The Clinical Utility of Maceration Dressings in the Treatment of Inpatient Hand Infections: An Evaluation of Treatment Outcomes Compared to Standard Care

Abstract

Background: In cases of oral antibiotic-resistant infection of the hand, we propose utilizing a heated, moist maceration dressing to help shorten and simplify the in-hospital clinical course by increasing the efficacy of antibiotic deliverance to infection sites, increasing the success of nonoperative management, and decreasing eradication time of infection of the hand. Methods: Fifty-six patients older than 18 years of age who presented with hand infections requiring inpatient intravenous antibiotics at our suburban academic hospital over a 30-month period were included and randomly assigned to either the maceration dressing group or the standard treatment group. Maceration dressings included warm and moist gauze, kerlix, webril, Orthoglass, Aqua K Pad, and sling. Results: Fifty-two patients who were mostly male and younger than 60 years of age were included. Patients who used the maceration dressing had significantly shorter hospital lengths of stay (P = .02) and intravenous antibiotics duration before transition to oral antibiotics (P = .04), and decreased need for formal operating room irrigation and debridement to obtain source control (P = .02) compared to patients treated with the standard dressing. Post-hoc analysis yielded improved outcomes when using the maceration dressing regardless of whether initial bedside incision and drainage was needed to decompress a superficial abscess or not. Conclusion: The maceration dressing can be used along with proper intravenous antibiotic treatment to improve the treatment course of patients with hand infections regardless of whether the patient needs an initial bedside incision and drainage or not. Level of Evidence: Therapeutic Level II.

Introduction

Hand infections can create long-lasting impairment if not treated promptly and effectively, costing patients time and money for treatment as well as functional loss if complications occur. Infections can arise secondary to trauma that breaks the skin barrier, inflammation, ongoing skin infections, edema, and lymphatic obstruction.^1,2 Superficial infections can manifest as an area of skin erythema, edema, and warmth with or without purulent drainage or exudate. Patients can also present with systemic signs of infection along with pain or tenderness, inflammation, or “peau d’orange.”^3,4 These, and all other infections, must be closely monitored in high-risk patients, including diabetics and immunocompromised patients.⁵

The most common superficial hand infections, caused by Staphylococcus aureus, include cellulitis, an acute inflammatory condition involving the dermal and subcutaneous tissue layers of the skin,³ and erysipelas, a bacterial infection involving the upper dermis and cutaneous lymphatics.⁶ These infections can develop into superficial abscesses, including paronychia⁷ or felons,⁸ if not promptly treated. Diagnosis in uncomplicated cases is mostly clinical,^9-13 with blood cultures, needle aspiration, and punch biopsy being reserved for more toxic, complicated infections because of the tests yielding inconsistent accuracies and increased cost.^14-18 Along with elevation and sufficient hydration of the affected area,³ antibiotic therapy should be started and properly dosed based on the offending pathogen, purulence, and the weight of the patient.^19-22 Superficial abscesses might need a bedside incision and drainage versus a formal operative debridement to evacuate any purulent fluid collection in addition to appropriate intravenous antibiotic treatment, with deeper infections generally warranting a formal irrigation and debridement in the operating room if a trial of intravenous antibiotics does not help fully treat the infection. Physicians should be extremely wary of clinical signs that have been documented as markers of a more complicated clinical course, including objective fever when presenting to the emergency department, an elevated lactate level, or hemodynamic instability.²³

In cases of community-acquired infections of the hand, we propose utilizing a heated, moist maceration dressing to help shorten and simplify the inpatient clinical course. We hypothesized this intervention would be as absorbent as past dressings²⁴ while increasing efficacy of antibiotic deliverance to infection sites, increasing the success of nonoperative management, and decreasing eradication time of infection of the hand. Moisture-based dressings have been previously documented in the treatment of wound management in conditions such as diabetic skin ulcerations,²⁵ perioperative wound complications,²⁶ and gangrenous tissue.²⁷ However, there is a lack of studies evaluating the clinical utility of these dressings in the treatment of hand infections. This study looks to compare the clinical course and outcomes of patients treated with our heat based-moisture dressing combined with intravenous antibiotic treatment compared to patients treated under the established guidelines of care including splinting and intravenous antibiotic treatment,³ comparing clinical course, need for formal surgical intervention, and recurrence rate.

