Treating Secondary Infection In A Patient With Severe Tinea Pedis

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Author(s): 
Michael Moharan, DPM, Mohamed Abdelmegeed Ahmed, MD, DPM, and Oleg Karpenko, MD, DPM

   Ceftazidime alone or in combination with either trimethoprim-sulfamethoxazole or amoxicillin clavulanate is the therapy of choice for B. pseudomallei.12 The organism is usually sensitive to imipenem, penicillin, doxycycline (Adoxa, PharmaDerm), azlocillin, ceftazidime, ticarcillin-clavulanic acid (Timentin, GlaxoSmithKline) and ceftriaxone (Rocephin, Hoffmann-La Roche). Initiate treatment early in the course of the disease. The organism is resistant to ciprofloxacin and aztreonam (Azactam, Bristol-Myers Squibb). Treatment is often prolonged, from three to 12 months, with the longest duration of therapy used for chronic extrapulmonary disease.

   Management of pseudomonal cellulitis includes the use of a PO antibiotic for seven to 10 days. This often resolves a localized infection.

   Pseudomonal toe web infections require initial debridement with applications of silver nitrate or 5% acetic acid to the toe webs and the dorsal and plantar areas. Following this initial treatment, apply a topical antibiotic, silver sulfadiazine cream or Castellani paint until infection resolves. A PO quinolone effectively reduces the duration of infection.

   Pseudomonal folliculitis is often "self-limiting." Treatment may require only application of silver sulfadiazine cream or 5% acetic acid wet compresses for 20 minutes two to four times daily with topical antibiotics.

In Conclusion

Interdigital toe web space is a warm, moist, protected environment that predisposes to the proliferation of both dermatophytes and gram-negative organisms. Tinea pedis is by far the most common fungal infection. Maceration, scaling and fissures result, allowing for overgrowth of bacteria that normally inhabit this interspace. Proliferation of these organisms, which include, most prominently, Pseudomonas aeruginosa, other gram-negative bacteria (e.g., Escherichia coli and Proteus mirabilis) and gram-positive bacteria, leads to an aggressive, painful infection.

   In our case, we used all appropriate diagnostic, therapeutic and prophylactic tools recommended by many authors to succeed in treatment of the patient. Some authors also recommend treatment with topical amikacin 5% gel (Amikin, Sopharma), Castellani paint and compresses with 2% to 5% acetic acid, which we might add to our treatment approach. In terms of antibiotic treatment, in our opinion, a first-generation quinolone such as ciprofloxacin might be more effective versus the second-generation levofloxacin or third-generation moxifloxacin that cover gram-negative organisms but are more active against gram-positive flora.

   In addition, the patient was getting treatment in different wound care facilities for long periods of time with medications such as amoxicillin-clavulanate and antifungal creams that were not covering P. aeruginosa infection. This might lead to antibiotic resistance.

   Dr. Moharan is the Former Chief Podiatry Resident at St. John’s Episcopal Hospital in Far Rockaway, N.Y. and Senior Resident at Kennedy University Hospital in Turnersville, N.J.

   Dr. Ahmed is a Former Chief Podiatry Resident at Mount Sinai Hospital of Queens, N.Y. and currently a Wound Care Fellow at St. John’s Episcopal Hospital.

   Dr. Karpenko is Former Chief Resident at Kingsbrook Jewish Medical Center in Brooklyn, N.Y. and is currently practicing in Brooklyn.

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man ying leesays: September 23, 2012 at 5:41 am

I have seen patients with Pseudomonas aeruginosa infection secondary to interdigital fungi infection. Instead of using topical cream, I use silver dressing with exudate control ability such as Aquacel Ag or Acticoat with aligiste m, together with oral antibiotics. The infected toe webs dried up, became less swollen and the foot healed up within two weeks.

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