Welcome to the Podiatry Arena forums, for communication between foot health professionals about podiatry and related topics.
You are currently viewing our podiatry forum as a guest which gives you limited access to view all podiatry discussions and access our other features. By joining our free global community of Podiatrists and other interested foot health care professionals you will have access to post podiatry topics (answer and ask questions), communicate privately with other members (PM), upload content, view attachments, receive a weekly email update of new discussions, earn CPD points and access many other special features. Registered users do not get displayed the advertisments in posted messages. Registration is fast, simple and absolutely free so please, join our global Podiatry community today!
If you have any problems with the registration process or your account login, please contact contact us.
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?
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.
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."?
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.
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)
Quote:
Oral antibiotics are rarely required, and in general are used only if there is frank suppuration from the lateral nail fold or cellulitis developing around the toe. Di/flucloxacillin or cephalexin may be used empirically (see Acute paronychia); however, the most appropriate antibiotic will be determined by culture and sensitivities.
Acute paronychia
Acute paronychia is due to bacterial (usually staphylococcal) or, rarely, viral (herpes simplex virus) infection. It may aggravate chronic paronychia. The proximal nail fold becomes painful and pus should be drained.
For staphylococcal infection not responding to drainage, use
di/flucloxacillin (child: 25 mg/kg up to) 500 mg orally, 6-hourly for 7 days.
For patients hypersensitive to penicillin (excluding immediate hypersensitivity), use
cephalexin (child: 12.5 mg/kg up to) 500 mg orally, 6-hourly for 7 days.
For patients with immediate penicillin hypersensitivity, use
clindamycin (child: 10 mg/kg up to) 450 mg orally, 8-hourly for 7 days.
For infection caused by herpes simplex virus (herpetic whitlow), use
valaciclovir 500 mg orally, 12-hourly for 7 to 10 days
OR
famciclovir 250 mg orally, 12-hourly for 7 to 10 days
OR
aciclovir (child: 5 mg/kg up to) 200 mg orally, 5 times daily for 7 to 10 days.
Aciclovir is the preferred treatment in children with acute paronychia caused by herpes simplex virus.
__________________ Stephen Tucker Calvary Health Care
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.
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.)
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!
Very close. The Health Minister should sign off on the formulary this month (but we were told that in December as well)
__________________ Stephen Tucker Calvary Health Care
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.
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
I HAVE sent patients for ABs but only where
Quote:
i have spreading cellulitis, or occasionally in patients with systemic pathology.
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!
BACKGROUND: Antibiotic prophylaxis in nail surgery is not clearly established, and there is scant scientific evidence regarding the need for its use in preventing surgical site infection, hematogenous total joint infection, and infective endocarditis.
OBJECTIVES: To propose an algorithm based on the evidence for the management of antibiotic prophylaxis in onychocryptosis surgery.
METHODS: A literature review was performed in Medline, Pubmed, Cochrane database and Scopus and recent prospective studies were examined. The most-current authoritative guidelines together with new classification system of the pathology have been taken into account.
RESULTS: In non-risk patients with onychocryptosis stage II or III phenol technique can be used without the need for antibiotics. In stages IV and V, specific antibiotic treatment should be administered before surgery together with partial ablation of nail until the infection is resolved and the process remits to stage II or III. In the case of long-developing onychocryptosis, osteomyelitis should be ruled out, and specific antibiotic treatment besides the preoperative dose should be administered. In high-risk cardiac patients with infective onychocryptosis, the need for prophylaxis for bacterial endocarditis should be considered.
CONCLUSION: Current evidence does not support the use of preoperative antibiotic prophylaxis in onychocrytosis surgery except in special patients with infective onychocryptosis.
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?
The best person to talk about this with is your local microbiologist. Read up about local resistance patterns and antibiotic prescribing. Flucloxacillin is commonly used for staph aureus, as are cephalosporins and some of the macrolides in patients with penicillin allergy. There is a small percentage of patients with a penicillin allergy that will have a similar reaction to cephalosporins due to their chemical structure similarities. Aside from speaking to microbiology, go and spend time in your local multidisciplinary foot clinic. This will give you the best real world experience of antibiotic provision for foot infections, but microbiology links will keep you up to date as local resistance patterns change.
Amoxicillin is susceptible to beta-lactamases, so would not be particularly effective against staph aureus - unless combined with clavulanic acid (a beta-lactamase inhibitor).
Having said all this, spreading cellulitis is not usually caused by staph aureus, so you have to go on clinical signs, your knowledge of infection and advice from micro (and possibly blood cultures, although these are not particularly specific) to choose a reasonable antibiotic in these cases. Cellulitis is often caused by some form of streptococcus and may respond to amoxicillin (but, again, check with local practices). As others have said, you need to remove the nail spike too or in isolation depending on extent of infection.
Background: Excisional toenail matrixectomies are performed on the area of the foot that has been reported to have the highest concentration of resident microorganisms. A retrospective infection audit was performed to identify whether this unique area of the foot was more susceptible to postoperative infection.
Methods: A retrospective audit reviewing the postoperative infection rate over a 6-year period after excisional nail matrixectomy in 111 patients was undertaken.
Results: The postoperative infection rate was found to be high (18.9%) relative to that of clean orthopedic foot and ankle surgery (0.5%–6.5%).
Conclusions: The unique concentration of resident microbes found in the nail folds could help explain the high rate of postoperative infections identified in this study. This may provide some argument to classify excisional nail matrixectomy as clean-contaminated surgery and, thus, warrant routine antibiotic prophylaxis. Further research is recommended to confirm the results of this study and to determine whether appropriately timed oral antibiotic prophylaxis will reduce the infection rate after nail surgery
Antibiotics for Ingrown toenails
Linear Mode
