How should I treat an infected testosterone pellet insertion site?

Management of Infected Testosterone Pellet Insertion Site

For an infected testosterone pellet insertion site, remove the pellet, obtain cultures from any drainage and blood cultures, initiate systemic antibiotics based on culture results, and consider incision and drainage if an abscess is present, with 7-10 days of antibiotic therapy required. 1

Immediate Assessment and Diagnosis

Obtain cultures before initiating antibiotics:

• Swab any purulent drainage or exudate from the insertion site for Gram stain and culture 1
• Draw paired blood cultures—one from a peripheral vein and one if any other vascular access is present 1
• Look specifically for erythema, warmth, tenderness, induration, purulent drainage, and systemic signs including fever, chills, or sepsis 1

Treatment Algorithm

For Uncomplicated Exit Site Infection (No Systemic Signs)

• Start with topical antimicrobial therapy based on culture results (e.g., mupirocin ointment for S. aureus, ketoconazole for Candida) 1
• If topical therapy fails or purulent drainage develops, escalate to systemic antibiotics 1

For Complicated Infection (Systemic Signs, Purulence, or Abscess)

• Remove the pellet immediately 1, 2
• Perform incision and drainage if an abscess has formed 1
• Administer 7-10 days of systemic antibiotics tailored to culture and susceptibility results 1
• If the pellet cannot be removed and systemic antibiotics fail, removal becomes mandatory 1

Antibiotic Selection

Use empiric broad-spectrum coverage initially, then narrow based on cultures:

• Cover common skin flora including Staphylococcus aureus (including MRSA in high-risk settings) and streptococci 1
• Adjust therapy once culture results and sensitivities return 1
• Continue antibiotics for the full 7-10 day course even after clinical improvement 1

Skin Preparation and Wound Care

Clean the infected site with appropriate antiseptic:

• Use 2% chlorhexidine gluconate in 70% isopropyl alcohol as the preferred antiseptic for cleaning the site 1
• Allow antiseptic to air dry completely before applying dressings 1
• If chlorhexidine is contraindicated, use alcoholic povidone-iodine solution 1

Apply appropriate dressings:

• Use sterile transparent semi-permeable polyurethane dressing for non-draining sites, changed every 7 days 1
• Use sterile gauze dressing if significant drainage, bleeding, or oozing is present, changed when damp or soiled 1
• Consider chlorhexidine-impregnated dressings to reduce extraluminal contamination 1

Common Pitfalls to Avoid

Do not apply antimicrobial ointments routinely to the insertion site as they are not effective for prevention and may promote resistance 1

Do not use topical antibiotics for established infections—they should be reserved for uncomplicated exit site infections only, with systemic therapy required for anything more severe 1

Do not delay pellet removal in the presence of purulence, abscess formation, or systemic infection, as this significantly increases morbidity 1

Prevention for Future Insertions

The infection rate with testosterone pellets ranges from 0.3% to 6.8% depending on technique and pellet manufacturing 3, 4, 5

Key preventive measures include:

• Maximal sterile barrier precautions during insertion (sterile gown, gloves, drapes) 1
• Skin preparation with 2% chlorhexidine in 70% alcohol before insertion 1
• Modified "V" technique for pellet placement reduces infection rates to 1.2% compared to 5% with standard technique 3
• Ensure pellets are placed deep enough in subcutaneous tissue to minimize extrusion risk 3, 4
• Strict adherence to post-procedure care instructions by patients 4

Alternative Testosterone Formulations

Consider switching to alternative delivery methods if recurrent infections occur:

• Transdermal gels have only a 5% skin reaction rate and avoid insertion site infections entirely 6
• Intramuscular injections provide stable levels without pellet-related complications 6, 2
• These alternatives eliminate the risk of pellet extrusion and insertion site infection 1