What is the diagnosis and treatment for a 48-year-old male patient with a painful infection on his right third finger, presenting with inflammation, peeled skin, and yellowish drainage, after initial treatment with triamcinolone (BID - twice a day)?

From the Guidelines

I strongly recommend treating this 48-year-old male's finger infection with amoxicillin-clavulanate 875/125 mg twice daily for 10 days, along with daily wound care and obtaining a wound culture, as this provides good coverage against common skin pathogens including Staphylococcus aureus (including MRSA), Streptococcus species, and anaerobes, which are commonly found in skin and soft tissue infections 1. The patient's presentation of inflammation, peeling skin, and yellowish drainage suggests a bacterial infection that has likely progressed from an initial dermatitis. The previous use of triamcinolone (a topical steroid) may have suppressed the immune response locally, potentially allowing the infection to worsen.

Key Considerations

• The wound culture will help identify the specific pathogen and its antibiotic sensitivities, allowing for targeted therapy if the infection doesn't respond to initial treatment.
• Daily wound care should include gentle cleansing with mild soap and water, application of an antiseptic solution, and covering with a clean, dry dressing.
• The patient should be advised to keep the area dry, elevate the hand when possible to reduce swelling, and return for follow-up in 2-3 days to assess treatment response.
• According to the guidelines, amoxicillin-clavulanate is a recommended empiric choice for skin and soft tissue infections, including those caused by MRSA 1.

Antibiotic Choice

• Amoxicillin-clavulanate is a broad-spectrum antibiotic that covers a wide range of pathogens, including Staphylococcus aureus, Streptococcus species, and anaerobes.
• The dose of 875/125 mg twice daily is recommended for adults with skin and soft tissue infections 1.
• Other antibiotics, such as doxycycline or clindamycin, may also be effective, but amoxicillin-clavulanate is a preferred choice due to its broad coverage and efficacy 1.

From the FDA Drug Label

If an infection develops, the use of occlusive dressings should be discontinued and appropriate antimicrobial therapy instituted. The patient's use of triamcinolone may have contributed to the development of the infection, as the drug label warns that infection can occur with its use, especially under occlusive dressings.

• The patient should be advised to discontinue the use of triamcinolone and occlusive dressings.
• The decision to start the patient on Bactrim DS and order a wound culture and daily wound care is appropriate, as it addresses the infection directly 2.

From the Research

Patient Assessment and Treatment

• The patient is a 48-year-old male with a painful infection on his right third finger, which began as a rash and was initially treated with triamcinolone.
• The patient presents with an inflamed finger, peeled skin, and yellowish drainage, indicating a possible bacterial infection.
• The treatment plan includes Bactrim DS (trimethoprim-sulfamethoxazole) BID for 10 days, wound culture, and daily wound care.

Rationale for Treatment

• Trimethoprim-sulfamethoxazole is active against a variety of gram-positive and gram-negative bacteria, making it a suitable choice for treating skin infections 3.
• Studies have shown that trimethoprim-sulfamethoxazole is effective in treating uncomplicated skin infections, including cellulitis and abscesses, with similar cure rates to clindamycin 4, 5.
• In cases of community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) skin infections, trimethoprim-sulfamethoxazole and clindamycin have been shown to be effective treatment options, with similar failure rates 6.

Considerations for Treatment

• The patient's treatment plan should be monitored for efficacy and potential side effects, as trimethoprim-sulfamethoxazole can be associated with adverse events, although the proportion of patients with adverse events is similar to that of clindamycin 4.
• The use of trimethoprim-sulfamethoxazole in patients with renal impairment requires dosage adjustment, as the drug is excreted primarily in the urine 3.
• The treatment of Staphylococcus aureus infections, including endocarditis, may require combination therapy with other antibiotics, such as clindamycin and rifampicin, and a rapid switch to oral administration of trimethoprim-sulfamethoxazole and clindamycin may be effective in reducing mortality and hospital stay 7.