- Email: [email protected]
Soft tissue infections of the upper extremities with special consideration of abscesses in parenteral drug abusers
SOFT TISSUE INFECTIONS OF THE UPPER EXTREMITIES WITH SPECIAL CONSIDERATION OF ABSCESSES IN PARENTERAL DRUG ABUSERS A prospective study
H. P. S1MMEN, P. GIOVANOLI, H. BATTAGLIA,J. WUST and V. E. MEYER From the Department of Surgery, the Division of Hand, Plastic and Reconstructiye Surgery, Universityof Zurich Medical School and the Institute of Medical Microbiology, University'of Zurich, Switzerland Despite surgical advances and new antibiotics, upper extremity infections continue to present a serious problem. Soft tissue infections of the upper extremities were prospectively examined to elucidate incidence, cause, bacterial pathogens involved, and treatment. Special attention was paid to infections associated with parenteral drug abuse. During an 18-month period all patients over 16 years of age presenting for treatment of an established infection were included in the study. Conservative treatment consisted of immobilization and antibiotics. Radical d6bridement with removal of all necrotic tissue was the guideline for operative care. In addition, for both regimens a penicillinase-resistant antibiotic was administered. A total of 415 patients (271 men and 144 women; mean age 36.7 ± 14.5 years) were enrolled into the study, 55 of whom were parenteral drug abusers; 45 of these were HIV-reactive. Infections of fingers (excluding paronychia), paronychia, and abscesses at injection sites were the most common diagnoses. Operative and conservative treatment were performed in 285 and 130 patients respectively. Staphylococcus and streptococcus species were the predominant organisms recovered from 212 specimens of pus. Anaerobic bacteria and yeasts were of minor importance. Therefore, a penicillinase-resistant antibiotic is a good initial choice. Journal of Hand Surgery (British and European Volume, 1995) 20B: 6:797-800
In a prospective investigation, soft tissue infections of the upper extremities were studied with respect to incidence, site and cause of infection, bacterial pathogens involved, duration of disability of work, and operative or conservative treatment performed. Special attention was paid to soft tissue infections associated with parenteral drug abuse. So far there is little information regarding the association of HIV and hand infection (Glickel, 1988). Drug abuse has long been viewed as a social and psychiatric problem. However, both medical and surgical complications account for an increasing number of hospital admissions. Parenteral drug abuse is responsible for significant morbidity and mortality (Baker et al, 1991; Orangio et al, 1984). Abscesses at the site of injection are the most common complications requiring surgical intervention. Despite surgical advances and newer antibiotics, upper extremity infections continue to present a serious problem, with significant morbidity or severe impairment of function and potential long-term disability. Most infections arise from relatively minor injuries that have been neglected (Stevenson and Anderson, t993). The knowledge of causative bacterial organisms enables the physician to institute antimicrobial therapy empirically before culture results are available. Recommendations in the current literature for the choice of antimicrobial drugs stress the inclusion of a penicillinase-resistant penicillin. The actual importance of coverage of anaerobic bacteria is not known (Dellinger et al, 1988).
