When should antibiotics be prescribed for hand wounds, including prophylactic indications and treatment of established infection?

When to Give Antibiotics for Hand Wounds

Prophylactic antibiotics are NOT indicated for simple hand lacerations but ARE strongly recommended for high-risk hand wounds including bite injuries, wounds penetrating joints or periosteum, wounds in immunocompromised patients, and wounds presenting within 24 hours that meet specific risk criteria. 1

Simple Hand Lacerations (Non-Bite)

Do not prescribe antibiotics for uncomplicated hand lacerations. The infection rate for simple hand lacerations is approximately 5%, and prophylactic antibiotics do not reduce this risk. 2, 3

• Meticulous wound management—thorough irrigation, debridement, and proper closure technique—is the cornerstone of preventing infection, not antibiotics. 2
• Age, gender, diabetes status, and closure technique do not significantly affect infection risk in simple lacerations. 3
• This recommendation aligns with the broader principle that clinically uninfected wounds should not receive antibiotic therapy. 4

High-Risk Hand Wounds Requiring Prophylactic Antibiotics

Prescribe prophylactic antibiotics for 3-5 days when ANY of the following high-risk features are present: 1

Wound Characteristics:

• Bite wounds (human, dog, or cat)—these carry polymicrobial flora with infection rates of 20-25% for human bites, 5-25% for dog bites, and 30-50% for cat bites 1
• Deep puncture wounds that may have penetrated periosteum or joint capsule 1
• Wounds near or involving joints—particularly metacarpophalangeal joints in "fight-bite" clenched fist injuries 5, 6
• Moderate to severe tissue damage 1

Patient Risk Factors:

• Immunocompromised status 1
• Diabetes mellitus 1
• Advanced liver disease 1
• Asplenia (particularly concerning for Capnocytophaga canimorsus from dog bites) 1
• Prosthetic joints or heart valves 1
• Pre-existing or resultant edema of the hand 1

Critical Timing Consideration:

• Antibiotics should NOT be prescribed if the patient presents ≥24 hours after injury without signs of infection, as prophylactic benefit only exists when given early (within 24 hours). 1

First-Line Antibiotic Selection

Amoxicillin-clavulanate 875/125 mg twice daily is the preferred oral agent for both prophylaxis and treatment of hand wound infections. 1

• This provides comprehensive coverage against the polymicrobial flora including Pasteurella species (50% of dog bites), Staphylococcus aureus (40%), Streptococcus species (40%), Eikenella corrodens (human bites), and anaerobes. 1, 6

Alternative Options for Penicillin Allergy:

• Doxycycline 100 mg twice daily—excellent activity against Pasteurella multocida 1
• Moxifloxacin as monotherapy 1
• Clindamycin plus a fluoroquinolone 1

Treatment of Established Hand Infections

All clinically infected hand wounds require antibiotic therapy combined with appropriate wound care. 4

Signs of Established Infection:

• Increasing pain, erythema, warmth, swelling 7
• Purulent discharge 7
• Systemic symptoms (fever, lymphangitis) 1

Treatment Duration:

• 7-10 days for uncomplicated soft tissue infections 1
• 3-4 weeks for septic arthritis 1
• 4-6 weeks for osteomyelitis 1
• Hand infections often require longer treatment due to their serious nature and anatomic complexity 1

Intravenous Therapy Indications:

• Systemic symptoms present 1
• Moderate to severe infections 1
• Initial IV therapy for 3-5 days, then transition to oral when afebrile and improving 1

IV options include: piperacillin-tazobactam, carbapenems (ertapenem, imipenem, meropenem), cefoxitin, or ceftriaxone plus metronidazole. 1

Special Considerations for Specific Hand Infections

Clenched-Fist Injuries ("Fight-Bite"):

• Always suspect metacarpophalangeal joint penetration—these require aggressive surgical exploration, copious irrigation, debridement, and antibiotics covering Eikenella corrodens and S. aureus. 5, 6
• Penicillin plus dicloxacillin is economical for outpatient management if uninfected and less than 24 hours old. 8

Pyogenic Flexor Tenosynovitis:

• Requires parenteral antibiotics AND surgical sheath irrigation—antibiotics alone are insufficient. 5

Early Paronychia and Cellulitis:

• May be treated without surgery using elevation, warm soaks, and oral antibiotics. 5

Critical Pitfalls to Avoid

• Never use first-generation cephalosporins, macrolides, or penicillinase-resistant penicillins alone—they have poor activity against Pasteurella multocida (present in 50% of dog bites). 1, 8
• Do not prescribe antibiotics "just in case" for late presentations (≥24 hours) without infection—this violates guidelines and promotes resistance. 1
• Do not rely on antibiotics as a substitute for meticulous wound management—irrigation, debridement, and proper closure are essential. 2
• Do not forget tetanus prophylaxis—indicated if vaccination not current within 5-10 years for contaminated wounds. 7
• Do not overlook rabies risk—consult local health officials for bite wounds. 1, 7