Infectious Tenosynovitis: Organism -Tailored Therapy

Creator: Dr. Samarth Mishra
Published: 2023-01-24T18:00:49

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Infective tenosynovitis is a synovium inflammation borne of a pathogenic cause. Read this article to know about the disease and cause-specific therapy.

Written by

Dr. Samarth Mishra

Medically reviewed by

Dr. Kaushal Bhavsar

January 24, 2023

September 8, 2023

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Contents

What Is Infectious Tenosynovitis?
Who Is Susceptible to Infectious Tenosynovitis?
What Causes Infectious Tenosynovitis?
What Is the Pathophysiology of Infectious Tenosynovitis?
What Are the Signs and Symptoms of Infectious Tenosynovitis?
What Are the Evaluation Methods for Infectious Tenosynovitis?
How to Treat Infectious Tenosynovitis?
What Is the Prognosis of Infectious Tenosynovitis?
What Are the Complications of Infectious Tenosynovitis?

What Is Infectious Tenosynovitis?

Tenosynovitis is an inflammation of the fluid-filled synovium, which is present inside the tendon sheath. The condition commonly manifests as pain, swelling, and stiffness. Infective tenosynovitis is caused due to infiltration and proliferation of infective pathogens within the tendon sheath. The pathogens reach the sheath either through direct inoculation or spread from local or distant foci of infection.

Who Is Susceptible to Infectious Tenosynovitis?

The stenosing form of tenosynovitis is found in about 1.7 to 2.6 percent of the general population, which increases to 10 to 20 percent in patients with diabetes mellitus. About 2.5 to 9.4 percent of the patients who develop some kind of hand infection will go on to develop infectious tenosynovitis. Patients with predisposing rheumatoid arthritis are at the highest risk of tenosynovitis, with 55 percent incidence reporting an average of 3.1 number of tendon inflammations.

What Causes Infectious Tenosynovitis?

Infectious tenosynovitis is caused by inoculation, spread, and growth of pathogens in the tendon sheaths. The most common organisms causing infectious tenosynovitis are Staphylococcus aureus (40 to 75 percent of the cases), MRSA - Methicillin-resistant Staphylococcus aureus (29 percent of the cases), other common skin commensal bacteria like Staphylococcus epidermidis, beta-hemolytic streptococcus, Pseudomonas aeruginosa, Eikenella in human bites, and Pasturella multocida in animal bites.

What Is the Pathophysiology of Infectious Tenosynovitis?

The mechanism of tenosynovitis is similar to the findings in inflammation within the tendon sheath. Various etiological pathways affect the tendon synovium or the tendon itself, which results in inflammation and thickening of the tendon, which comprises the natural gliding ability of the tendon sheath. Not all tendons are capsulated within a sheath like the Achilles tendon. The progression of infectious tenosynovitis is through a series of surgically significant steps. The first step demonstrates exudative distension of the tendon sheath apparatus. The second stage demonstrates purulent filling, and the final stage results in necrosis and destruction of the sheath, tendon, and adjacent structures.

What Are the Signs and Symptoms of Infectious Tenosynovitis?

Infectious tenosynovitis presents with a history of injury, fever, ulceration, or purulence with acute digit contracture or pain upon flexion or extension.

To diagnose infectious flexor tenosynovitis, the criteria to be satisfied are:

Pain in the flexor sheath.
Symmetric enlargement of the affected tendon.
Baseline contracture of the infected tendon.
Passive straightening of the tendon with tenderness.

What Are the Evaluation Methods for Infectious Tenosynovitis?

Laboratory Studies: Elevated WBC (white blood cells), bacteremia, and culture studies.
Microscopic examination to distinguish infectious pathology from crystalline pathology.
Radiographic shreds of evidence are not always useful.
CT (computed tomography) scan can detect bony abnormalities but soft tissue sensitivity for synovitis and tenosynovitis is low.
Ultrasound may show echotexture changes in tendons and blurring of tendon margins. Additionally, tendon thickening, sheath cysts, and further abnormalities of the metacarpophalangeal joints may also be observed.
MRI (magnetic resonance imaging) may reveal peritendinous edema and increased thickening of the extensor brevis longus (EBL) and abductor pollicis longus (APL) tendons.

How to Treat Infectious Tenosynovitis?

Various pathogens involved in infectious tenosynovitis are:

Methicillin-susceptible Staphylococcus aureus.
Methicillin-resistant Staphylococcus aureus (MRSA).
Streptococcus species.
Pseudomonas aeruginosa.
Neisseria gonorrhoeae.
Pasteurella multocida.
Mycobacterium marinum.
Sporothrix schenckii.
Coccidioides species.

