XIV INTERNATIONAL POZNAN

COURSE IN UPPER EXTREMITY

SURGERY

HAND PROBLEMS:
SMALL BUT
TROUBLESOME
WHY I DON’T GIVE ANTIBIOTICS
IN HAND INFECTIONS ?

Christian Dumontier
(with A. DORFMANN and S. CARMÈS)
Centre de la Main, Guadeloupe-FWI
WHEN WOULD YOU GIVE ANTIBIOTICS ?
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 WHEN THE PATIENT GET INJURED ?
• You are not here !

• Not logical : Most cutaneous

effractions do not get infected

• Costs would be outrageous

• Risk of allergy (5,9% of patients

are allergic to penicillin)

• Antibiotic resistance

• Economic cost

West RM et al: 'Warning: allergic to penicillin': association between penicillin allergy status in 2.3 million NHS general
practice electronic health records, antibiotic prescribing. J Antimicrob Chemother. 2019 Jul 1;74(7):2075-2082
 INFLAMMATORY PHASE ?

• I do not give antibiotics !

• This question is debated

since the introduction of
antibiotics

• This is probable the case for

discussion

Pilcher RS, Dawson RL. Infections of the ngers and hand. Lancet 1948;1:777–83
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 ABSCESS PHASE
• An abscess must be surgically
evacuate !

• « Ubi pus, ibi evacuat »

• Very old idea !, (also quoted in American Medical

Journal 1876; 6(6): 226).

• But still accurate !

Stevens DL et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the
Infectious Diseases Society of America. Clinical Infectious Diseases, Volume 59, Issue 2, 15 July 2014, Pages e10–e52
Kamath RS et al. Guidelines vs Actual Management of Skin and Soft Tissue Infections in the Emergency Department. Open
Forum Infect Dis. 2018 Jan. 5 (1):ofx188.
Sartelli M et al. 2018 WSES/SIS-E consensus conference: recommendations for the management of skin and soft-tissue infections.
World J Emerg Surg. 2018. 13:58.
 CAN WE TREAT AN ABSCESS WITH ANTIBIOTICS ?

• This question is raised, in the literature, for vital organs, dif cult to
access (liver, brain, kidneys,…).

• Estimated success aroud 85.9%.

• Unfavorable factors include abscess size ≥ 5 cm (OR = 37.7; P =

.0003), more then a germ (OR = 5.2; P = .014), BG- bacteria
(OR = 3.4; P = .022), antibiotherapy < 4 weeks (OR = 49.1; P <
.0001), and the use of an amino acid only (OR = 11.8; P = .008)

• Bronchial tubes and ovarian abscesses do respond well to

antiboitics…because they spontaneously evacuate (Fallopian tubes,
bronchial tube)

Bamberger DM. Outcome of Medical Treatment of Bacterial Abscesses Without Therapeutic Drainage: Review of Cases
Reported in the Literature. Clin Infect Dis 1996;23:592-603
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 CONSTITUTION OF AN ABSCESS
• Continuum which starts with an
in ammation and ends up with the
formation of a capsule (in 4 days).

• At the intermediate, there is not yet a

frank suppuration, nor a brous capsule

• The abscess is made of an external

collagen brous wall, an internal line of
leucocytes (95% of neutrophils) and a
central zone ful lled with necrotic debris.
Picture of a meningeal abscess

Bartlett JG: Experimental aspects of intraabdominal abscess. Am J Med 1984;76:91–98

Joiner KA, Lowe BR, Dzink JL, Bartlett JG: Antibiotic levels in infected and sterile subcutaneous abscess in mice. J Infect Dis 1981;
143: 487-494.
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 AN ABSCESS IS POORLY VASCULARIZED

• Capillaries are present only at

the periphery,

• Penetrance of antibiotics through

the membrane of the abscess is
possible only by permeation
(passive migration of a liquid
through a solid membrane)

