Hand infections secondary to human bites

Predicting serious complications and high cost of treatment of tooth-knuckle injuries: a systematic literature review

PURPOSE

The tooth-knuckle injury (TKI) is a serious and potentially costly injury seen in orthopaedic practice. The aim was to conduct a systematic literature review on the factors associated with serious complications and high treatment costs in tooth-knuckle injuries.

METHODS

MEDLINE, Scopus and CINAHL were used as the literature sources.

INCLUSION CRITERIA

Original research papers that reported on factors predicting serious complications and high treatment costs in TKIs were included. There were no restrictions placed on study size, language, study design or date of publication.

EXCLUSION CRITERIA

Case studies, case series and review articles were not included.

RESULTS

After duplicates were removed, 403 unique studies remained; after titles and abstracts were screened, 48 titles remained and were retrieved in full text. Of these, 14 titles met the inclusion criteria and were included in the data synthesis. Tenosynovitis, septic arthritis, osteomyelitis and residual stiffness were common serious complications occurring in up to 36.3, 70.0, 47.6 and 65.3 % of cases, respectively. Amputation was also common in up to 18.0 % of injuries. Treatment costs were measured by length of hospital stay and the number of debridements required. On average, patients required 3.8-8 days of admission and 1.3-2.7 debridements each.

CONCLUSION

Increased time delay from injury to treatment, deeply penetrating injuries, proximal interphalangeal joint (PIPJ) injuries and, possibly, E. corrodens infections were associated with serious complications in TKIs. Delayed treatment, inadequate treatment, PIPJ injuries and deeply penetrating injuries predicted higher treatment costs.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42016029949 ( http://www.crd.york.ac.uk/PROSPERO/display_record.asp?ID=CRD42016029949 ).

Epidemiology of bacterial hand infections

OBJECTIVE

The aim of the study was to delineate and update the bacteriological spectrum, characterize patterns and sites of injury, evaluate laboratory tests and possible causes of complications in patients with bacterial hand infections.

METHODS

All hand infections operated on in the department of orthopedics at Odense University Hospital during the period 1992-2001 were reviewed retrospectively. A standard protocol was used to collect data for each patient. We also examined all laboratory reports and recorded the identity of the etiologic organism, if known, for all cases of bacterial hand infections.

RESULTS

Four hundred and eighteen patients (296 men and 122 women) with hand infections were operated on between 1992 and 2001 in our department. The median age of the patients was 40 years (range 1-93). The average interval from primary injury to operation was 10 days (range 1-50). The etiology was laceration/puncture in 35%. The site of infection was subcutaneous in 45% followed by tendon, joint and bone in 27, 18 and 5%, respectively. The bacteria isolated from the patients showed that 184 cultures (44%) were pure Staphylococcus aureus followed by 49 cultures (11.7%) of mixed organisms. Body temperature and C-reactive protein (CRP) were normal in three quarters of all patients with hand infections in our series. However the erythrocyte sedimentation rate (ESR) was elevated in 50% of the patients and was a significantly better test for infection in this study than CRP (p = 0.002). Neither the severity of infection nor the etiology of infection was related in any way to the initial temperature, CRP or ESR in this study. Complications were noted in 14.8% of all patients, and were especially related to diabetes, and mixed infection.

CONCLUSION

Despite modern antibiotics, hand infections with a variety of organisms continue to be a source of morbidity and possible long-term disability. Most hand infections are the result of minor wounds that have been neglected. A complete history and physical examination is necessary to exclude other associated medical conditions (diabetes, arthritis, immunosuppression) that may compromise therapy. Furthermore, our study confirms that Staphylococcus aureus is responsible for most instances of hand infection, followed by mixed organisms. Gram-negative organisms are frequently cultured in patients with diabetes and intravenous drug abuse.