Treatment regimens against methicillin-susceptible Staphylococcus aureus:

Penicillin G (4 million units Intravenous (IV) every four hours).
Nafcillin (2 g (grams) IV every four hours).
Oxacillin (2 g IV every four hours).
Cefazolin (2 g IV every eight hours).
Cephalexin (250 to 1000 mg (milligram) every six hours).

Duration of therapy: 7 to 14 days (uncomplicated infection) or 14 to 21 days (complicated infections).

Treatment regimens against methicillin-resistant Staphylococcus aureus (MRSA):

Doxycycline (100 mg twice a day).
Trimethoprim-sulfamethoxazole (160 mg or 800 mg twice a day).
Clindamycin (300 to 600 mg thrice a day).
Vancomycin (15 to 20 mg/kg (milligram per kilogram) two to three times a day).
Linezolid (600 mg twice a day).
Daptomycin (four to six mg/kg IV one time per day).

Vancomycin is the first-line drug of choice against MRSA in hospitalized patients.
Duration of therapy: 7 to 14 days (uncomplicated infection) or 14 to 21 days (complicated infections).

Treatment regimens against Streptococcus species:

Penicillin G (4 million units IV every 4 hours).
Clindamycin (300 to 600 mg thrice a day).
Ceftriaxone (1 g IV once a day).
Amoxicillin-Clavulanate (875 mg or 125 mg twice a day).
Ampicillin-Sulbactam (one to two g IV four times per day).

Duration of therapy: 7 to 14 days (uncomplicated infection) or 14 to 21 days (complicated infections).

Treatment regimens against Neisseria gonorrhoeae:

Ceftriaxone (1 g IM (intramuscular) or IV once a day) plus single-dose Azithromycin 1 g.
Cefotaxime (1 g IV thrice a day) plus single-dose Azithromycin 1 g.
Ceftizoxime (1 g IV thrice a day) plus single-dose Azithromycin 1 g.

Duration of therapy: 24 to 48 hours and transition to Cefixime 400 mg (twice a day) for at least one week.

Treatment regimens against Pasteurella multocida:

Amoxicillin-clavulanate (875 mg or 125 mg twice a day).
Ampicillin-sulbactam one to two g IV (four times per day).
Doxycycline 100 mg (twice a day).

Duration of therapy: 7 to 14 days (uncomplicated infection) or 14 to 21 days (complicated infections).

Treatment regimens against Mycobacterium marinum:

Clarithromycin (500 mg twice a day) plus Rifampin (600 mg once daily).
Clarithromycin (500 mg twice a day) plus Ethambutol (15 mg/kg once daily).
Minocycline (100 mg twice a day).
Doxycycline (100 mg twice a day).

Duration of therapy: four to six weeks after symptoms subside with three months minimum duration.

Treatment regimens against Sporothrix schenckii:

Itraconazole (200 mg twice a day).
Amphotericin B (three to five mg/kg/day IV per day) until resolution, then continue with Itraconazole (200 mg twice a day).
Deoxycholate Amphotericin B (0.7 to 1 mg/kg/day) until resolution, then continue with Itraconazole (200 mg twice a day).

Duration of therapy: at least 12 months.

Treatment regimens against Coccidioides species:

Itraconazole (200 mg twice a day).
Fluconazole (400 to 800 mg once a day).
Lipid amphotericin B (three to five mg/kg IV once daily) until improving, then continue with Itraconazole (200 mg twice a day).

Duration of therapy: at least 6 to 12 months.

What Is the Prognosis of Infectious Tenosynovitis?

The best outcomes of infectious tenosynovitis are related to early empiric antibiotic therapy and early irrigation or debridement when necessary. The poor prognosis of infectious tenosynovitis is due to superinfection by Streptococcus pyogenes, delayed antibiotic therapy and surgical intervention, purulence of the tissue, diabetes mellitus, renal failure, and peripheral vascular disease. Stage III disease involving necrosis and destruction offers the worst outcomes, with a high amputation rate.

What Are the Complications of Infectious Tenosynovitis?

Long-term stiffness of fingers.
Deformation of underlying bones or tendons.
Deep space infections of the hand.
Tendon necrosis (death of the tendons).
Adhesions (scar tissue between two surfaces that fuse them).
Amputation (surgical removal of a body part).