PATIENTS AND M E T H O D S
During an 18-month period all patients over 16 years of age presenting for treatment of an established soft tissue infection were included in this study. A total of 415 patients were enrolled. A detailed history was taken, including the mechanism of injury, likely cause of infection and any other relevant medical conditions or predisposing factors. Use of antibiotics prior to hospital admission and study entry did not exclude patients. Operative or conservative procedures depended upon local findings as well as general conditions and were performed according to institutional policies. Before any antibiotics were given, infected material was obtained whenever possible. Every effort was made to obtain the culture from the depth of the wound, which was studied for aerobic and anaerobic organisms and for fungi. Treatment of patients whose infections failed to resolve with a single operative procedure and single course of antibiotics was considered a failure. Conservative therapy consisted of immobilization and elevation, and a penicillinase-resistant antibiotic was administered. Treatment was started intravenously and changed to the oral route. The actual duration of intravenous therapy was determined by clinical judgement. Amoxicillin and clavulanic acid 3 x 3.2 g a day intravenously, followed by 4 x 625 mg a day by oral administration were the antibiotics of first choice. Radical d6bridement with removal of all necrotic tissue as completely as possible was our guideline for operative care, followed by immobilization and elevation until wound healing was secured. 797
THE JOURNAL OF HAND SURGERY VOL. 20B No. 6 DECEMBER 1995
798
An identical antibiotic policy as in conservative treatment was applied. Treatment was continued until all signs of infection had resolved. RESULTS A total of 415 patients (271 men and 144 women) ranging in age from 16 to 85 years (mean 36.7+14.5) were enrolled into the study. 55 parenteral drug abusers (31 men, 24 women, mean age 29 years, range 17 39) were given special attention. The patients presented for treatment after a mean disability of 5 days, two-thirds of them during working hours, one third during the night and holidays. 253 (61%) were treated as outpatients, and the condition of 162 (39%) required hospitalization. Operative and conservative treatment was performed in 285 (69%) and 130 (31%) patients, respectively. In the presence of lymphangitis, the surgical treatment was performed under general anaesthesia. As shown in Table 1, infections of fingers other than paronychia, paronychia, and abscesses at injection sites were the most common diagnoses. The term paronychia was assigned to infections involving only the folds of tissue surrounding the fingernail. A minor or even unnoticed trauma was the predominant reason for an infection (Table 2). 55 out of 61 abscesses at an injection site were associated with parenteral drug abuse. The digits were involved in two-thirds of all upper extremity infections (Table 3). The most common cause of deterioration in the patient's general condition was the use of illicit drugs (Table 2), along with HIV-reactivity (Table 4). 45 out of 55 drug addicts were HIV-reactive. The HIV staging is shown in Table 5; there were no seriously ill AIDS patients. Most of the HIV-positive Table 1--Most common diagnoses in 415 patients
Diagnosis" Infection of finger other than paronychia Paronychia Abscess at an injection site Phlegmon of forearm Infected laceration Deep palmar space infection Bite injury (animal 13; human 3) Flexor tendon sheath infection Bursitis Furuncle Infectious arthritis
Number [%]
Men
Women
154 (37.1)
100
54
79 (19.0) 55 (13.3) 40 (9.6) 23 (5.5) 19 (4.6) 16 (3.9) 14 (3.4) 6 (1.5) 4 (1.0) 4 (1.0)
48 31 29 17 14 11 8 6 3 2
31 24 11 6 5 5 6 0 1 2
Table 2--Predominant causes in 415 upper extremity infections
Minor or unnoticed trauma Major trauma Drug injection Bite injury Unknown
202 114 61 16 22
Table 3--Local distribution of 415 upper extremity infections
Digits Hand Forearm Upper arm
289 96 84 30
(69.6%) (23.1%) (20.2%) (7.2%)
Table 4--Associated conditions in 415 patients
Number (%) None HIV-positive Diabetes Other infections Steroids Immunosuppression after renal transplant Malignant tumours
353 (85.1) 45 (10.8) 7 (1.7) 5 (1.2) 3 (0.7) 1 (0.2) 1 (0.2)
Table 5--Staging in 45 HIV-positive patients
1 2A 2B 3A 4A 4C
0 23 13 5 2 2
(0%) (51.1%) (28.9%) (11.1%) (4.4%) (4.4%)
Classification system for HIV infection from Centres for Disease Control, Atlanta, USA Group 1: Group 2: Group 3: Group 4: Subgroup Subgroup Subgroup Subgroup Subgroup
