Bacteria and Reoperation Rates in Septic Hand Tenosynovitis

In This Article

Abstract and Introduction

Abstract

Background: The anatomy of the hand makes it uniquely sensitive to complications after bacterial infection. The causative organism has been implicated as a predictor of complications after surgery. We hypothesize that bacterial etiology is associated with different operation and reoperation rates in patients with flexor tenosynovitis.

Methods: The Nationwide Inpatient Sample 2001–2013 database was queried for cases of tenosynovitis by using International Classification of Diseases, 9th Revision (ICD-9) diagnostic codes 727.04 and 727.05. The pathogen cultured was also identified with ICD-9 codes, and surgical intervention was determined using ICD-9 procedural codes. χ2 analysis and logistic regression were used to determine predictors of outcomes. Outcomes included initial surgery and the need for additional surgery, which was defined as records having ICD-9 procedural codes repeated for the same patient.

Results: A total of 17,476 cases were included. The most common bacterial etiology was methicillin-sensitive Staphylococcus aureus followed by Streptococcus species. Infections with gram-positive organisms, including methicillin-sensitive and methicillin-resistant S aureus, unspecified Staphylococcus, and Streptococcus species were significantly associated with higher rates of initial surgery for tenosynovitis. Patients receiving Medicaid and Hispanic patients had a statistically significant lower likelihood of surgery. Higher rates of reoperation were reported in patients aged 30 to 50 years, 51 to 60 years, 61 to 79 years, and ≥80 years; other factors associated with higher reoperation rates were Streptococcus and Staphylococcus infections and use of Medicare.

Conclusions: The data show that cultures of Streptococcus and certain species of Staphylococcus in patients with septic tenosynovitis are predictive of operation and reoperation rates. Patients with these infectious etiologies may have more severe presentations that warrant operative intervention. This data may allow for more informed decision-making in the preoperative period.

Introduction

The anatomy of the hand makes it uniquely sensitive to complications after bacterial infection. An intricate system of pulleys, tendon sheaths, compartments, and other closed systems can cause increases in pressure when inflamed, obstructing blood flow and predisposing patients to necrosis and potentially devastating complications.^[1] Distension between the visceral and parietal layers of tendon sheaths can disrupt normal anatomic barriers and can also lead to cellulitis, erysipelas, fasciitis, and compartment syndrome.^[2] Contractures, stiffness, and the need for more aggressive interventions, such as amputation, can result from improper or untimely treatment. While up to 80% of infections involve Staphylococcus aureus and Streptococcal species, there has been an increase in prevalence of methicillin-resistant S aureus (MRSA), with rates reported above 70%.^[3–5] Patients with various comorbid conditions as well as those with injuries sustained from various mechanisms are prone to infection with specific pathogenic etiologies.

MRSA infections are more prevalent in patients who are immunocompromised, have diabetes, or are intravenous drug users,^[6,7] whereas Eikenella species are more common in human-bite injuries,^[8,9] and Pasteurella species are more common in infections caused by animal bites.^[10–12] These conditions most frequently manifest as cellulitis and/or abscess formation that often require numerous surgical debridements.^[13,14] Optimal management requires the identification of patients at risk for increased surgery to reduce complication rates. Indeed, the causative organism has been implicated as a predictor of complications after surgery and may be responsible for unplanned, repeated operations.^[15] Such research suggests that there may be a clinically significant difference in virulence and disease severity of these organisms.

Despite the frequent need for secondary surgery for hand infections, there is little published literature regarding pathogenic etiology that may predispose a patient to the need for a repeated operative procedure in cases of septic tenosynovitis. We hypothesize that bacterial etiology is associated with different rates of initial operation and reoperation in these patients. We also hypothesize that patients with polymicrobial infections will have higher incidence of reoperation than those who have infections with individual organisms.

Table 1. International classification of disease, 9th revision (ICD-9)
CODES
ICD-9 Diagnostic Codes, Tenosynovitis	727.04, 727.05
ICD-9 Diagnostic Codes, Pathogen Etiology	3.11, 3.18, 3.19, 41.0x, 41.11, 41.12, 41.19, 41.20, 41.30, 41.41, 41.42, 41.43, 41.49, 41.5, 41.6, 41.7, 41.8x, 112.89, 112.9, 117.1, 117.5
ICD-9 Procedural Codes	80.70, 80.74, 82.01, 82.03, 82.04, 82.09, 82.12, 82.19, 82.32, 82.33, 82.34, 82.34, 82.35, 82.36, 82.39, 82.43, 82.43, 82.44, 82.45, 82.46, 82.52, 82.53, 82.54, 82.56, 82.57, 82.58, 82.59, 82.72, 82.79, 82.92, 82.93, 82.94, 82.95, 82.96, 82.99, 84.01, 84.02, 86.22, 86.28, 96.59

