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treatment and the knowledge of the available options for reconstruction of STL is essential for proper
[1]
management .
[2]
The combination of antibiotics and sequential debridement is crucial in infection management . The
number of debridements and the interval before tissue coverage are primarily dictated by clinical
examination, blood test and imaging diagnostics aiming to verify infection resolution.

Although rapid wound closure remains crucial, preserving hand function through adequate soft tissue
coverage is the primary goal . This can be obtained, provided that soft tissue reconstruction permits good
[3]
tendon gliding and early postoperative rehabilitation.

At present, there is no consensus in the literature on standard treatment for the initial management and
secondary reconstructive procedures, because patients may show different infection patterns and different
host characteristics. Therefore, treatment strategy should be evaluated on a case-by-case basis . This
[1-3]
review aims to describe the acute treatment and subsequent defect coverage in post-infection hand STL to
help surgeons in their practice when facing this complex multidisciplinary setting.

SEARCH STRATEGY AND STUDY SCREENING
A comprehensive literature search to identify studies that analyzed hand coverage in infected STL was
performed on PubMed, Scopus, Cochrane Library, Web of Sciences, and Embase. The search was limited to
September 2022. After collecting the studies, duplicates were removed. The remaining studies were screened
based on title, abstract, and full text. The quality of the studies was assessed. Any information relevant to the
review was considered to summarize acute treatment and subsequent defect coverage in infected hand STL.
A treatment algorithm treatment for infected soft tissue loss was reported in Figure 1.

PRINCIPLES OF TREATMENT IN ACUTE PHASE
Antibiotic therapy
Clinical data supporting antibiotic therapy in infected STL of the hand is limited. Immediate empiric
antibiotic therapy should only be performed in cases of severe and acutely evolving soft tissue infections.
For established infection cases, wound cultures should be taken prior to antibiotic administration. After
that, empiric antibiotic therapy can be started. Once cultures and antibiotic sensitivity data are available, an
[4]
appropriate, agent-specific antibiotic treatment should be performed .

[5]
The empiric antibiotic therapy should be evaluated according to clinical history . Infected STL related to
human or animal bites and marine environment are often polymicrobial. Farming accidents are often
caused by gram-negative (e.g., Enterobacter and Klebsiella species) or anaerobic strains (e.g.,
Clostridium) . In contrast, infected STL related to domestic injuries, and post-surgical cases are usually
[6]
associated with Staphylococcus epidermidis, Staphylococcus aureus, and Streptococcus group D.

In open contaminated injuries, antibiotic therapy should be started as soon as possible. In recent guidelines
published by the British Orthopedic Association (BOA) and the British Association of Plastic
Reconstructive Aesthetic Surgeons (BAPRAS), cephalosporin or amoxicillin-clavulanate has been suggested
for 24-48 h. Furthermore, a single dose of gentamycin (3 mg/kg) can also be added at the time of surgical
[7]
debridement .