Acute infection. Asymptomatic infection. Persistent generalized lymphadenopathy. Other disease. A: Constitutional disease B: Neurological disease C: Secondary infectious disease D: Secondary neoPlasms E: Other conditions
patients enrolled in our study were also positive for hepatitis B. Upper extremity infections accounted for considerable morbidity and even permanent disability. Return to normal activity was delayed for 3 to 6 weeks or even longer (Table 6). In 212 of the 285 surgically treated patients, infectious material for bacteriologic assessment could be obtained (Tables 7 and 8). In 181 out of 212 (83%) cultures grew micro-organisms. A single organism was isolated in 99 specimens, and multiple organisms could be recovered from 82 specimens, respectively. The predominant organisms recovered were Staphylococcus aureus, [3-haemolytic streptococcus group A and coagulase-negative staphylococcus. Anaerobic bacteria and candida species were seldom isolated. 43 out of 55 (78%) abscesses of parenteral drug abusers were culture-positive with evidence of a single organism in 26 specimens and multiple organisms in specimens from 17 patients. Streptococcus species ([3-haemolytic streptococcus group A and Streptococcus milleri) were the most common isolates, whereas staphy-
SOFT TISSUE INFECTIONS AND DRUG ABUSERS
799
Table 6--Inability to work
Diagnosis Flexor tendon sheath infection Bursitis Infectious arthritis Infection of finger (excluding paronychia) Abscess at injection site Furuncle Phlegmon of forearm Deep palmar space infection Paronychia Bite injury Infected laceration
Time off"work (mean in days)
Range (days)
35 26 26 22
6-136 5-70 13-21 3-250
21 21 18 14 13 11 8
4-71 5 39 3-110 4-65 1-40 3-29 3 16
Table 7--Isolated micro-organisms from 212 upper extremity infections
Micro-organism Staphylococcus aureus Streptococcus [3-haemolytic group A Staphylococcus coagulase-negative
Streptococcus viridans Haemophilus influenzae Streptococcus milleri Streptococcus I~-haemolytic group B
Klebsiella oxytoca Anaerobes
Enterobacter cloacae Enterococcus Corynebacterium
Klebsiella pneumoniae Escherichia coli Citrobacter
Morganella morganii Candida species
Number (%) 102 51 26 22 19
(34.7) (17.3) (8.8) (7.5) (6.5)
18 (6.1) 10 (3.4) 7 (2.4) 6 (2.0) 5 (1.7) 5 (1.7) 5 (1.7) 4 (1.4) 6 (2) 2 (0.7) 1 (0.3) 5 (11.5)
Table 8--Isolated micro-organisms from 43 abscesses at injection sites of 55 drug addicts
Micro-organisms Streptococcus ]3-haemolytic group A
Streptococcus milleri Staphylococcus aureus Staphylococcus coagulase-negative Anaerobes
Streptococcus viridans Haemophilus influenzae Klebsiella pneumoniae Enterococcus Streptococcus l~-haemolytic group B
Number (%) 15 (28.8) 10 (19.2) 7 (13.4) 6 (11.5) 4 (7.7) 4 (7.7) 2 (3.8) 2 (3.8) 1 (1.9) 1 (1.9)
lococci, anaerobic bacteria, as well as candida species, were of minor importance. Resistant pathogens were not found. Apart from the classical local signs and symptoms of infection, there were no other findings that could be associated with the presence of an infection in 219 (54%) patients. Evidence of lymphangitis could be found in 98
(24%), elevated white blood cell count in 49 (12%), and elevated temperature in 49 (12%) patients, respectively. Operative procedures were indicated in 285 out of 415 (69%) patients. The response to primary operative treatment was satisfactory in all but 23 out of 285 (80/0) patients, who required re-operation due to inadequate primary d6bridement. 15 patients had to be re-operated on once, :seven patients twice, and one patient four times, respectively. The proportion requiring surgical treatment in the parenteral drug abusers was particularly high--49 out of 55 (89%)--indicating the advanced disease in these young, often immunocompromised, addicts (45 out of 55 were HIV-reactive). The drugs injected included mainly heroin, cocaine and some obscure mixtures. A major problem in the care of parenteral drug abusers was their low compliance. The mean delay in presentation after the infection had become symptomytic was 4 days. Skin and oropharyngeal pathogens were recovered from soft tissue abscesses associated with the use of illicit drugs. The major source of infection was the addict himself by preparation and administration of the drug. Blowing clots out of the needle was probably responsible for the high incidence of oropharyngeal flora recovered from the wounds of drug abusers. Local surgical procedures often resulted in soft tissue defects requiring later skin grafting.
