Treatment of Infectious Tenosynovitis

Diagnosis and Evaluation

The American College of Physicians recommends evaluating for classic signs of infection, including pain, swelling, and limited range of motion over the affected tendon sheath, as well as assessing for systemic signs of infection, such as fever and elevated inflammatory markers, to guide diagnosis and treatment 1
Obtaining cultures from the tendon sheath fluid is crucial to guide targeted antibiotic therapy, according to the Infectious Diseases Society of America 1
Imaging studies, such as ultrasound or MRI, should be considered to confirm diagnosis and identify any fluid collections, as recommended by the American College of Radiology 2

Early surgical drainage is essential for infectious tenosynovitis, and thorough irrigation and debridement of the infected tendon sheath should be performed, as recommended by the American Academy of Orthopaedic Surgeons 1
The American College of Surgeons recommends careful debridement with preservation of tendon function, especially in hand infections 1

Broad-spectrum coverage is recommended initially, with options including vancomycin plus piperacillin-tazobactam, vancomycin plus a carbapenem, or vancomycin plus ceftriaxone and metronidazole, according to the Infectious Diseases Society of America 1, 2
For Staphylococcal infections, including MRSA, vancomycin 15 mg/kg IV every 12 hours is recommended, with an alternative option of linezolid 600 mg IV/PO twice daily, as suggested by the American College of Physicians 1
For Streptococcal infections, penicillin plus clindamycin is recommended for documented Group A streptococcal infections, while cefazolin or antistaphylococcal penicillin (nafcillin/oxacillin) is recommended for susceptible strains, according to the Infectious Diseases Society of America 1, 2
For mixed infections, such as those common in bite wounds, amoxicillin-clavulanate 875/125 mg orally twice daily is recommended, with an alternative option of ampicillin-sulbactam 1.5-3.0 g IV every 6 hours, as suggested by the American College of Emergency Physicians 2

Initial IV antibiotics should be administered for 24-48 hours after clinical improvement begins, and then switched to oral antibiotics once clinically improved with no evidence of bacteremia, as recommended by the Infectious Diseases Society of America 1, 2
The total duration of antibiotic therapy should be 2-3 weeks, according to the American College of Physicians 1, 2
Repeat imaging studies should be performed in patients with persistent symptoms or bacteremia to identify undrained foci of infection, as recommended by the American College of Radiology 2

Delayed surgical intervention can lead to tendon necrosis, adhesions, and permanent functional impairment, while inadequate debridement can result in persistent infection, and premature discontinuation of antibiotics can lead to treatment failure, according to the American Academy of Orthopaedic Surgeons 1
Clinical improvement should be evident within 48-72 hours of appropriate treatment, and early recognition and aggressive treatment of infectious tenosynovitis are crucial to prevent complications, as recommended by the Infectious Diseases Society of America 1, 2