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Infections of the Hand and Fingers: Common is good but, Unusual is interesting

SBHPP Speaker - Tom Gocke
By: Tom Gocke, DMSc, ATC, PA-C, DFAAPA

Infections of the hand and fingers are common medical problems that are seen in a variety of medical facilities. Like most things in medicine, we see the typical presentations for hand and finger infections. The infection responds to conventional therapy, and the patient recovers in a reasonable amount of time. However, on occasion, our patients throw us a curveball, and things don’t always go as planned. Please review this brief summary on hand and finger infections then, check out the link attached below. I trust this will help broaden your differential diagnosis the next time you treat a patient with a hand or finger infection. 

Many finger infections are superficial, self-limited, and respond well to early intervention. Common organisms associated with hand and finger injuries include Staphylococcus and Streptococcus species. The majority of Staphylococcus bacteria are methicillin-sensitive Staphylococcus aureus (MSSA). Methicillin-resistant Staphylococcus aureus (MRSA) organisms continue to pose a concern for clinicians who treat patients for skin-related infections. Traditionally, first-generation Cephalosporin antibiotics are mainstays in the treatment of bacterial hand and finger infections.1-6 When an MRSA infection is suspected, clindamycin, trimethoprim/sulfamethoxazole (TMP/SMX), and doxycycline are frequently used as oral antibiotic front-line therapy. Vancomycin remains the drug of choice in the empiric treatment of hospitalized patients with hand and finger infections.1-6 In this era of increasing antibiotic-resistant organisms, the use of culture-based organism identification and refined antibiotic coverage will limit the spread of drug-resistant organisms.2 The patient who is immunocompromised, takes immune-suppressing medications, uses tobacco, has poorly controlled diabetes, and has a history of IV drug abuse, are at an increased risk of developing infections.1-6 These contributing factors can exacerbate finger infections leading to treatment failures and severe long-term disabilities1,2. Paronychia (acute and chronic), bacterial Felon, and cellulitis are common finger infections.1-6 

Flexor tenosynovitis [FTS], also referred to as pyogenic, suppurative, or septic FTS and results from a closed space infection involving the finger flexor tendon sheath. This infection can spread and, if left untreated, can lead to septic arthropathy of the wrist. The diagnosis of septic FTS is based on clinical presentation and is not solely based on diagnostic imaging. Pathogens associated with septic FTS are predominantly MSSA with MRSA infections occurring in 15-30% of cases.1,2 Other organisms seen in septic FTS are Pseudomonas and other gram-negative bacteria. Injuries causing FTS are puncture wounds, bites wounds (animal/human), IV drug use, and other penetrating wounds to the finger/hand. Clinical presentation could include fevers, chills, erythema, finger(s) swelling, and painful finger(s) ROM. Kanavel signs are associated with FTS. They include swelling of the involved digit(s), tenderness on palpation of the flexor tendon, pain with passive finger extension, and fingers held in the flexed position. Tenderness on palpation of the flexor tendon and pain with passive finger extension is the most reliable of the Kanavel signs for predicting septic FTS.2 The patients who you suspect of having septic FTS should be admitted and started on appropriate empiric IV antibiotic (Vancomycin, or Piperacillin-Tazobactam).1-4,6 Frequently, patients will respond to antibiotic therapy in 12 to 24 hours.2 However, patients who are diabetic, smoke, have a hx of IV drug abuse, who are malnourished, or are immunocompromised may not respond to IV antibiotic therapy. If patients fail to respond to antibiotic therapy or present with an advanced infection, they will require surgical intervention in addition to antibiotic therapy.1-4,6 

In summary, most patients presenting with paronychia, Felon, or cellulitis can be treated with warm soaks and oral antibiotic therapy. In those patients with recalcitrant paronychia infections, remember that this may be the result of nail-biting. Their infection is comprised of both skin and oral flora, requiring a broader spectrum of antibiotic therapy. For patients with advanced cellulitis or septic FTS, who fail to improve after 12 to 24 hours of empiric vs. organism-specific IV antibiotic therapy, may require surgical intervention to resolve their infection.  

https://www.nytimes.com/2020/12/16/magazine/mycobacterium-marinum.html?smid=em-share 

REFERENCES  

1. Patel DB, Emmanuel NB, Stevanovic MV, et al, Hand Infections: Anatomy, Types and Spread of Infection, Imaging Findings, and Treatment Options, RadioGraphics 2014;34(7):1968-1986 

2. Bilolikar VK, Seigerman DA, Ilyas AM, Diagnosis and Management of Common Hand Infections, JBJS Reviews 2020;8(4): E0188 

3. Rerucha CM, Ewing JT, Oppenlander KE, Cowan WC, Acute Hand Infections, Am Fam Physician 2019;99(4):228-236 

4. Rabarin F, Jeudy J, Cesari B, et al, Acute finger-tip infection: Management and Treatment, Orthopaedic & Traumatology & Research, 2017;103:933-936 

5. Nardi NM, Schaefer TJ. Felon. [Updated 2018 Dec 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019, accessed November 21, 2019 

6. Koshy JC, Bell B. Hand Infections. J Hand Surg Am. 2019 Jan;44(1):46-54  

See Tom Gocke, DMSc, ATC, PA-C, DFAAPA speak at a 2021 Skin, Bones, Hearts & Private Parts CME Conference in Destin, Myrtle Beach, Pensacola Beach , Orlando, or Las Vegas.

In-person, Live Stream, or On-demand