Community-associated methicillin-resistant Staphylococcus aureus hand infections in an urban setting

PURPOSE: The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) infection appears to be increasing. The purpose of this study was to determine prospectively the incidence of MRSA in community-associated hand infections in an urban hospital. METHODS: Sixty-one patients presented to our institution over a 9-month period with community-acquired hand infections that were evaluated and treated by the hand service. The specimens obtained during the initial evaluation and treatment were cultured and subjected to antibiotic susceptibility testing. Four nosocomial infections and 5 fight bites were excluded. RESULTS: Of the remaining 52 patients, 38 (73.1%) were MRSA positive. CONCLUSIONS: The rate of community-associated MRSA hand infections in an urban setting is higher than previously suspected. This should be taken into account when managing seemingly routine hand infections given that the treatment options are different for MRSA infections. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.     

Infections of the hand in the immunocompromised host

Individuals who are immunocompromised, such as those with a diagnosis of diabetes or acquired immunodeficiency syndrome (AIDS), as well as patients immunosuppressed after transplantation or chemotherapy for oncologic reasons, are more prone to the development of infections in general, and, more specifically, infections of the hand. Most commonly, these hand infections are caused by organisms that are common to the skin but may show an unusual aggressive or atypical course. A small percentage of these patients are infected by atypical organisms that rarely cause infections in an immunocompetent individual. The surgeon who treats hand infections also must be aware of systemic conditions that can negatively impact the treatment of hand infections.     

Increasing Multidrug Antibiotic Resistance in MRSA Infections of the Hand: A 10-Year Analysis of Risk Factors

Background: Methicillin-resistant Staphylococcus aureus (MRSA) is the most common pathogen isolated from hand abscesses. The purpose of this study was to understand trends and changes in longitudinal antibiotic resistance profiles and risk factors for these infections to better guide empiric treatment of hand infections. Methods: We performed a retrospective review of culture-positive hand infections over a 10-year period at an urban academic institution from 2005 to 2014. A subset of MRSA hand infections from 2013 to 2014 was then subanalyzed for risk factors for antibiotic resistance for antibiotics with increasing antibiotic resistance during this period. Results: MRSA grew in 46% of hand infections, with a decreasing incidence over the 10-year study period. However, in the same time period clindamycin and levofloxacin resistance increased from 7% to 31% and 12% to 56%, respectively. Risk factors for clindamycin resistance included nosocomial infections and a history of intravenous drug use and hepatitis C. Risk factors for levofloxacin resistance included a history of diabetes and a fever upon initial presentation. Conclusions: The incidence of multidrug resistance remains high, with growing resistance to clindamycin and levofloxacin. There remains a trend for increased clindamycin resistance for patients with history of intravenous drug use and nosocomial infections. Our findings indicate that clindamycin and levofloxacin should be avoided for empiric treatment for hand infections in patients with these risk factors.     

Community-Acquired Methicillin-Resistant <Emphasis Type="Italic">Staphylococcus aureus</Emphasis> in the Suburban Hand Surgery Patient Population

Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent cause for patients to present to a physician’s office or emergency department. We observed increasing numbers of community-acquired MRSA infections in patients admitted to the hand surgery service at our suburban academic center. It is an important issue as unsuspected community-acquired MRSA hand infections can be admitted to the hospital, inadequately treated, and allowed for nosocomial spread. This study was performed to examine the trend in the incidence of community-acquired MRSA infections in patients admitted to the hand surgery service in order to sensitize practitioners to have a high index of suspicion for this entity and promote early recognition and treatment of this organism. A multihospital retrospective chart review was undertaken to compare the total number of community-acquired MRSA infections in our hospital as well as the number in patients admitted to the hand surgery service with community-acquired MRSA from 2000 through 2008. Statistical analysis was provided by linear regression. Two community-acquired hand MRSA infections were treated in 2000, as compared to three in 2001 and 2002, four in 2003, five in 2004, six in 2005, 14 in 2006, 13 in 2007, and ten in 2008. This increase was statistically significant (p = 0.038). This retrospective review documents a rapidly rising number of community-acquired MRSA hand infections in the suburban environment. The hand surgeon must be aware of the increased prevalence of this entity to adequately combat this organism and prevent prolonged hospital stays, expanded morbidity, and inflated treatment costs.     

Clean hands campaign: no chance for healthcare associated infections

About 500,000 healthcare associated infections can be observed each year in Germany, about 20-30 %, that means 100,000 to 150,000 cases, are avoidable. Healthcare associated infections lead to increased mortality and prolongation of stay. The average prolongation of stay are 4 days, therefore about 2 Million additional hospital days can be determined. In other words about 6 hospitals with 1000 beds each are only caring for patients with healthcare associated infections. Experts agree that careful hand disinfection is the most important procedure to avoid transmission of pathogens. Studies demonstrate that an increasing compliance to hand disinfection leads to a reduction of healthcare associated infections. The clean hands campaign is a joint effort of the National Reference Centre for Surveillance of Nosocomial Infections, the German Society for Quality Management in Healthcare and the Patient Safety Campaign has the objective to achieve a significant improvement of hand hygiene.     