• Antibiotic penetration is then

very limited and dependent of
the degree of maturation of the
abscess

Barza M: Pharmacokinetics of antibiotics in shallow and deep compartments. J Antimicrob Chemother 1993;31(suppl D):17–27.
Wagner C et al. Principles of antibiotic penetration into abscess uid. Pharmacology 2006;78(1):1-10
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 ANTIBIOTICS CAN PENETRATE INTO
ABSCESSES (EXPERIMENTALLY)
• Antibiotic level in the abscess is 17 to 53% of the serum level

• But the ef cacy of the antibiotics is modi ed by a number of

factors like:

➡A low pH, xation to proteins, degradation by bacterial

enzymes, delay of administration, bacterial concentration, the
pose of multiplication of the germs, ionic composition , O2
tension, Zinc concentration…
Bartlett JG: Experimental aspects of intraabdominal abscess. Am J Med 1984;76:91–98
Joiner KA, Lowe BR, Dzink JL, Bartlett JG: Antibiotic levels in infected and sterile subcutaneous abscess in mice. J Infect Dis 1981;
143: 487-494.
Bryant R. Effect of the suppurative environment on antibiotic activity. In: Root RK, Sande MA, eds. New dimensions in
antimicrobial therapy: contemporary issues in infectious diseases. Vol. 1. New York: Churchill Livingstone, 1984:313- 37.
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 FIXATION TO PROTEINS

• Fixation to proteins in
abscesses inactivate antibiotics

• Eric level may be high, but the

free level of antibiotics in the
tissues is very low Atomic structure of Penicillin Binding Protein 3 from
Pseudomonas aeruginosa (Wikipedia)

Barza M: Pharmacokinetics of antibiotics in shallow and deep compartments. J Antimicrob Chemother 1993;31(suppl D):17–27.
Wagner C et al. Principles of antibiotic penetration into abscess uid. Pharmacology 2006;78(1):1-10
Merrikin DJ. Effects of protein binding on antibiotic activity in vitro. J Antimicrob Chemother 1983; 11:233-238
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 DELAY BEFORE ANTIBIOTIC TREATMENT
Curve of bacterial growth

• In experimental models,
antibiotherapy is ef cient if given ≤ 24
hours.

• This is due to the speed of bacterial

multiplication

• But also to diminution of zinc and iron

concentration that place the bacteria
in a stationary phase (less sensible to Doubling time of Staphylococcus
Aureus 27-30 mn
antibiotics)

Haley EC Jr, Costello GT, Rodeheaver GT, Winn HR, Scheid WM. Treatment of experimental brain abscess with penicillin and
chloramphenicol. J Infect Dis 1983;148:737-44.
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 BACTERIAL CONCENTRATION
• Huge: up to 1012 bacteriae/gram of
tissues

• Due to the high speed of

multiplication (2n)

• For Staph Aureus, after 5 hours (210)

• 1000 bacteriae give 1024000

bacteriae

• 1 million bacteria, becomes 1 billion

Bartlett JG: Experimental aspects of intraabdominal abscess. Am J Med 1984;76:91–98

Todar K. The growth of bacterial population. textbookofbacteriology.net/growth_3.html
 ONE COULD THEORETICALLY GIVE
ANTIBIOTICS AT THE ABSCESS STAGE

• You need high doses Impossible in

practice
• IV administration (sorte the
delay of absorption)

• Very early

• And for very long time

 ANTIBIOTICS PRESCRIPTION AT THE ABSCESS
STAGE IS DELETERIOUS !

• 125 nger/hand infections

• Patients seen with complications were

those presenting late (p< 0,01) and/or
having received antibiotics (p < 0,09)

Dorfmann A et al. Advanced nger infection. More frequent than expected and mostly iatrogenic. HSR 2021; 40: 326-330
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 THE KNIFE IS MUCH MORE
EFFICIENT THAN ANTIBIOTICS

• 90% of the 125 patients were

cured by surgery

• 94% of the non complicated

patients were cured without
prescription of antibiotics
postop.