DISCUSSION Serious infections of the hand and upper extremity are associated with a high incidence of morbidity. Surgical d6bridement is the treatment of choice, and although antimicrobial drugs given early may prevent suppuration or spread of an existing abscess, they cannot be substituted for surgical d6bridement. Staphylococcus species and streptococcus species are the most common isolates from soft tissue infections of the upper extremities. Anaerobic bacteria are of minor importance. Similar findings are reported by Stevenson and Anderson (1993) and Stromberg (1985). In all infections the antibiotic must be selected empirically on a best guess basis, taking account of the likely pathogens. The recovery rates of aerobes and anaerobes reported in this study are similar to the isolation rates in other studies that have investigated the microbiological characteristics of soft tissue infections of the upper extremities (Brook and Frazier, 1990). Soft tissue infections cause considerable morbidity and time off work. The inability to work in parenteral drug abusers presenting with abscesses accounts for a mean of 21 days (Table 6). However, these figures may be misleading since many of the drug addicts do not work at all. 10% of our patients enrolled in this study are parenteral drug abusers. Drugs and alcohol in connection with emergency hand patients are not uncommon findings. Hutchinson et al (1992) found
800
approximately 40% of the emergency patients to be positive for drugs and/or alcohol. The surgical procedure is the key to curing most hand infections. In most cases treatment should include incision/excision, d6bridement and drainage. Simple incision and drainage, a standard procedure in otherwise healthy people, is not adequate in immunocompromised drug addicts, since HIV is common in parenteral drug abusers. Radical d6bridement is mandatory (Kfich et al, 1993; Kossmann et al, 1994). In addition, antibiotics have proved invaluable and can decrease morbidity and shorten the time of recovery. Initial selection of antibiotics should be empirically based on suspected microorganisms and subsequently altered in accordance to the results of culture and sensitivity tests. In general, penicillinase-resistant antibiotics are a good initial choice for the treatment of upper extremity infections. Antibiotic cover for anaerobic bacteria depends, above all, on the results of culture and sensitivity tests and on the individual situation. References BAKER, E. J., BERGSTEIN, J. M. and WITTMANN, D. H. (1991). Microbiology and treatment of abscesses in intravenous drug abusers. Surgical Research Communications, 10 (Suppl): 105.
THE JOURNAL OF HAND SURGERY VOL. 20B No. 6 DECEMBER 1995 BROOK, I. and FRAZIER, E. H. (1990). Aerobic and anaerobic bacteriology of wounds and cutaneous abscesses. Archives of Surgery, 125:1445 1451. DELLINGER, E. P., WERTZ, M. J. and MILLER, S. D. (t988). Hand infections: Bacteriology and Treatment: A prospective study. Archives of Surgery, 123:745 750. GLICKEL, S. Z. (1988). Hand infections in patients with acquired immunodeficiency syndrome. Journal of Hand Surgery, 13A: 770 775. HUTCHINSON, D. T., McCLINTON, M. A., WILGIS, E. F. S. and FRISKMILLNER, N. (1992). Drug and alcohol use in emergency hand patients. Journal of Hand Surgery, 17A: 576-577. KACH, K., KOSSMANN, T. and TRENTZ, O. (1993). Nekrotisierende Weichteilinfekte. Unfallchirurg, 96: 181-191. KOSSMANN, T., SIMMEN, H. P., BATTAGLIA, H. and BRULHART, K. B. (1994). Nekrotisierende Weichteilinfektionen an Extremitfiten. Schweizerische Rundschau fiir Medizin, 83: 654-657. ORANGIO, G. R., PITLICK, S. D., DELLA-LATTA, P. et al. (1984). Soft tissue infections in parenteral drug abusers. Annals of Surgery, 199: 97-100. STEVENSON, J. and ANDERSON, I. W. R. (1993). Hand infections: An audit of 160 infections treated in an Accident and Emergency Department. Journal of Hand Surgery, 18B: I15-118. STROMBERG, B. V. (1985). Changing bacteriologic flora of hand infections. Journal of Trauma, 25:530 533.
