SCIENTIFIC ARTICLE

Community-Acquired Methicillin-Resistant
Staphylococcus aureus in Surgically Treated
Hand Infections
Scott D. Imahara, MD, Jeffrey B. Friedrich, MD

Purpose An increase in the incidence of community-acquired methicillin-resistant Staphylo-

coccus aureus (CA-MRSA) infections has been observed. The purpose of this study is to
determine the change in proportion of surgically treated CA-MRSA hand infections over the
last decade and to identify associated risk factors.
Methods A retrospective review was performed of all 159 hand infections treated in the
operating room over an 11-year period (1997–2007). Mean age overall was 40 years, mean
inpatient length of stay was 4.9 days, and 115 of the 159 patients were male. Examined data
included known risk factors for MRSA, including human immunodeficiency virus infection,
diabetes mellitus, intravenous drug use, incarceration, and homelessness.
Results Forty-eight patients had surgery for hand infections due to CA-MRSA. The yearly
proportion of CA-MRSA increased over the study period, and the risk of having an MRSA
infection was 41% higher with each progressive calendar year during the study period
relative to the apparent incidence of non-MRSA hand infections. Other factors associated
with CA-MRSA were intravenous drug use, felon-type infection, and prior hand infection.
Multivariable logistic regression identified intravenous drug use as a significant, independent
risk factor for CA-MRSA hand infection.
Conclusions The proportion of surgically treated hand infections due to CA-MRSA has
increased during the last decade. Intravenous drug use was the only independent risk factor
for CA-MRSA infections treated in the operating room at our institution. (J Hand Surg 2010;
35A:97–103. © 2010 Published by Elsevier Inc. on behalf of the American Society for
Surgery of the Hand.)
Key words Hand infection, methicillin-resistant Staphylococcus aureus.

RISE IN METHICILLIN-RESISTANT
Staphylococcus media.1–5 In the past, this type of drug-resistant infec-

A aureus (MRSA) infections has been observed

over the last decade, resulting in considerable
attention from both the medical community and the lay
tion was chiefly found to inhabit medical environments,
populations with recent antibiotic exposure or invasive
devices, or settings in which large numbers of people
were housed in close proximity.4,6,7 However, more
From the University of Washington, Seattle, WA. pediatric and adult patients who have had no prior
Received for publication January 5, 2009; accepted in revised form September 3, 2009.
exposure to these types of high-risk settings are pre-
senting with MRSA infections.2 This type of infection,
No benefits in any form have been received or will be received related directly or indirectly to the
subject of this article. known as community-acquired MRSA (CA-MRSA),
Corresponding author: Jeffrey B. Friedrich, MD, Division of Plastic and Reconstructive Surgery,
has been associated with a high incidence in certain at-risk
University of Washington, 325 9th Avenue, Box 359796, Seattle, WA 98104-2499; e-mail: populations, including extremes of age, contact sports,
jfriedri@uw.edu. shared athletic equipment, and immunosuppression.1,2,7–17
0363-5023/10/35A01-0018$36.00/0 Hand infections are common problems that fre-
doi:10.1016/j.jhsa.2009.09.004
quently warrant surgical treatment; however, existing

