What is the management for an infected gout of the big toe?

Management of Infected Podagra (Big Toe Gout with Infection)

When podagra (gout of the big toe) appears infected, you must first rule out septic arthritis through joint aspiration before treating as gout, as the two conditions can coexist and septic arthritis requires urgent antibiotic therapy. 1, 2

Immediate Assessment and Diagnosis

Perform arthrocentesis urgently to:

• Identify monosodium urate crystals under polarized light microscopy to confirm gout 1, 3
• Send synovial fluid for Gram stain, culture, and cell count to rule out septic arthritis 1, 4
• Note that infection and gout can coexist in the same joint, so finding crystals does not exclude infection 2

Clinical features suggesting infection rather than uncomplicated gout include:

• Fever >38.5°C (101.3°F)
• Systemic toxicity or sepsis
• Synovial fluid white blood cell count >50,000-100,000/μL
• Positive Gram stain or culture 4, 3

Treatment Algorithm

If Septic Arthritis is Confirmed or Highly Suspected:

• Start empiric IV antibiotics immediately covering Staphylococcus aureus and other common pathogens
• Delay anti-inflammatory gout treatment until infection is controlled
• Consider surgical drainage if needed 2

If Infection is Ruled Out (Pure Gout Flare):

First-line anti-inflammatory therapy (choose based on patient factors): 1, 2

Oral corticosteroids (preferred in most patients):

• Prednisone 30-35 mg daily for 3-5 days, OR
• 0.5 mg/kg/day for 5-10 days
• Safest option in patients with renal disease, heart failure, or cirrhosis 2

NSAIDs (if no contraindications):

• Full anti-inflammatory doses started immediately
• Avoid in renal disease, heart failure, cirrhosis, or active GI disease 1, 2

Colchicine (most effective if started within 12 hours):

• 1.2 mg immediately, followed by 0.6 mg one hour later (total 1.8 mg)
• Do NOT use higher doses—they increase side effects without improving efficacy 1, 5
• Reduce dose in renal or hepatic impairment 2, 5

Intra-articular corticosteroid injection:

• Highly effective for single joint involvement like podagra
• Only after infection is definitively ruled out 1, 2

Adjunctive therapy:

• Topical ice application to the affected joint 1
• Rest and elevation of the foot 6

Critical Pitfalls to Avoid

• Never start anti-inflammatory treatment without considering septic arthritis in a swollen, red, hot joint—this can mask infection and delay appropriate treatment 1, 4
• Do not start urate-lowering therapy (allopurinol, febuxostat) during an acute flare—this can worsen the attack 1, 2, 7
• Avoid high-dose colchicine (>1.8 mg in first hour)—it provides no additional benefit and significantly increases GI side effects 1, 5
• Do not use NSAIDs in patients with significant renal impairment (eGFR <30 mL/min/1.73m²), heart failure, or cirrhosis 2

After Acute Flare Resolution

Assess need for long-term urate-lowering therapy (ULT):

Start ULT if patient has: 1, 2, 7

• ≥2 gout flares per year
• Tophi present
• Chronic kidney disease
• Radiographic joint damage
• History of urolithiasis

Do NOT start ULT after first attack or if flares are infrequent (<2/year) 2

When initiating ULT: 2, 7

• Start allopurinol 100 mg daily, increase by 100 mg every 2-4 weeks
• Target serum uric acid <6 mg/dL (360 μmol/L)
• Provide flare prophylaxis with colchicine 0.5-1 mg daily for at least 6 months when starting ULT 1, 2, 7
• Adjust allopurinol dose in renal impairment 1, 2

Lifestyle modifications: 1, 2

• Weight loss if overweight/obese
• Limit alcohol (especially beer)
• Avoid high-fructose corn syrup and sugar-sweetened beverages
• Limit purine-rich foods (organ meats, shellfish)
• Encourage low-fat dairy products 7