistant Staphylococcus aureus (MRSA) prevention bundle results in decreased MRSA surgical site infections. Am J Surg 2009;198:607–10. 24. Lai KW, Foo TL, Low W, et al. Surgical hand antisepsis—a pilot study comparing povidone iodine hand
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scrub and alcohol-based chlorhexidine gluconate hand rub. Ann Acad Med Singapore 2012;41:12–6. Weber WP, Reck S, Neff U, et al. Surgical hand antisepsis with alcohol-based hand rub: comparison of effectiveness after 1.5 and 3 minutes of application. Infect Control Hosp Epidemiol 2009; 30:420–6. O’Farrell DA, Kenny G, O’Sullivan M, et al. Evaluation of the optimal hand-scrub duration before total hip arthroplasty. J Hosp Infect 1994;26:93–8. Bannister GC, Auchincloss JM, Johnson DP, et al. The timing of tourniquet application in relation to prophylactic antibiotic administration. J Bone Joint Surg Br 1988;70:322–4. Oragui E, Parsons A, White T, et al. Tourniquet use in upper limb surgery. Hand (N Y) 2011;6:165–73. Burke JF. The effective period of preventive antibiotic action in experimental incisions and dermal lesions. Surgery 1961;50:161–8. Harness NG, Inacio MC, Pfeil FF, et al. Rate of infection after carpal tunnel release surgery and effect of antibiotic prophylaxis. J Hand Surg Am 2010;35: 189–96. Bykowski MR, Sivak WN, Cray J, et al. Assessing the impact of antibiotic prophylaxis in outpatient elective hand surgery: a single-center, retrospective review of 8,850 cases. J Hand Surg Am 2011;36:1741–7. Tosti R, Fowler J, Dwyer J, et al. Is antibiotic prophylaxis necessary in elective soft tissue hand surgery? Orthopedics 2012;35:e829–33. Whittaker JP, Nancarrow JD, Sterne GD. The role of antibiotic prophylaxis in clean incised hand injuries: a prospective randomized placebo controlled double blind trial. J Hand Surg Br 2005;30:162–7. Amland PF, Andenaes K, Samdal F, et al. A prospective, double-blind, placebo-controlled trial of a single dose of azithromycin on postoperative wound infections in plastic surgery. Plast Reconstr Surg 1995;96:1378–83. Garibaldi RA, Cushing D, Lerer T. Risk factors for postoperative infection. Am J Med 1991;91:158S–63S. Griego RD, Rosen T, Orengo IF, et al. Dog, cat, and human bites: a review. J Am Acad Dermatol 1995; 33:1019–29. Haley RW, Culver DH, Morgan WM, et al. Identifying patients at high risk of surgical wound infection. A simple multivariate index of patient susceptibility and wound contamination. Am J Epidemiol 1985; 121:206–15. Stevenson J, McNaughton G, Riley J. The use of prophylactic flucloxacillin in treatment of open fractures of the distal phalanx within an accident and emergency department: a double-blind randomized placebo-controlled trial. J Hand Surg Br 2003;28: 388–94. Classen DC, Evans RS, Pestotnik SL, et al. The timing of prophylactic administration of antibiotics
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40.
