How should an infected subcutaneous testosterone pellet be managed, including incision and drainage and antibiotic therapy?

Management of Infected Subcutaneous Testosterone Pellet Incision

Primary Management: Incision and Drainage

The cornerstone of treatment for an infected testosterone pellet site is immediate incision and drainage with complete evacuation of purulent material, followed by removal of any extruding pellets and allowing the wound to heal by secondary intention with regular dressing changes. 1, 2

• Open the infected incision completely to evacuate all purulent material and remove any pellets that are accessible or extruding 1, 2
• Irrigate the wound cavity thoroughly to remove debris and residual infected material 1
• Leave the wound open to heal by secondary intention—do not attempt primary closure of contaminated tissue 3, 2
• Apply clean, sterile dressings with daily changes using clean technique until complete healing occurs 1

Antibiotic Decision Algorithm

Antibiotics are NOT routinely necessary after adequate incision and drainage unless specific systemic criteria are met. 1, 2, 4

Withhold antibiotics when ALL of the following are present:

• Temperature < 38.5°C 1, 2
• Heart rate < 100-110 beats/minute 1, 2
• Erythema and induration < 5 cm from the incision margins 1, 2
• White blood cell count < 12,000 cells/µL 1, 2
• No purulent drainage after initial drainage procedure 1, 2
• No systemic signs of toxicity 1, 2

Initiate antibiotics when ANY of the following develop:

• Temperature ≥ 38.5°C 1, 2
• Heart rate ≥ 110 beats/minute 1, 2
• Erythema extending > 5 cm from wound margins with induration 1, 2
• White blood cell count > 12,000 cells/µL 1, 2
• New or persistent purulent drainage after drainage 1, 2
• Evidence of systemic toxicity or SIRS 1, 4
• Immunocompromised status or diabetes 3, 1
• Inadequate source control despite drainage 1, 4

Empiric Antibiotic Selection (When Indicated)

If systemic criteria are met, initiate a short 24-48 hour course of antibiotics targeting Staphylococcus aureus, the most common pathogen in subcutaneous device-related infections. 1, 2

For methicillin-susceptible S. aureus (MSSA):

• First-generation cephalosporin (e.g., cephalexin) or antistaphylococcal penicillin (e.g., dicloxacillin) for 7 days 2

For MRSA risk or unknown susceptibility:

• TMP-SMX 1-2 double-strength tablets twice daily for 7-10 days 2
• Alternative: vancomycin, linezolid, or daptomycin for severe cases 2

Wound Culture Technique

Obtain tissue culture from the wound base after debridement using the Levine technique to identify causative organisms and guide antibiotic therapy if needed. 3, 2, 4

• Cleanse the wound thoroughly first 2
• Apply pressure to express fluid from deeper tissue 2
• Swab the wound base—avoid superficial swabs that only capture skin colonizers 3, 2
• Tissue biopsy from the wound margin is superior to swabs when feasible 3

Follow-Up Protocol

Schedule routine follow-up within 48-72 hours to assess wound healing and ensure adequate source control. 1, 2

Instruct patients to return immediately if they develop:

• Increasing pain, swelling, or redness 1
• Fever or systemic symptoms 1
• Purulent drainage that increases or changes character 1
• Failure of symptoms to improve within 48 hours 1

Common Pitfalls to Avoid

• Inadequate initial drainage is the most common cause of treatment failure—ensure complete evacuation of all purulent material and accessible pellets 1, 2
• Do not prescribe antibiotics reflexively for simple localized infections after adequate drainage—this provides no clinical benefit and promotes resistance 3, 1, 2, 4
• Avoid premature wound closure before complete resolution—infected wounds must heal by secondary intention 1, 2
• Do not rely on superficial swabs—they grow contaminants rather than true pathogens 3, 2
• Do not order imaging (CT/ultrasound) for superficial infections—reserve it only for suspected deep collections > 3 cm 2

Special Considerations for Testosterone Pellet Infections

Infection rates with testosterone pellets range from 0.3% to 6.8% depending on technique and pellet manufacturing, with extrusion occurring in 8.5-12% of cases with older techniques. 5, 6, 7, 8

• Modern implantation techniques (such as the "V" technique with two angulated tracks) reduce infection rates to 1.2% and extrusion rates to 0.8% 5
• Infection is strongly associated with subsequent pellet extrusion—60% of patients with infection later experience extrusion 8
• Multiple pellet extrusions from a single site occur 4.6-fold more often than expected by chance, suggesting local tissue factors 7
• Patients on anticoagulation can safely undergo drainage without significant bleeding risk 5

When to Escalate Care

Surgical consultation is warranted for severe infections characterized by profound toxicity, fever or hypotension despite antibiotics, skin necrosis with easy fascial dissection, or suspicion of necrotizing fasciitis. 2

• Early infections (< 48 hours) with visible organisms on Gram stain may indicate aggressive pathogens like Group A Streptococcus or Clostridium requiring immediate surgical intervention 2
• Persistent purulent discharge or signs of deep infection warrant timely debridement 2