What antibiotic would you choose for paronychia with erythema in an 86-year-old female with a history (hx) of diabetes mellitus and hypertension?

From the Guidelines

For an 86-year-old female with diabetes mellitus and hypertension presenting with paronychia with erythema, I would recommend oral cephalexin 500 mg four times daily for 7-10 days. This first-generation cephalosporin provides good coverage against the most common causative organisms in paronychia, particularly Staphylococcus aureus and Streptococcus species 1. Given the patient's advanced age and diabetes, which increases her risk for complications from infection, oral antibiotics are preferred over topical treatment alone. The diabetes is particularly concerning as it may impair wound healing and increase susceptibility to more severe infections.

Key Considerations

• The patient's age and comorbidities (diabetes and hypertension) increase the risk of complications from infection, making prompt and effective antibiotic therapy crucial 1.
• The choice of antibiotic should be based on the likely causative pathogens and their antibiotic susceptibilities, as well as the clinical severity of the infection 1.
• A course of antibiotic therapy of 1–2 weeks is usually adequate for most soft tissue infections, including paronychia 1.

Alternative Options

• If the patient has a penicillin allergy, clindamycin 300 mg three times daily for 7-10 days would be an appropriate alternative 1.
• Other options, such as levofloxacin or amoxicillin-clavulanate, may also be considered based on the patient's specific needs and the suspected causative pathogens 1.

Adjunctive Measures

• Warm soaks 3-4 times daily and drainage if fluctuance is present are important adjunctive measures to help manage the infection and promote healing.
• The patient should be advised to keep the affected area clean and dry, avoid manipulation of the nail, and monitor for signs of worsening infection such as increased pain, swelling, or purulent drainage, which would warrant reassessment.
• Blood glucose monitoring should be emphasized during the infection period as infections can affect glycemic control 1.

From the Research

Antibiotic Selection for Paronychia with Erythema

• The patient is an 86-year-old female with a history of diabetes mellitus and hypertension, presenting with paronychia and erythema.
• According to the study 2, paronychia is typically caused by polymicrobial infections, and treatment consists of warm soaks with or without Burow solution or 1% acetic acid, as well as topical antibiotics and steroids.
• However, in cases where the patient is immunocompromised, such as those with diabetes, oral antibiotics may be necessary 2.
• A study from 2003 3 found that patients with type 1 diabetes mellitus have a higher frequency of paronychia, suggesting that diabetes may be a contributing factor to the development of paronychia.
• When selecting an antibiotic, it is essential to consider the most likely pathogens and local resistance patterns 2.
• Cephalexin is a commonly used antibiotic for treating skin infections, including paronychia, and has been shown to be effective against Staphylococcus aureus, a common cause of paronychia 4.
• However, another study 5 reported a case of fixed-drug eruption due to cefalexine, highlighting the importance of monitoring for potential adverse reactions.
• An alternative antibiotic, cefadroxil, has been shown to have similar in vitro activity to cephalexin against methicillin-susceptible Staphylococcus aureus (MSSA) isolates 6.
• Considering the patient's age and medical history, it is crucial to select an antibiotic with a suitable safety profile and efficacy against the likely causative pathogens.

Potential Antibiotic Options

• Cephalexin: a commonly used antibiotic for skin infections, effective against Staphylococcus aureus, but may require monitoring for potential adverse reactions 5, 4.
• Cefadroxil: an alternative antibiotic with similar in vitro activity to cephalexin against MSSA isolates, potentially offering a suitable option for patients with paronychia 6.
• Other antibiotics: may be considered based on local resistance patterns and the patient's specific needs, but should be selected in consultation with a healthcare professional and based on the most up-to-date evidence 2, 4.