What is the recommended emergency department management of a foot puncture wound, including assessment, irrigation, imaging, tetanus prophylaxis, antibiotic therapy, wound dressing, and follow‑up?

Emergency Department Management of Foot Puncture Wounds

Irrigate the wound thoroughly with tap water or sterile saline, perform wound exploration and debridement of any devitalized tissue, update tetanus prophylaxis, apply an occlusive dressing, and reserve antibiotics only for high-risk wounds or established infection. 1, 2

Initial Wound Assessment and Exploration

Examine the wound for:

• Depth of penetration and involvement of deeper structures (tendons, joints, bone) 2, 3
• Presence of retained foreign material (glass, nail fragments, shoe material) 3, 4
• Location on the foot (forefoot punctures through rubber-soled shoes carry higher Pseudomonas risk) 2
• Time since injury and footwear worn at time of injury 2, 3
• Patient's underlying health status, particularly diabetes, immunosuppression, or peripheral vascular disease 2

Wound Irrigation and Debridement

Cleanse the wound thoroughly:

• Irrigate with tap water or sterile saline solution under pressure to remove bacterial contamination 1
• Avoid povidone-iodine or other antiseptic agents, as they do not reduce infection rates compared to simple irrigation 1
• Perform sharp debridement of any necrotic, devitalized, or contaminated tissue using scalpel or scissors 1, 5
• Explore the wound tract to identify and remove any retained foreign bodies 3, 4

Common pitfall: Superficial cleansing without adequate irrigation pressure fails to remove bacterial contamination and increases infection risk. 1

Imaging Considerations

Obtain plain radiographs when:

• Suspicion exists for retained radiopaque foreign body (glass, metal) 3, 6
• Deep penetration raises concern for bone involvement 6
• The wound fails to heal or shows signs of infection on follow-up 6

Tetanus Prophylaxis

Update tetanus immunization according to standard wound management protocols for contaminated wounds. 5

Antibiotic Decision-Making

Do NOT prescribe antibiotics for clean, uncomplicated puncture wounds in healthy patients. 7, 8 Routine prophylactic antibiotics are not indicated and promote antimicrobial resistance without proven benefit. 7

Prescribe oral antibiotics ONLY when clear clinical signs of infection are present:

• Localized erythema, warmth, swelling, or purulent drainage 7
• Pain or tenderness (may be blunted in diabetic neuropathy) 7
• Systemic signs: fever, elevated white blood cell count, or elevated inflammatory markers 7

For mild infection in immunocompetent patients, use oral agents targeting aerobic gram-positive cocci:

• Cephalexin 500 mg every 6 hours, OR 7
• Dicloxacillin 500 mg every 6 hours, OR 7
• Clindamycin 300-450 mg three times daily (for penicillin-allergic patients) 7
• Duration: 1-2 weeks 7, 8

Add empiric MRSA coverage when:

• Prior MRSA infection or colonization 7
• Recent hospitalization or antibiotic exposure 7
• High local MRSA prevalence 7
• Lack of improvement after 48-72 hours of standard therapy 7

MRSA-active oral options:

• Trimethoprim-sulfamethoxazole (double strength) twice daily, OR 7
• Doxycycline 100 mg twice daily 7

Special Considerations for High-Risk Patients

Diabetic patients require more aggressive management:

• Assess for neuropathy, peripheral vascular disease, and metabolic stability 7
• Obtain tissue cultures from the debrided wound base via curettage or biopsy if infection is present 1, 7
• Never rely on swab cultures from undebrided wounds—they yield misleading colonization data 1, 8
• Ensure glycemic optimization to enhance healing 7
• Arrange off-loading of plantar wounds to prevent ongoing trauma 1, 7

Hospitalize and initiate IV antibiotics for moderate-to-severe infection:

• Systemic toxicity (fever, tachycardia, hypotension, WBC >15,000/µL) 7
• Metabolic instability (severe hyperglycemia or acidosis) 7
• Deep tissue involvement or suspected osteomyelitis 7
• Rapid progression despite oral therapy 7

IV regimens for severe infection:

• Ampicillin-sulbactam 3 g IV every 6 hours, PLUS 7
• Vancomycin 15-20 mg/kg IV every 8-12 hours (when MRSA risk is high) 7

Wound Dressing and Follow-Up

Apply an occlusive dressing (film, petrolatum, hydrogel, or cellulose/collagen) to promote moist wound healing. 1 Antibiotic or antibacterial dressings do not improve outcomes in clean wounds. 1

Instruct the patient to return immediately if:

• Redness, swelling, or warmth develops or worsens 1
• Foul-smelling drainage appears 1
• Pain increases 1
• Fever develops 1

Schedule routine follow-up:

• Re-evaluate in 3-5 days (or sooner if worsening) for patients treated with antibiotics 7
• For uncomplicated wounds without antibiotics, instruct the patient on warning signs and provide return precautions 1

Critical Pitfalls to Avoid

• Do not prescribe antibiotics for uninfected wounds—this promotes resistance without benefit 7, 8
• Do not use superficial swab cultures—obtain tissue specimens from the debrided base if cultures are needed 1, 7, 8
• Do not overlook retained foreign bodies—inadequate exploration is a common source of complications and litigation 3, 4
• Do not continue antibiotics until complete wound closure—stop once infection signs resolve 7