What is the treatment plan for a 28-year-old male patient undergoing partial medial ablation of the left great toenail, with a prescription for Bactrim (Trimethoprim/Sulfamethoxazole) twice daily for seven days?

From the Guidelines

I strongly recommend proceeding with the planned partial medial ablation of the left great toenail for this 28-year-old male patient, followed by Bactrim DS (trimethoprim-sulfamethoxazole) twice daily for five days as prophylactic antibiotic coverage, as the recommended duration of antimicrobial therapy is 5 days, but treatment should be extended if the infection has not improved within this time period 1. The procedure involves removing only the medial portion of the toenail that is likely causing symptoms such as ingrowth or infection. Bactrim DS is an appropriate antibiotic choice as it provides good coverage against common skin flora including Staphylococcus aureus and streptococci that might cause post-procedural infection. Some key points to consider when managing skin and soft tissue infections include:

• Typical cases of cellulitis without systemic signs of infection should receive an antimicrobial agent that is active against streptococci 1
• For empirical coverage of CA-MRSA in outpatients with SSTI, oral antibiotic options include the following: clindamycin, trimethoprim-sulfamethoxazole (TMP-SMX), a tetracycline (doxycycline or minocycline), and linezolid 1
• The use of rifampin as a single agent or as adjunctive therapy for the treatment of SSTI is not recommended 1 The standard adult dose is one double-strength tablet (160mg trimethoprim/800mg sulfamethoxazole) taken every 12 hours for the full five days, even if symptoms improve before completion. The patient should be advised to keep the surgical site clean and dry, change dressings daily, monitor for signs of infection (increasing pain, redness, swelling, discharge), and follow up if these occur. According to the WHO's essential medicines and aware: recommendations on first- and second-choice antibiotics for empiric treatment of clinical infections, for mild infections, the first choice antibiotics include amoxicillin-clavulanic acid, cloxacillin, and cefalexin 1. This regimen balances infection prevention while minimizing antibiotic resistance risk through the limited five-day course.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION ... The usual adult dosage in the treatment of urinary tract infections is 4 teaspoonfuls (20 mL) of sulfamethoxazole and trimethoprim oral suspension every 12 hours for 10 to 14 days. ... For Patients with Impaired Renal Function ... Creatinine Clearance (mL/min) Recommended Dosage Regimen Above 30 Usual standard regimen 15 to 30 ½ the usual regimen Below 15 Use not recommended

The patient is being prescribed Bactrim DS BID for seven days, but the indication for the patient is not explicitly stated in the provided information. However, based on the dosage information provided, the recommended duration of treatment for urinary tract infections is 10 to 14 days.

• The prescribed duration of 7 days is shorter than the recommended duration.
• There is no information provided about the patient's renal function, which could affect the dosage regimen. Given the lack of explicit information about the indication and the patient's renal function, it is unclear if the prescribed dosage and duration are appropriate. 2

From the Research

Procedure and Treatment

• The patient is scheduled for a partial medial ablation of the left great toenail, a common procedure for treating ingrown toenails 3, 4, 5.
• The procedure involves removing part of the nail matrix to prevent future ingrowth 4.
• Studies have shown that partial nail ablation with phenol ablation has a high success rate and low morbidity 3, 5.

Postoperative Care

• The choice of postoperative treatment may not significantly impact patient outcomes, and individualized advice may be more effective 6.
• A study found that patients who kept a bandage on after partial nail ablation had lower signs of infection after one week, compared to those who used soap baths 6.
• However, the study also found that all three treatment alternatives had similar patient-reported outcomes after two weeks 6.

Antibiotic Prescription

• The patient will be prescribed Bactrim DS BID for seven days, which contains trimethoprim-sulfamethoxazole (TMP-SMX) 7.
• TMP-SMX is commonly used to treat various infections, but its dosing and outcomes can vary depending on the specific condition being treated 7.
• A study on pulmonary nocardiosis found that low- and intermediate-dose TMP-SMX were not associated with poor outcomes compared to high-dose therapy 7.