What is the recommended treatment for infectious tenosynovitis?

Treatment of Infectious Tenosynovitis

The recommended treatment for infectious tenosynovitis includes prompt surgical drainage combined with appropriate antibiotic therapy, similar to the approach used for other deep space infections. 1

Diagnosis and Initial Assessment

• Evaluate for classic signs of infection: pain, swelling, and limited range of motion over the affected tendon sheath
• Assess for systemic signs of infection (fever, elevated inflammatory markers)
• Obtain cultures from the tendon sheath fluid to guide targeted antibiotic therapy
• Consider imaging (ultrasound, MRI) to confirm diagnosis and identify any fluid collections

Treatment Algorithm

1. Surgical Management

• Early surgical drainage is essential for infectious tenosynovitis
• Perform thorough irrigation and debridement of the infected tendon sheath
• Consider open drainage technique for persistent or severe infections 2
• For hand infections, careful debridement with preservation of tendon function is critical

2. Antimicrobial Therapy

Initial Empiric Therapy

• Broad-spectrum coverage is recommended initially:
  • Vancomycin plus piperacillin-tazobactam, OR
  • Vancomycin plus a carbapenem, OR
  • Vancomycin plus ceftriaxone and metronidazole 1

Targeted Therapy Based on Organism

• Staphylococcal infections (including MRSA):

  • Vancomycin 15 mg/kg IV every 12 hours
  • Alternative: Linezolid 600 mg IV/PO twice daily

• Streptococcal infections:

  • Penicillin plus clindamycin for documented Group A streptococcal infections 1
  • Cefazolin or antistaphylococcal penicillin (nafcillin/oxacillin) for susceptible strains 1

• Mixed infections (common in bite wounds):

  • Amoxicillin-clavulanate 875/125 mg orally twice daily 1
  • Alternative: Ampicillin-sulbactam 1.5-3.0 g IV every 6 hours

3. Duration of Therapy

• Initial IV antibiotics for 24-48 hours after clinical improvement begins
• Switch to oral antibiotics once clinically improved with no evidence of bacteremia
• Total duration of antibiotic therapy: 2-3 weeks 1

4. Adjunctive Measures

• Immobilization and elevation of the affected area initially
• Once infection is controlled, begin passive range of motion exercises to prevent adhesions
• Consider NSAIDs for pain and inflammation control

Special Considerations

Specific Pathogens

• Mycobacterial infections: Require extended antibiotic therapy and often multiple surgical debridements 3
• Occupational exposures: Consider unusual pathogens based on patient's occupation (e.g., Erysipelothrix rhusiopathiae in those who handle animal products) 4

Monitoring Response

• Repeat imaging studies should be performed in patients with persistent symptoms or bacteremia to identify undrained foci of infection 1
• Clinical improvement should be evident within 48-72 hours of appropriate treatment

Common Pitfalls to Avoid

• Delayed surgical intervention: Failure to promptly drain the infection can lead to tendon necrosis, adhesions, and permanent functional impairment
• Inadequate debridement: Incomplete removal of infected tissue may result in persistent infection
• Premature discontinuation of antibiotics: Complete the full course of antibiotics even if symptoms improve quickly
• Missing extensor tenosynovitis: This condition can be more difficult to diagnose than flexor tenosynovitis as it may not present with the classic Kanavel signs 5

Early recognition and aggressive treatment of infectious tenosynovitis are crucial to prevent complications such as tendon rupture, joint destruction, and permanent functional disability.