What antibiotics are recommended for a patient with a dirty puncture wound through a shoe, being treated as an outpatient, with no contraindications?

From the Guidelines

For a dirty puncture wound through a shoe, I recommend starting empiric antibiotic therapy with amoxicillin-clavulanate 875/125 mg orally twice daily for 5-7 days. This provides coverage against common skin flora and environmental organisms that may contaminate such wounds, as suggested by the Infectious Diseases Society of America guidelines 1. The choice of amoxicillin-clavulanate is based on its broad-spectrum activity against streptococci, S. aureus, and Eikenella corrodens, as well as multiple anaerobic organisms, including Fusobacterium, Peptostreptococcus, Prevotella, and Porphyromonas species.

Some key points to consider when managing a dirty puncture wound through a shoe include:

• Thorough cleaning of the wound with soap and water
• Tetanus prophylaxis if the patient's immunization status is not up to date (within 5 years for dirty wounds)
• Keeping the wound clean and dry, with daily dressing changes
• Monitoring for signs of infection, including increasing pain, redness, swelling, warmth, purulent drainage, red streaking, or fever

It's also important to note that puncture wounds through shoes are considered high-risk for infection because shoes harbor bacteria and the puncturing object may carry deep contamination that is difficult to clean. Pseudomonas aeruginosa is a particular concern with wounds through rubber-soled shoes, which is why broader spectrum coverage is recommended. Alternative antibiotic regimens, such as cephalexin 500 mg four times daily plus metronidazole 500 mg three times daily, or doxycycline 100 mg twice daily, may be considered in patients with penicillin allergy or other contraindications, as outlined in the guidelines 1.

From the FDA Drug Label

Anaerobes: Serious respiratory tract infections such as empyema, anaerobic pneumonitis, and lung abscess; serious skin and soft tissue infections; septicemia; intra- abdominal infections such as peritonitis and intra-abdominal abscess Streptococci: Serious respiratory tract infections; serious skin and soft tissue infections. Staphylococci: Serious respiratory tract infections; serious skin and soft tissue infections.

The most suitable antibiotic for a dirty wound through a shoe, for an outpatient with no contraindications, is clindamycin (PO) 2 or amoxicillin-clavulanate (PO).

• Clindamycin (PO) is indicated for serious skin and soft tissue infections caused by susceptible anaerobic bacteria, streptococci, and staphylococci.
• Amoxicillin-clavulanate (PO) can be used for skin and soft tissue infections, but the provided label does not specify the types of bacteria it is effective against for this type of infection. Given the information provided, clindamycin (PO) seems to be a more suitable option for this type of infection 2.

From the Research

Puncture Wound Antibiotics for Dirty Wound Through Shoe

• The management of puncture wounds, including those through a shoe, is crucial to prevent infection and other complications 3.
• A study on nail puncture wounds through rubber-soled shoes found that 37.5% of patients were treated conservatively, while 62.5% required surgical treatment 4.
• The use of antibiotics in the treatment of puncture wounds is important, especially in cases where there is a high risk of infection 5.
• Amoxicillin-clavulanate acid has been shown to be effective in treating severe wound infections, including those caused by Actinomyces 6.
• Current guidelines recommend antibiotic prophylaxis for dirty procedures, and the selection of antibiotics should be based on the type of procedure and the organisms most commonly causing wound infection 5.

Antibiotic Selection

• Cefazolin is often recommended for surgical procedures, but the choice of antibiotic may depend on the specific type of procedure and the patient's individual needs 5.
• Amoxicillin-clavulanate acid may be a suitable option for patients with puncture wounds, especially if there is a risk of infection with Actinomyces or other bacteria 6.

Treatment Approach

• The decision to treat a puncture wound surgically or conservatively should be based on the individual patient's needs and the severity of the wound 4.
• Ultrasound examination may be useful in detecting foreign bodies, but it has low sensitivity and should not be relied on solely to decide whether to perform surgery 7.
• A high index of suspicion for retained foreign bodies should be maintained, especially in cases where the patient presents with a puncture wound through a rubber-soled shoe 7.