The risk of wound infection after simple hand laceration

Antibiotic treatment of hand wounds in children: Contribution of a decision tree

BACKGROUND

The need for prophylactic antibiotic treatment of hand wounds in children requiring emergency surgical exploration is still controversial. Our starting hypothesis was that the absence of prophylactic antibiotic treatment in this setting (as specified by a decision tree) does not increase the likelihood of surgical site infection.

METHODS

A decision tree for antibiotic prescription was developed by a working group in compliance with the guidelines issued by the French High Authority for Health, as part of a clinical pathway. One injection of intravenous antibiotics was prescribed for bite injuries, open joint injuries, injuries left untreated for more than 24 h, and suspected contaminated wounds. All children admitted for surgical treatment of a hand wound between July 2018 and March 2023 were included. Demographic data, antibiotic prescription and onset of postoperative surgical site infection were recorded.

RESULTS

The 238 children included had a mean age of 8 ± 4.8 years; 102 received antibiotics and 136 did not. Eleven children (4.6%) had superficial surgical site infection requiring no revision surgery or antibiotic therapy. 206 children (86.5%) were treated following the decision tree. Ten had superficial surgical site infection: 3 received antibiotics (3.7% of the 80 who were treated) and 7 did not (5.5% of the 126 not treated) (p = 0.74). Thirty-two patients (13.5%) were off-protocol, only 1 of whom received antibiotics for superficial surgical site infection.

DISCUSSION

Applying the decision tree standardized the prescription of antibiotics in hand wounds, was not associated with a significantly greater rate of surgical site infection, and avoided exposure to antibiotics for 61.1% of the children, thus limiting potential adverse events.

LEVEL OF EVIDENCE

III.

Antibiotic Prophylaxis in the Management of Distal Fingertip Amputation and Crush Injury

Purpose

We sought to investigate the role of prophylactic antibiotics for distal fingertip crush injury or transphalangeal amputation treated outside of an operating room and better understand the factors that contribute to antibiotic-prescribing decisions. We hypothesized that prophylactic antibiotics do not meaningfully reduce the incidence of infection and that antibiotics are prescribed in a predictable way.

Methods

This is a retrospective review of all patients treated in a MedStar-affiliated emergency department or urgent care for nonsurgical distal fingertip trauma in 2019. Patient demographics, comorbidities, injury characteristics, interventions, and follow-up details were recorded. Exclusion criteria included signs of infection at the time of presentation, minor injuries not requiring intervention, bite wounds, one-time intravenous antibiotic administration without oral course, and surgical intervention. Outcomes included infection and interventions at follow-up. Chi-square analysis was performed, comparing antibiotic and no-antibiotic groups. A stepwise binomial regression was used to evaluate for variables predictive of antibiotic prescription.

Results

We identified eight infections in 323 patients included in the study (2.5% incidence of infection). There was no statistically significant difference in the incidence of infection between patients treated with antibiotics (2.7%) and those who did not receive antibiotics (2.2%). However, due to the low incidence of infections, we were likely underpowered for this analysis. We also created a model to predict antibiotic prescribing, which achieved an area under the receiver operating characteristic curve of 0.86 (P < .0001) based on age, bleeding disorders, depressive disorders, open wound status, amputation, fractures, and encounter type.

Conclusions

The low incidence of infection (2.5%) and lack of a meaningful difference between the groups call into question prophylactic antibiotic prescribing after these distal fingertip injuries. Our model does predict provider prescribing habits, identifying areas for potential practice pattern change.

Type of study/level of evidence

Therapeutic III.

Surgical Antimicrobial Prophylaxis in Pediatric Patients Undergoing Plastic Surgery: A RAND/UCLA Appropriateness Method Consensus Study

For many years, it was clearly shown that surgical procedures might be associated with surgical site infection (SSI). Many scientific institutions prepared guidelines to use in surgery to reduce abuse and misuse of antibiotics. However, in the general guidelines for surgical antibiotic prophylaxis, plastic surgical procedures are not addressed or are only marginally discussed, and children were almost systematically excluded. The main aim of this Consensus document is to provide clinicians with recommendations on antimicrobial prophylaxis for pediatric patients undergoing plastic surgery. The following scenarios were considered: clean plastic surgery in elective procedures with an exclusive skin and subcutis involvement; clean-contaminated/contaminated plastic surgery in elective procedures with an exclusive skin and subcutis involvement; elective plastic surgery with use of local flaps; elective plastic surgery with the use of grafts; prolonged elective plastic surgery; acute burns; clean contused lacerated wounds without bone exposure; high-risk contused lacerated wounds or with bone exposure; contused lacerated wound involving the oral mucosa; plastic surgery following human bite; plastic surgery following animal bite; plastic surgery with tissue expander insertion. Our Consensus document shows that antimicrobial perioperative prophylaxis in pediatric patients undergoing plastic surgery is recommended in selected cases. While waiting the results of further pediatric studies, the application of uniform and shared protocols in these procedures will improve surgical practice, with a reduction in SSIs and consequent rationalization of resources and costs, as well as limiting the phenomenon of antimicrobial resistance.

