What is the recommended treatment for a finger web infection?

Treatment of Finger Web Infection

For a finger web infection (web space abscess), immediate surgical incision and drainage is the primary treatment, combined with empiric antibiotic therapy targeting Staphylococcus aureus and streptococci, using amoxicillin-clavulanate 875/125 mg twice daily orally or ampicillin-sulbactam 1.5-3.0 g IV every 6-8 hours for moderate to severe infections. 1

Surgical Management

• Surgical drainage is essential and takes priority over antibiotics alone for any finger web infection with purulent collection or abscess formation 2
• Perform excision and extensive lavage under digital anesthesia in the emergency setting, with systematic bacteriological sampling from deep tissue 2
• Avoid primary wound closure; wounds should be left open for drainage and may be approximated only after adequate debridement 1
• Copious irrigation and cautious debridement are critical components of initial management 1

Empiric Antibiotic Selection

First-Line Oral Therapy (Mild to Moderate Infections)

• Amoxicillin-clavulanate 875/125 mg twice daily is the preferred empiric oral agent, providing coverage against S. aureus, streptococci, and anaerobes 1
• Alternative: Clindamycin 300 mg three times daily for penicillin-allergic patients, offering good activity against staphylococci, streptococci, and anaerobes 1

Parenteral Therapy (Severe Infections)

• Ampicillin-sulbactam 1.5-3.0 g IV every 6-8 hours for patients requiring hospitalization 1
• Alternative: Piperacillin-tazobactam 3.37 g IV every 6-8 hours for broader coverage 1

MRSA Coverage Considerations

• Add vancomycin 30 mg/kg/day IV in 2 divided doses if MRSA is suspected based on prior MRSA history, high local prevalence, or severe infection 3
• Oral alternatives for MRSA include trimethoprim-sulfamethoxazole 160-800 mg twice daily or linezolid 600 mg twice daily 1

Microbiological Considerations

• The most common pathogens are methicillin-resistant S. aureus (MRSA), beta-hemolytic Streptococcus, and methicillin-susceptible S. aureus (MSSA) 4
• Polymicrobial infections occur in approximately 16.5% of hand infections 2
• Obtain deep tissue cultures via biopsy or curettage after debridement; avoid superficial swabs as they provide less accurate results 1

Treatment Duration

• Continue antibiotics for 1-2 weeks for mild infections and 2-3 weeks for moderate to severe infections 1, 3
• Antibiotic therapy should continue until resolution of infection signs (erythema, warmth, purulent drainage), but not necessarily until complete wound healing 1
• First dressing change should occur at 5-7 days to monitor progression and adjust therapy if needed 2

Important Caveats

• Do not treat clinically uninfected wounds with antibiotics; antibiotic therapy is insufficient without appropriate surgical drainage and wound care 1
• Consider Candida infection (erosio interdigitalis blastomycetica) if the infection involves the third web space between fingers, appears as erythematous erosion with white macerated rim, and occurs in patients with frequent water exposure 5
• Rule out herpetic whitlow if vesicles are present, as this requires antiviral rather than antibiotic therapy 6
• Ensure tetanus prophylaxis if the patient has not received tetanus toxoid within 10 years; Tdap is preferred over Td if not previously given 1

Monitoring and Follow-up

• Reassess within 2-5 days for outpatient management 3
• Change antibiotic therapy based on culture results and clinical response 3
• Consider surgical re-exploration if no improvement occurs despite appropriate antibiotic therapy 3
• Mean hospitalization for severe hand infections requiring surgical drainage is approximately 6 days 4