Table 2. Demographics data, patients with septic tenosynovitis
Variable	Frequency, n (%)	P value^a
Total	47,690 (100.0%)
Race		.012 *
White	32,699 (68.6%)
African American	7775 (16.3%)
Hispanic	4798 (10.1%)
Other	2418 (5.1%)
Age, years		<.001 *
19–29	7790 (16.3%)
30–50	21,587 (45.3%)
51–60	8848 (18.6%)
61–79	7490 (15.7%)
>80	1974 (4.1%)
Female	19,329 (40.5%)	<.001 *
HIV/AIDS positive status	257 (0.5%)	.129
Diabetes mellitus	6624 (13.9%)	<.001 *
Culture		<.001 *
No positive culture	34,072 (71.4%)
Positive cultures	13,618 (28.6%)
	Frequency (% among positive cultures: isolated, overall)
Streptococcus spp	2209 (16.2%, 21.9%)
Unspecified Staphylococcus sp	545 (4.0%, 5.5%)
MSSA	6311 (46.3%, 50.8%)
MRSA	2644 (19.4%, 20.1%)
Mycobacteria	69 (0.5%, 0.5%)
Other unspecified bacteria	782 (5.7%, 8.9%)
Fungal	36 (0.3%, 0.6%)
Polymicrobial	1023 (7.5%, 7.5%)
Initial surgery	28,067 (58.9%)
Reoperation (% overall, % of patients having initial surgery)	4682 (9.8%, 16.7%)

^aBased on χ2 analysis for reoperation.
*Indicates significance, defined as P < .05.

Table 3. Rates of initial and repeat surgery, by organism ( P > .001)
Organism	Initial surgery, n (% of patients with positive culture)	Reoperation, n (% of patients with positive culture, % of those who had initial surgery)
Streptococcus spp	1683 (76.2)	365 (16.5, 21.7)
Unspecified	397 (72.8)
Staphylococcus sp		73 (13.4%, 18.4)
MSSA	4715 (74.7)	1069 (16.9%, 22.7%)
MRSA	1897 (71.7)	404 (15.3%, 21.3%)
Mycobacteria	55 (79.7)	9 (13.0%, 16.4%)
Other unspecified bacteria	559 (71.5)	72 (9.2%, 12.9%)
Fungal	15 (42.9)	5 (28.6%, 33.3%)
Polymicrobial	816 (79.8)	249 (24.3%, 30.5%)

Table 4. Predictors of operation and reoperation for tenosynovitis, by binary logistic regression
Initial operation			Reoperation
Variable	P value	OR (95% CI)	P value	OR (95% CI)
Race
White	Refa	Refa	Refa	Refa
African American	<.001*	0.84 (0.79–0.88)	.209	1.06 (0.97–1.15)
Hispanic	<.001*	0.88 (0.82–0.93)	.141	1.08 (0.98–1.20)
Other	<.001*	0.86 (0.79–0.93)	.339	0.93 (0.80–1.08)
Age, years
19–29	Refa	Refa	Refa	Refa
30–50	.438	0.98 (0.93–1.03)	<.001*	1.21 (1.10–1.33)
51–60	.547	0.98 (0.92–1.05)	<.001*	1.31 (1.17–1.46)
61–79	<.001*	0.85 (0.79–0.90)	<.001*	1.39 (1.24–1.57)
>80	<.001*	0.51 (0.46–0.57)	<.001*	1.38 (1.16–1.64)
Female	<.001*	0.85 (0.82–0.89)	<.001*	0.86 (0.81–0.92)
Pathogen
No positive culture	Refa	Refa	Refa	Refa
Streptococcus spp	<.001*	2.78 (2.52–3.08)	<.001*	2.61 (2.31–2.94)
Unspecified	<.001*
Staphylococcus sp		2.34 (1.94–2.83)	<.001*	2.02 (1.57–2.59)
MSSA	<.001*	2.57 (2.41–2.73)	<.001*	2.64 (2.44–2.85)
MRSA	<.001*	2.23 (2.04–2.44)	<.001*	2.36 (2.10–2.64)
Mycobacteria	<.001*	3.67 (2.02–6.68)	.135	1.72 (0.85–3.50)
Other unspecified bacteria	<.001*
Other unspecified bacteria		2.29 (1.96–2.68)	.093	1.24 (0.97–1.58)
Fungal	.273	0.69 (0.36–1.34)	<.001*	4.67 (2.26–9.67)
Polymicrobial	<.001*	3.41 (2.92–3.98)	<.001*	4.07 (3.51–4.73)
Diabetes mellitus	<.001*	1.12 (1.06–1.19)	<.001*	1.48 (1.36–1.60)

* Significance defined as P < .003.
a Reference category.
Abbreviations: CI, confidence interval; MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-sensitive Staphylococcus aureus, OR, odds ratio.