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and the risk of surgical-wound infection. N Engl J Med 1992;326:281–6. Henley MB, Jones RE, Wyatt RW, et al. Prophylaxis with cefamandole nafate in elective orthopedic surgery. Clin Orthop Relat Res 1986;(209):249–54. Culver DH, Horan TC, Gaynes RP, et al. Surgical wound infection rates by wound class, operative procedure, and patient risk index. National Nosocomial Infections Surveillance System. Am J Med 1991;91: 152S–7S. Peel AL, Taylor EW. Proposed definitions for the audit of postoperative infection: a discussion paper. Surgical Infection Study Group. Ann R Coll Surg Engl 1991;73:385–8. Mangram AJ, Horan TC, Pearson ML, et al. Guideline for Prevention of Surgical Site Infection, 1999. Centers for Disease Control and Prevention (CDC) Hospital Infection Control Practices Advisory Committee. Am J Infect Control 1999;27:97–132 [quiz: 133–4; discussion: 196]. Robson MC. Wound infection. A failure of wound healing caused by an imbalance of bacteria. Surg Clin North Am 1997;77:637–50. Botte MJ, Davis JL, Rose BA, et al. Complications of smooth pin fixation of fractures and dislocations in
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the hand and wrist. Clin Orthop Relat Res 1992;(276):194–201. Stahl S, Schwartz O. Complications of K-wire fixation of fractures and dislocations in the hand and wrist. Arch Orthop Trauma Surg 2001;121:527–30. Eberlin KR, Babushkina A, Neira JR, et al. Outcomes of closed reduction and periarticular pinning of base and shaft fractures of the proximal phalanx. J Hand Surg Am 2014;39:1524–8. Lineaweaver WC, Hill MK, Buncke GM, et al. Aeromonas hydrophila infections following use of medicinal leeches in replantation and flap surgery. Ann Plast Surg 1992;29:238–44. Green PA, Shafritz AB. Medicinal leech use in microsurgery. J Hand Surg Am 2010;35:1019–21. Ardehali B, Hand K, Nduka C, et al. Delayed leechborne infection with Aeromonas hydrophilia in escharotic flap wound. J Plast Reconstr Aesthet Surg 2006;59:94–5. Whitaker IS, Kamya C, Azzopardi EA, et al. Preventing infective complications following leech therapy: is practice keeping pace with current research? Microsurgery 2009;29:619–25. Ong YS, Levin LS. Hand infections. Plast Reconstr Surg 2009;124:225e–33e.
KEY POINTS Prophylactic measures that may reduce the risk of postoperative infection include hand washing, skin preparation, sterile technique, and perioperative antibiotics. Perioperative antibiotics are indicated for operations lasting more than 2 hours, contaminated or dirty wounds, and most open fractures. Local, superficial infections around a suture or pin are treated with removal of the suture or pin alone when removal is appropriate and antibiotics when the suture or pin should be retained. More extensive superficial infections are treated with oral or parenteral antibiotics. Deep infections are treated with operative debridement and parenteral antibiotics.
Deep infection after hand surgery is uncommon, but when present, can contribute to scarring, stiffness, and even amputation.1 The incidence of infection is variable and may depend on the criteria used for diagnosis. For instance, the rate of infection after clean elective procedures such as carpal tunnel release has been reported as between 1%2 and 11%.3–5 In the authors’ experience, deep infection is uncommon. Suture abscesses and small colonized wound separations occur more often but typically resolve without sequelae. Proposed risk factors for infection after hand surgery include diabetes, immunosuppression, severe burns, and malnutrition.6,7 Open fractures,3,8 animal9 or human10 bites, and severely crushed or contaminated wounds11 may also predispose patients to postoperative infection. The most common organism involved in postoperative infection is Staphylococcus aureus.12,13
Some infections are caused by Streptococci or mixed flora.14 Patients with diabetes or a history of intravenous drug abuse are more likely to develop infections with gram-negative organisms, although S aureus remains the most common.13 Methicillin-resistant S aureus (MRSA) has become increasingly prevalent, community-acquired MRSA (caMRSA) in particular.15–18 caMRSA has toxins that cause greater tissue damage than typical S aureus infections. Necrotizing fasciitis can be caused by a wide spectrum of different organisms: polymicrobial infections are most common, but monomicrobial necrotizing infections are typically caused by group A Streptococcus.19 Other less common organisms include enterococci, pseudomonas, vibrio species, nocardia, mycobacteria, and Aeromonas hydrophilia, among others.20 This review addresses prophylaxis, diagnosis, and treatment of postoperative infections in the hand.
