Epidemiology and Management of Surgical Upper Limb Infections in Patients with End-stage Renal Failure

Abstract

Introduction: Hand infections in patients with end-stage renal failure (ESRF) are more difficult to treat and have had the worse outcomes. This paper examines the epidemiology, bacteriology and outcomes of surgically managed upper limb infections in these vulnerable patients. Materials and Methods: All patients from a single centre with surgically-managed upper limb infections between 2001 and 2007 were reviewed. We collected epidemiological data on demographics, type and site of infection, bacteriology, surgical treatment, complications and mortality. Results: Forty-seven out of 803 (6%) patients with surgically managed upper limb infections in the study period had ESRF. The average age was 59 years. ESRF was secondary to diabetes in 88% of cases. Patients presented on average 7 days after onset of symptoms. Abscesses (34%), wet gangrene (26%) and osteomyelitis (11%) were the commonest infections. Methicillin-resistant Staphylococcus aureus (MRSA) was the commonest pathogen (29%), occurring either in isolation or with other organisms. Eighteen percent of single organisms cultured were gram-negative. Multiple organisms occurred in 29%. A median of 2 operations were required. Thirty-six percent of all cases required amputation. Twenty-five percent of patients had a life-threatening event (myocardial infarction or septic shock) during treatment. Conclusions: ESRF patients present late with severe upper limb infections. Nosocomial infections are common. Initial empirical antibiotic treatment should cover MRSA and gram-negative bacteria. Immediate referral to a hand surgery unit is recommended. Multi-disciplinary management of the patient with input from physicians and anaesthetists or intensivists in the perioperative period is necessary to optimise the patient for surgery and to manage active medical comorbidities and complications after surgery. Key words: Bacteriology, Complications, Diabetes mellitus, Hand infections, Upper limb amputation