Dorfmann A et al. Advanced nger infection. More frequent than expected and mostly iatrogenic. HSR 2021; 40: 326-330
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 ANTIBIOTIC TREATMENT POSTOP ?

• « The use of antibiotics in the postop period

should be limited to high-risks patients
(immuno-de cient) and in patients with
systemic signs »

• Equation of Altemeier: I = NV/R

Stevens DL et al. Practice Guidelines for the Diagnosis and Management of Skin and Soft Tissue Infections: 2014 Update by the
Infectious Diseases Society of America. Clinical Infectious Diseases, Volume 59, Issue 2, 15 July 2014, Pages e10–e52
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 I = NV / R (ALTEMEIER)

• William A. Altemeier
(1910-1983) born and died
in Cincinnati (Ohio)

• 349 publications, most

about surgical infections

• I = infection rate (between

0 to 1)
I= NV/R

N = NUMBER

• Bacteria double within 30

mn

• It takes 10 hours to reach

230 (> 1 million bacteria)

• It takes 25 hours to get one

gram of bacteria
I= NV/R

V = VIRULENCE

• Intrinsic parameter of the germ

• Capacity for bacteria to

produce an infection

• Capacity to develop under

favorable conditions
I= NV/R

R =RESISTANCE
• Host resistance (Diabetes,
AIDS, Leukemia,
Immunosuppression…)

• LOCAL RESISTANCE:

• A necrotic tissue has a

resistance tending to 0

• If lim R →0, so Infection →1

• Only surgery can remove

necrotic tissues
SURGERY IS THE SOLUTION TO INFECTION

• Antibiotics cannot reach a

necrotic tissue

• Deep penetration of
antibiotics in abscesses is very
limited (Wagner)

• Surgeons can diminished N,

not eradicate bacteria

• Removing Necrotic tissues Abcès layers: 1 necrotic tissue

Increases R and cure patients

Wagner C, Sauermann R, Joukhadar C. Principles of antibiotic penetration into abscess uid. Pharmacology. 2006, 78: 1-10
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MANY CLINICAL SERIES SUPPORT THIS OPINION

• 125 hand infection, 94% cured without antibiotics

(Dorfmann)

• 46 whitlows, 45 cure w/o antibiotics (Pierrart)

• No difference between children group w/wo antibiotics in

CA-MRSA Abscesses (Lee)

• 99,6% of 242 Inappropriately treated infected patients

went to healing (Paydar) Dorfmann A et al. HS 2021;40(3)326-330
Pierrart J et al. HSR 2016;35:40-43
Lee MC et al. Ped infect. Dis J. 2004;23:123-127
Paydar KZ et al. Arch Surg 2006;141:850-854
 THE INFLAMMATORY PHASE ?
• Use of antibiotic is logical • Risk of prescription of
at this stage antibiotics ?

• Non collected infection • Uncertainty of the exact

• In ammation probably
increases the diffusion
of antibiotics
• Germs are multiplying
and then sensible to
antibiotics
stage
• Strict follow-up of
patients (must be cured
within 2 days)
« In almost all cases of serious infection the dif culty is to make a correct
diagnosis both as to the nature of the infection and the position of the
pus. » Kanavel AB. Infections of the Hand. 1939. 17-410.

➡ We prefer not to prescribed antibiotics to diminish the risk of complications.

➡ But we do an active « medical » treatment (hand elevation, rest,

antiseptics…) ≠ antibiotics only
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 CONCLUSION

• Surgery is aggressive

• But this a complete and safe treatment

• This is the treatment of abscesses ! Ubi Pus, Ibi Evacuat !

• At the hand, the prescription of antibiotics is most often

useless, and some times deleterious

• Nothing new since centuries: Surgery is the solution to hand

infections.
WIELKIE DZIĘKI