What antibiotic should be prescribed for a patient who has stepped on a rusty nail through the sole of their shoe?

Antibiotic Treatment for Rusty Nail Puncture Wound Through Shoe

For a puncture wound from stepping on a rusty nail through the sole of a shoe, amoxicillin-clavulanate should be prescribed as first-line antibiotic therapy. 1

Initial Assessment and Treatment Approach

Wound Classification

• Puncture wounds through shoes are considered moderate-risk wounds due to:
  • Deep penetration
  • Foreign material introduction (rubber sole particles)
  • Potential for anaerobic environment
  • Risk of Pseudomonas and mixed bacterial infections

Antibiotic Selection Algorithm

1. First-line therapy: Amoxicillin-clavulanate 875/125 mg twice daily 1

   • Provides coverage against common pathogens including:
     • Staphylococcus aureus
     • Streptococci
     • Anaerobes
     • Many gram-negative organisms

2. For penicillin-allergic patients:

   • Non-severe allergy: Cefuroxime 500 mg twice daily (with or without metronidazole for anaerobic coverage) 1
   • Severe allergy: Ciprofloxacin 500-750 mg twice daily plus clindamycin 300-450 mg three times daily 1

3. For suspected Pseudomonas infection (common in puncture wounds through rubber-soled shoes):

   • Ciprofloxacin 750 mg twice daily 2

Evidence-Based Considerations

Puncture wounds through rubber-soled shoes present unique challenges. A retrospective study of 96 adult patients with nail puncture wounds through rubber-soled shoes found that delayed presentation (>2 days) was associated with poorer outcomes 3. This supports early antibiotic intervention.

The IDSA guidelines specifically recommend amoxicillin-clavulanate for animal and human bite wounds, which share similar infection risks with puncture wounds (deep penetration, mixed bacterial flora including anaerobes) 1. The broad coverage provided by amoxicillin-clavulanate makes it appropriate for puncture wounds as well.

Duration of Therapy

• Uncomplicated wound: 5-7 days
• Signs of deeper infection: 10-14 days
• Evidence of bone involvement: 14+ days (may require IV therapy initially) 2

Additional Important Interventions

1. Tetanus prophylaxis:

   • Administer tetanus toxoid if no vaccination within past 10 years
   • Tdap preferred over Td if not previously given 1

2. Wound care:

   • Thorough cleansing and irrigation
   • Remove any visible foreign material
   • Consider imaging (ultrasound or X-ray) if foreign body retention suspected 3

Special Considerations

• Diabetic patients: Higher risk of complications and treatment failure 3

  • Consider more aggressive therapy with early surgical consultation
  • May require IV antibiotics initially

• Delayed presentation (>48 hours):

  • Higher risk of treatment failure 3
  • Consider broader coverage or surgical evaluation

Warning Signs Requiring Immediate Reevaluation

• Increasing pain, swelling, or redness
• Purulent drainage
• Fever or systemic symptoms
• Failure to improve within 48-72 hours of antibiotic initiation

By following this approach, most puncture wounds from rusty nails through shoes can be effectively treated, minimizing the risk of serious complications such as deep tissue infection, osteomyelitis, or sepsis.