©  Published by Elsevier, Inc. on behalf of the ASSH. 䉬 97

98 MRSA HAND INFECTIONS

TABLE 1. ICD-9 Procedure Codes and Diagnosis TABLE 2. Demographics, Surgical Treatment,
Codes Used to Identify Surgically Treated Hand and Comorbid Illness Among Surgically Treated
Infections Hand Infections
ICD-9 Procedure Codes Non- p
80.14 Arthrotomy—hand/finger Overall MRSA MRSA Value
82.01 Exploration tendon sheath, hand Total 159 (100) 111 48
82.03 Bursotomy of hand Male (%) 72.3 72.1 72.9 .999
82.04 Incision and drainage palmar/thenar space Mean age (y) 40.1 40.7 38.6 .311
82.09 Incision soft tissue hand NEC Mean inpatient length 4.9 4.9 5.0 .830
82.92 Aspiration bursa of hand of stay (d)
82.93 Aspiration soft tissue hand NEC No. of surgeries 1.2 1.2 1.3 .633
ICD-9 Diagnosis Codes ⬎1 surgery (%) 13.8 12.6 16.7 .617
680.30 Infection of skin and subcutaneous tissue, upper arm Second infection (%) 5.7 2.7 12.5 .023
and forearm Admit to final 707 784 541 .084
680.40 Infection of skin and subcutaneous tissue, hand follow-up (d)
681.00 Cellulitis and abscess, unspecified, finger Potential risk factors
681.01 Felon Homeless (%) 32.1 28.8 39.6 .199
681.02 Onychia and paronychia of finger Inmate (%) 6.9 5.4 10.4 .309
711.04 Pyogenic arthritis, hand Diabetes mellitus (%) 6.3 7.2 4.2 .724
727.05 Tenosynovitis, hand and wrist Human 4.4 2.7 8.3 .200
immunodeficiency
virus (%)
IVDU (%) 35.2 27.0 54.2 .002
studies describing CA-MRSA hand infections have had Any comorbidity (%) 3.8 4.5 2.1 .669
relatively short study periods and minimal description Any complication (%) 6.3 7.1 4.4 .720
of risk factors for MRSA.18 –20 The purposes of this
study are to determine the change in proportion of IVDU, intravenous drug use.
Boldface values indicate statistical significance.
surgically treated CA-MRSA hand infections over the
last decade (1997–2007) at a single urban level I trauma
center and to analyze the risk factors associated with
hand infections caused by this pathogen. During the 11-year period encompassed by this
study, 159 patients had surgical intervention in the
PATIENT POPULATION AND METHODS
operating room for a hand infection. There were 115
Demographic data male and 44 female patients, with an average age of 40
After the study was approved by the institutional review years (range, 11– 82 y; Table 2). Mean length of hos-
board, applicable patients were identified from the pital stay was 4.9 days (median, 4 days; range, 0 –22 d).
records of a level I trauma center. Using a discharge Mean follow-up was 21 months (range 0 days–10 y);
database from 1997 to 2007, patients were identified however, because the study was focused on pathogens
using the International Classification of Diseases, 9th and risk factors, the length of follow-up was not an
Edition/Revision (ICD-9) procedure codes for surgical inclusion criterion. Many patients had potential risk
drainage of an infection of the hand in the operating factors for community-acquired drug-resistant infec-
room (Table 1). Patients identified by ICD-9 procedure tion, including homelessness (51), incarceration (11),
codes were confirmed to have an infection by indepen- intravenous drug use (IVDU) (57), history of diabetes
dent chart review. Current procedural terminology mellitus (10), and documented history of human immu-
codes were not available for use in identifying patients. nodeficiency virus (5). Because of the retrospective
Bacterial pathogens were identified by microbiologic nature of the data, the authors were unable to determine
culture and susceptibility data obtained from each sur- whether patients lived in communal living quarters such
gery. In addition, patients were coded by specific diag- as barracks or dormitories. Patients who had drainage of
noses using ICD-9 diagnosis codes, which included a hand infection in the emergency department were
suppurative tenosynovitis, abscess, septic arthritis, excluded, chiefly because the fluid from these infections
felon, and paronychia. was not routinely sent for gram stain and culture. Pa-

