Antibiotic Regimen for Flexor Tenosynovitis
For flexor tenosynovitis, the recommended antibiotic regimen should include broad-spectrum coverage with vancomycin plus either piperacillin-tazobactam, ampicillin-sulbactam, or a carbapenem to address both gram-positive and gram-negative pathogens, including potential MRSA coverage. 1
Initial Empiric Therapy
Vancomycin (15-20 mg/kg IV every 8-12 hours) plus one of the following: 1
- Piperacillin-tazobactam (3.375 g IV every 6 hours or 4.5 g IV every 8 hours)
- Ampicillin-sulbactam (3 g IV every 6 hours)
- A carbapenem (imipenem 500 mg IV every 6 hours, meropenem 1 g IV every 8 hours, or ertapenem 1 g IV every 24 hours)
Alternative regimen: Vancomycin plus ceftriaxone (1 g IV every 24 hours) and metronidazole (500 mg IV every 8 hours) 1
Targeted Therapy Based on Culture Results
For methicillin-sensitive Staphylococcus aureus (MSSA): Cefazolin (1-2 g IV every 8 hours) or antistaphylococcal penicillin (nafcillin or oxacillin 2 g IV every 6 hours) 1
For methicillin-resistant Staphylococcus aureus (MRSA): Continue vancomycin (15-20 mg/kg IV every 8-12 hours) or switch to linezolid (600 mg IV/PO twice daily) 1
For group A Streptococcus: Penicillin plus clindamycin (600-900 mg IV every 8 hours) 1
For polymicrobial infections: Continue broad-spectrum coverage based on culture and sensitivity results 1
Duration and Route of Administration
Antibiotics should be administered intravenously initially 1
Once clinical improvement is evident and bacteremia has cleared (if present), transition to oral antibiotics may be appropriate 1, 2
Total duration of antibiotic therapy should be 2-3 weeks 1, 2
Important Considerations
Surgical consultation is essential as most cases require drainage and debridement in addition to antibiotic therapy 3, 4
Catheter irrigation techniques have shown better outcomes compared to open washout procedures (71% excellent vs. 26% excellent outcomes) 3
Early initiation of antibiotic therapy is crucial for improved functional outcomes 3, 5
Repeat imaging studies should be performed in patients with persistent bacteremia to identify undrained foci of infection 1
Recent evidence suggests that oral antibiotics may be effective for postoperative management in selected cases, particularly amoxicillin-clavulanic acid for 7-14 days 2
Common Pitfalls to Avoid
Delaying antibiotic therapy while awaiting surgical intervention can lead to worse outcomes 3, 5
Inadequate coverage for MRSA in high-prevalence areas or in patients with risk factors 1
Insufficient duration of therapy, especially when treating for less than 7 days 2
Failure to obtain appropriate cultures before initiating antibiotics 1, 4
Not considering animal bite etiology, which may require different antibiotic coverage (amoxicillin-clavulanic acid) 1, 6