What antibiotic treatment is recommended for an infected ingrown toenail?

Antibiotic Treatment for Infected Ingrown Toenails

For infected ingrown toenails, empiric antibiotic therapy should target aerobic gram-positive cocci, with oral antibiotics such as cephalexin, dicloxacillin, or clindamycin being appropriate for mild to moderate infections, while more severe infections may require broader coverage. 1

Initial Assessment and Classification

When evaluating an infected ingrown toenail, assess the severity of infection:

• Mild infection: Local inflammation, minimal purulence, no systemic symptoms
• Moderate infection: More extensive erythema, purulence, and pain
• Severe infection: Extensive cellulitis, systemic symptoms, or immunocompromised patient

Antibiotic Selection Algorithm

1. Mild to Moderate Infections (Most Common)

• First-line therapy: Antibiotics targeting aerobic gram-positive cocci 1

  • Cephalexin 500mg QID
  • Dicloxacillin 500mg QID
  • Clindamycin 300-450mg TID (if penicillin-allergic)

• Duration: 1-2 weeks for mild infections, 2 weeks for moderate infections 1

2. Special Considerations

• Prior MRSA history or high local prevalence: Add MRSA coverage 1

  • Trimethoprim-sulfamethoxazole DS BID
  • Doxycycline 100mg BID

• Diabetic patients: Consider broader coverage 1

  • Amoxicillin-clavulanate 875/125mg BID
  • For moderate infections: Consider initial parenteral therapy

3. Severe Infections

• Parenteral therapy initially: 1

  • Vancomycin + piperacillin-tazobactam OR
  • Vancomycin + ceftriaxone + metronidazole

• Switch to oral therapy when clinically improved and culture results available

Important Clinical Pearls

• Culture before antibiotics when possible, especially for moderate to severe infections or treatment failures 1

• Antibiotics alone are insufficient without appropriate wound care and addressing the underlying ingrown nail 1

• Local wound care is essential:

  • Warm soaks with dilute povidone-iodine or vinegar (50:50 dilution) 1
  • Proper nail trimming and cotton wisps under the lateral nail edge 1
  • Consider partial nail avulsion for moderate to severe cases 1

• Avoid unnecessary antibiotic use: Clinically uninfected ingrown toenails should not receive antibiotics 1

Common Pitfalls to Avoid

1. Prolonged antibiotic courses: Continue only until resolution of infection signs, not through complete healing 1

2. Treating without addressing the underlying nail problem: Surgical intervention may be necessary for definitive treatment 1, 2, 3

3. Overlooking diabetes or vascular disease: These patients require more aggressive management and closer follow-up 1

4. Misdiagnosing paronychia: True paronychia involves the nail folds and may require different management approaches 4

5. Relying solely on antibiotics: Studies show that in otherwise healthy patients, surgical management without antibiotics can be equally effective for localized infections 5

Remember that the primary goal is to resolve the infection while preventing recurrence through appropriate management of the underlying ingrown toenail.