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 MRSA HAND INFECTIONS 99

tients with iatrogenic infections or a history of recent

TABLE 3. Discharge Antibiotic Usage Among
hospitalization were excluded.21 In addition, patients Patients With Surgically Treated Hand
with infections due to a human bite were excluded Infections
because these cases often involve flora intrinsic to the
Antibiotic Non-MRSA MRSA
oral cavity.
Trimethoprim-sulfamethoxazole 8 26
Hospital course and infection characteristics Levofloxacin 7 7
The number of surgical procedures performed on each Clindamycin 16 8
patient was dictated by clinical circumstance and the Cephalexin 37 3
discretion of the treating surgeon. All patients had at Amoxicillin-clavulanate 42 2
least 1 surgical procedure for infection drainage. Twenty- Vancomycin 0 2
two patients required more than 1 surgery. Twenty-two Ciprofloxacin 0 2
patients had a second procedure; 10 patients, a third Rifampin 0 2
procedure; 5 patients, a fourth procedure; and 1 patient Linezolid 0 1
required a total of 10 procedures to obtain infection Nafcillin 1 0
control. Average follow-up time was 21 months (me- None 3 0
dian, 345 d; range, 1 d–10 y). Sixteen patients did not Penicillin VK 3 0
have follow-up after discharge from the hospital; there- Amoxicillin 1 0
fore, no assessment about their clinical results can be Trovafloxacin 1 0
made. Infection types requiring surgical drainage were Dicloxacillin 1 0
most commonly tenosynovitis (107), followed by ab- Metronidazole 1 0
scess (27), septic arthritis (19), felon (3), and 1 each of Doxycycline 1 0
paronychia, cellulitis and acute wound associated with
Total 122 53
phalangeal osteomyelitis, and laceration infection.
Eight patients had a second anatomically and tempo- Entries include patients who received more than 1 antibiotic.
rally distinct surgically treated hand infection after the
first infection was resolved.
accounted for 85% of the discharge antibiotics for the
Complications
group. Within the subgroup of patients who had CA-
Complications were assessed by presence of any resid- MRSA infections, trimethoprim/sulfamethoxazole was
ual dysfunction, arthritis, osteomyelitis, or other dis- the most commonly prescribed discharge agent, ac-
crete problems resulting from the infection or surgery. counting for 53% of the discharge antibiotics.
Because stiffness and edema of the affected part was
nearly universal, this was not counted as a complica- Statistical analysis
tion. A total of 9 patients had complications. Three
Bivariate analysis was conducted to determine which
patients required finger amputation due to digital isch-
variables were significantly associated with CA-MRSA.
emia following infection drainage. Three patients de-
Analysis was performed using a chi-square test for
veloped subsequent osteomyelitis, 1 of whom required
discrete variables and unpaired t-tests for continuous
ray amputation. Finally, 1 patient each had the follow- variables. Logistic regression analyses were used to
ing complications: delayed cutaneous wound healing, determine proportional risk for MRSA over the du-
mallet finger due to attritional rupture of the terminal ration of the study relative to the risk of being ad-
extensor tendon, and osteoarthritis of the proximal in- mitted for treatment of a non-MRSA infection. Non-
terphalangeal joint. MRSA infections were used as the comparison group
in all analyses because we did not have access to
Antibiotic usage population data. Because the numbers of people ad-
Antibiotic usage varied throughout the study cohort. mitted for treatment of non-MRSA hand infections
The 5 most common antibiotic regimens were single- remained stable over the course of the years evalu-
agent regimens and included amoxicillin/clavulanic ated, we determined that this comparison likely pro-
