Improving the outcomes of hand infections in low- and middle-income countries (LMICs)

Keywords Hand infections, hand surgery, low- and middle-income countries, global surgery Systematic review, health resource mapping, clinical trials Background

Hand infections often happen after hand injuries and are common in high-income countries. These infections can mean people lose the use of their hand, and in the worst cases, fingers or parts of the hand need to be surgically removed to save their life. Even less serious infections can affect people's ability to work and manage daily life.

In poorer countries, hand infections may be more common, due to a higher proportion of manual workers and therefore hand injuries, inadequate hand trauma management and increased diabetes and HIV rates. The resulting disability and catastrophic patient expenditure can be even more devastating in these settings.

Currently we do not know the scale of the problem of hand infections in low- and middle-income countries (LMICs), what healthcare is available and how to best treat these infections in these countries.

Evidence from HICs indicate that hand infection management should involve a combination of surgery and antibiotics. Hand surgery capacity in LMICs remains largely unknown, with sporadic availability. Specialist hand surgery care is usually only available in large centres, with minimal specialist skills in rural areas.

For severe hand infections, patients are often hospitalised for intravenous antibiotics and surgery in most settings. Intravenous antibiotics can result in prolonged admission and increased cost to the healthcare system and patient. This is particularly problematic in resource-constrained settings.

Parenteral administration carries risks of infection, thrombosis and antibiotic allergy. Oral therapy is more widely available, can be given without specially trained staff and equipment and reduces resource use. Oral antibiotics have been demonstrated to be non-inferior to intravenous therapy for treatment of established musculoskeletal infection, including skin and soft tissue, and bone and joint.

Aim

To undertake high-quality research to improve hand infection outcomes in LMICs, and establish the feasibility of plastic surgery trials in low resource settings. Methods

I will undertake three work packages. Work package 1 will consist of a systematic review of surgical hand infection management and outcomes in LMICs. Work package 2 will aim to map the healthcare resources available for management of hand infections across South Africa, Malawi and Tanzania.

This will be done using the World Health Organisation Service Availability and Readiness Assessment (SARA) tool. My final work package will be a feasibility trial of oral vs intravenous antibiotics following surgical management of primary hand infections. Patients will be recruited from the hand surgery unit at Groote Schuur Hospital, Cape Town.

Impact of Studentship

This studentship will equip me with specialist research skills and expertise in systematic review, healthcare resource mapping, clinical trials methodology and statistics. This will enable me to deliver high-quality research to benefit surgical patients in both the NHS and LMICs during my career.

I will be working with human participants and will gain ethical approval through the Research Ethics Committees at relevant institutions for the healthcare resource mapping and feasibility trial.