What is the treatment for an infected toe?

Treatment of Infected Toe

The treatment of an infected toe requires antibiotics selected based on infection severity, with mild-to-moderate infections typically treated with oral antibiotics targeting gram-positive cocci, while severe infections require broader spectrum parenteral therapy and possible surgical intervention. 1

Assessment of Infection Severity

Infected toes should be classified by severity to guide appropriate treatment:

• Mild infection: Local inflammation limited to skin/subcutaneous tissue with ≤2 cm erythema
• Moderate infection: Cellulitis >2 cm or deeper tissue extension
• Severe infection: Systemic toxicity or metabolic instability 1

Antibiotic Therapy

Mild Infections

• First-line options:
  • Dicloxacillin 500 mg PO QID
  • Cephalexin 500 mg PO QID
  • Clindamycin 300-450 mg PO TID (if penicillin-allergic)
  • Amoxicillin-clavulanate 875/125 mg PO BID 1, 2
• Duration: 5-7 days (extend if not improved) 2
• Route: Oral therapy is appropriate for mild infections 2

Moderate Infections

• Treatment options:
  • Amoxicillin-clavulanate 875/125 mg PO BID
  • Levofloxacin 750 mg PO daily plus metronidazole 500 mg PO TID
  • Consider MRSA coverage if risk factors present 1, 2
• Duration: 1-2 weeks 1
• Route: Oral therapy for stable patients; consider initial parenteral therapy if concerns about absorption 2

Severe Infections

• Treatment options:
  • Piperacillin-tazobactam 4.5 g IV q6-8h
  • Imipenem-cilastatin 500 mg IV q6h
  • Vancomycin 15-20 mg/kg IV q12h (for MRSA coverage) 1, 2
• Duration: 2-4 weeks 1
• Route: Parenteral therapy initially to ensure adequate tissue concentrations 2

Special Considerations

MRSA Coverage

Add MRSA coverage (vancomycin, linezolid, or daptomycin) if:

• Prior MRSA history
• Recent hospitalization
• Severe infection
• High local MRSA prevalence 1, 2

Diabetic Foot Infections

Diabetic patients require special attention:

• More aggressive treatment approach
• Lower threshold for hospitalization
• Consider vascular assessment
• Multidisciplinary team involvement 1
• Early surgical consultation for deep infections 2

Wound Care

1. Cleansing: Thoroughly clean the wound with saline or mild antiseptic solution
2. Debridement: Remove necrotic tissue, foreign bodies, and slough
3. Drainage: Incise and drain any abscesses or purulent collections 2, 1
4. Elevation: Elevate the affected area to reduce edema 2
5. Offloading: For toe wounds, especially in diabetic patients, reduce pressure on the affected area 1

Surgical Intervention

Urgent surgical consultation is indicated for:

• Deep abscess
• Extensive necrosis or gangrene
• Crepitus
• Compartment syndrome
• Severe systemic symptoms 1

Surgery should be performed within 24-48 hours for moderate to severe infections to eliminate infected and necrotic tissue 1.

Follow-up and Reassessment

• Evaluate response to therapy within 48-72 hours
• Reassess daily for inpatients and every 2-5 days for outpatients
• Continue antibiotics until resolution of infection signs, not necessarily until complete wound healing 1
• Consider changing antibiotics if no improvement after 48-72 hours of appropriate therapy

Common Pitfalls to Avoid

1. Treating uninfected wounds with antibiotics: Only clinically infected wounds require antibiotic therapy
2. Inadequate debridement: Failure to remove all necrotic tissue can lead to persistent infection
3. Inappropriate antibiotic selection: Using too broad or too narrow spectrum antibiotics
4. Insufficient duration of therapy: Premature discontinuation before infection resolves
5. Neglecting underlying conditions: Failing to address predisposing factors such as diabetes, vascular insufficiency, or immunosuppression

By following this approach, most infected toes can be effectively treated with resolution of infection and prevention of complications.