acid, cephalexin, trimethoprim/sulfamethoxazole, clin- vides an estimate of the change in the absolute inci-
damycin, and levofloxacin (Table 3). These 5 agents dence of CA-MRSA infections over the study period.

JHS 䉬 Vol A, January 

100 MRSA HAND INFECTIONS

TABLE 4. Infection Type, Anatomic Location,

and Microbiology of Surgically Treated Hand
Infections
Non- p
Overall MRSA MRSA Value

n 159 111 48
Infection type
Tenosynovitis (%) 67.3 69.4 62.5 .462
Abscess (%) 17.0 13.5 25.0 .106
Septic arthritis (%) 11.9 15.3 4.2 .061
Felon (%) 1.9 0.0 6.3 .026
Paronychia (%) 0.6 0.0 2.1 .302
FIGURE 1: Proportion of patients with surgically treated hand
Cellulitis/osteomyelitis 0.6 0.9 0.0 .999
infections due to CA-MRSA over time. Values above each bar
(%)
represent the percentage of patients with CA-MRSA among
Infected laceration (%) 0.6 0.9 0.0 .999
the total number of patients each year.
Anatomic location
Finger and thumb (%) 2.5 2.7 2.1 .999
Hand (%) 13.8 13.5 14.6 .999
RESULTS
Forearm (%) 0.6 0.9 0.0 .999
During the 11-year period between 1997 and 2007, 48
Multiple sites (%) 11.3 11.7 10.4 .999
of 159 patients had cultures positive for CA-MRSA.
Wrist (%) 2.5 1.3 4.2 .585
The number of patients admitted with CA-MRSA in-
Finger joint (%) 6.9 7.2 6.3 .999
fections requiring surgical drainage rose significantly
Finger, no thumb (%) 73.0 74.8 68.8 .442
between 1997 and 2007. In contrast, the number of
Thumb only (%) 13.2 11.7 16.7 .447
patients admitted who required surgical drainage of
Non-MRSA microbiology
non-MRSA infections, although varying from year to
year, did not steadily increase (Fig. 1). Logistic regres- AHS (%) 3.8 5.4 0.0 .179
sion was used to compare the odds of being treated for GABHS (%) 29.6 36.9 12.5 .002
a CA-MRSA hand infection in each subsequent study MSSA (%) 31.4 45.0 0.0 ⬍.001
year during the period of study. The risk of having an N gonorrhea (%) 17.6 25.0 0.0 ⬍.001
MRSA infection was found to be 41% higher each Atypical (%) 6.3 9.0 0.0 .033
progressive calendar year during the study period rela- AHS, alpha-hemolytic Streptococcus; GABHS, group A beta-hemo-
tive to the risk of having a non-MRSA infection (odds lytic; MSSA, methicillin-sensitive Staphylococcus aureus; N gonor-
rhea, Neisseria gonorrhea.
ratio [OR], 1.41; 95% confidence interval [CI], 1.21– Boldface values indicate statistical significance.
1.64; p ⬍ .001).
Variables found by univariate analysis to be associ-
ated with CA-MRSA were IVDU (p ⫽ .002); a second
distinct, temporally unrelated hand infection (p ⫽ .01); p ⫽ .003) was independently associated with a higher
and felon-type hand infection (p ⫽ .026) (Tables 2 and risk of CA-MRSA hand infections (Table 5).
4). Factors not associated with CA-MRSA were age,
gender, other types of infection (tenosynovitis, abscess, DISCUSSION
etc.), location of infection on the hand, number of The proportion of methicillin-resistant Staphylococcus
surgeries, homelessness, incarceration, and other co- aureus infections continues to grow in hospital-
morbidities. Of the 143 patients for whom follow-up associated settings and, more recently, in community
data were available, there was no significant difference settings in the United States.4,22,23 Infection due to
in complication rates among the CA-MRSA and non- Staphylococcus aureus imposes a high and increasing
CA-MRSA groups (p ⫽ .72) (Table 2). Variables found burden on health care resources.4 A growing concern is
to be associated with CA-MRSA were analyzed by the emergence of MRSA infections among patient pop-
logistic regression to determine risk factors for CA- ulations with no apparent risk factors.21 Outbreaks of
MRSA. Only IVDU (OR, 3.58; 95% CI, 1.55– 8.29; CA-MRSA infections have emerged among healthy