a Hand Surgery Service, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA; b Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Wang Ambulatory Care Center 435, 15 Parkman Street, Boston, MA 02114, USA; c Department of Orthopedic Surgery, Massachusetts General Hospital, Harvard Medical School, Yawkey 2C, 55 Fruit Street, Boston, MA 02114, USA * Corresponding author. Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Wang Ambulatory Care Center 435, 15 Parkman Street, Boston, MA 02114. E-mail address: [email protected]
Hand Clin 31 (2015) 355–360 http://dx.doi.org/10.1016/j.hcl.2014.12.007 0749-0712/15/$ – see front matter Ó 2015 Elsevier Inc. All rights reserved.
hand.theclinics.com
INTRODUCTION
356
Eberlin & Ring PREVENTION OF POSTOPERATIVE INFECTIONS Adequate surgeon hand washing can result in lower bacterial counts21,22 and may help to prevent surgical site infections.23 Povidone iodine, chlorhexidine, and alcohol-based products can all be effective for preparation of the surgeon’s hands if used properly. This entails routine cleaning of subungual areas, scrubbing the hands and fingers before the forearm, avoidance of contamination of surgical attire during hand washing, and rinsing in one direction from the fingertips to the elbow.21,24 The duration of washing should last for at least 90 seconds, but one study showed no difference in reduction of bacterial colony forming units between 90 and 180 seconds of surgical hand antisepsis.25 Another study in patients undergoing hip arthroplasty demonstrated that prolonged duration of hand-scrub (10 vs 5 minutes) does not provide additional benefit.26 There is no consensus on the optimal solution and duration for hand washing before surgery. Preoperative surgical hand preparation should last at least 90 seconds and should involve organized, meticulous scrubbing. Preoperative prophylactic antibiotics are ideally administered at least 5 minutes but no more than 60 minutes before insufflation of an extremity tourniquet so they are present at adequate levels in the desired tissue at the time of incision.27,28 In a study of 37 patients undergoing knee replacement, Bannister and colleagues27 found that 61% of patients developed bactericidal levels of antibiotics 30 seconds after administration, 83% at 2 minutes after administration, and 100% at 5 minutes after administration. Antibiotics are more effective if given before bacteria have been present in the tissues longer than 3 hours.29 The use of preoperative prophylactic antibiotics for small elective soft tissue procedures such as trigger finger or carpal tunnel release is debated. In 1997, Kleinert and colleagues4 described more than 2000 patients undergoing elective upperextremity surgery and reported an overall infection rate of 1.4%, with a deep infection rate of 0.3%. Similar results were found by Hanssen and colleagues,2 who retrospectively studied 3620 patients undergoing elective carpal tunnel release and found an overall infection rate less than 1%. These findings were further supported by Harness and colleagues,30 who reported a similarly low rate of infection in a multicenter, retrospective review of elective carpal tunnel surgery. These authors concluded that the routine use of antibiotics in carpal tunnel surgery was not indicated, even for patients with diabetes.
In another large, retrospective review of almost 9000 patients undergoing small elective soft tissue procedures in the hand, Bykowski and colleagues31 found that the administration of prophylactic antibiotics did not reduce the overall 1% incidence of postoperative infections. These findings were corroborated in a study by Tosti and colleagues,32 who demonstrated an infection rate of 0.66% in 600 patients undergoing elective hand surgery procedures, with no difference between those who did and did not receive preoperative antibiotics. In one prospective, randomized trial of 160 patients with skin, tendon, and nerve injuries without debris or devitalized tissue in the wound, there was no significant difference in the rate of infection between patients who received and did not receive antibiotics.33 It is important to note that the overall infection rate of 10% in this study is higher than other studies, perhaps because of prospective evaluation and stringent criteria for diagnosis of infection with inclusion of suture abscesses. Prophylactic antibiotics are routine in patients having soft tissue surgeries lasting longer than 2 hours, surgeries involving bone or implants, and patients with debris or devitalized tissue in the wound,11,34 as well as animal or human bites.3,9,35–37 This routine use of prophylactic antibiotics is mostly based on wisdom and rationale. There are clinical trials that address the use of antibiotics for open fractures of the distal phalanx with conflicting evidence. One study of 85 patients found an infection rate of 30% in patients who did not receive antibiotics and less than 3% in patients treated with antibiotics.8 However, another double-blind, randomized placebo-controlled trial of 193 patients presenting to the emergency room with open fractures of the distal phalanx demonstrated similar rates of infection in patients treated with and without antibiotics (3% in the group receiving antibiotics and 4% in the group without antibiotics).38 Both prospective and retrospective studies have identified that operations lasting longer than 2 hours have a higher risk of postoperative infection.37,39,40 Other factors such as the American Society of Anesthesiologists’ assessment and the level of contamination may also play a role; composite risk indices incorporating such information can help in the stratification of risk for postoperative infections.41 Although it is often difficult to predict the precise duration of an operation, those that may take longer than 2 hours may benefit from prophylactic antibiotics given the higher risk of postoperative infection (Table 1).
