American Association for Hand Surgery
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Empiric Treatment of Hand Infections -- Is Vancomycin Over-utilized?
Connor Arquette, MD; Paige M Fox, MD, PhD; Shannon Francis, BS
Stanford University, Palo Alto, CA

Introduction Hand infections are common diagnoses and efficient treatment is paramount in achieving optimal outcomes. Often, hand infections are treated empirically as upwards of 90% of patients donít have positively identified bacteria. Methicillin-resistant staphylococcus aureus (MRSA) is believed to be a rising cause of hand infections. Therefore, vancomycin is frequently used on admission but this requires close monitoring to reach effective target concentration, which can be challenging in patients with obesity and renal insufficiency. Clinically, vancomycin trough levels are measured with target levels between 15-20 mcg/liter for soft tissue infections. Maintenance of trough levels >10 mcg/mL prevents the development of antibiotic resistance. The present study aims to evaluate the prevalence of inaccurate vancomycin dosing, defined as serum trough < 10 mcg/mL, and its correlation with obesity, renal insufficiency, and overall length of stay.
Materials and Methods This is a retrospective cohort study of patients admitted to VA Palo Alto Hospital with a primary diagnosis of hand infection between 1999 and 2015. 233 patients met the inclusion criteria, of which 7 were excluded due to artificially prolonged length of stays due to comorbid diagnoses leaving 226 included patients. GraphPad (GraphPad Software, La Jolla, California) statistical software was used to perform analysis.
Results Of these 226 patients, 138 received vancomycin as part of their inpatient antibiotic regimen despite only 38 patients having culture positive MRSA and 48 having MSSA. 20 patients received inaccurate dosing and 43 had documented accurate dosing throughout the course of their admission. Those with inaccurate dosing had longer length of stay, 8.15 days, compared to a length of stay of 6.76 days for those with accurate dosing, however this was not statistically significant. Additionally, serum creatinine levels and body mass index were not found to be statistically significant predictors of inaccurate dosing.
Conclusions Based on culture data from patients admitted to the Palo Alto VA Hospital, it appears vancomycin is over utilized as an empiric treatment antibiotic which led to longer length of stay in those with inaccurate dosing, albeit not statistically significant. However, contrary to our hypothesis, serum creatinine nor body mass index were statistically significant predictors of prolonged length of stay.


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