What is the appropriate management for a 10-year-old female presenting with a laceration between the 4th and 5th toes, with macerated skin, scant foul-smelling discharge, and currently on Keflex (Cephalexin) after receiving 1 suture in the emergency room?

From the Guidelines

The patient should continue the current treatment with Keflex (cephalexin) to address the infected laceration between her 4th and 5th toes, as it is a first-choice antibiotic for mild skin and soft tissue infections, according to the Infectious Diseases Society of America guidelines 1. The infection is evidenced by the scant smelling discharge and skin maceration. The antibiotic should be completed for a full 7-10 day course, even if symptoms improve before then.

Wound Care Modifications

The wound care should be modified to include:

• Daily gentle cleansing with mild soap and water, followed by thorough drying of the area
• Instead of taping the toes together, which may be contributing to the maceration, consider using a toe spacer or gauze between the toes to prevent skin-to-skin contact and promote air circulation
• Discontinue the bacitracin ointment as it may be keeping the area too moist
• The patient should wear open-toed shoes or sandals when possible to allow air circulation

Monitoring and Follow-up

If the discharge increases, changes color, or if the patient develops fever or increasing pain, she should return for reevaluation. The suture on the dorsal foot has been removed and appears well-healed, which is a positive sign. This treatment approach addresses both the bacterial infection with appropriate antibiotics while modifying wound care to reduce moisture that can delay healing in the web space between toes. The patient's response to therapy should be carefully observed, with daily follow-up for inpatients and every 2-5 days for outpatients, as recommended by the Clinical Infectious Diseases guidelines 1.

From the FDA Drug Label

PRECAUTIONS General Prescribing cephalexin capsules, cephalexin for oral suspension, or cephalexin tablets in the absence of a proven or strongly suspected bacterial infection or a prophylactic indication is unlikely to provide benefit to the patient and increases the risk of the development of drug-resistant bacteria

• The patient is on Keflex (cefalexin) for a laceration between the 4th and 5th toe with scant smelling discharge.
• The FDA drug label does not provide direct information on the management of this specific condition.
• However, it does mention that cephalexin should only be used to treat bacterial infections and that patients should be followed carefully for any side effects or unusual manifestations of drug idiosyncrasy 2.
• Given the presence of scant smelling discharge, it is possible that the patient has a bacterial infection, but the label does not provide guidance on the specific management of this condition.
• The patient should be monitored closely for any signs of superinfection or other adverse effects, and the antibiotic therapy should be adjusted as needed 2.

From the Research

Patient Presentation

• A 10-year-old female presents with a laceration between her 4th and 5th toes, which she sustained while running up the steps and cutting her toe on the banister.
• The patient was initially evaluated in the emergency room at Penn State, where 1 suture was placed.
• The mother reports that they have been washing the wound daily, applying bacitracin, and taping the 4th and 5th toes together.
• The patient is currently on Keflex (cephalexin) and has scant smelling discharge from the laceration.

Antibiotic Treatment

• The patient is being treated with cephalexin, a first-generation cephalosporin antibiotic 3.
• Cephalexin has been shown to be effective against non-extended-spectrum beta-lactamase-producing (ESBL) Enterobacteriaceae, which are commonly found in skin and soft tissue infections 3.
• The choice of cephalexin as an antibiotic is appropriate, given its spectrum of activity and potency against common bacterial pathogens, including Streptococcus pneumoniae and Staphylococcus aureus 4.

Dosage and Administration

• The dosage and administration of cephalexin in children require consideration of multiple factors, including microbiological data, site of infection, pharmacokinetics, and pharmacodynamic targets 5.
• Cephalexin can be conveniently administered as 500 mg twice or thrice daily, making it a practical choice for many clinicians 3.

Alternative Antibiotic Options

• Amoxicillin and amoxicillin-clavulanic acid are alternative antibiotic options that may be considered for the treatment of skin and soft tissue infections 6.
• However, the use of amoxicillin-clavulanic acid is often associated with a higher risk of gastrointestinal side effects, including Clostridium difficile infection, and may limit the maximum daily dose of amoxicillin that can be given 6.