Conclusion

Tenosynovitis requires an inter-departmental approach to treatment, including physicians, infection specialists, nurses, and surgeons, all collaborating across disciplines to achieve optimal patient results. The consultation of an infectious disease specialist is a must in infectious tenosynovitis, which will prompt early diagnosis and empirical antibiotic treatment. Early detection of pain, contracture, enlargement, or any such changes to the extremities of the patient is important in establishing an early diagnosis and treatment regime.

Frequently Asked Questions

1. What Is the Recommended Timeframe for Performing Surgery in Cases of Infectious Tenosynovitis?

The recommended timeframe for performing surgery in cases of infectious tenosynovitis depends on various factors, such as the severity of the infection and the response to conservative treatments. However, it is generally recommended to perform surgery promptly to prevent further infection spread and minimize potential complications. Early surgical intervention, often within 24 to 48 hours of diagnosis, is commonly advised to effectively remove infected tissues, drain abscesses, and improve outcomes. Timely surgical management is crucial in reducing the risk of long-term damage and promoting successful recovery.

2. When Is Surgical Intervention Necessary for Infectious Flexor Tenosynovitis?

Surgical intervention is typically necessary for infectious flexor tenosynovitis when conservative treatments fail to control the infection or worsening symptoms, such as increasing pain, swelling, or limited hand mobility. Other indications for surgery include the presence of an abscess, extensive tissue damage, or the development of complications like septic arthritis. Prompt surgical treatment aims to remove infected tissue, drain any abscesses, and potentially repair damaged tendons or structures within the flexor sheath. The decision for surgical intervention is usually made on a case-by-case basis, considering the severity and progression of the infection.

3. What Is Meant By Infectious Tenosynovitis?

Infectious tenosynovitis is an inflammatory condition characterized by the infection of the synovial sheath surrounding a tendon. It occurs when bacteria or other microorganisms invade the protective covering of the tendon, leading to inflammation, swelling, and pain. Various pathogens, such as Staphylococcus aureus or Streptococcus species, can cause the infection. Common risk factors include penetrating injuries, open fractures, or compromised immune systems. Prompt diagnosis and treatment are crucial to prevent the spread of infection and to preserve the function of the affected tendon.

4. What Is the Typical Healing Time for Infectious Tenosynovitis?

The typical healing time for infectious tenosynovitis can vary depending on several factors, including the severity of the infection, the timeliness of treatment, and individual patient factors. In general, with appropriate and timely treatment, symptoms can improve within a few days to a week. However, complete healing of infectious tenosynovitis may take several weeks or months. It is important to follow the prescribed treatment plan, including antibiotics, immobilization, and rehabilitation, to optimize the healing process and prevent complications or recurrence. Regular monitoring by a healthcare professional is advised to ensure adequate healing progress.

5. Which Antibiotic Is Commonly Prescribed for the Treatment of Tenosynovitis?

The choice of antibiotic for the treatment of tenosynovitis depends on several factors, including the suspected or identified infectious organism and its sensitivity to different antibiotics. Commonly prescribed antibiotics for tenosynovitis include broad-spectrum options such as penicillinase-resistant penicillins (for example, Dicloxacillin), cephalosporins (for example, Cefazolin), or fluoroquinolones (for example, Ciprofloxacin). However, the specific antibiotic regimen should be determined by a healthcare professional based on factors such as the severity of the infection, local resistance patterns, and individual patient characteristics or allergies. It is important to complete the full course of antibiotics as prescribed to eradicate the infection and minimize the risk of recurrence effectively.

6. What Is the Duration of Treatment for Infectious Tenosynovitis?

The duration of treatment for infectious tenosynovitis can vary depending on the severity of the infection, the chosen antibiotic, and the individual patient's response to treatment. Typically, antibiotics are prescribed for a duration of ten to 14 days. However, in more severe cases or when complications arise, a longer course of treatment may be necessary. It is important to follow the healthcare professional's instructions regarding the duration of antibiotic therapy and complete the full course of treatment to ensure the infection is adequately treated and to prevent the development of antibiotic resistance. Regular monitoring and follow-up with a healthcare provider are essential to assess the response to treatment and adjust the duration if needed.

7. How Long Does It Typically Take for Flexor Tenosynovitis to Heal?

The healing time for flexor tenosynovitis can vary depending on the severity of the condition, the promptness of treatment, and individual factors. In general, it may take several weeks to months for flexor tenosynovitis to heal completely. Early and appropriate treatment, which often includes a combination of antibiotics, immobilization, and hand therapy, can help expedite the healing process. However, the recovery timeline may be influenced by factors such as the extent of tissue damage, complications, and the patient's overall health. It is important to follow the prescribed treatment plan and to consult with a healthcare professional for proper management and guidance throughout the healing process.

