What is the recommended treatment for an infected toenail in the Emergency Department (ED)?

From the Guidelines

The recommended treatment for an infected toenail in the Emergency Department involves incision and drainage if an abscess is present, followed by oral antibiotics, with the selection of antibiotics based on the severity of the infection and the likely causative pathogen(s), as suggested by the most recent guidelines 1.

Key Considerations

• For mild to moderate infections, cephalexin 500mg four times daily for 7-10 days is typically prescribed, as it covers common causative organisms such as Staphylococcus aureus and Streptococcus species.
• Alternatives include clindamycin 300mg four times daily or amoxicillin-clavulanate 875/125mg twice daily for the same duration, considering the patient's allergy history and local resistance patterns.
• For severe infections or in patients with diabetes or immunocompromise, broader coverage may be necessary, potentially including methicillin-resistant Staphylococcus aureus (MRSA) coverage with trimethoprim-sulfamethoxazole or doxycycline, as indicated by the patient's risk factors and the severity of the infection 1.

Additional Recommendations

• Warm water soaks for 15 minutes 3-4 times daily should be recommended, along with elevation of the affected foot when possible to reduce swelling.
• Adequate pain control with acetaminophen or ibuprofen is important for patient comfort and to reduce the risk of worsening infection due to untreated pain.
• Patients should be advised to follow up with primary care or podiatry within 2-3 days, and to return to the ED if symptoms worsen, fever develops, or if redness extends beyond the toe, to ensure prompt identification and management of potential complications.

Surgical Intervention

• Surgical consultation should be considered for patients with severe infections, abscesses, or those who do not respond to initial medical therapy, as surgical intervention may be necessary to drain deep infections or remove necrotic tissue 1.
• The decision for surgical intervention should be made on a case-by-case basis, taking into account the patient's overall health, the severity of the infection, and the potential benefits and risks of surgery.

From the FDA Drug Label

Terbinafine tablets are indicated for the treatment of onychomycosis of the toenail or fingernail due to dermatophytes (tinea unguium) Prior to initiating treatment, appropriate nail specimens for laboratory testing [potassium hydroxide (KOH) preparation, fungal culture, or nail biopsy] should be obtained to confirm the diagnosis of onychomycosis Toenail onychomycosis: One 250 mg tablet once daily for 12 weeks

The recommended treatment for an infected toenail in the Emergency Department (ED) is terbinafine 250 mg tablet once daily for 12 weeks. However, prior to initiating treatment, appropriate nail specimens for laboratory testing should be obtained to confirm the diagnosis of onychomycosis. It is also important to evaluate patients for evidence of chronic or active liver disease before administering terbinafine tablets 2.

Key considerations:

• Confirm diagnosis of onychomycosis with laboratory testing
• Evaluate patients for liver disease before treatment
• Monitor liver function tests during therapy
• Discontinue terbinafine tablets if liver injury develops 2

From the Research

Treatment Options for Infected Toenail in ED

• The recommended treatment for an infected toenail in the Emergency Department (ED) depends on the causative agent of the infection 3.
• Fungal infections are the most common cause of infected toenails, with dermatophytes being the primary causative agents 3.
• For fungal infections, treatment options include:
  • Topical antifungal agents such as amorolfine and ciclopirox 3.
  • Oral antifungal agents such as terbinafine, fluconazole, and itraconazole 3, 4, 5.
• Terbinafine is a commonly used oral antifungal agent for the treatment of dermatophyte toenail onychomycosis, with studies showing high mycologic and clinical cure rates 6, 4, 5.
• The duration of treatment with terbinafine can vary, with studies showing effective treatment durations of 12-24 weeks 4.
• For bacterial infections, treatment options include:
  • Topical antiseptic agents such as octenidine 3.
  • Topical antibiotics such as nadifloxacin and gentamicin 3.
  • Oral antibiotics such as ciprofloxacin for Pseudomonas infections 3.

Considerations for Treatment

• The choice of treatment should be based on the severity of the infection, the causative agent, and the patient's medical history 3.
• Treatment should be continued for an adequate duration to ensure complete resolution of the infection 4.
• Patients should be monitored for signs of treatment failure or recurrence, and alternative treatments should be considered if necessary 6, 4.