What is the best course of treatment for an 89-year-old female with heart failure (HF) and left bundle branch block (LBBB) presenting with an infected ingrown toenail?

Management of Infected Ingrown Toenail in an 89-Year-Old Female with Heart Failure and LBBB

The optimal treatment for an infected ingrown toenail in this elderly patient with heart failure and LBBB is partial nail avulsion with phenolization, without the need for systemic antibiotics, along with careful monitoring of her cardiac condition.

Initial Assessment and Considerations

• The patient's advanced age (89) and cardiac comorbidities (HF and LBBB) require special attention when planning treatment for the infected ingrown toenail 1
• Left bundle branch block (LBBB) in this patient with heart failure indicates potential electrical and mechanical dyssynchrony that may affect her cardiac function and treatment options 1, 2
• Patients with heart failure require careful monitoring during any procedure due to increased risk of complications 1

Treatment of the Infected Ingrown Toenail

Recommended Procedure

• Partial nail avulsion with phenolization is the preferred surgical technique for treating the infected ingrown toenail, as it has shown significantly better results than matrix excision with lower recurrence rates 3, 4
• Local anesthesia should be used, with careful consideration of the patient's cardiac status 1, 3
• The procedure involves:
  • Removal of the ingrown portion of the nail
  • Application of phenol to destroy the nail matrix
  • Proper wound care post-procedure 3, 4

Antibiotic Considerations

• Systemic antibiotics are not necessary for locally infected ingrown toenails when appropriate surgical management is performed 5, 3
• Multiple studies have demonstrated that the use of oral antibiotics as adjunctive therapy does not decrease healing time or post-procedure morbidity 5, 3, 4
• Local application of antibiotics after the procedure also does not reduce signs of infection or recurrence rates 3

Cardiac Management During Treatment

• Prior to the procedure, assess the patient's current heart failure status and optimize medical therapy if needed 1
• Monitor vital signs closely during the procedure, especially in this patient with LBBB and heart failure 1
• For patients with heart failure and LBBB:
  • Ensure the patient is on appropriate heart failure medications according to current guidelines 1
  • Be aware that patients with LBBB may have altered hemodynamics and increased risk of arrhythmias 1, 2

Post-Procedure Care

• Provide clear instructions for wound care and follow-up 1, 6
• Elevate the foot when possible to reduce edema and pain 6
• Monitor for signs of infection progression or complications 1, 6
• Schedule follow-up visits at 2 days, 1 week, and 1 month post-procedure 3, 4

Special Considerations for This Patient

• Due to the patient's age and cardiac comorbidities, perform the procedure in a setting where cardiac monitoring is available 1
• Consider consultation with the patient's cardiologist before the procedure to optimize heart failure management 1
• Avoid procedures that might cause significant pain or stress, which could potentially worsen heart failure symptoms 1
• If signs of spreading infection develop (extending beyond the toe), promptly initiate systemic antibiotics and consider infectious disease consultation 1, 6

Common Pitfalls to Avoid

• Unnecessary use of systemic antibiotics for localized infection, which does not improve outcomes but may cause adverse effects 5, 3
• Inadequate pain control during and after the procedure, which could increase cardiac stress 1, 6
• Failure to recognize signs of osteomyelitis, which would require more aggressive treatment 1, 6
• Overlooking the need to adjust heart failure medications if the patient's condition changes 1