Methods

Approval for this prospective, single-blinded, randomized controlled trial was obtained from our hospital institutional review board. Patients older than 18 years of age who presented with hand infections requiring inpatient admission and intravenous antibiotics in our suburban academic hospital over a 30-month period were included. Those who presented for the first time and were deemed to be candidates for initial outpatient oral antibiotic therapy, those who had documented previous ipsilateral upper extremity infections, and those who had the need for immediate formal operative incision and drainage due to a toxic clinical picture were excluded. Patients who presented with superficial abscesses underwent bedside incision and drainage as a standard treatment before randomization to a treatment arm. An a priori power analysis was performed to determine the sample size needed to demonstrate a significant difference between treatment cohorts, yielding 25 patients per arm of the study.

Fifty-six eligible patients were randomly assigned to either the maceration treatment group or the standard treatment group. Patients who were to utilize maceration dressings as part of their therapy first had their affected area thoroughly cleaned using disinfectants. Several 4 x 4 gauze bandages were soaked in warm water, partially wrung out, and loosely placed between all the digits, with two between the thumb and index fingers, and one between the others. A ball of the same type of wet gauze bandage was placed in the palm as well. A 3-inch webril cast padding was then soaked in warm water, wrung out and used to cover the hand, wrist, and forearm. Orthoglass fiberglass splinting material was then applied over the cast padding. The splint was wrapped in an ace bandage and allowed to harden. A plastic bag was then placed over the entire splint and secured using IV tape. A K-pad heating pad with connecting tubes was placed over the plastic bag with the temperature set to 107°F. Finally, the arm was elevated in a Richard’s blue foam sling and intravenous antibiotics were administered as per hospital protocol. Standard therapy included a washing of the limb with disinfectants, followed by application of dry webril cast padding, an Orthoglass splint and ace bandage. No moist bandages were utilized. A K-pad heating pad with connecting tubes was placed over the ace bandage with the temperature set to 107°F. The patient was then elevated in a Richard’s blue foam sling, and intravenous antibiotics were administered per hospital protocol. If a bedside irrigation and debridement was performed, the patients underwent a 15-minute dilute betadine soak each day at the time of wound evaluation, followed by repacking if needed at the time of the dressing change.

Dressings from both treatment arms were taken down daily, and the infected area was evaluated. Subjective patient complaints, such as sweats, chills, burning, and pain, were used along with objective presence of tenderness, erythema, swelling, range of motion, lymphangitis, fluctuance, vital signs, and laboratory values (white blood cell count, erythrocyte sedimentation rate, C-reactive protein) to evaluate the progression/regression of the infection and the effectiveness of treatment. Patients who showed significant improvement, as judged by the senior author, with lack of tenderness, fluctuance, and lymphangitis combined with improved erythema, swelling, and range of motion, were transitioned to oral antibiotics before discharge from the hospital. Any patient that did not improve or that worsened after 24 hours of care or demonstrated signs of systemic illness was taken to the operating room for a formal washout and debridement of the infected area.

For each patient, lab values, physical exam findings, length of time intravenous antibiotics were administered before transitioning to oral antibiotics, hospital length of stay, the need for a formal washout and debridement in the operating room, and rate of infection recurrence within 6 months were recorded. Data were analyzed using descriptive statistics, t-tests, Chi squared tests, or Fisher’s Exact Tests as appropriate to determine associations (IBM SPSS Version 23 Statistics for Windows, Armonk, NY: IBM Corp). For all analyses, P < 0.05 denotes statistical significance.

Results

Overall, 52 patients were included in our study. Four patients were excluded because they either left against medical advice before treatment was completed or rapidly demonstrated signs of systemic progression prior to the initiation of nonoperative management. Half of our patients were randomly enrolled in the maceration dressing group and the other half in the standard dressing control group. Most of our patients were male (n = 29, 55.8%), younger than 60 years of age (n = 40, 76.9%), and did not have a history of diabetes (n = 38, 73.1%). A majority of our patients presented with an infection after a traumatic injury (n = 22, 42.3%), after an animal bite or scratch (n = 8, 15.4%) or as intravenous drug users (n = 5, 9.6%) (Table 1). Average lab values are listed in Table 2. Most patients in both groups presented with 1 or 2 Kanavel signs as assessed during initial physical examination (Table 2).

Table 1.

Demographic Breakdown of Our Sample Population.

