Antibiotics in Hand Surgery: Guidelines and Review

Surgical site infection (SSI) remains an important concern in hand surgery, despite low baseline infection rates, especially in clean, elective soft tissue procedures. This manuscript synthesizes current evidence and guidelines on preoperative antibiotic prophylaxis in hand surgery, focusing on procedure type, patient-specific risk factors, and implications for antimicrobial stewardship. Contemporary guidelines advise against routine prophylaxis in clean orthopedic soft tissue procedures, yet practice patterns vary. Evidence from retrospective studies and prospective trials consistently shows no significant reduction in SSI rates with prophylactic antibiotics in common soft tissue hand procedures, including carpal tunnel and trigger finger release, even when performed in procedure room settings. In implant-related hand surgery, theoretical infection risk is elevated because of potential biofilm formation. However, emerging evidence similarly indicates no significant difference in infection rates with or without prophylaxis in clean cases. Patient-related factors such as diabetes, immunosuppression, smoking, obesity, and prolonged operative duration are associated with increased SSI risk, but the extent to which prophylactic antibiotics mitigate this risk remains unclear. Notably, even in higher-risk populations, data supporting routine antibiotic use are inconsistent. Cefazolin is the preferred prophylactic agent because of its efficacy, safety profile, and low cross reactivity in patients with reported penicillin allergy. Substitution with alternative agents such as clindamycin or vancomycin is associated with higher complication and infection rates. Adverse events related to antibiotic use, including allergic reactions, Clostridioides difficile infection, and antimicrobial resistance, further emphasize the need for judicious use. Given the low baseline SSI rates in hand surgery, cost-effectiveness analyses support the selective rather than routine prophylactic strategy given high total numbers needed to treat to prevent infection. Overall, an individualized, risk-based approach aligned with antimicrobial stewardship principles represents the most evidence-based framework. Further high-quality randomized studies are required to define optimal prophylactic strategies in both soft tissue and implant-based hand surgery.