What antibiotics are recommended for a subungual hematoma with signs of infection?

Antibiotic Management for Infected Subungual Hematoma

For a subungual hematoma with signs of infection, first-line treatment should be amoxicillin-clavulanic acid or cloxacillin, with drainage of the hematoma as the primary intervention. 1

Initial Management

• Drainage of the subungual hematoma is the most important first step in management, regardless of infection status 2, 3
• Trephination (creating a small hole in the nail plate) allows blood to drain, reducing pressure and pain 3
• If signs of infection are present, antibiotic therapy should be initiated after drainage 1

Antibiotic Selection for Infected Subungual Hematoma

First-Line Options:

• Amoxicillin-clavulanic acid - Provides coverage against both Staphylococcus aureus and Streptococcus species, the most common pathogens in skin and soft tissue infections 1
• Cloxacillin - Effective against methicillin-susceptible S. aureus (MSSA), which is a common pathogen in these infections 1, 4
• Cephalexin - A first-generation cephalosporin that is effective against MSSA and streptococci 1, 5

For MRSA Suspicion or Penicillin Allergy:

• Clindamycin - Effective against most community-acquired MRSA and MSSA 1
• Trimethoprim-sulfamethoxazole - Effective against MRSA but has less activity against streptococci 1
• Doxycycline - Alternative for MRSA coverage in adults and children over 8 years 1

Treatment Duration and Approach

• For mild infections with minimal systemic symptoms, a 5-day course of antibiotics is typically sufficient 1
• Treatment should be extended if the infection has not improved within this time period 1
• If there are signs of severe infection (temperature >38.5°C, heart rate >110 beats/minute, or erythema extending >5 cm), more aggressive antibiotic therapy may be needed 1

Special Considerations

• If the patient has diabetes or is immunocompromised, consider broader antibiotic coverage and longer duration of therapy 1
• For severe infections or those not responding to oral antibiotics, intravenous therapy may be necessary 1
• Obtain cultures if the infection is severe, not responding to initial therapy, or in immunocompromised patients 1

Common Pitfalls to Avoid

• Failure to drain the hematoma - Drainage is the primary treatment for subungual hematoma and should be performed regardless of infection status 2, 3
• Overlooking nail bed injuries - After drainage, inspect for underlying nail bed lacerations that may require repair 3
• Inappropriate antibiotic selection - Consider local resistance patterns when selecting empiric antibiotics 1
• Inadequate follow-up - Monitor for resolution of infection and potential complications such as permanent nail deformity 2

Remember that while antibiotics are important for infected subungual hematomas, proper drainage of the hematoma is the cornerstone of treatment and should not be delayed 2, 3.