Postoperative Hand Infections
Table 1 Recommendations for prophylactic antibiotic use in hand surgery Patient Group
Recommendations
Clean, elective procedures with an operative duration less than 2 h Clean, elective procedures longer than 2 h in duration
Use of prophylactic antibiotics is not necessary
Elective procedures in the setting of clean, isolated hand injuries with simple lacerations Traumatic contaminated or dirty wounds including human and animal bites
Open fractures of the phalanges or metacarpals
Patients with diabetes and other systemic diseases such as rheumatoid arthritis
Preoperative and perioperative prophylactic use of antibiotics are recommended, not to exceed 24 h in duration Prophylactic antibiotics are optional but not necessary
Targeted antibiotic use preoperatively and perioperatively based on type and degree of contamination, typically given for 1–2 wk Prophylactic antibiotics targeting grampositive bacteria are recommended until at least 24 h after wound closure; gramnegative coverage recommended for high-grade injuries Routine use of prophylactic antibiotics for elective, clean procedures less than 2 h in duration is not necessary
DIAGNOSIS OF INFECTION AFTER HAND SURGERY A consensus is needed for diagnostic criteria for infection after hand surgery that are reliable. It will be difficult to test the accuracy of diagnostic criteria because there is no reference standard (eg, cultures are often negative). Peel and Taylor42 diagnosed postoperative infection based on the simultaneous presence of erythema, tenderness, edema, wound separation, and the presence of purulence—criteria most
appropriate for deep infections. Some erythema and swelling can be normal postoperatively, particularly around sutures. A small wound separation may be colonized, but not necessarily infected. According to the criteria set by the Centers for Disease Control and Prevention (CDC), a surgical site infection can be superficial or deep.30 Superficial infections occur within 30 days after the procedure and involve only the skin and subcutaneous tissue of the incision, in the presence of other cardinal signs of infection. Deep infections occur within 30 days after the operation (or 1 year if an implant has been placed) and involves the deep soft tissues, such as fascial and muscle layers.32 Both categories require objective criteria to meet the diagnosis, or diagnosis by a surgeon or other attending physician. Given the stringency of the criteria provided by the CDC, consistent application of these definitions within the hand surgery community may contribute to more impactful and meaningful data within the literature.
