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Can anyone tell me which antibiotics are effective in dealing with a simple Staph infected ingrown toenail? I find GPs medicate with a wide variety. Is amoxycillin the drug of choice?

According to my antibiotics update course that I did, Flucloxacillin is THE first choice, dependant of course on medical history.

Brummy & Jos,
What if your patient is allergic to penicillins? Amoxicillin doesn't seem to work on skin problems, anyway. So it is basically useless for ingrown nails.
I'm going out on a limb here saying that cephalexin is the best for ingrown nail.
Removal of the spicule is of course necessary or no antibiotic can be counted on to kill the infection. On the other hand, antibiotics are usually not needed if the spicule is removed.

Tony Jagger

Anthony,

With regards to your post, "what if the patient is allergic to penicillins," 110% correct, which is why I deliberately put in my post, the words, "dependant on medical history." Noting down any allergies is part of the medical history questioanire, is it not? Meant in the nicest possible way (sorry but there is so much rudeness on some forums nowadays), what else did you think I meant /implied by "dependant on medical history."?

Brummy Pod

Hi Jos,

I have to agree with brummy pod, you would initially start on Flucloxacillin 500mg qds. Don't go down the route of 250mg as that would be about as useful as treating the infection with acupuncture.

If penicillin allergy is present, the initial drug of choice would be Erythromycin.

Couple of things to consider are:-

Does your patient actually need them, if you have a healthy young chap with a localised infection, once you have removed the offending nail, it is likely it would settle on its own. I tend to only request AB's if i have spreading cellulitis, or occasionally in patients with systemic pathology.

Secondly, do you have a POM certificate, as Fluclox is covered by it, so you could start the initial therapy yourself.

As always it will rely on your observations, obviously if the area isn't responding to initial therapy, alternative AB's may be required.

Dr Jagger, here in the UK, the first line therapy in a minor infection like this is almost always Fluclox, cefalexin is usually reserved for further down the line to combat gram -ve bacteria also. It is more commonly used for UTI's. I appreciate what your saying in terms of its use in skin infections, because mistakenly a number of people think it is a broad spectrum AB, when in which case you would be looking at amoxycillin or co-amoxiclav.


Yours,

George

thanks for the replies!
This post wasn"t in relation to a particular Pt, just observations over the past decade that GPs prescribe a wide variety of antibiotics (generally BEFORE i see the Pt). I was just wondering which is more specific/appropriate for skin infections.
I have had a few over the years prescribed Keflex, which I always thought was for respiratory infections....??

From the Australian Therapeutic Guidelines (Antibiotics and Dermatology)

__________________
Stephen Tucker
Eastern Health
Podiatry Manager

My location

If we could only get the GPs to refer immediately to a podiatrist , the need for antibiotics would be reduced significantly. How many times do you see a patient that has had two or even three courses of AB and still the problem is there? It is because they do not understand the etiology of the IGTN and are not aware of the treatment available. I have never sent a patient for AB and removal of the offending nail spike has always resolved the problem.

Cornmerchant

G'Day all,

I rarely refer for antibiotics for my ingrown toenails, except for the heavily infected, cellulitis type infections. Removal of the nail spike, clearing of the area of debris, drain any purrulent exudate, irrigation with saline, and meticulos patinet self management with regards to daily bathing in saline and keeping the toe dressed with betadine and a good breathable dressing (i.e. cutiplast/hansaplast etc. not bandaids!) sees most of them resolve very quickly.

Here in Victoria we can't prescribe any antibiotics anyway, so I try to avoid a second medical bill for my patinet by having to send them back to their GP. That being said, I make myself available to the patinet if circumstances with the toe change.

Steven, where are we at really with this S4 debate at the moment? I'm waiting to get into it, have done the Advanced Pharmacology for Podiatrists through UniSA, as well as the 4 year degree at La Trobe Uni. Just curious.

Cheers all!

__________________
Adrian Misseri
B.Pod.,M.Hlth.Sci.(Pod.)

You know.. we could just cut it off.....?

Very close. The Health Minister should sign off on the formulary this month (but we were told that in December as well)

__________________
Stephen Tucker
Eastern Health
Podiatry Manager

My location

1: Arch Fam Med. 2000 Sep-Oct;9(9):930-2. Links
Are antibiotics necessary in the treatment of locally infected ingrown toenails?Reyzelman AM, Trombello KA, Vayser DJ, Armstrong DG, Harkless LB.
Ankle and Foot Clinic, 1114 Broadway St, Longview, WA 98665, USA.

CONTEXT: A wide variety of generalists and specialists treat locally infected ingrown toenails, with perhaps the most common treatment regimen including resection of the nail border coupled with oral antibiotics. OBJECTIVE: To determine whether oral antibiotic therapy is beneficial as an adjunct to the phenol chemical matrixectomy in the treatment of infected ingrown toenails. DESIGN: We prospectively enrolled healthy patients with infected ingrown toenails. Each patient was randomly assigned to 1 of 3 groups that received either 1 week of antibiotics and a chemical matrixectomy simultaneously (group 1), antibiotics for 1 week and then a matrixectomy (group 2), or a matrixectomy alone (group 3). SETTING: Institutional ambulatory outpatient clinic. PATIENTS: Fifty-four healthy patients with infected ingrown toenails were studied. Patients with immunocompromised states, peripheral vascular disease, or cellulitis proximal to the hallux interphalangeal joint were excluded. Groups were age matched for comparison. RESULTS: Mean healing times for groups 1, 2, and 3 were 1.9, 2.3, and 2.0 weeks, respectively. Subjects receiving antibiotics and a simultaneous chemical matrixectomy (group 1) healed significantly sooner than those receiving a 1-week course of antibiotics followed by a matrixectomy (group 2). There was not a significant difference in healing time between those that received a chemical matrixectomy alone (group 3) and those that received a matrixectomy coupled with a course of oral antibiotics (group 1). CONCLUSION: The use of oral antibiotics as an adjunctive therapy in treating ingrown toenails does not play a role in decreasing the healing time or postprocedure morbidity.

PMID: 11031403 [PubMed - indexed for MEDLINE]

I HAVE sent patients for ABs but only where
As George nicely puts it.

Lets face it, if there is a damn great hole in the foot you could blast it with vancomycin if you were that way inclined, it will just re infect when the patient has a shower and everything they wash off their bodies ends up sloshing around their feet!

R

Have you any evidence to support that statement, Robert?

Or is this from your experience?