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Use of Antibiotics in Hand Injuries
Abstract & Commentary
By John Shufeldt, MD, JD, MBA, FACEP, Chief Executive Officer, NextCare, Inc.; Attending Physician/Vice Chair, Department of Emergency Medicine, St. Joseph's Hospital and Medical Center, Mesa, AZ, is Editor for Urgent Care Alert.
Dr. Shufeldt reports no financial relationship to this field of study.
Synopsis: Examines the use of routine prophylactic antibiotics for with simple hand lacerations.
Source: Zehtabchi, S. Evidence-based emergency medicine/critically appraised topic. The role of antibiotic prophylaxis for the prevention of infections in patients with simple hand lacerations. Ann Emerg Med. 2007;49:682-689
Simple hand lacerations are a common presenting chief complaint in emergency departments. This evidence-based study evaluated the existing data about the utility of prophylactic antibiotic usage in patients with simple hand lacerations. Zehtabchi poses a common scenario about whether or not to use antibiotics in the treatment of a 3.5 cm palmer laceration not involving tendons, vessels, or other deeper structures, and then reviews the available literature using MEDLINE, EMBASE and the Cochrane Library.
A study was initially selected for use if the authors randomly assigned the use of prophylactic antibiotics in patients with simple hand lacerations. A simple or uncomplicated hand laceration was a laceration not caused by human or animal bite or burn, not communicating with a fracture or joint, and not involving extensive soft tissue damage or associated with tendon, nerve, or large vessel occurring below the radiocarpal joint. Outcome was measured by lack of infection, adequate cosmetic appearance, and complete wound healing. The study question was subsequently reformatted to: Do prophylactic antibiotics lower the incidence of hand infections in patients with hand lacerations that are managed by proper cleansing and wound closure, which are closed within 12 hours of the injury and are within the scope of care of ED physician?
After initially identifying more than 100 articles that fit loosely into the search criteria, Zehtabchi ultimately narrowed the review to 3 studies which met the inclusion criteria. Two of the studies used more than one antibiotic "AB" regimen. The results of the 3 studies were as follow: Study 1 (Grossman, et al). Infection rate in AB group 1.15% and 1.1% in the placebo group, RR was 1.05 (0.09-11.38, 95% CI); Study 2 (Roberts, Teddy). Infection rate in AB group 8.8% and 12.0% in the placebo group, RR was 0.73 (0.37-1.46, 95% CI); Study 3 (Beesley, et al). Infection rate in AB group 1.4% and 1.3% in the placebo group, RR was 1.07 (1.07-16.8, 95% CI).
Simple hand lacerations are common presenting complaints in urgent care centers. A crucial component in the treatment of these lacerations is aggressive wound debridement and copious irrigation. This article concludes that the use of prophylactic antibiotics is, at best, controversial in the management of simple hand infections. In 2 of the studies, there was no statistically significant difference between the 2 groups, and in one of the studies, there seemed to be evidence, albeit not statistically significant, that the use of antibiotics decreased the incidence of infection.
So where does that leave us? How do we treat the patient in the aforementioned scenario? The simple answer is to give the patient informed consent. Zebtabchi suggests the following language: "We have closed your laceration after cleaning it and examining it thoroughly. We have determined that you have not done any damage to the special structures that affect your hand function, such as nerves, bones, or ligaments. There is only a small amount of scientific evidence on whether taking antibiotics affects the likelihood of infection and none on whether they influence the visibility of the final scar. The evidence suggests no difference for uncomplicated wounds, a possible benefit in patients whose wounds are contaminated. On the other hand, antibiotics may cause uncomfortable adverse effects, such as diarrhea and rash. Physicians are being asked to decrease the use of antibiotics for conditions in which they are not mandatory because of concern for increasing antibiotic resistance of common bacteria."
The documentation of that paragraph can be as simple as, "The patient was given informed consent about the risks of benefits of using prophylactic antibiotics for hand lacerations. The patient chooses to take antibiotics (or not to take antibiotics), understanding and verbalizing the risks, etc."
Unfortunately, the jury is still out on the use of prophylactic antibiotics in simple hand lacerations. Until a definitive answer is determined through a randomized, placebo-controlled study, we are left with basing our treatment on individual practices, provider experience, and patient concerns. However, at the end of the day, the use of evidence-based practice, along with adequate informed consent, remains the Holy Grail of state-of-the-art, cost-conscious, "defensive" medicine and should continue to guide our practice patterns.