Clinical Presentation and Bacteriologic Analysis of Infected Human Bites in Patients Presenting to Emergency Departments

Previous studies of infected human bites have been limited by small numbers of patients and suboptimal microbiologic methodology. We conducted a multicenter prospective study of 50 patients with infected human bites. Seventy percent of the patients and assailants were young adult men. Fifty-six percent of injuries were clenched-fist injuries and 44% were occlusional bites. Most injuries were to the hands. Fifty-four percent of patients were hospitalized. The median number of isolates per wound culture was 4 (3 aerobes and 1 anaerobe); aerobes and anaerobes were isolated from 54% of wounds, aerobes alone were isolated from 44%, and anaerobes alone were isolated from 2%. Isolates included Streptococcus anginosus (52%), Staphylococcus aureus (30%), Eikenella corrodens (30%), Fusobacterium nucleatum (32%), and Prevotella melaninogenica (22%). Candida species were found in 8%. Fusobacterium, Peptostreptococcus, and Candida species were isolated more frequently from occlusional bites than from clenched-fist injuries. Many strains of Prevotella and S. aureus were beta-lactamase producers. Amoxicillin-clavulanic acid and moxifloxacin demonstrated excellent in vitro activity against common isolates.

Infectious complications associated with toothpick injuries of the hand

PURPOSE

Although rare, hand injury caused by toothpicks can result in serious complications similar to hand injury produced by human biting. To emphasize its clinical significance this article describes a group of patients sustaining hand injury induced by toothpicks.

METHOD

Eight patients who developed cellulitis, abscess, septic arthritis, and/or pyogenic tenosynovitis of flexor tendons after toothpick injuries of the hand were treated at our hospital. Seven of them required admission for antibiotics and surgical treatment.

RESULTS

The 7 admitted patients required multiple debridements (3 times on average) to control infection and administer intravenous antibiotics for mixed aerobic and anaerobic infections showing in wound cultures. The average hospital stay for the 7 patients was 26 days. At follow-up evaluation, 4 patients had full recovery of hand function after various cutaneous flap resurfacing of the wounds or staged tendon reconstruction, whereas the remaining 4 patients had arthritis with flexion contracture of interphalangeal joints or persistent paresthesia of the finger.

CONCLUSIONS

Patients injured by contaminated toothpicks should be treated with antibiotics that inhibit the growth of both aerobic and anaerobic organisms immediately after these organisms have been identified from cultures. Moreover early surgical treatment might avoid complications and obtain satisfactory results.

Microbiology and management of human and animal bite wound infections

This article describes the microbiology, diagnosis, and management of human and animal bite wound infections. Various organisms can be recovered from bite wounds that generally result from aerobic and anaerobic microbial flora of the oral cavity of the biting animal, rather than the victim's own skin flora. The role of anaerobes in bite wound infections has been increasingly appreciated. Anaerobes were isolated from more than two thirds of human and animal bite wound infections, especially those associated with abscess formation. This article describes several of the organisms found in the bites of various species. In addition to local wound infection, other complications may occur, including lymphangitis, local abscess, septic arthritis, tenosynovitis, and osteomyelitis. Rare complications include endocarditis, meningitis, brain abscess, and sepsis with disseminated intravascular coagulation, especially in immunocompromised individuals. Wound management includes the administration of proper local care and the use of proper antimicrobial agents when needed.

Osteomyelitis of the hand after a human bite

Twenty-four cases of osteomyelitis of the hand after human bite were reviewed. The mechanism of injury was equally divided between incisor bites and clenched fists. Eleven of twelve of the clenched-fist injuries showed a tooth mark in the bone or cartilage at the site of inoculation. The incisor bites showed initial infection of the soft tissues or joint with a secondary infection of the bone. Factors leading to the development of osteomyelitis included a delay of more than 24 hours before debridement or inadequate initial treatment. Bacteriologic study commonly showed mixed infections with skin and oral flora. The infections were prone to relapse, and nine patients required more than one surgical debridement.

Treatment of mammalian bite wounds of the maxillofacial region

Infected human bites may result in devastating consequences. Failure to recognize the destructive potential of infections of bone, tendons, joints, and soft tissue caused by oral microorganisms can lead to serious loss of intrinsic functions. Rapid prevention or resolution of infection by appropriate use of antibiotics and surgical treatment continues to be a therapeutic challenge.

Bite wounds to the upper extremity

The complications secondary to mismanaged or neglected bite wounds to the upper extremity can be devastating to upper extremity functioning. An organized approach to treatment can prevent infection and permanent disability.

