treatment of acute paronychia and empiric treat of puncture wound

[Painter1]

i can't seem to find any consensus in antibiotic treatment of acute paronychia. one source says pencillin or cephalosporin such as keflex, another source says clinda or augmentin yet another source tmp-smx in case of mrsa!!! damn, i wish it were easier!

for diabetics with nail puncture wound through tennis shoes, you guys treating emprically? cipro or levaquin x7days?

[Radiohead]

The definitive treatment is I&D, or warm soaks if no obvious pus is present. Any of the abx you listed are ok, and it will vary on what your attending wants to do. Here in charlotte, we have a ton of MRSA, so I use Bactrim often, but as long as you get the pus out, you will be fine w/ Keflex/Augmentin.

[EctopicFetus]

For whatever reason we choose Clinda in Tucson. Bactrim is also used but for some reason the attendings here arent fond of it.

I prefer it because it is cheaper and covers MRSA.. of course it seems like 25% of people have sulfa allergies..

[waterski232002]

The antibiotic choice should be directed at the suspected mechanism of infection and severity of infection on exam. Any of the antibiotics you listed may be appropriate in different situations (except PCN), but lateral incision is always warranted if it is indurated and fluctuant. The reason why Clinda is listed as an antibiotic of choice is b/c many paronychias arise from people biting at their finger nails, thus oral flora/anaerobes should be considered.

Simple Paronychia, denies nail biting - Keflex (covers G+, probably okay.... no antibiotics at all is probably okay too)
Severe Paronychia, or admits to nail biting - Clinda (covers G+, CA-MRSA, Anaerobes/oral flora, but is expensive and requires qid dosing)

Obviously there are other choices/alternatives based on the exact clinical picture and cost/compliance issues.

PCN - some G+, Anaerobes/Oral Flora, may be adequate for nail biters but I would never use b/c it doesn't cover S. Aureus
Bactrim or Doxy - G+, CA-MRSA, may not be adequate for nail biters but a cheaper and more compliant friendly alternative to Clinda in treating CA-MRSA.

[waterski232002]

Originally Posted by Painter1

for diabetics with nail puncture wound through tennis shoes, you guys treating emprically? cipro or levaquin x7days?

Yes, treat with Cipro... they are at risk for Pseudomonas. That probably goes for anyone with a nail puncture wound through the shoe, not just diabetics (I would hate to develop pseudomonas osteo in my foot from a puncture wound). Also use Cipro with anyone who has a laceration that occured while swimming or standing in water. You don't necessarily need to start it emperically, but if it becomes infected you definitely need to cover Pseudomonas and Aeromonas in particular.

[docB]

Originally Posted by Painter1

i can't seem to find any consensus in antibiotic treatment of acute paronychia.

Anytime you get consensus on anything in EM it's unusual. The only thing we all agreee on unequivocally is TPA for stroke.

[BKN]

Originally Posted by docB

Anytime you get consensus on anything in EM it's unusual. The only thing we all agreee on unequivocally is TPA for stroke.

[DrQuinn]

Originally Posted by docB

Anytime you get consensus on anything in EM it's unusual. The only thing we all agreee on unequivocally is TPA for stroke.

[kbrown]

Originally Posted by EctopicFetus

For whatever reason we choose Clinda in Tucson. Bactrim is also used but for some reason the attendings here arent fond of it.

I prefer it because it is cheaper and covers MRSA.. of course it seems like 25% of people have sulfa allergies..

here in my neck of the woods we have a fair amount of resistance to clinda with the mrsa, but bactrim is like 97% sensitive. plus it's hella cheap.

my suggestion is to check with the hospital antibiotogram to see what regional sensitivities are then treat as they dictate. ours are broken down into inpt vs outpt, etc..

[Dr.Evil1]

We love Bactrim here in Detroit, home of killer spiders that will seem to bite people on their thigh and deltoid muscles almost every day!!!!

[beyond all hope]

Yes, the spider that bit me and gave me my abscess. Three times this week.
*sighs wistfully*

Where I used to work was often called the abscess clinic. One of the attendings said "If you haven't found the abscess, you haven't finished your physical exam."

What we need to do is sic those two dudes on our vicious spiders...

[12R34Y]

We use bactrim almost exclusively.

Clinda is soooooooooo expensive (more than 100 bucks for my wife's 7 day course for a tooth abscess).

nobody at my county hospital can afford that!