	Treatment		Total
	Maceration dressing	Standard dressing
Age
18 years-39 years	9 (17.3%)	9 (17.3%)	18 (34.6%)
40 years-59 years	12 (23.1%)	10 (19.2%)	22 (42.3%)
60 years-79 years	5 (9.6%)	3 (5.8%)	8 (15.4%)
80 years+	0 (0.0%)	4 (7.7%)	4 (7.7%)
Gender
Male	13 (25.0%)	16 (30.8%)	29 (55.8%)
Female	13 (25.0%)	10 (19.2%)	23 (44.2%)
Diabetes
Yes	8 (15.4%)	6 (11.5%)	14 (26.9%)
No	18 (34.6%)	20 (38.5%)	38 (73.1%)
Mechanism of injury
Trauma	11 (21.2%)	11 (21.2%)	22 (42.3%)
Animal trauma	3 (5.8%)	5 (9.6%)	8 (15.4%)
IVDU	3 (5.8%)	2 (3.8%)	5 (9.6%)
Other	9 (17.3%)	8 (15.4%)	17 (32.7%)
Total	26 (50%)	26 (50%)	52 (100%)

Note. Animal trauma = cat or dog bite or scratch; IVDU = intravenous drug user.

Table 2.

Clinical Presentation of Sample Population in Each Treatment Group.

	Treatment
	Maceration dressing	Standard dressing
Laboratory values
Average WBC	10.3	10.6
Average ESR	37.4	36.2
Average CRP	27.6	32.3
Kanavel signs
0 signs	3	6
1 signs	8	10
2 signs	9	10
3 signs	5	0
4 signs	1	0

Note. WBC = white blood cell count; ESR = erythrocyte sedimentation rate; CRP = C-reactive protein.

Patients who used the maceration dressing as part of their treatment had shorter hospital length of stay (n = 48 hours vs 72 hours, P = .02) (Figure 1) and duration of intravenous antibiotics before transition to oral antibiotics (n = 24 hours vs 60 hours, P = .04) (Figure 2) compared to patients who used the standard dressing. Patients in the maceration dressing group were less likely to need formal operating room irrigation and debridement (n = 2 patients) to obtain infection source control compared to patients in the standard dressing group (n = 9 patients) (P = .02) (Table 3). Patients in both the groups had similar infection recurrences (maceration dressing group = 0 patients; standard dressing group = 3 patients; P = .23) (Table 4).

Figure 1.

Hospital length of stay. Hospital length of stay in days for overall sample population, patients who had I & D, and patients who did not have I & D. Maceration = maceration dressing group; control = standard dressing group; I & D = bedside incision and drainage; No I&D = no bedside incision and drainage; P = value determined by Chi-squared or Fisher’s Exact Test.

Figure 2.

Duration of intravenous antibiotic treatment. Hospital length of stay in days for overall sample population, patients who had I & D, and patients who did not have I & D. Maceration = maceration dressing group; Control = standard dressing group; I & D = bedside incision and drainage; No I&D = no bedside incision and drainage; P = value determined by Chi-squared or Fisher’s Exact Test.

Table 3.

Rate of Formal Washouts in an Operating Room for Maceration Dressing Group versus the Control Standard Dressing Group.

	Maceration			Control			P value
	Formal OR washout			Formal OR washout
	Yes	No	Total	Yes	No	Total
Overall	2	24	26	9	17	26	.02
I & D	0	7	7	1	6	7	1
No I & D	2	17	19	8	11	19	.02

Rate of formal washouts in each sample population, separated out by total patients in each group, patients in each group that had obtained a bedside I&D, and patients that did not obtain a bedside I&D. Maceration = maceration dressing group; Control = standard dressing group; I & D = bedside incision and drainage; No I&D = no bedside incision and drainage; P = value determined by Chi-squared or Fisher’s Exact Test.

Table 4.

Rate of Infection Recurrence for Maceration Dressing Group versus Standard Dressing Group.

	Maceration			Control			P value
	Yes	No	Total	Yes	No	Total
Overall	0	26	26	3	23	26	.23
I & D	0	7	7	3	4	7	.19
No I & D	0	19	19	0	19	19	N/A

Rate of infection recurrence in the overall sample group population, patients who needed initial bedside incision and drainage, and those who did not need bedside incision and drainage. Maceration = maceration dressing group; Control = standard dressing group; I & D = bedside incision and drainage; No I&D = no bedside incision and drainage; P = value determined by Chi-squared or Fisher’s Exact Test.

Overall, a subset of 14 patients needed bedside incision and drainage before randomization and placement of their dressing to decompress superficial abscesses. Among this group, patients who used the maceration dressing had trended toward a shorter hospital length of stays (n = 2 days vs 3 days, P = .05) (Figure 1) and a significantly shorter duration of intravenous antibiotics (n = 24 hours vs 72 hours, P = .01) (Figure 2) compared to those who used the standard dressing. Patients in the maceration dressing group had no difference of formal operating room irrigation and debridement (n = 0 patients vs 1 patient, P = 1.00) (Table 3) or infection recurrence (n = 0 patients vs 3 patients, P = .19) compared to patients in the standard dressing group (Table 4).

