Is hand imaging necessary in a patient with cellulitis (infection of the skin and subcutaneous tissues) and purulent drainage, showing clinical improvement after incision and drainage (I&D), with leukocytosis (elevated white blood cell count)?

From the Guidelines

Imaging is not necessary for a patient with a cellulitic swollen finger with purulent drainage who shows clinical improvement following incision and drainage (I&D). When a patient presents with these symptoms and an elevated white blood cell count of 20,000/μL, the initial management should focus on proper I&D of the abscess, obtaining wound cultures, and starting empiric antibiotics. Appropriate antibiotic choices include dicloxacillin 500 mg orally four times daily, cephalexin 500 mg orally four times daily, or clindamycin 300-450 mg orally four times daily for 5-7 days, as recommended by the Infectious Diseases Society of America 1. If the patient demonstrates clinical improvement after I&D (decreased pain, swelling, erythema, and normalization of white blood cell count), advanced imaging such as X-ray, ultrasound, or MRI is not routinely indicated, according to the guidelines for the diagnosis and management of skin and soft-tissue infections 1. However, imaging should be considered if there is concern for deeper infection such as osteomyelitis, septic arthritis, retained foreign body, necrotizing fasciitis, or if the patient fails to improve despite appropriate treatment, as suggested by the practice guidelines for the diagnosis and management of skin and soft-tissue infections 1. The rationale is that most uncomplicated finger infections respond well to I&D plus antibiotics, and the additional information from imaging would not change management in a patient showing clear clinical improvement.

Some key points to consider in the management of cellulitis include:

• The importance of clinical assessment of the severity of infection, as emphasized by the guidelines for the diagnosis and management of skin and soft-tissue infections 1
• The need for prompt treatment with antibiotics effective against the typical Gram-positive pathogens, especially streptococci, as recommended by the Infectious Diseases Society of America 1
• The consideration of imaging studies if there is concern for deeper infection or if the patient fails to improve despite appropriate treatment, as suggested by the practice guidelines for the diagnosis and management of skin and soft-tissue infections 1
• The importance of wound care, including elevation of the affected area and promotion of gravity drainage of the edema and inflammatory substances, as emphasized by the guidelines for the diagnosis and management of skin and soft-tissue infections 1.

Overall, the management of cellulitis should be guided by the principles of prompt treatment, careful clinical assessment, and consideration of imaging studies when necessary, as recommended by the Infectious Diseases Society of America 1 and the practice guidelines for the diagnosis and management of skin and soft-tissue infections 1.

From the Research

Clinical Presentation and Diagnostic Considerations

• The patient presents with a cellulitic swollen finger, purulent drainage, and a high white cell count of 20, indicating a potential infection.
• The clinical improvement following incision and drainage (I&D) suggests that the infection may be responding to treatment.

Imaging Considerations

• There is no direct evidence from the provided studies to suggest that hand imaging is necessary in this specific case, as the studies focus on osteomyelitis and septic arthritis of the foot and ankle 2, 3.
• However, the studies do emphasize the importance of early diagnosis and treatment of infections, and imaging may be considered if there are concerns about underlying bone or joint involvement 2, 3.
• In cases where MRI is contraindicated, a three-phase bone scan may be used as an alternative imaging modality 2, 3.

Wound Management

• The study on wound healing by secondary intention highlights the challenges of managing complex wounds, including infection and prolonged healing times 4.
• While this study does not directly address the need for imaging in cases like the one presented, it underscores the importance of careful wound management and consideration of treatment options, including negative pressure wound therapy 4.