What is the recommended antibiotic regimen for a patient with a hand laceration and possible tendon involvement?

Antibiotic Choice for Hand Laceration with Possible Tendon Involvement

For a hand laceration with possible tendon involvement, amoxicillin-clavulanate is the recommended first-line oral antibiotic, or ampicillin-sulbactam intravenously if hospitalization is required, providing coverage against the polymicrobial flora typical of hand wounds including S. aureus, streptococci, and anaerobes. 1

Rationale for Antibiotic Selection

Hand wounds with potential tendon involvement represent high-risk injuries requiring empirical antimicrobial therapy due to:

• Critical anatomic location: Hand injuries, particularly those near joints or involving deeper structures like tendons, have significantly higher infection rates and risk of serious complications including septic arthritis, tenosynovitis, and osteomyelitis 1

• Polymicrobial nature: Hand lacerations typically harbor 5 different aerobic and anaerobic organisms, most commonly S. aureus, streptococci, and various anaerobes 1

Specific Antibiotic Recommendations

Outpatient Oral Therapy

• Amoxicillin-clavulanate 875/125 mg twice daily is the preferred agent, providing comprehensive coverage against the expected polymicrobial flora 1
• Alternative oral regimens if amoxicillin-clavulanate is contraindicated:
  • Doxycycline 100 mg twice daily PLUS a beta-lactam (e.g., cephalexin) for dual coverage 1
  • Clindamycin 300-450 mg three times daily (covers anaerobes and most gram-positives but may miss some streptococci) 1

Inpatient Intravenous Therapy

For severe injuries requiring hospitalization or with signs of deep infection:

• Ampicillin-sulbactam (first-line) 1
• Piperacillin-tazobactam 1
• Cefoxitin (second-generation cephalosporin) 1
• Carbapenems (ertapenem, imipenem, meropenem) for severe cases 1

MRSA Considerations

If community-acquired MRSA is suspected or the patient fails initial therapy:

• Add vancomycin 30 mg/kg/day IV in 2 divided doses to the regimen 1
• Alternative oral options: TMP-SMX or doxycycline combined with a beta-lactam for streptococcal coverage 1

Critical Pitfalls to Avoid

Do NOT use the following antibiotics as monotherapy for hand lacerations with tendon involvement:

• First-generation cephalosporins (cephalexin) alone - poor activity against Pasteurella and anaerobes 1
• Penicillinase-resistant penicillins (dicloxacillin) alone - inadequate anaerobic coverage 1
• Macrolides (erythromycin) alone - poor activity against Pasteurella 1
• Clindamycin alone - may miss aerobic gram-negative organisms 1

Duration and Adjunctive Management

• Antibiotic duration: 3-5 days for fresh, deep wounds in critical areas (hands, near joints) 1
• Surgical exploration is mandatory if tendon involvement is confirmed - antibiotics are adjunctive to surgical debridement 1
• Tetanus prophylaxis: Administer if not current within 10 years 1
• Wound management: Deep irrigation with sterile saline, avoid primary closure of infected wounds, elevate the injured hand 1

Special Populations

Pediatric Patients

• Amoxicillin-clavulanate 25 mg/kg/day (of amoxicillin component) in 2 divided doses 1
• Consider broader anaerobic coverage in children due to higher rates of mixed infections from digital sucking/biting (20% mixed infections in pediatric series) 2
• Avoid tetracyclines in children <8 years 1

High-Risk Features Requiring Hospitalization

Admit for IV antibiotics if:

• Severe cellulitis extending beyond wound margins 1
• Signs of deep space infection or tenosynovitis 1
• Immunocompromised status 1
• Delayed presentation (>24 hours) with established infection 1

Follow-Up Requirements

• Re-evaluate within 24 hours to assess response to therapy 1
• Repeat imaging (MRI preferred) if persistent symptoms despite appropriate antibiotics to identify undrained collections or deeper involvement 1
• Transition to oral antibiotics once clinically improved with IV therapy, completing 2-3 weeks total for complicated infections involving tendons 1