Accepted: 2 March 1995 PD Dr H.P. Simmen, Department of Surgery, University Hospital, CH-8091 Zurich, Switzerland.
© 1995 The British Society for Surgery of the Hand
H. P. S1MMEN, P. GIOVANOLI, H. BATTAGLIA,J. WUST and V. E. MEYER From the Department of Surgery, the Division of Hand, Plastic and Reconstructiye Surgery, Universityof Zurich Medical School and the Institute of Medical Microbiology, University'of Zurich, Switzerland Despite surgical advances and new antibiotics, upper extremity infections continue to present a serious problem. Soft tissue infections of the upper extremities were prospectively examined to elucidate incidence, cause, bacterial pathogens involved, and treatment. Special attention was paid to infections associated with parenteral drug abuse. During an 18-month period all patients over 16 years of age presenting for treatment of an established infection were included in the study. Conservative treatment consisted of immobilization and antibiotics. Radical d6bridement with removal of all necrotic tissue was the guideline for operative care. In addition, for both regimens a penicillinase-resistant antibiotic was administered. A total of 415 patients (271 men and 144 women; mean age 36.7 ± 14.5 years) were enrolled into the study, 55 of whom were parenteral drug abusers; 45 of these were HIV-reactive. Infections of fingers (excluding paronychia), paronychia, and abscesses at injection sites were the most common diagnoses. Operative and conservative treatment were performed in 285 and 130 patients respectively. Staphylococcus and streptococcus species were the predominant organisms recovered from 212 specimens of pus. Anaerobic bacteria and yeasts were of minor importance. Therefore, a penicillinase-resistant antibiotic is a good initial choice. Journal of Hand Surgery (British and European Volume, 1995) 20B: 6:797-800
In a prospective investigation, soft tissue infections of the upper extremities were studied with respect to incidence, site and cause of infection, bacterial pathogens involved, duration of disability of work, and operative or conservative treatment performed. Special attention was paid to soft tissue infections associated with parenteral drug abuse. So far there is little information regarding the association of HIV and hand infection (Glickel, 1988). Drug abuse has long been viewed as a social and psychiatric problem. However, both medical and surgical complications account for an increasing number of hospital admissions. Parenteral drug abuse is responsible for significant morbidity and mortality (Baker et al, 1991; Orangio et al, 1984). Abscesses at the site of injection are the most common complications requiring surgical intervention. Despite surgical advances and newer antibiotics, upper extremity infections continue to present a serious problem, with significant morbidity or severe impairment of function and potential long-term disability. Most infections arise from relatively minor injuries that have been neglected (Stevenson and Anderson, t993). The knowledge of causative bacterial organisms enables the physician to institute antimicrobial therapy empirically before culture results are available. Recommendations in the current literature for the choice of antimicrobial drugs stress the inclusion of a penicillinase-resistant penicillin. The actual importance of coverage of anaerobic bacteria is not known (Dellinger et al, 1988).
