What antibiotic is recommended for a patient with an infected gouty toe?

Antibiotic Treatment for Infected Gouty Toe

For an infected gouty toe, flucloxacillin is the first-line antibiotic treatment, with oral flucloxacillin 1g four times daily recommended for a duration of 2 weeks. 1

Pathogen Considerations and Initial Treatment

When treating an infected gouty toe, it's important to consider the likely causative organisms:

• Staphylococcus aureus is the most common pathogen in infected gouty toes 1, 2
• Streptococcal species may also be present

First-line Treatment Options:

1. Methicillin-susceptible S. aureus (MSSA) infections:

   • Flucloxacillin 1g orally four times daily for 2 weeks 1
   • Cephalexin (if non-immediate penicillin allergy) 3

2. For penicillin-allergic patients:

   • Clindamycin is appropriate for penicillin-allergic patients 4, 3
   • Dosage: 300-450mg orally four times daily

Diagnostic Approach

Before starting antibiotics, obtain appropriate samples:

• Perform aspiration or deep tissue sampling rather than superficial swabs 5
• Send samples for culture and crystal analysis to differentiate between infection and acute gout 2
• Look for both bacteria and urate crystals, as they can coexist 2

Caution: Never assume symptoms are due to gout alone without ruling out infection, especially in patients with risk factors for infection 2

Treatment Algorithm

1. Assess severity of infection:

   • Mild infection (limited to skin/superficial tissue, no systemic signs):

     • Oral antibiotics targeting gram-positive cocci
     • Flucloxacillin 1g four times daily for 7-10 days

   • Moderate infection (deeper tissue involvement):

     • Consider initial parenteral therapy followed by oral therapy
     • Amoxicillin-clavulanate or flucloxacillin for 10-14 days

   • Severe infection (with systemic signs):

     • Hospitalization with IV antibiotics
     • Vancomycin plus piperacillin-tazobactam or imipenem-cilastatin 5

2. For MRSA suspicion or confirmed MRSA:

   • Vancomycin IV or Linezolid 600mg twice daily 6
   • Consider local resistance patterns

3. Adjust based on culture results:

   • Modify antibiotic choice based on sensitivity testing 1

Additional Management Considerations

• Surgical debridement may be necessary for infected tophi 7
• Continue antibiotics until resolution of infection signs but not necessarily through complete healing 5
• Manage underlying gout with appropriate urate-lowering therapy after infection resolves 8
• Monitor inflammatory markers (WBC, CRP) to assess treatment response 5

Common Pitfalls to Avoid

• Failing to distinguish between acute gout and infection (they can coexist) 2
• Using oral glucocorticoids without ruling out infection first 2
• Inadequate sampling for cultures before starting antibiotics 5
• Insufficient duration of antibiotic therapy, especially with deeper infections 5
• Neglecting glycemic control during infection in diabetic patients 5

Remember that infected gouty toes require both antimicrobial therapy and management of the underlying gout condition, but infection control takes priority initially.