Relevance of antibiotic prophylaxis in the management of surgical emergency open hand trauma

Surgical site infection after emergency hand surgery can cause considerable morbidity and, in the most severe forms, even toxic shock syndrome. Postoperative antibiotic prophylaxis aims to reduce the number of surgical site infections. However, excessive use of antibiotics induces side-effects for patients and antibiotic resistance for society. Contrary to other orthopedic sites, there is no consensus on postoperative antibiotic prophylaxis in open hand trauma beyond analogic reasoning with no proven scientific validity. Our hypothesis was that absence of postoperative antibiotic prophylaxis after open hand trauma surgery does not affect the rate of surgical site infections. A prospective cohort study included 405 patients, operated on in the emergency hand trauma unit without intra- or post-operative antibiotic prophylaxis. Patients were followed up in consultation at 7, 14 and 30 days. Surgical site infection was defined by need for surgery for detersion and flattening, followed by curative antibiotic therapy. The surgical site infection rate was 2.22%. Four patients were lost to follow-up and counted as surgical site infection as originally planned in the worst-case analysis. There were five surgical revisions followed by antibiotic therapy. These results do not differ from those reported in the literature, and thus confirm our hypothesis that postoperative antibiotic prophylaxis is not indicated in open hand trauma management.

Updates in emergency department laceration management

Lacerations are a common reason for patients to seek medical attention, and are often acutely managed in the emergency department. Recent studies pertaining to closure techniques, sedation and analgesia, advances in wound care, and various other topics have been published, which may enhance our understanding of this injury and improve our management practices. This article will review pertinent studies published in the past few years relevant to laceration management. Understanding the current literature and appreciating which areas warrant further investigation will help us optimize outcomes for patients who sustain laceration injuries.

Meta-analysis of antibiotics for simple hand injuries requiring surgery

BACKGROUND

Simple hand trauma is very common, accounting for 1·8 million emergency department visits annually in the USA alone. Antibiotics are used widely as postinjury prophylaxis, but their efficacy is unclear. This meta-analysis assessed the effect of antibiotic prophylaxis versus placebo or no treatment on wound infection rates in hand injuries managed surgically.

METHODS

Embase, MEDLINE, PubMed, Cochrane Central, ClinicalTrials.gov and the World Health Organization International Clinical Trials Portal were searched for published and unpublished studies in any language from inception to September 2015. The primary outcome was the effect of antibiotic prophylaxis on wound infection rates. Open fractures, crush injuries and bite wounds were excluded. Study quality was assessed using the Cochrane risk-of-bias tool. Data were pooled using random-effects meta-analysis, and risk ratios (RRs) and 95 per cent c.i. obtained.

RESULTS

Thirteen studies (2578 patients) were included, comprising five double-blind randomized clinical trials, five prospective trials and three cohort studies. There was no significant difference in infection rate between the antibiotic and placebo/no antibiotic groups (RR 0·89, 95 per cent c.i. 0·65 to 1·23; P = 0·49). Subgroup analysis of the five double-blind randomized clinical trials (864 patients) again found no difference in infection rates (RR 0·66, 0·36 to 1·21; P = 0·18).

CONCLUSION

There was moderate-quality evidence that routine use of antibiotics does not reduce the infection rate in simple hand wounds that require surgery.

Assessing the Prevalence of Traumatic Head Injury amongst Recreational Surfers in the United States

Surfing is a popular recreational sport that carries a substantial risk of injury. Although head injuries are frequently documented in the surfing population, an in depth assessment of the prevalence of surfing-related head injury has not been reported. A web-based survey was conducted in May of 2015. Participants were asked a series of questions regarding surfing-related injuries and demographic characteristics. A total of 50 responses were obtained, of which 35 (70%) reported sustaining a head injury. The most common injury was laceration of the head/face (n=27), followed by concussion (n=13). Other injuries, such as skull fracture and broken nose, were also reported. Only 2 of the 50 participants reported wearing a protective helmet. Neurosurgical intervention was required in 2 instances. Increased emphasis on preventative measures by the medical community may reduce the future incidence of such injuries. Medical professionals should be aware of the most common forms of injury sustained by the surfing population in order to better recognize and treat these conditions.