PATIENTS AND M E T H O D S
During an 18-month period all patients over 16 years of age presenting for treatment of an established soft tissue infection were included in this study. A total of 415 patients were enrolled. A detailed history was taken, including the mechanism of injury, likely cause of infection and any other relevant medical conditions or predisposing factors. Use of antibiotics prior to hospital admission and study entry did not exclude patients. Operative or conservative procedures depended upon local findings as well as general conditions and were performed according to institutional policies. Before any antibiotics were given, infected material was obtained whenever possible. Every effort was made to obtain the culture from the depth of the wound, which was studied for aerobic and anaerobic organisms and for fungi. Treatment of patients whose infections failed to resolve with a single operative procedure and single course of antibiotics was considered a failure. Conservative therapy consisted of immobilization and elevation, and a penicillinase-resistant antibiotic was administered. Treatment was started intravenously and changed to the oral route. The actual duration of intravenous therapy was determined by clinical judgement. Amoxicillin and clavulanic acid 3 x 3.2 g a day intravenously, followed by 4 x 625 mg a day by oral administration were the antibiotics of first choice. Radical d6bridement with removal of all necrotic tissue as completely as possible was our guideline for operative care, followed by immobilization and elevation until wound healing was secured. 797
THE JOURNAL OF HAND SURGERY VOL. 20B No. 6 DECEMBER 1995
798
An identical antibiotic policy as in conservative treatment was applied. Treatment was continued until all signs of infection had resolved. RESULTS A total of 415 patients (271 men and 144 women) ranging in age from 16 to 85 years (mean 36.7+14.5) were enrolled into the study. 55 parenteral drug abusers (31 men, 24 women, mean age 29 years, range 17 39) were given special attention. The patients presented for treatment after a mean disability of 5 days, two-thirds of them during working hours, one third during the night and holidays. 253 (61%) were treated as outpatients, and the condition of 162 (39%) required hospitalization. Operative and conservative treatment was performed in 285 (69%) and 130 (31%) patients, respectively. In the presence of lymphangitis, the surgical treatment was performed under general anaesthesia. As shown in Table 1, infections of fingers other than paronychia, paronychia, and abscesses at injection sites were the most common diagnoses. The term paronychia was assigned to infections involving only the folds of tissue surrounding the fingernail. A minor or even unnoticed trauma was the predominant reason for an infection (Table 2). 55 out of 61 abscesses at an injection site were associated with parenteral drug abuse. The digits were involved in two-thirds of all upper extremity infections (Table 3). The most common cause of deterioration in the patient's general condition was the use of illicit drugs (Table 2), along with HIV-reactivity (Table 4). 45 out of 55 drug addicts were HIV-reactive. The HIV staging is shown in Table 5; there were no seriously ill AIDS patients. Most of the HIV-positive Table 1--Most common diagnoses in 415 patients
Diagnosis" Infection of finger other than paronychia Paronychia Abscess at an injection site Phlegmon of forearm Infected laceration Deep palmar space infection Bite injury (animal 13; human 3) Flexor tendon sheath infection Bursitis Furuncle Infectious arthritis
Number [%]
Men
Women
154 (37.1)
100
54
79 (19.0) 55 (13.3) 40 (9.6) 23 (5.5) 19 (4.6) 16 (3.9) 14 (3.4) 6 (1.5) 4 (1.0) 4 (1.0)
48 31 29 17 14 11 8 6 3 2
31 24 11 6 5 5 6 0 1 2
Table 2--Predominant causes in 415 upper extremity infections
Minor or unnoticed trauma Major trauma Drug injection Bite injury Unknown
202 114 61 16 22
Table 3--Local distribution of 415 upper extremity infections
Digits Hand Forearm Upper arm
289 96 84 30
(69.6%) (23.1%) (20.2%) (7.2%)
Table 4--Associated conditions in 415 patients
Number (%) None HIV-positive Diabetes Other infections Steroids Immunosuppression after renal transplant Malignant tumours
353 (85.1) 45 (10.8) 7 (1.7) 5 (1.2) 3 (0.7) 1 (0.2) 1 (0.2)
Table 5--Staging in 45 HIV-positive patients
1 2A 2B 3A 4A 4C
0 23 13 5 2 2
(0%) (51.1%) (28.9%) (11.1%) (4.4%) (4.4%)
Classification system for HIV infection from Centres for Disease Control, Atlanta, USA Group 1: Group 2: Group 3: Group 4: Subgroup Subgroup Subgroup Subgroup Subgroup
