In a patient with an infected testosterone pellet extrusion, should the pellet be removed before starting antibiotics, or should the infection be treated first?

Management of Infected Testosterone Pellet Extrusion

Remove the pellet immediately and start antibiotics concurrently—do not delay removal to treat the infection first. 1

Rationale for Immediate Removal

The fundamental principle in managing infected foreign body infections is that antibiotics alone cannot sterilize infected implanted material. 1 Foreign bodies, including testosterone pellets, create a biofilm environment where bacteria exhibit phenotypic resistance to nearly all antibiotics, with minimal bactericidal concentrations increasing up to 1000-fold. 2

• Newly placed implants (within 1 month) with any degree of infection require both antibiotic therapy AND complete removal of the foreign material, regardless of infection extent. 1
• The presence of an infected foreign body fundamentally alters the host-pathogen interaction, reducing the threshold at which contaminating bacteria become infectious. 2
• Antibiotics supplement immune control but do not sterilize the infected site—they limit bacterial proliferation while the source (the pellet) remains. 3, 4

Treatment Algorithm

Step 1: Immediate Actions (Concurrent, Not Sequential)

• Remove the pellet without delay upon diagnosis of infection. 1
• Start empirical antibiotics immediately after obtaining cultures but before removal. 1, 5
• Obtain blood cultures and wound cultures before antibiotic administration. 4

Step 2: Empirical Antibiotic Selection

• Initiate vancomycin as first-line empirical coverage, as staphylococcal species (particularly S. aureus and coagulase-negative staphylococci) cause the majority of implant infections. 1, 3
• Vancomycin should continue until microbiological results identify the pathogen and susceptibility. 1
• If oxacillin-susceptible staphylococci are identified, switch to cefazolin or nafcillin and discontinue vancomycin. 1
• For oxacillin-resistant organisms or β-lactam allergies, continue vancomycin. 1

Step 3: Surgical Management

• Perform complete pellet removal with generous debridement of infected tissue. 1
• Open and drain any associated abscess or purulent collection. 1
• The wound should heal by secondary intention with dressing changes. 1

Step 4: Post-Removal Antibiotic Duration

• For localized pocket infection without bacteremia: 10-14 days of antimicrobial therapy after pellet removal. 1
• For documented bacteremia: minimum 2 weeks of parenteral therapy after device extraction. 1
• If blood cultures remain positive ≥24 hours after removal despite appropriate antibiotics: extend to 4 weeks of parenteral therapy. 1
• Switch to oral antibiotics only after susceptibility results confirm an active oral agent is available and the pellet has been removed. 1

Critical Pitfalls to Avoid

Do NOT attempt to treat the infection with antibiotics alone before removal. 1 This approach fails because:

• Biofilm-encased bacteria on the pellet surface are essentially impervious to antibiotic penetration. 2
• Clinical studies of subcutaneous abscesses and surgical site infections show no benefit for antibiotics without drainage/removal. 1
• Delaying removal while treating with antibiotics risks progression to bacteremia, septic emboli, or systemic sepsis. 1

Do NOT use antibiotics as monotherapy for any infected implant. 1 The single most important therapy is source control—removing the infected foreign material. 4

Do NOT close the infected pocket primarily—allow healing by secondary intention after debridement. 1

Special Considerations

• If the patient is clinically unstable or septic, pellet removal becomes even more urgent and should not be delayed for any reason. 1, 5
• For patients with minimal systemic signs (temperature <38.5°C, pulse <100 bpm) and limited local infection (<5 cm erythema), antibiotics may be unnecessary after complete pellet removal and drainage. 1
• Rifampin combinations may be considered for established staphylococcal foreign body infections if removal is somehow delayed, but this does not replace the need for removal. 2, 6