A second subset of 38 patients did not need bedside incision and drainage during their clinical course. Among this group, patients who used the maceration dressing trended toward having a shorter hospital length of stay (n = 2 days) compared to patients who used the standard dressing (n = 3 days) (P = .07) (Figure 1), as well as shorter times of intravenous antibiotic administration (n = 24 hours) compared to patients in the standard dressing group (n = 48 hours) (P = .05) (Figure 2). However, patients in this subset who used the maceration dressing were less likely to need an operating room washout and debridement (n = 2 patients) compared to patients in the standard dressing group (n = 8 patients) (P = .02) (Table 3). Both groups in this subset had zero patients who had infection recurrence (Table 4).

Discussion

Infections of the hand require prompt and effective treatment to avoid the spread of infection as well as long-term local sequelae. A detailed history and physical exam^14-23 will lead to a diagnosis of these conditions and allow for timely and effective treatment. Treatment for oral antibiotic resistant infection includes splinting for comfort, elevation, hydration, and intravenous antibiotics. We believe that using a heated, moist maceration dressing will improve effectiveness of antibiotic treatment, improving outcomes and shortening hospital stay.

Current literature includes treatment guidelines that have been proven successful if tailored to the specific type of infection.^28-30 Our results indicate that the maceration dressing does improve the clinical course of superficial and deep infections in the hand with or without superficial abscesses compared to other standard treatment modalities. The potential mechanism of action includes improved vasodilatory effects within the moist heat environment this dressing provided to deliver higher concentrations of antibiotics to the site of infection improving efficacy, although this was not directly studied. Successful treatment provided by a maceration dressing combined with intravenous antibiotics may minimize the risk of long-term sequelae known to result from infections, such as contractures and loss of function, or short-term sequelae, such as the development of a superficial or deep abscess. Recurrence rate was low in both groups, pointing to the efficacy of either treatment in achieving ultimate resolution of the infection, but no significant difference was found between the two. It should be noted that while note specifically evaluated, patients with flexor tenosynovitis were included in the subset that did not need bedside incision and drainage in both arms of the study. While recommendations classically recommend immediate incision and washout and debridement in the operating room, newer studies have discussed the efficacy of conservative treatment with antibiotics and close monitoring,³¹ a treatment algorithm our practice uses in most cases. However, only 4 patients had 3 or more Kanavel signs (10.5% of patients that did not have bedside incision and drainage), making the percentage of patients in this cohort that had presumed flexor tenosynovitis too low for individual analysis.

While standard of care of patients with clinical signs of septic shock continues to be source control with operating room incision and drainage with washout and debridement of the infected site, patients who are not yet at that stage seem to be able to be managed effectively with the maceration dressing and intravenous antibiotics during their hospital stay.³² This is true whether the patient needs a bedside incision and drainage initially or not. It should be noted that our cohort was made up of a relatively low percentage of diabetics. A larger percentage of these patients, who are more prone to infections and wound healing complications, could skew outcomes and overall effectiveness of any treatment.

The major weakness of our study is the lack of a clinical risk score to determine when a patient can be transitioned from intravenous to oral antibiotics. The decision was made based on the clinical judgment of our fellowship trained orthopedic hand surgeon based on objective improvements. However, as these decisions are usually made clinically and not based on published risk scores, observational bias may be present. Patients who were lost to follow-up could also skew the rates of recurrent infections, an important marker of the success our treatment has in achieving resolution of local infection. However, recurrent infection can be caused by secondary trauma or patient conditions such as intravenous drug use even if initial treatment did fully eradicate local infectious bacteria. Finally, our analysis did not evaluate individual antibiotic choice. Our practice typically utilizes cefazolin or clindamycin (if a documented cephalosporin allergy exists) in most infections with ampicillin/sulbactam utilized in the treatment animal bites. Initial antibiotic choice is based on history of infections, mechanism of injury, and contamination of any wounds. The wrong antibiotic choice might lead to progression of the infection regardless of treatment type used. It is important for all health care providers involved in patient care to obtain a detailed history and constantly monitor the patient for clinical changes and modify treatment plan, including antibiotic choice, as needed.

Conclusion

The maceration dressing can be used along with proper intravenous antibiotic treatment to improve the treatment course of patients with hand infections regardless of whether the patient needs an initial bedside incision and drainage or not.