Scenario: A 10-year-old boy steps on a nail while wearing sneakers. Does he need prophylactic antibiotics?

Plantar puncture wounds are common and the anatomy of the foot makes it an excellent environment for infection to rapidly spread. Puncture wounds in particular can inoculate bacteria deep into the soft tissues.

The lack of data makes it difficult to offer recommendations on antibiotic therapy and duration. There are no real studies comparing outcomes in patients who receive antibiotics for puncture wounds versus those who don’t. This leaves the decision to administer antibiotics in high-risk patients to the discretion of the treating clinician.

If the wound is less than 24 hours old and there is no risk factor for an infected wound (in other words if the wound is not grossly contaminated, the patient has immunocompetece, etc), then local wound care and good return precautions are likely adequate. If the wound is over 24 hours old and there is concern for infection (presence of gross contamination or immunosuppression for instance), antibiotics are likely to be of benefit.

Ciprofloxacin is classically the empiric antibiotic of choice for this type of injury. However, fluoroquinolones should generally be avoided in children due to the risk of arthropathy. In fact, currently, fluoroquinolones are only FDA-approved in individuals less than 18 years of age for complicated UTI and for treatment of inhalation anthrax. However, while fluoroquinolones can lead to adverse musculoskeletal events, it is typically transient. Tendinopathy is more likely to occur in older patients, patients taking corticosteroids, and patients with renal disease.

If antibiotics are prescribed, the ideal agent is something like cephalexin for plantar puncture wounds in which the patient was barefoot. If footwear is involved, then the concern for Pseudomonas infection warrants a 3-5 day course of fluoroquinolones.

Summary:

Evaluate the wound with a high index of suspicion for retained foreign bodies. X-rays can be helpful. Update tetanus status. Irrigate and cleanse the wound. Engage in shared decision-making with the patient: weigh the risk/benefit and together decide on prophylactic antibiotic coverage.

Dr. Sajid Khan Sajid R. Khan, MD, is a board-certified Emergency Medicine physician with over 10 years of experience working in a variety of settings from inner-city level 1 trauma centers serving 100,000 patients per year to 3-bed rural Eds. A published author, Dr. Khan has written a number of books including, The Ultimate Emergency Medicine Guide, a comprehensive review book that is the highest-rated and most up-to-date text for Emergency Medicine physicians preparing to certify.

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