8. What Are the Potential Risks Associated with Tenosynovitis?

There are potential risks associated with tenosynovitis that can vary depending on the specific circumstances and severity of the condition. Some common risks include the spread of infection to nearby tissues or joints, development of abscesses or septic arthritis, impaired hand function or mobility, and potential scarring or adhesion formation within the affected tendon sheath. Tenosynovitis can lead to chronic inflammation, tendon damage, or even systemic complications if left untreated or inadequately managed. Early diagnosis, prompt treatment, and regular follow-up with a healthcare professional can help mitigate these risks and improve outcomes.

9. Is It Possible for a Tendon Infection to Spread?

Yes, a tendon infection can spread if left untreated or if the infection is not effectively controlled. In cases of tenosynovitis, where the infection affects the synovial sheath surrounding the tendon, there is a risk of the infection spreading to nearby tissues, joints, or even into the bloodstream. This can lead to more severe complications, such as septicemia or systemic infection. Prompt medical attention, proper antibiotic treatment, and surgical intervention, if necessary, are crucial to prevent the spread of the infection and minimize the risk of complications. Regular monitoring and follow-up care are important to ensure the infection is effectively treated and to prevent further spread.

10. Is Tenosynovitis Considered a Chronic Condition?

Tenosynovitis can be either acute or chronic. While an infection typically causes acute tenosynovitis, chronic tenosynovitis can have various causes, including repetitive strain or overuse injuries, underlying inflammatory conditions like rheumatoid arthritis, or mechanical factors. Chronic tenosynovitis is characterized by persistent tendon sheath inflammation, leading to ongoing symptoms such as pain, swelling, and limited mobility. It is important to identify the underlying cause of tenosynovitis to determine the most appropriate treatment approach, which may involve a combination of rest, physical therapy, anti-inflammatory medications, or in some cases, surgical intervention.

11. Does an Infection Always Cause Tenosynovitis?

No, tenosynovitis is not always caused by an infection. While infection of the tendon sheath characterizes infectious tenosynovitis, there are also non-infectious forms of tenosynovitis. Non-infectious tenosynovitis can be caused by various factors such as repetitive motion, overuse, trauma, or underlying inflammatory conditions like rheumatoid arthritis. These non-infectious forms involve inflammation of the tendon sheath without an associated infection. The treatment and management approach for non-infectious tenosynovitis may differ from that of infectious tenosynovitis and may involve strategies to reduce inflammation, relieve symptoms, and address the underlying cause.

12. What Are the Surgical Options for Treating Flexor Tenosynovitis?

The surgical treatment of flexor tenosynovitis typically involves incision and drainage (I&D) or debridement. During this surgery, a small incision is made in the affected area to drain any pus or fluid buildup and remove infected or necrotic tissue. The goal of the surgical intervention is to effectively remove the source of infection, reduce inflammation, and promote healing. In some cases, tendon repair or reconstruction may be necessary if there is significant damage to the tendon or surrounding structures. The specific surgical approach and techniques may vary depending on the severity and extent of the infection.

13. How Long Does the Recovery Process Usually Take After Surgery for Infectious Flexor Tenosynovitis?

The recovery process after surgery for infectious flexor tenosynovitis can vary depending on factors such as the extent of the infection, the surgical technique used, and individual healing capabilities. Generally, the initial recovery period may involve immobilizing the affected hand or finger with a splint or cast for proper healing. Physical therapy and hand exercises are typically recommended to restore hand function and mobility gradually. The complete recovery from infectious flexor tenosynovitis surgery can take several weeks to months, during which regular follow-up visits with the healthcare provider are important to monitor progress and ensure optimal healing.

14. What Is the Estimated Healing Time for Wrist Tenosynovitis?

The estimated healing time for wrist tenosynovitis can vary depending on factors such as the severity of the condition, the chosen treatment approach, and individual healing factors. With appropriate treatment, wrist tenosynovitis can take several weeks to a few months to heal completely. Treatment may include a combination of rest, immobilization with a splint or brace, anti-inflammatory medications, physical therapy, and possibly corticosteroid injections. Following the recommended treatment plan and consulting a healthcare professional for guidance and monitoring throughout the healing process is important to ensure optimal recovery.

Sources

Dr. Kaushal Bhavsar

Pulmonology (Asthma Doctors)

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