Acute infection. Asymptomatic infection. Persistent generalized lymphadenopathy. Other disease. A: Constitutional disease B: Neurological disease C: Secondary infectious disease D: Secondary neoPlasms E: Other conditions
patients enrolled in our study were also positive for hepatitis B. Upper extremity infections accounted for considerable morbidity and even permanent disability. Return to normal activity was delayed for 3 to 6 weeks or even longer (Table 6). In 212 of the 285 surgically treated patients, infectious material for bacteriologic assessment could be obtained (Tables 7 and 8). In 181 out of 212 (83%) cultures grew micro-organisms. A single organism was isolated in 99 specimens, and multiple organisms could be recovered from 82 specimens, respectively. The predominant organisms recovered were Staphylococcus aureus, [3-haemolytic streptococcus group A and coagulase-negative staphylococcus. Anaerobic bacteria and candida species were seldom isolated. 43 out of 55 (78%) abscesses of parenteral drug abusers were culture-positive with evidence of a single organism in 26 specimens and multiple organisms in specimens from 17 patients. Streptococcus species ([3-haemolytic streptococcus group A and Streptococcus milleri) were the most common isolates, whereas staphy-
SOFT TISSUE INFECTIONS AND DRUG ABUSERS
799
Table 6--Inability to work
Diagnosis Flexor tendon sheath infection Bursitis Infectious arthritis Infection of finger (excluding paronychia) Abscess at injection site Furuncle Phlegmon of forearm Deep palmar space infection Paronychia Bite injury Infected laceration
Time off"work (mean in days)
Range (days)
35 26 26 22
6-136 5-70 13-21 3-250
21 21 18 14 13 11 8
4-71 5 39 3-110 4-65 1-40 3-29 3 16
Table 7--Isolated micro-organisms from 212 upper extremity infections
Micro-organism Staphylococcus aureus Streptococcus [3-haemolytic group A Staphylococcus coagulase-negative
Streptococcus viridans Haemophilus influenzae Streptococcus milleri Streptococcus I~-haemolytic group B
Klebsiella oxytoca Anaerobes
Enterobacter cloacae Enterococcus Corynebacterium
Klebsiella pneumoniae Escherichia coli Citrobacter
Morganella morganii Candida species
Number (%) 102 51 26 22 19
(34.7) (17.3) (8.8) (7.5) (6.5)
18 (6.1) 10 (3.4) 7 (2.4) 6 (2.0) 5 (1.7) 5 (1.7) 5 (1.7) 4 (1.4) 6 (2) 2 (0.7) 1 (0.3) 5 (11.5)
Table 8--Isolated micro-organisms from 43 abscesses at injection sites of 55 drug addicts
Micro-organisms Streptococcus ]3-haemolytic group A
Streptococcus milleri Staphylococcus aureus Staphylococcus coagulase-negative Anaerobes
Streptococcus viridans Haemophilus influenzae Klebsiella pneumoniae Enterococcus Streptococcus l~-haemolytic group B
Number (%) 15 (28.8) 10 (19.2) 7 (13.4) 6 (11.5) 4 (7.7) 4 (7.7) 2 (3.8) 2 (3.8) 1 (1.9) 1 (1.9)
lococci, anaerobic bacteria, as well as candida species, were of minor importance. Resistant pathogens were not found. Apart from the classical local signs and symptoms of infection, there were no other findings that could be associated with the presence of an infection in 219 (54%) patients. Evidence of lymphangitis could be found in 98
(24%), elevated white blood cell count in 49 (12%), and elevated temperature in 49 (12%) patients, respectively. Operative procedures were indicated in 285 out of 415 (69%) patients. The response to primary operative treatment was satisfactory in all but 23 out of 285 (80/0) patients, who required re-operation due to inadequate primary d6bridement. 15 patients had to be re-operated on once, :seven patients twice, and one patient four times, respectively. The proportion requiring surgical treatment in the parenteral drug abusers was particularly high--49 out of 55 (89%)--indicating the advanced disease in these young, often immunocompromised, addicts (45 out of 55 were HIV-reactive). The drugs injected included mainly heroin, cocaine and some obscure mixtures. A major problem in the care of parenteral drug abusers was their low compliance. The mean delay in presentation after the infection had become symptomytic was 4 days. Skin and oropharyngeal pathogens were recovered from soft tissue abscesses associated with the use of illicit drugs. The major source of infection was the addict himself by preparation and administration of the drug. Blowing clots out of the needle was probably responsible for the high incidence of oropharyngeal flora recovered from the wounds of drug abusers. Local surgical procedures often resulted in soft tissue defects requiring later skin grafting.
