How To Achieve Optimal Treatment Of Puncture Wounds
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. For inpatients, she will use an IV variation such as piperacillin/tazobactam or ampicillin/ sulbactam.
“I keep a very close eye on these patients and if there is no evidence of improvement after 72 hours, I need to consider that I have overlooked something,” says Dr. Judge.
For someone with a penicillin allergy, Dr. Judge uses trimethoprim-sulfamethoxazole DS (160/800) bid and clindamycin 300 mg qid as alternatives, noting that one can give both medications via oral or IV routes. As she points out, it seems like a common pattern that some strains of methicillin-resistant Staphylococcus aureus are sensitive to trimethoprim-sulfamethoxazole. Accordingly, Dr. Judge makes this drug her first choice in patients who are allergic to penicillin but not allergic to sulfa.
“Each year, the infection control department gives an annual report for each individual hospital/facility regarding current bacterial strains and resistances,” adds Dr. Judge. “This is a good reference to help prevent the selection of an agent that has proved to be ineffective within a particular facility.”
Q: When do you consider primary closure of these wounds?
A: If the initial injury occurred less than eight hours before irrigation, drainage and debridement of all devitalized tissue, Dr. Keller says one may choose to close the wound primarily. If more than eight hours have elapsed, he suggests leaving the wound open to drain and using packing. If a reexamination of the wound shows no clinical signs of infection, Dr. Keller says one may close the wound five to seven days later.
For a wound that Dr. Judge sees in the “golden period” of a few hours after the injury, she often can clean the wound definitively, get cultures and do a loose primary closure. If she finds any contamination or a lot of tissue damage due to high energy trauma, such as a gunshot wound, Dr. Judge says it is probably best to debride, irrigate and pack the wound open even if one has treated it within six hours after the injury. As Dr. Judge notes, a delayed primary closure is frequently a good alternative to primary closure since it gives the DPM an opportunity to see the culture and sensitivity report, consider alternate antibiotics if necessary and then pursue a subsequent debridement prior to closure.
Dr. Karlock considers primary closure with acute wounds that have been irrigated thoroughly and are extremely clean. If he has any question as to whether the wound should be closed, Dr. Karlock recommends packing the wound open and performing primary closure later or even letting the wounds granulate in.
Dr. Judge is a Fellow of the American College of Foot and Ankle Surgeons. She completed a three-year surgical residency program in major reconstructive surgery for the leg, foot and ankle. She is board-certified in reconstructive rearfoot and ankle surgery. She has offices in Port Clinton, Ohio and Lambertville, Mich. Dr. Judge is the Official Foot and Ankle Physician for The Jamie Farr Owens Corning LPGA Classic.
Dr. Karlock is a Fellow of the American College of Foot and Ankle Surgeons, and practices in Austintown, Ohio. He is the Clinical Instructor of the Western Reserve Podiatric Residency Program in Youngstown, Ohio. Dr. Karlock is a member of the Editorial Advisory Board for WOUNDS, a Compendium of Clinical Research and Practice.
Dr. Keller is a Fellow of the American College of Foot and Ankle Surgeons. He is the Residency Director of the Benedictine Podiatric Residency Program (PM&S-36). He practices at Hudson Valley Foot Associates in Kingston, N.Y.