Gram staining in hand phlegmona

1. Department of Plastic, Reconstructive and Hand Surgery
University Hospital of Lausanne (CHUV), Switzerland
GRAM STAINING IN HAND PHLEGMONA
Müller C., Erba P., Beaulieu J., Uckay I., Christen T.

2. ANY CLINICAL DIFFERENCES?
Mm.F 56 ans, 07.06.2014
http://dx.doi.org/10.1016/j.bjps.2014.05.025

3. History

4. Today

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METHODS
retrospective single-centre study
Included:
Adult patients hospitalized for community-acquired
hand phlegmon
Excluded:
Paediatric patients
Atypical pathogens / recurrent episodes
concomitant septic arthritis
http://dx.doi.org/10.1016/j.bjps.2014.05.025

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RESULTS I
126 episodes
42 episodes (33%) revealed a positive Gram-staining and
16 episodes (13%) positive Acridine-orange staining
eighteen episodes with prior antibiotic therapy
47% of later identified pathogens Gram-positive
13% Gram-negative
http://dx.doi.org/10.1016/j.bjps.2014.05.025

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Table 1 – Variables associated with a positive Gram-staining
result (Unmatched logistic regression analysis; Receiver
operating curve (ROC) value 0.81, goodness-of-fit test 0.5)
*Only significant p values ≤0.05 (two-tailed) are displayed
+Immune suppression = Diabetes mellitus, steroids, dialysis, cirrhosis CHILD C, active canc
°Serum C-reactive protein level (continuous variable)
Univariate analysis Multivariate analysis
Hand phlegmona episodes (n=126) Odds ratio (95% confidence interval) p value* Odds ratio (95% confidence interval) p value*
Male gender 0.7 (0.3-1.4) -
Age (continuous variable) 1.0 (0.98-1.03) 1.0 (0.9-1.1)
Immune suppression+
2.7 (0.7-10.7) 1.4 (0.2-9.0)
Infection due to bites 0.6 (0.2-1.8) -
Prior antibiotic exposure 0.6 (0.3-1.1) 0.2 (0.1-0.8) 0.015
Concomitant lymphangitis 2.1 (0.6-7.8) -
Concomitant abscess 5.5 (2.3-12.7) <0.001 11.6 (3.0-44.3) <0.001
Concomitant fever 3.6 (0.8-16.1) 3.8 (0.4-34.6)
CRP° on admission 1.0 (0.99-1.01) 1.0 (1.0-1.0)

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RESULTS III
Gram staining $23
Acridine-orange staining $29
http://dx.doi.org/10.1016/j.bjps.2014.05.025

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CONCLUSION
We conclude that Gram-staining is relatively costly
and has a very low sensitivity in the immediate
confirmation of clinical hand phlegmona, especially if
the patients are pre-treated with antibiotics.
3 Mirrett, S., Lauer, B. A., Miller, G. A. & Reller, L. B. Comparison of acridine orange,
4 methylene blue, and Gram stains for blood cultures. J Clin Microbiol 15, 562-566 (1982).

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Merci
Camillo Theo Müller, MD
#phlegmon, #DGH2016,
#camillomueller