DISCUSSION Serious infections of the hand and upper extremity are associated with a high incidence of morbidity. Surgical d6bridement is the treatment of choice, and although antimicrobial drugs given early may prevent suppuration or spread of an existing abscess, they cannot be substituted for surgical d6bridement. Staphylococcus species and streptococcus species are the most common isolates from soft tissue infections of the upper extremities. Anaerobic bacteria are of minor importance. Similar findings are reported by Stevenson and Anderson (1993) and Stromberg (1985). In all infections the antibiotic must be selected empirically on a best guess basis, taking account of the likely pathogens. The recovery rates of aerobes and anaerobes reported in this study are similar to the isolation rates in other studies that have investigated the microbiological characteristics of soft tissue infections of the upper extremities (Brook and Frazier, 1990). Soft tissue infections cause considerable morbidity and time off work. The inability to work in parenteral drug abusers presenting with abscesses accounts for a mean of 21 days (Table 6). However, these figures may be misleading since many of the drug addicts do not work at all. 10% of our patients enrolled in this study are parenteral drug abusers. Drugs and alcohol in connection with emergency hand patients are not uncommon findings. Hutchinson et al (1992) found
800
approximately 40% of the emergency patients to be positive for drugs and/or alcohol. The surgical procedure is the key to curing most hand infections. In most cases treatment should include incision/excision, d6bridement and drainage. Simple incision and drainage, a standard procedure in otherwise healthy people, is not adequate in immunocompromised drug addicts, since HIV is common in parenteral drug abusers. Radical d6bridement is mandatory (Kfich et al, 1993; Kossmann et al, 1994). In addition, antibiotics have proved invaluable and can decrease morbidity and shorten the time of recovery. Initial selection of antibiotics should be empirically based on suspected microorganisms and subsequently altered in accordance to the results of culture and sensitivity tests. In general, penicillinase-resistant antibiotics are a good initial choice for the treatment of upper extremity infections. Antibiotic cover for anaerobic bacteria depends, above all, on the results of culture and sensitivity tests and on the individual situation. References BAKER, E. J., BERGSTEIN, J. M. and WITTMANN, D. H. (1991). Microbiology and treatment of abscesses in intravenous drug abusers. Surgical Research Communications, 10 (Suppl): 105.
THE JOURNAL OF HAND SURGERY VOL. 20B No. 6 DECEMBER 1995 BROOK, I. and FRAZIER, E. H. (1990). Aerobic and anaerobic bacteriology of wounds and cutaneous abscesses. Archives of Surgery, 125:1445 1451. DELLINGER, E. P., WERTZ, M. J. and MILLER, S. D. (t988). Hand infections: Bacteriology and Treatment: A prospective study. Archives of Surgery, 123:745 750. GLICKEL, S. Z. (1988). Hand infections in patients with acquired immunodeficiency syndrome. Journal of Hand Surgery, 13A: 770 775. HUTCHINSON, D. T., McCLINTON, M. A., WILGIS, E. F. S. and FRISKMILLNER, N. (1992). Drug and alcohol use in emergency hand patients. Journal of Hand Surgery, 17A: 576-577. KACH, K., KOSSMANN, T. and TRENTZ, O. (1993). Nekrotisierende Weichteilinfekte. Unfallchirurg, 96: 181-191. KOSSMANN, T., SIMMEN, H. P., BATTAGLIA, H. and BRULHART, K. B. (1994). Nekrotisierende Weichteilinfektionen an Extremitfiten. Schweizerische Rundschau fiir Medizin, 83: 654-657. ORANGIO, G. R., PITLICK, S. D., DELLA-LATTA, P. et al. (1984). Soft tissue infections in parenteral drug abusers. Annals of Surgery, 199: 97-100. STEVENSON, J. and ANDERSON, I. W. R. (1993). Hand infections: An audit of 160 infections treated in an Accident and Emergency Department. Journal of Hand Surgery, 18B: I15-118. STROMBERG, B. V. (1985). Changing bacteriologic flora of hand infections. Journal of Trauma, 25:530 533.
Accepted: 2 March 1995 PD Dr H.P. Simmen, Department of Surgery, University Hospital, CH-8091 Zurich, Switzerland.
© 1995 The British Society for Surgery of the Hand