沿海地区手部低毒感染病例的临床分析

目的 探讨沿海地区手部低毒性感染的发病机制，治疗和预后。方法 复习24例手部低毒感染病史的发病特点，特征及治疗结果，并分析其病因学及流行病学特点。结果 该病多有海洋生物刺伤史。临床特征与手部分支杆感染的表现相同，但没有结核感染的全身表现。病理学检查多数可见慢性肉芽肿。24例均作病灶清除术，并辅助应用抗分支杆菌的药物化疗。术后用TAM系统评定功能，结果优7例，良9例，可2例，差1例。结论 该病多发于沿海地区，有分支杆菌病的流行因素，病理报告提示与分支杆菌有关。彻底的病灶清除手术可收到较好的疗效。     

Hand infections secondary to fish bone injuries.

Hand injuries associated with fish bones and fin spines are not common but can cause morbidity out of proportion to the original injury. This is because such injuries often leave residual fragments of foreign organic matter in the tissues, leading to troublesome secondary infections. This report details 1 year's experience with nine hand infections after fish bone injury in a busy regional hand surgery referral centre. There were five males and four females with an average age of 45 years. Radiographs taken on presentation in five patients revealed a radiolucent foreign body in only two patients. Two patients presented with a flexor tendon sheath infection, three with a pulp space infection, one with infection of the hypothenar space, one with a subungual infection, one with cellulitis of the dorsum of the hand and one with an abscess on the dorsum of the hand. Antibiotics were prescribed for six patients and all patients except the one with cellulitis of his hand underwent surgical débridement. A single surgical procedure was adequate in five patients. One patient with a hypothenar space infection only had the foreign body removed during the third surgical débridement. The two patients with flexor tendon sheath infections required ray amputation. Fish bones cause a number of different infections in the hand. A foreign body should always be sought even if not present on the radiograph. Antibiotic selection should be tailored to eradicate the causative organism.     

Infections secondary to intravenous drug abuse

The author describes his experience in a Miami hospital, where an average of three to five cases per week of infections to the hand related to intravenous drug abuse were seen. The infections are classified along with the appropriate treatment techniques.     

Hand infections caused by delayed inoculation of Vibrio vulnificus: does human skin serve as a potential reservoir of vibrios?

Vibrio vulnificus may cause severe soft tissue infections of the upper extremity. This pathogen usually gains access to soft tissues either by direct inoculation through a penetrating injury by an infected marine animal or by exposing abraded skin to contaminated water. We report five patients with Vibrio vulnificus hand infections following superficial hand injuries incurred within 24 hours after uneventful handling of fish. This clinical observation, together with the fact that the physiologic characteristics of human sweat simulate the natural environment of the Vibrio vulnificus, support the assumption that human skin may serve as a reservoir for Vibrios. The anamnesis in patients presenting with hand infection should essentially include an inquiry regarding recent, albeit uneventful, fish handling.     

Hand infections in patients with acquired immunodeficiency syndrome

Eight patients are reported with hand infections and a diagnosis of acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (ARC). Seven patients had AIDS and one ARC. Four were homosexually active males, three were intravenous drug abusers, and one was the wife of a presumed drug abuser. The hand infections were not truly opportunistic; three patients had herpes, two had osteomyelitis, one had septic arthritis, and two had bacterial abscesses. The presentation or course of the infection was atypical in the majority of patients. The infections were seen early in the course of the disease and in one half of the patients preceded the diagnosis of AIDS. Unusual hand infections, then, may suggest the development of AIDS in a patient at risk.     

Mycobacterium szulgai Infection after Carpal Tunnel Release Requiring Extensive Debridement and ALT Flap Reconstruction

Nontuberculous mycobacteria (NTM) refer to all mycobacteria species not associated with the Mycobacterium tuberculosis complex. NTM have been shown to cause superficial and deep tissue infections of the hand, the vast majority of which are attributed to Mycobacterium marinum . There have been only eight cases of Mycobacterium szulgai -associated infections of the hand described in the English literature, none requiring surgical reconstruction. We describe a severe case of M. szulgai -associated carpal tunnel infection reported in an immunocompetent patient requiring extensive soft tissue debridement and reconstruction. This case illustrates the importance of a multidisciplinary team approach with microbiology specialists when managing severe soft tissue infections of the hand.     

Mycobacterial infections

Mycobacterial infections of the hand are increasing in frequency, and at least seven atypical mycobacteria have been reported in the hand. The authors present several types of atypical mycobacteria, the types of infections they cause, accurate diagnosis methods, and proper treatment protocols.     