Controversies in antibiotic choices for bite wounds

In the last decade much progress has been made in our understanding of animal bites. Two major areas of remaining controversy are discussed. Recent study of human bites has shown that the early literature depicting all human bites as having an extraordinarily high infection and complication rate was biased by its emphasis on human bites of the hand that presented late with infection already present. These bites, the so-called closed-fist injuries (CFI), do indeed have a poor prognosis, but it may be as much due to their location and initial neglect as to the source of the injury. Human bites elsewhere do not seem to have any higher risk than animal bites, which have an infection rate of about 10%. Human bites of the face, lips, and ears are at very low risk for infection (less than 3%) if properly treated. The CFI should be identified early and aggressively irrigated and debrided (if possible). CFI wounds can be treated on an outpatient basis if uninfected and less than 24 hours old. The economical outpatient antibiotics of choice for CFI are penicillin plus dicloxacillin; the former is needed to cover Eikenella corrodens and the latter to cover Staphylococcus aureus, both common in these wounds. Diabetics with hand infection frequently have Gram-negative infection and may warrant parenteral aminoglycosides. Second- and third-generation cephalosporins are very effective but should be reserved for special situations due to their expense. Prophylactic antibiotics are not indicated for typical bite wounds, which are low risk. The choice of antibiotic (when needed) in other bite wounds is a matter of confusion, because the only scientific data available are in vitro sensitivities, which are a very poor and crude reflection of the clinical reality. Antibiotic effectiveness in vivo is dependent on a complex summation of absorption, tissue levels (not just serum levels), host immune defenses, and the interrelationships between bacterial species present. For dog bite wounds, dicloxacillin and cephalexin are both good choices because they cover most of the broad spectrum of infecting pathogens; dicloxacillin is significantly cheaper.(ABSTRACT TRUNCATED AT 400 WORDS)

Mammalian bites

Mammalian bites account for one percent of all visits to emergency departments. More than 95% of all complications consist of local wound infections. Risk factors for infection include location on the hand or foot, puncture wounds, and treatment delay, as well as general risk factors for infection. "Clenched fist" injuries have a high risk for very severe complications. The mainstay of treatment is meticulous local wound care with debridement and irrigation. Antibiotics should only be considered as a secondary modality to prevent wound infection.

Extensor tendon repair in the emergency department

Extensor tendon lacerations of the hand are commonly seen in the emergency department. These injuries can often be definitively managed by the emergency physician who has a working knowledge of the complex extensor mechanism anatomy plus basic surgical skills. A thorough initial assessment including a tourniquet examination for adequate exposure is the key to making the complete diagnosis. Surgical indications, materials, techniques, complications, and postoperative management involved in extensor tendon repair are reviewed. The emergency physician's decision to treat or refer these injuries will depend greatly on the clinical setting, familiarity with the procedure, and the availability of and relationship with appropriate consultants.

Human bites of the hand: a study of one hundred six patients

One hundred six patients with human bites of the hand (HBH) were studied in detail. This study was characterized by a higher than expected incidence among women, by a large number of patients who presented for treatment more than 1 week after injury, and by a high complication rate and a low incidence of hospitalization. The overall morbidity rate of these patients was considerable. Early and delayed cases of HBH were typified by an absence of complications. Except for partial or complete traumatic amputations, their recovery time was short, and the final functional result was usually favorable. Late cases were characterized by a high rate of infection-related complications, a prolonged morbidity period, and a less favorable final functional result. One hundred of our patients were successfully treated as outpatients. This led us to believe that most HBH can be treated on an outpatient basis. Hospitalization should be mainly reserved for patients with infection-related complications and for extremely unreliable patients. The time interval between injury and the commencement of treatment appears to be the single most important factor governing the final result in HBH.

Established hand infections: a controlled, prospective study

A randomized, prospective study of 200 consecutive established hand infections was designed to compare the efficacy of two antibiotics, cefamandole and nafcillin. Bacteriologic data revealed 63.5% of the patients grew multiple organisms (2.3 organisms per culture) and 26% of the patients had anaerobic infections. Complications were noted in 13% of all patients--26% in patients who grew aerobes and anaerobes and 9.8% in patients who grew aerobes alone (p less than 0.05). Despite the fact that 95% of all organisms were sensitive in vitro to cefamandole whereas only 67% of organisms were sensitive to nafcillin (p less than 0.01), complications occurred more frequently in patients treated with cefamandole. We conclude that the empirical selection of a broad-spectrum antibiotic is reasonable based on in vitro sensitivity studies; however, other factors such as treatment delay, initial extent of infection, anatomic location of infection, cause of infection, and extent of surgical debridement are important in the development of complications.

