Treatment of an Infected Toe
For an infected toe, treatment should include appropriate antibiotics based on infection severity, along with proper wound care and surgical intervention when necessary. 1
Assessment of Infection Severity
First, determine the severity of the infection:
- Mild infection: Local inflammation, erythema limited to ≤2 cm around the wound, no systemic symptoms
- Moderate infection: Erythema >2 cm, lymphangitis, deeper tissue involvement, no systemic symptoms
- Severe infection: Systemic toxicity (fever, chills), metabolic instability, extensive tissue involvement 1, 2
Signs of Limb-Threatening Infection Requiring Urgent Intervention
- Crepitus on examination or tissue gas on imaging
- Extensive necrosis or gangrene
- Bullae (especially hemorrhagic)
- New onset wound anesthesia
- Extensive ecchymoses or petechiae
- Pain out of proportion to clinical findings
- Critical limb ischemia 1
Treatment Algorithm
1. Antibiotic Therapy
For mild infections:
- Dicloxacillin 500 mg orally four times daily
- Cephalexin 500 mg orally four times daily
- Clindamycin 300-450 mg orally three times daily (for penicillin-allergic patients)
- Amoxicillin-clavulanate 875/125 mg orally twice daily 2
- Duration: 1-2 weeks 1, 2
For moderate infections:
- Amoxicillin-clavulanate 875/125 mg orally twice daily
- Levofloxacin 750 mg orally daily plus metronidazole
- Consider MRSA coverage if risk factors present
- Duration: 2-3 weeks 1, 2
For severe infections:
- Parenteral therapy required:
- Piperacillin-tazobactam 4.5 g IV every 6-8 hours
- Imipenem-cilastatin 500 mg IV every 6 hours
- Vancomycin plus ceftazidime (with or without metronidazole)
- Duration: 2-4 weeks 1, 2
2. Surgical Management
Indications for urgent surgical consultation:
- Deep abscess
- Extensive necrosis or gangrene
- Crepitus
- Necrotizing fasciitis
- Compartment syndrome
- Severe systemic symptoms 1, 2
Surgical procedures may include:
- Incision and drainage of abscesses
- Debridement of necrotic tissue
- Partial toe amputation if necessary
- Revascularization for ischemic limbs 1
For early, evolving infections, it may be appropriate to delay surgery to avoid scarring and deformity. However, if clinical findings worsen, surgical intervention becomes necessary 1.
3. Wound Care
- Sharp debridement of necrotic tissue and callus using scalpel, scissors, or tissue nippers 1
- Appropriate dressing selection based on wound characteristics:
- Continuously moistened saline gauze for dry/necrotic wounds
- Hydrogels for dry/necrotic wounds
- Alginates for exudative wounds
- Hydrocolloids for absorbing exudate 1
- Off-loading pressure from the affected area is crucial for healing 1
- Daily wound inspection 1
Special Considerations
Diabetic Foot Infections
Diabetic patients require special attention due to:
- Impaired wound healing
- Increased risk of osteomyelitis
- Higher risk of limb-threatening infection 1
For diabetic patients, consider:
- More aggressive antibiotic therapy
- Earlier surgical consultation
- Evaluation for peripheral arterial disease 1
Toe Web Infections
Toe web infections often involve gram-negative bacteria and may be secondary to fungal infections 3, 4:
- Debridement of macerated skin and hyperkeratotic rim
- Obtain bacterial cultures to guide therapy
- Consider antifungal treatment if fungal infection is present 4
Follow-Up
- Evaluate response to therapy within 48-72 hours
- If no improvement within 3-4 days, consider:
- Changing antibiotics
- Surgical consultation
- Reassessing for deeper infection 2
- Continue antibiotics until infection resolves, but not necessarily until complete wound healing 1
Common Pitfalls to Avoid
- Treating colonization rather than true infection
- Inadequate surgical drainage when needed
- Using overly broad empiric therapy for mild infections
- Continuing antibiotics until wound healing rather than until infection resolution
- Neglecting proper wound care 2
- Failing to recognize underlying osteomyelitis 1