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The role of antibiotic prophylaxis for prevention of infection in patients with simple hand lacerations. Ann Emerg Med 2007;49:682-89.

Efficacy Endpoints

Infection, Cosmesis (Not reported)

Harm Endpoints

Diarrhea (Not reported)

Narrative

There are 3 reviews addressing the utility of antibiotic prophylaxis in simple hand lacerations. The oldest was published by Cummings and Del Beccaro in 1995 and found no benefit to antibiotic administration. This meta-analysis was limited, however, by the inclusion of several trials lacking in key methodologic standards. In the two most recent reviews, Zehtabchi and BestBets, more rigorous standards were employed for study selection. All 3 reviews reach the same conclusion.

The most relevant to the outpatient emergent and urgent care settings, Zehtabchi’s review excludes studies with complicated hand lacerations managed by surgical specialties. Simple laceration was further defined by a lack of involvement of structures like nerves, tendons, bones and large vessels. The 3 included studies (n = 778) described wound care management during the initial encounter. All wounds were irrigated with normal saline and prepped with an antiseptic agent such as chlorhexadine. Antibiotic regimens varied across studies both in terms of type and delivery method. Selected antibiotics included different penicillin preparations and cephalosporins and both oral and intramuscular routes of administration were compared to placebo or nothing. Overall, administration of a prophylactic antibiotic, in any form and of any type, to patients with uncomplicated hand lacerations did not reduce the rate of infection. In two of the included studies, infection rates were surprisingly low, roughly 1%. One trial had unusually high rates of infection (8.8 vs. 12%) but still found no statistical benefit to antibiotic usage.

Summary of Individual Trials:
Grossman et al. n = 265, infection rate 1.15% vs 1.1% (RR 1.05, 95% CI 0.09-11.38)
Roberts and Teddy, n = 305, infection rate 8.8% vs. 12%, (RR 0.73, 95% CI 0.37-1.46)
Beesley et al. n = 145, infection rate 1.4% vs 1.3%, (RR 1.07, 95% CI 0.07-16.8)

Caveats

While one study described diabetes as an exclusion criterion the others did not offer explicit information about the comorbidities of enrolled patients. Accordingly, for patients with conditions placing them at higher risk for infection, clinician judgment should factor into decision-making. Also, the most recent of the 3 included studies was performed about 30 years ago. But as wound care management has not changed dramatically over this time period, this factor should not affect applicability.

*Harms were not rigorously tracked in any of the included studies, however fungal vulvovaginitis, diarrhea, and other harms are common enough there is certain to be a fraction (likely 10-20% or more) of patients that will experience these adverse effects when administered antibiotics. Less common but more dangerous harms have not been as well described and cannot be as consistently expected.

Author

Ashley Shreves, MD

Published/Updated

April 23, 2011