JHS 䉬 Vol A, January 


TABLE 5. Logistic Regression for Potential Risk
Factors for CA-MRSA Among Surgically
Treated Hand Infections
Variable Odds Ratio 95% CI
Intravenous drug use 3.58 1.55–8.29
Homelessness 1.03 0.42–2.51
Inmate 3.48 0.77–15.65
Diabetes mellitus 0.63 0.10–3.92
Human immunodeficiency 2.89 0.48–17.37
virus infection
Second, separate hand 1.89 0.34–10.49
infection
Septic arthritis 0.32 0.05–1.88
Felon ⬎10.0 0.00–⬎10.0
Boldface values indicate statistical significance.
individuals, including athletic teams, suggesting a
change in the evolving distribution apart from previ-
ously identified high-risk populations.11,12,15–17 This
emergence of antibiotic-resistant infections in the com-
munity has generated great concern in the early part of
this decade, as evidenced by extensive lay media cov-
erage.3,5 In addition, as many as 75% of soft tissue
infections observed in U.S. emergency rooms are due to
CA-MRSA.24 Data also suggest that CA-MRSA has a
more severe clinical course compared to hospital-
acquired MRSA (HA-MRSA).25
The treatment of hand infections comprises a sub-
stantial proportion of many hand surgery practices. Re-
cent literature regarding CA-MRSA hand infections,
along with this institution’s recent experience, provided
the impetus for this investigation. LeBlanc and col-
leagues provided one of the initial reports of CA-
MRSA infections of the hand.18 This 3-year retrospec-
tive analysis examined patients treated at a large, urban
hospital and found that a majority of patients (61%)
treated for hand infections had MRSA as the principal
pathogen. In a similar study, Bach and co-workers
conducted a 9-month study of patients treated for com-
munity-acquired hand infections and found 73% cul-
ture-positive for MRSA.19 In a 21-month retrospective
review, Kiran and co-workers found incidences of
MRSA hand infections that corroborated those of LeB-
lanc and Bach.20 The more longitudinal nature of this
study confirms the suspicion of an increasing propor-
tion of CA-MRSA hand infections in recent years. Spe-
cifically, the proportion in the 5 most recent years was
considerably higher than the first portion of the time period
(46.1%), with yearly proportions of patients with
JHS 䉬 Vol A, January 
MRSA HAND INFECTIONS 101
MRSA ranging from 35% to 60% during 2003–2007.
Another benefit of the current study, when compared
to the earlier CA-MRSA hand infection studies men-
tioned, is an analysis of the risk factors thought to be
p Value
associated with this pathogen.
.003 Elucidating the risk factors for infection with CA-
.950 MRSA is an area of great research interest. Complicat-
.104 ing these efforts are recent findings that the domains of
.616 CA-MRSA and HA-MRSA infection have been in-
.245
creasingly indistinct. LeBlanc’s group found that in
many patients with what appeared to be CA-MRSA, the
.469 particular MRSA strain was clonally similar to strains
of HA-MRSA.18,26 This spread of HA-MRSA beyond
.217 the hospital domain makes the elucidation of risk fac-
.999 tors even more difficult. Various risk factors for CA-
MRSA infection have been delineated; however, not all
studies have demonstrated agreement.21 A common
theory postulated that persons living in close quarters
(such as in jails, barracks, and dormitories) were at
higher risk of MRSA infection.6 However, the current
analysis did not demonstrate incarceration to be a risk
factor. We were unable to reliably determine from the
medical record whether patients lived in barracks or
dormitories, and this could be considered a weakness of
the study. In addition, 2 recent studies analyzing prior
antibiotic usage found that antibiotic usage was associ-
ated with a higher risk of MRSA.6,24 The bivariate
analysis from the current study lends some credence to
this theory because prior hand infection had a stronger
association with presence of MRSA.
Intravenous drug use has been postulated to be
linked to CA-MRSA infection.21 Earlier studies dem-
onstrated IVDU to be a risk factor; however, Moran and
colleagues’ recent prospective emergency department
study of soft tissue infections found only a modest
association between IVDU and presence of CA-
MRSA.6,24 The current study found a significant asso-
ciation between IVDU and CA-MRSA, on both biva-
riate and multivariate analyses. However, illicit drug
habits have regional variations, so this finding may not
be generalizable.
The majority of patients in this study had uncompli-
cated resolution of the infection following surgical
drainage. This observation may indicate that with ap-
propriate surgical drainage, postoperative antibiotic ad-
ministration is of secondary importance. Moran’s study
of soft-tissue infections found that 96% of infections
resolved after treatment in the emergency department.24
In fact, Moran’s group suggests that drainage alone is
likely all that is necessary for treatment of soft-tissue
infections.24 Leblanc’s study of CA-MRSA hand infec-
tions mentioned a trend toward increasing drug resis-
102 MRSA HAND INFECTIONS
tance, but this finding has not been corroborated by
others.1,18 With surgically treated infections, multidrug
resistance is probably less important to the final out-
come than adequate drainage. However, multidrug re-
sistance does have far-reaching implications for the
treatment of infections in general. Finally, we found
that fully two-thirds of all patients in our series had
infections of the flexor tendon sheath. This observation
was different from Kiran’s findings in which most CA-
MRSA hand infections were in the form of abscesses.20
This may also reflect the fact that the current study
concentrates on surgically treated infections, and sup-
purative flexor tenosynovitis is not amenable to emer-
gency room treatment.
Our study has a number of important limitations.
Retrospective medical record reviews are subject to
incomplete or incorrect information. In particular, we
found that many records lacked antibiotic susceptibility
results for all cultures, which removed a potentially
valuable source of information for this study. Although
the inclusion of surgically treated infections alone al-
lowed some uniformity of the patient population, the
lack of culture data from most of the patients treated in
our emergency department greatly reduced the avail-
able population of the study. Further, the need for
surgical (versus bedside) drainage was entirely at the
discretion of the treating physician, thereby introducing
another source of selection bias. Finally, CA-MRSA
was defined among those patients without prior hospi-
talizations or hospital-acquired infections. Microbio-
logic identification of clonal strains associated with
CA-MRSA was not performed in this study, so the
designation of CA-MRSA depends solely on social and
clinical criteria. Defining CA-MRSA by the absence of
risk factors for health care exposure might underesti-
mate the true number of CA-MRSA cases.26
This study presents a longitudinal analysis of the
changing proportion of CA-MRSA hand infections and
the potential risk factors that are associated with this
problem. Multivariable analysis demonstrated that
more recent years of infection and admitted IVDU were
associated with increased odds of having MRSA as a
pathogen in the hand infection. Although we did not
find other risk factors such as homelessness and incar-
ceration to be associated with a higher risk of CA-
MRSA, these factors should be taken into consideration
when initially providing empiric antibiotic treatment for
hand infections. Fortunately, in cases of hand infections
involving fluid collection, drainage of the infected ma-
terial is usually adequate treatment. Future prospective
multi-institutional studies will be valuable in further
refining the risk profile of CA-MRSA hand infections
JHS 䉬 Vol A, January 
and in better elucidating the characteristics of multi-
drug-resistant bacterial infections.
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