How should I manage a patient with a tuft fracture who has been on cephalexin for seven days and now shows signs of infection?

Management of Infected Tuft Fracture After 7 Days of Cephalexin

Switch antibiotics immediately to amoxicillin-clavulanate or clindamycin plus an aminoglycoside, perform urgent surgical debridement with culture-guided therapy, and ensure adequate wound drainage.

Immediate Antibiotic Change Required

Cephalexin has poor activity against the polymicrobial flora typical of fracture-related infections and should not be continued. 1 First-generation cephalosporins like cephalexin lack coverage against anaerobes and many gram-negative organisms that commonly colonize infected fractures, particularly when there is communication with the skin surface. 1

Recommended Antibiotic Regimens:

• First-line oral therapy: Amoxicillin-clavulanate provides broad-spectrum coverage including anaerobes and is the preferred outpatient agent for fracture-related infections 1

• Alternative for penicillin allergy: Clindamycin (covers anaerobes and most staphylococci) plus an agent for gram-negative coverage such as a fluoroquinolone 1

• If hospitalization required: Intravenous ampicillin-sulbactam, piperacillin-tazobactam, or a carbapenem provide comprehensive coverage 1

Urgent Surgical Evaluation

At 7 days post-injury with signs of infection despite antibiotics, this represents a fracture-related infection requiring surgical intervention. 1 The presence of purulent drainage or wound breakdown are confirmatory criteria for fracture-related infection. 1

Surgical Management Steps:

• Perform urgent surgical debridement to remove all infected and non-viable tissue 1

• Obtain deep tissue cultures (at least 2 separate specimens) before administering new antibiotics to guide definitive therapy 1

• Ensure adequate drainage of any purulent collections 2

• Assess fracture stability and consider whether implant retention is feasible or if removal/exchange is needed 1

Key Diagnostic Considerations

Confirmatory signs of fracture-related infection include: 1

• Purulent drainage from the wound
• Wound breakdown exposing bone
• Sinus tract formation

Suggestive findings that support the diagnosis: 1

• Persistent pain, erythema, swelling at the fracture site
• Fever or systemic signs of infection
• Elevated inflammatory markers (CRP, ESR, WBC)

Duration of Antibiotic Therapy

After surgical debridement and culture results:

• If implant retained with adequate debridement: 12 weeks of biofilm-active antibiotics 1

• If implant removed: 6 weeks of antimicrobial therapy for osteomyelitis 1

• Culture results should guide definitive antibiotic selection based on sensitivities 1

Critical Pitfalls to Avoid

Do not continue cephalexin for a clinically infected fracture—it lacks adequate coverage for the polymicrobial flora and anaerobes commonly present 1

Do not rely on antibiotics alone without surgical debridement; biofilm formation on exposed bone requires mechanical removal of infected tissue 1

Do not delay surgical consultation beyond 24 hours once infection is recognized, as outcomes worsen with delayed intervention 3, 4

Do not assume the infection is superficial—tuft fractures with bone exposure and signs of infection after a week of antibiotics indicate deep tissue involvement requiring aggressive management 1

Wound Care Adjuncts

• Apply sterile dressings and consider negative pressure wound therapy after debridement 4
• Ensure tetanus prophylaxis is current 3, 4
• Immobilize the digit to promote healing 3
• Plan for soft tissue coverage within 7 days if significant tissue loss occurred 4