What is the initial management for a patient with a suspected bacterial infection of the left big toe, presenting with redness, pus, and drainage?

Physical Examination of Left Big Toe Infection with Redness and Drainage

Focused Physical Examination Findings

The left big toe shows localized erythema on the outer (lateral) aspect with purulent discharge and surrounding soft tissue swelling. Incision and drainage is required as the primary intervention for this abscess with surrounding cellulitis. 1

Inspection:

• Erythema (redness) on the lateral aspect of the left big toe
• Visible purulent drainage (yellow-white pus)
• Surrounding edema (swelling) extending approximately 1.5 cm from the site of infection
• Possible skin warmth in the affected area
• Potential skin dimpling or "orange peel" appearance due to superficial edema 1

Palpation:

• Tenderness to palpation at the site of infection
• Fluctuance suggesting fluid collection beneath the skin
• Assessment for crepitus (which would suggest gas-forming organisms)
• Evaluation of temperature difference compared to unaffected toe
• Assessment for foreign bodies that may have caused the infection

Neurovascular Assessment:

• Capillary refill time in the affected toe
• Sensation testing (may be diminished due to pain/swelling)
• Pulses in the foot (dorsalis pedis and posterior tibial)
• Temperature gradient between the affected and unaffected toes

Management Approach

The presence of purulent drainage indicates an abscess that requires incision and drainage as the primary intervention 1. This is consistent with the principle "don't let the sun set on pus" emphasized in clinical guidelines 1.

Immediate Management:

1. Incision and drainage of the abscess
2. Collection of deep tissue culture (not superficial swab) for microbiological analysis 1
3. Empiric antibiotic therapy covering Gram-positive organisms (particularly Staphylococcus aureus)

Antibiotic Selection:

• First-line: Cephalexin (500 mg orally four times daily) for 7-10 days 2
• Alternative for penicillin-allergic patients: Doxycycline (100 mg orally twice daily) 3

Post-Procedure Care:

• Daily wound care with cleansing and dressing changes
• Elevation of the affected foot to reduce edema
• Monitoring for signs of worsening infection (increasing erythema, fever, lymphangitis)

Important Considerations

Potential Complications:

• Spread of infection to deeper tissues or bone
• Development of osteomyelitis if infection is adjacent to bone
• Systemic infection in immunocompromised patients

Warning Signs Requiring Urgent Reassessment:

• Rapid progression of erythema beyond the initial margins
• Development of systemic symptoms (fever, chills)
• Crepitus on examination (suggesting gas-forming organisms)
• New onset of wound anesthesia
• Pain disproportionate to clinical findings 4

Common Pitfalls:

1. Relying on superficial swab cultures rather than deep tissue cultures after debridement 1
2. Failure to adequately drain all loculated collections of pus
3. Not considering underlying conditions that may predispose to infection (diabetes, peripheral vascular disease)
4. Inadequate follow-up to ensure resolution of infection

Remember that proper surgical drainage is the cornerstone of treatment for any purulent collection, with antibiotics playing a supportive role 1.