Prophylactic antibiotics are not indicated in uncomplicated hand lacerations

Prophylactic antibiotics are not indicated in uncomplicated hand lacerations

Report by Shafic S Al‐Nammari, SHO Orthopaedics and Trauma

Search checked by Adam J Reid, SHO Plastic Surgery

St Thomas' Hospital & Aberdeen Royal Infirmary

Abstract

A short cut review was carried out to establish whether prophylactic antibiotics should be used as part of the management of uncomplicated hand lacerations. From a search of 237 papers only five presented trials addressing the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of this paper are tabulated. The clinical bottom line is that there doesn't appear to be any evidence to support the use of prophylactic antibiotics in uncomplicated hand lacerations.

Three part question

In [a patient with an uncomplicated hand laceration] does [the use of prophylactic antibiotics] lead to a [reduced incidence of wound infection]?

Clinical scenario

A patient attends the emergency department with an ‘uncomplicated' hand laceration. You wonder whether prophylactic antibiotics are indicated to try to reduce the risk of infection. ‘Uncomplicated' is taken to mean a wound with no fracture, foreign body, tendon injury, bone injury, joint injury, or neurovascular injury.

Search strategy

OVID interface on the world wide web. 1966–January 2007

Cochrane Database of Systematic Reviews, January 2007

[(hand wound$.mp.) OR (hand laceration$.mp.) OR (hand injury.mp. or exp Hand Injuries)] AND [antibiotic$.mp. or exp Anti‐Bacterial Agents/]

Search outcome

Altogether 346 articles were found. Limiting it to “humans and English language” reduced the number to 237. Only five papers directly addressed the question. No additional papers were found in Cochrane.

Table 2.

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study weaknesses
Grossman JAI, et al 1981, USA	280 patients with uncomplicated hand lacerations requiring suture. 15 excluded as lost to follow up. Patients randomised to treatment groups with IM or oral antibiotics or control group with placebo. 96 patients given IM cefazolin, 78 oral cephalexin and 91 an IM placebo	RCT	IM antibiotics	0% infection rate	Only looked at hand lacerations requiring suturing
			Oral antibiotics	2.5% infection rate
			No antibiotic/Placebo	1.1% infection rate
			Overall	No statistically significant difference between the groups
Haughey RE et al, 1981, USA	394 patients with uncomplicated hand wounds presenting within 12 hours of initial injury. Included lacerations, crush wounds, puncture wounds, avulsions and combination injuries. Patients randomised to treatment group of 160 patients who received oral cephalexin and a control group of 234 patients who received no antibiotic.	RCT	Oral antibiotic	10.6%.infection rate	Does not give results for antibiotic vs no antibiotic infection rates between different wound types. Does not take into account other risk factors for wound infection.
			No antibiotic/Placebo	7.7% infection rate
			Overall	No statistically significant difference between the groups
Roberts AHN et al, 1977, UK	368 patients with uncomplicated hand lacerations requiring suture. Patients randomly allocated to treatment groups of IM or oral antibiotics and a control group of no antibiotic. Patients were reviewed at 7 days for infection and imperfect healing. 108 patients were assigned to the IM Triplopen group, 117 to the oral flucloxacillin and 113 to the no antibiotic group	RCT	IM antibiotic	Infection rate 8%, imperfect healing 15%.	Definition of infection was, “a clear collection of pus, which empties itself spontaneously, or after incision.” This omits milder infections which were grouped with other complications under the heading, “imperfect healing”. Study only looked at hand wounds, which were sutured.
			Oral antibiotic	Infection rate 9.5%, imperfect healing 29.5%
			No antibiotic/Placebo	infection rate 12%, imperfect healing 29%
			Overall	No statistically significant difference between the groups
Beesley JR et al, 1975, UK.	145 patients with uncomplicated hand lacerations. Patients randomised to either treatment group with oral Magnapan (flucloxacillin & ampicillin) or control group (placebo). Total number of patients 145. Treatment group 70 patients. Control group 75. Patients reviewed on day 5	RCT	Oral antibiotic	1.6% infection rate	Does not look into individual patient risk factors for infection. Does not give clinical criteria for diagnosing or excluding wound infection.
			No antibiotic/Placebo	1.5% infection rate
			Overall	No statistically significant difference between the groups
Whitaker JP, et al, 2005, UK	170 patients with clean hand incisions presenting within 24 hours of initial injury. Included uncomplicated injuries and tendon/nerve injuries. Patients all underwent operative debridement with or without repair and were randomised to receive antibiotics or placebo. 56 patients given IV flucloxacillin, 46 patients given oral flucloxacillin and 55 patients given placebo	RCT	IV antibiotics	13% infection rate	Only looked at hand injuries receiving operative debridement. Also included patients with tendon and nerve injury.
			Oral antibiotics	4% infection rate
			No antibiotic/placebo	15% infection rate
			Overall	No statistically significant difference between the groups

IM, intramuscular; IV, intravascular; RCT, randomised clinical trial

Comment(s)

These studies do not show any statistically significant difference in wound infection rates in uncomplicated hand lacerations in patients receiving either prophylactic antibiotics or not receiving antibiotics.

Clinical bottom line

No evidence to suggest prophylactic antibiotics reduce the rate wound infection in uncomplicated hand lacerations.

BET editor's comment

Antibiotics would not normally be given IM now.