Eikenella corrodens in hand infections

Clinical and therapeutic information on 21 patients with hand infection due to Eikenella corrodens is reported. Patients given empiric therapy ineffective against E. corrodens had a high incidence of complications, while proper empiric therapy was associated with good recovery. All hand wounds should be cultured aerobically and anaerobically and empiric antibiotic therapy should include a penicillinase-resistant penicillin or cephalosporin in combination with penicillin G.

Cefamandole therapy in hand infections

Hand lacerations, especially when inadequately treated, may result in infections caused by aerobic or anaerobic bacteria. Anaerobic infections most commonly result from human bite injuries in which there is contact between hand and mouth. The search continues for an ideal antibiotic to employ when anaerobic organisms are suspected. In this study cefamandole, a new cephalosporin antibiotic, was employed whenever anaerobic hand infections were suspected following trauma. In each patient quantitative cultures for both aerobic and anaerobic organisms were obtained. All organisms isolated were tested by standard susceptibility assays for both aerobes and anaerobes. In the case of anaerobes, minimum inhibitory concentration assays were also performed. After the initial culture was obtained, each patient received approximately 1.5 gm of cefamandole every 6 hours for a period of 5 days. This therapy was changed only if susceptibility studies indicated resistance to cefamandole. In our patients, 58% of the infectious organisms were aerobic and facultative anaerobic and 42% were obligate anaerobes. The predominant organisms isolated were Staphylococcus aureus and Peptostreptococcus anaerobius, which accounted for 42% of the infections. In most of the aerobic infections a single organism was isolated, whereas multiple organisms were identified in the anaerobic infections. All but one of the infections responded to cefamandole; the one that didn't was caused by Enterobacter cloacae and required treatment with an aminoglycoside. Because of its broad-spectrum coverage, which includes both aerobes and anaerobes, cefamandole is useful in treating infections, especially those resulting from human bites.

Human bites to the face: management, review of the literature, and report of a case

The therapeutic and surgical management of avulsive bite injuries to the face is discussed, and a case is presented in which a flap design was used to reconstruct the lower lip after a severe partial avulsion resulting from a human bite.

Unusual cause of gnawing pain in the hand

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Mammalian bite wounds

Clinical data were collected prospectively from a series of 160 patients presenting with mammalian bite wounds. Anaerobic and aerobic cultures were prepared from sterile swabs placed in 65 bite wounds prior to cleansing. Infection was noted in 11 of 22 cat bites, six of 37 human bites, three of 80 dog bites, and in none of the 21 bites caused by other mammals. Pasteurella multocida was recovered from six infected cat and dog bites, all of which developed infection within 24 hours of injury. Staphylococcus aureus and Streptococcus viridans were the principal pathogens isolated from the remaining infected cat, dog, and human bites. Infection most commonly followed puncture wounds caused by cats (10/19) and lacerations into subcutaneous tissue of the hand caused by humans (4/17). None of the 10 sutured wounds became infected. All infected bite wounds responded to antibiotic therapy. No conclusions regarding the value of prophylactic antibiotics could be made.

Infections following clenched-fist injury: a new perspective

Fifteen cases of clenched-fist injury were studied by aerobic, anaerobic, and 10% CO2 cultures. Anaerobic bacteria and Eikenella corrodens were prominent pathogens, being recovered in 60% and 20% of cases, respectively. These organisms are more susceptible to penicillin than to penicillinase-resistant penicillins or cephalosporins. All clenched-fist injuries should be cultured in aerobic, anaerobic, and 10% CO2 atmospheres. We recommend the use of both penicillin and a penicillinase-resistant penicillin as initial empiric therapy.

Human bites of the hand: twenty years of experience

A retrospective study of the records of 20 years of experience with injuries from human bites reviewed the results of treatment of 42 patients during the first 10 years and 94 in the second 10 years. In the later series there was less delay in the treatment due to better education of primary physicians as well as of patients. There were fewer complications also. A prospective study of 38 patients, whose treatment consisted of soap and water cleansing, thorough exploration and debridement, hospitalization for at least 48 hours, and administration of antibiotics, showed this treatment resulted in a reduction of the incidence of amputation and stiff fingers despite the fact that 61% of the patients still delayed seeking treatment.