The Natural History of Surgical Hand Infections: Patient, Presentation, Surgeon, and Microbiology Variables that Predict Clinical Course from Treatment to Discharge
Ketan Sharma, MD, MPH1; Aaron Mull, MD1; James Friedman, MD2; Deng Pan, BS1; Ida Fox, MD3; Moore M Amy, MD4; (1)Washington University St Louis, St Louis, MO, (2)University of Pennyslvania, Philadelphia, PA, (3)Washington University St. Louis, St Louis, MO, (4)Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, Saint Louis, MO
Surgical hand infections can be uniquely-challenging due to their diagnostic complexity, need for surveillance, and morbidity. Isolating the patient, infection, surgeon, and microbiology variables which govern the infection's clinical course can (1) provide prognostic factors to assist in anticipating patient trajectory, (2) deliver treatment recommendations to aid in operative decision-making, and (3) identify ways to improve care.
Materials and Methods
A prospective cohort study was created of all surgical hand infection consultations evaluated by our division over three years. For each patient, the clinical pathway was recorded, and included patient background, clinical presentation, surgical evaluation, pathogenic microbiology, and outcome variables. Surgical severity was classified by initial treatment: simple (bedside drainage, PO antibiotics); complicated (bedside drainage, IV antibiotics); severe (OR drainage, IV antibiotics). Outcomes included surgical recurrence (need for repeat therapeutic drainage) and inpatient length-of-stay (LOS). Multivariate regression identified predictors of outcomes.
388 patients were accrued. Average age was 42 years, with 67% male, 52% smokers, and 31% with history of IVDA. 23% were triaged as simple, 39% complicated, and 37% severe. Simple infections more frequently grew MSSA, while severe more frequently grew non-Staphylococcus Gram positives and Gram negatives.
On controlled analysis, the most important risk factors for severe surgical severity were hepatitis C (HCV) history, leukocytosis at presentation, fight bite mechanism, forearm location, and deep space abscess, osteomyelitis, tenosynovitis, joint, and necrotizing fasciitis types. Risk factors for surgical recurrence included history of diabetes, leukocytosis at presentation, deep space abscess, osteomyelitis, tenosynovitis, and necrotizing fasciitis types, the decision to initially triage as complicated, and MRSA-positive cultures. Extended LOS was predicted by leukocytosis at presentation and joint and necrotizing fasciitis types.
Initially, hand surgeons should consider operative drainage in HCV patients and in infections resulting from high-risk mechanisms or involving proximal locations or deeper anatomy. Subsequently, hand surgeons should anticipate that infections in diabetics, growing MRSA, or involving bone, tendon sheaths, and fascia may require additional therapeutic drainage. Prognostically, leukocytosis at presentation serves as an important marker for infection severity. Diabetics may benefit from stricter glycemic control, and complicated infections may benefit from earlier operative drainage.
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