TREATMENT OF INFECTION AFTER HAND SURGERY Cellulitis (infection of the skin and subcutaneous tissues) around a wound typically occurs approximately 1 week after surgery. Patients often present with an edematous, painful hand with erythema at the incision site. This erythema may involve a small area around the suture penetration site (so-called suture abscess).43,44 Most superficial infections resolve with suture removal with or without empiric oral antibiotics. Worsening infection or lymphangitic spread usually merits intravenous antibiotics and close monitoring, often with hospital admission. Kirschner wires and external fixation pins protruding from the skin can become infected. In one review of 422 pins used in hand surgery, there was a 7% infection rate and a 4% rate of pin loosening without infection.45 Stahl and Swartz46 studied 236 patients undergoing K-wire fixation in the hand, 13 of whom (5.5%) developed pin site infection between 2 and 8 weeks after surgery. In another study of percutaneous pinning of proximal phalanx fractures, 2 of 50 patients (4%) developed pin-tract infections.47 Factors associated with pin-tract infections may include motion at the bony interface, necrotic bone or soft tissue adjacent to the pin, and/or motion or tension on the skin. Pin infections usually resolve without antibiotics after pin removal. Oral antibiotics are used when it is too early to remove the pin, when the pin is loose or there is deep purulence, or when the pin crosses a joint. Infections with extensive cellulitis
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Eberlin & Ring might benefit from intravenous antibiotics initially. Operative treatment is considered for pin infection associated with substantial radiolucency around the pin (so-called ring sequestrum).1 Patients undergoing hand or finger replantation or reconstructive flap coverage of wounds are at risk of infection because of contamination from the initial injury, leech therapy, and relative ischemia and/or vascular congestion in the tissues. If medicinal leeches are used, infection with A hydrophila can occur within the first day or even weeks after initiation of leech therapy.48 A common prophylactic antibiotic choice is a fluoroquinolone such as ciprofloxacin,49 and established infections can be treated with third-generation cephalosporins, aminoglycosides, fluoroquinolones, tetracycline, trimethoprim/sulfamethoxazole, or a combination of agents.50 It is important to provide prophylaxis during therapy with medicinal leeches and to know the local characteristics of Aeromonas resistance.51 Surgery for debridement of necrotic tissue and irrigation of involved tissues are recommended when there is deep purulence. Deep space infections following hand surgery are uncommon. There are 4 confined spaces in the hand in which infection can develop; these include the thenar space, hypothenar space, midpalmar space, and web space.52 For thenar and hypothenar space abscesses, a volar incision is made over the thenar or hypothenar eminence, respectively. Postoperative deep space infections in the midpalmar space are often decompressed through a direct incision; most commonly, an existing surgical incision is used for access. Web space infections typically require both a volar and a dorsal approach; longitudinal incisions are preferred to prevent contracture. Deep space infections following hand surgery are rare but most require surgical drainage. There are no established guidelines for duration of antibiotic therapy in postoperative hand infections. In a recent article by Osterman and colleagues,20 recommendations were made for antibiotic duration in suture abscesses (7–10 days); deep space infection (7–10 days); cat, dog, or human bites (7–14 days); tenosynovitis (2–3 weeks); septic arthritis (3–4 weeks); and osteomyelitis (6–8 weeks). In the absence of prospective data comparing multiple different regimens, these guidelines are reasonable and consistent with current practice.
DIRECTIONS FOR FUTURE RESEARCH The study of a large, multicenter prospective cohort of patients having hand surgery would help determine risk factors for superficial and
deep infection. There may be subsets of patients who benefit from specific prophylactic measures such as perioperative antibiotics, particularly those with significant systemic disease, such as diabetes and rheumatoid arthritis, among others. Given the infrequency of deep infection after hand surgery, prospective randomized trials comparing the advantages and disadvantages of various prophylactic measures (eg, skin preparation, preoperative antibiotics) would need to be very large to detect a difference. If an acceptable rate of deep infection after hand surgery can be agreed on in terms of resource utilization, lost time from work, and the risk of permanent impairment from the infection and operative treatment, the difference in infection rate that would be meaningful can be determined. Prospective studies would then be powered to detect this difference. It is possible that we are already within the acceptable rate of infection with current practices. In the authors’ opinion, it is likely that a combination of factors, including the patient’s age, nature of injury, comorbidities, type of procedure or procedures, and operative duration will provide a composite measure of risk of infection after surgery. Such a probability score might help guide perioperative patient care and inform patient and surgeon decision-making. Because the acceptable rate of infection after surgery is a balance of the risks of harm (eg, allergic reaction or colitis from prophylactic antibiotics) as well as a matter of values and preferences, a probability score would help patients and surgeons make an informed, shared decision.
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