Changing bacteriologic flora of hand infections

To assess the possibility of a changing bacteriologic flora of hand infections and an alteration in antibiotic susceptibility, a 20-year review of acute hand infections was undertaken. Representative years were completely evaluated during the 20-year span. Over the course of the study Staphylococcus aureus infections decreased from 82% of cultures in 1960 to 34% in 1980. Pure Gram-positive cultures decreased from 85% in 1960 to 50% in 1980. Mixed Gram-positive and Gram-negative infections rose significantly from 8 to 39% over the 20-year study period. Susceptibility of Staphylococcus aureus to penicillin changed from 72% in 1960 to 9% in 1980. Susceptibility of Staphylococcus aureus to the penicillinase-resistant antibiotics and the cephalosporin antibiotics was at 81% and 97%, respectively, in 1980.     

Health-care-associated infections and prevention

Health-care-associated infections (HAIs) are an important cause of perioperative morbidity and mortality. Currently, one out of every 10 surgical patients develops an HAI. Causes of HAIs vary, but include the transient immunodeficiency associated with surgery,immobility, and the presence of indwelling devices. With rates of antimicrobial resistance increasing, prevention remains the best solution. The investigators review the most frequently encountered health-care-associated infections with an emphasis on preventative strategies. The article addresses issues related to the diagnosis,treatment, and prevention of health-care-related pneumonia,health-care-associated urinary tract infections, and intravascular-catheter-related infections. The article also discusses the utility of hand hygiene policies.     

Methicillin-resistant Staphylococcus aureus hand infections in a suburban community hospital

Of hand infections treated in a suburban community hospital, 65% were found to have cultures positive for methicillin-resistant Staphylococcus aureus (MRSA). This incidence of MRSA infection is comparable to MRSA infection rates found in county hospitals and trauma center hand infection populations. MRSA should be recognized as a common primary pathogen in hand infections.     

The World Health Organization '5 moments of hand hygiene': the scientific foundation

The World Health Organization (WHO) launched the first Global Patient Safety Challenge in 2005 and introduced the '5 moments of hand hygiene' in 2009 in an attempt to reduce the burden of health care associated infections. Many NHS trusts in England adopted this model of hand hygiene, which prompts health care workers to clean their hands at five distinct stages of caring for the patient. Our review analyses the scientific foundation for the five moments of hand hygiene and explores the evidence, as referenced by WHO, to support these recommendations. We found no strong scientific support for this regime of hand hygiene as a means of reducing health care associated infections. Consensus-based guidelines based on weak scientific foundations should be assessed carefully to prevent shifting the clinical focus from more important issues and to direct limited resources more effectively. We recommend caution in the universal adoption of the WHO '5 moments of hand hygiene' by orthopaedic surgeons and other health care workers and emphasise the need for evidence-based principles when adopting hospital guidelines aimed at promoting excellence in clinical practice.     

Gentamicin-PMMA-Miniketten bei Infektionen der Hand

Hitherto a prolonged treatment and immobilization was necessary in case of bone and soft tissue infections of the hand. The result was frequently a poor function of the hand due to ankylosis. The infection period can be shortened by an early, carefully performed sequestrotomy with additional temporary implantation of gentamicin-PMMA minichains. The evaluation of 200 cases shows the good results of this therapy method.     

Therapie des Weichteiltraumas in der Akutphase von schweren Handverletzungen

INTRODUCTION: Complex hand injuries are characterized by a combination of soft tissue injury and additional trauma to functional structures such as nerves, bones, tendons, vessels and joints. A good functional result requires the reconstruction of the injured structures and early mobilisation. Good vascularized soft tissue and stable osteosyntheses are the major prerequisites to avoid infections and to allow early mobilisation. The optimal timing for soft tissue reconstruction remains controversial with respect to the incidence of infections. METHODS: We have evaluated retrospectively our series of complex hand injuries addressing the question whether a delay of soft tissue coverage for up to 72 hours causes significant increase of infection rates. RESULTS: 48 patients were treated with complex injuries of the hand within a three year period between December 1998 and December 2000. The lowest incidence of infections occurred in the group, where soft tissue coverage was completed as an emergency procedure. DISCUSSION: Ideally primary reconstruction of complex hand injuries should be strived for to minimize scar formation as a result of secondary operations and further immobilisation periods. This includes, if necessary, free tissue transfer. Exceptions are situations where the vitality of soft remains uncertain. In these cases, definitive surgery is delayed for a maximum period of 72 hours.     

„AKTION Saubere Hände“

There are approximately 500,000 hospital acquired infections per year in Germany of which about 20–30% (100,000–150,000) could be prevented. Hospital acquired infections are associated with increased mortality and prolonged hospital stay. Based on approximately 4 additional days of hospital stay, nosocomial infections cause additional 2 million hospital days per year. In other words, 6 hospitals each with 1,000 beds would be caring solely for patients with nosocomial infections for 1 year in Germany. Experts agree that careful hand hygiene is the single most effective measure to prevent transmission of pathogens. The rate of nosocomial infections can be reduced by improved compliance of hand hygiene as demonstrated in the literature. The ‘‘AKTION Saubere Hände’’ (Clean Hands Campaign) is a national campaign by the National Reference Centre for the Surveillance of Nosocomial Infections, the Society for Quality Management in the Health System and the Action Alliance Patient Safety aimed at the sustained improvement of hand hygiene behaviour in German hospitals.