Hand Phlegmons: Clinical Burden, Microbiological Spectrum, and Predictors of Surgical Complexity

Background: Hand phlegmons are rapidly progressive bacterial soft-tissue infections that may lead to severe functional impairment, repeated surgical interventions, and prolonged hospitalization if diagnosis and treatment are delayed. Although Gram-positive skin flora are considered the predominant pathogens, microbiological findings and clinical severity may vary considerably depending on the extent of infection and host factors. Methods: This single-center retrospective study analyzed 100 patients surgically treated for hand phlegmons at a university hospital between 2020 and 2025. Clinical data included demographics, portal of entry, microbiological findings, inflammatory markers, antibiotic therapy, number of surgical procedures, and length of hospital stay. Pathogens were classified according to Gram stain characteristics, and statistical analyses were performed using nonparametric methods and correlation analyses. Results: The cohort consisted of 69 male and 31 female patients with a mean age of 50.5 ± 20.9 years. Mean hospital stay was 12.9 days (range 1–77), and patients underwent an average of 2.18 surgical procedures (range 0–11). Wounds and bite injuries represented the most common portals of entry, although many cases lacked a clearly identifiable cause. Microbiological cultures were negative in 62% of cases. Among positive cultures, Gram-positive organisms predominated (84.2%), with Staphylococcus aureus and Streptococcus pyogenes representing the most frequent pathogens. MRSA was detected in three patients and was associated with significantly more surgical procedures (p = 0.04) and a tendency toward prolonged hospitalization. Admission CRP levels differed significantly according to Gram stain classification (p = 0.008) and correlated positively with both length of hospital stay (r = 0.431, p < 0.001) and number of surgical interventions (r = 0.272, p = 0.006). Patients with microbiologically confirmed infections required significantly more operative procedures than patients without pathogen detection (p < 0.001). Empiric antibiotic therapy primarily consisted of ampicillin/sulbactam, cefuroxime, and clindamycin, followed by oral therapy with amoxicillin–clavulanate or clindamycin. Conclusion: Hand phlegmons remain clinically challenging infections characterized by heterogeneous presentation, frequent culture-negative findings, and substantial surgical burden. Gram-positive pathogens continue to predominate, while resistant organisms such as MRSA may be associated with more complex clinical courses. Elevated inflammatory markers at admission correlate with prolonged hospitalization and increased operative requirements, suggesting their potential value as indicators of disease severity. Early diagnosis, prompt surgical debridement, and individualized antimicrobial therapy remain essential for infection control and preservation of hand function.