How To Achieve Optimal Treatment Of Puncture Wounds
Given the common incidence of puncture wounds, our roundtable experts continue their discussion (see page 32, November 2006 issue) by sharing key insights on appropriate antibiotic selection and how they prefer to close these wounds. Without further delay, here is what they had to say … Q: What empiric antibiotics do you prescribe for puncture wounds? A: For Michael Keller, DPM, the antibiotic selection depends upon three factors: the timing of presentation, the type of puncture and the type of patient. If the patient presents with a simple but contaminated wound, one should direct antibiotics toward gram-positive organisms such as Staphylococcus spp. and Streptococcus spp., according to Dr. Keller. He notes one can give the patient ancef and nafcillin intravenously, and give cefdinir (Omnicef, Medicis) and cephalexin po. If one sees the patient in the delayed setting and he or she has a gross clinical infection, Dr. Keller says DPMs must have a high index of suspicion for deep space infection. This would require antibiotics as well as adequate incision and drainage, usually in the OR setting, according to Dr. Keller. If the patient presents with a puncture wound through the plantar aspect of a shoe and there is a distinct possibility of osseous inoculation, Dr. Keller recommends both gram-positive and Pseudomonas spp. coverage. One can use imipenem/cilastin or clindamycin/ aztreonam IV. Dr. Keller says if the patient has diabetes and is brittle, one should administer a broad-spectrum antibiotic due to the high rate of polymicrobial infection. He suggests amoxicillin/clavulanic acid PO or pipercillin/tazobactam IV. For all metallic or dirty puncture wounds, Dr. Keller advises clinicians to consider appropriate tetanus prophylaxis. For Molly Judge, DPM, empiric oral antibiotic treatment depends on the nature of the wound. For a wound resulting from stepping on a sharp object in the home (a wound that is otherwise clean), she often prescribes a first-generation cephalosporin and awaits the results of my wound culture. Dr. Judge says the twice-a-day dosing of the oral third-generation cephalosporin, cefdinir, helps improve patient compliance. Dr. Judge notes that cefdinir covers Staph, Strep and E. coli, which can accompany cellulitus due to a foreign body. If the puncture wound involves a substance like soil or grass, she says the odds of having an anaerobe present are higher and amoxicillin-clavulanate is a good choice for an oral agent. For patients allergic to penicillin, Dr. Judge may use clindamycin due to its coverage of anaerobes in addition to Staph and Strep. She advises looking at the Medical Letter (www. medletter.com), which publishes guidelines for the choice of antibacterial drugs every spring. Lawrence Karlock, DPM, typically prefers gram-positive Staph strips and the majority of these puncture wounds will grow gram-positive organisms. Q: What antibiotics do you empirically use in a patient with no penicillin allergy? How about a patient with a penicillin allergy? A: Dr. Judge suggests “keeping in mind that obtaining well-prepared wound cultures is paramount to successful infection management and that empiric antibiotic therapy does have a role.” When it comes to the empiric use of antibiotics in a patient who is not allergic to penicillin, Dr. Judge calls herself a “purist.” She asserts that the most common pathogens in superficial wounds and ulcerations are Staph and Strep, adding that she will start with a course of cephalexin 500 mg qid, depending on the patient’s age and weight. In certain instances, she will adjust the dosage downward, particularly for an elderly patient, a patient with chronic renal dysfunction or an adult with a very frail size and stature. Whenever a patient is admitted for inpatient care for an infection, Dr. Judge’s first priority is getting an infectious disease consult. If she encounters a severe ulcer or wound in a patient with diabetes who has several comorbidities and may have suspected poor glycemic control, Dr. Judge will use an agent with a beta lactamase inhibitor such as amoxicillin/ clavulanate for outpatients.