Volume VI, Number 1 | March 2022

Risk Factors for Failed Outpatient Management of Hand and Upper Extremity Infections

1Allen M, 2Benson E, 1Gluck J, 1Saini A
1Community Memorial Health System, Ventura, CA, United States; 2Ventura County Medical Center, Ventura, CA, United States

Hand and upper extremity infections are heterogeneous; some may undergo outpatient management with or without oral antibiotics and some require inpatient admission. There are no strict guidelines for determining which patients should undergo lab workup, which should receive antibiotics and which are likely to require admission for effective and successful treatment.

We conducted a retrospective chart review of patients across all hospital systems within our county who presented to an ED for hand or upper extremity infection over a 5 year period from 2014-2019. A list of ICD-9 and 10 codes for hand infections was created for screening. Charts with hand infection codes were reviewed for presenting vitals, lab markers CRP, ESR, Na, Glucose, Lactate, WBC, comorbid conditions, ED and home antibiotic prescriptions. Patients who returned to the ED and were admitted for inpatient therapy were considered failure of outpatient management. 
Patients who never returned, or returned but were discharged from the ED were considered a success. Continuous variables were compared with student t test, demographic data with chi squared test. 

4645 patients were diagnosed with hand and upper extremity infections. 755 (16.25%) were admitted on initial presentation to the ED. 121 (2.60%) failed outpatient treatment and were admitted on return to the ED. 3769 (81.14%) were successfully treated as an outpatient, without admission to the hospital. Age (p<0.01) and length of ED stay (p<0.01) were higher in failure versus success. Odds of failure was 85% higher in those who were given antibiotics in the ED (p<0.01), 205% higher in those with diabetes (p<0.01), 74% higher in those with hypertension (p=0.01), and 952% higher in those who received a transplant (p=0.02). CRP was 5.48 mg/dL ±5.07 in failure vs 3.68 ±4.74 in success (p=0.11). Glucose was 157.40 ±103.80 in failure vs 130.10 ±74.67 in success (p=0.07).

Failure was higher with DM, HTN, transplant, increasing age, longer ED treatment time, and for those who received antibiotics in the ED. No labs were significantly associated with failure. Elevated glucose and higher CRP trended toward significance. Alcohol, dialysis, and steroid use trended towards significance.  For patients who have DM, HTN, h/o transplant, and receive antibiotics in the ED, a high index of suspicion for failure is needed. Additional lab values may help clarify the risk for failure, specifically elevated Glucose and CRP values. 

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The Journal of the American Osteopathic Academy of Orthopedics

Steven J. Heithoff, DO, FAOAO

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Authors in This Edition

J. Michael Anderson BS, OMS IV
Rigel Bacani BA, BS, OMS II
David Beckett OMS I
Bhakti Chavan MBBS, MPH
Jake Checketts DO
Grant Chudik OMS II
Adam Dann
Marc Davidson MD
Clinton J. Devin MD
Jeffrey Dulik DO
Bryan Dunford BS, OMS II
Diego Galindo DO
Gregory Galvin DO
Curtis Goltz DO

Jordan Grilliot DO
Brian Handal
Safet Hatic
Scott Dean Hodges DO
David Houserman DO
Jenna Jarrell MS IV
Michael Jones DO
Anthony Kamson DO
Tyler Metcalf MS IV
Anna Elisa Muzio DO
Cesar Cornejo Ochoa OMS I
Brandi Palmer MS
Joseph Patrick
David Phillips DO

Jonathan Phillips MD
Kornelis Poelstra MD
Jesse Raszewski DO, MS
Katherine Sage DO
Steven Santanello DO, FAOAO
Jared Scott DO
Julieanne Sees
James Seymour DO
Jonathan Schneider DO
John Alex Sielatycki MD
Benjamin Taylor MD, FAAOS
Trevor Torgerson BS, OMS IV
Phong Truong DO
Matt Vassar PhD