Medication Summary
The goals of pharmacotherapy are to eradicate the infection and to prevent complications. With the rise of methicillin-resistant Staphylococcus aureus (MRSA) as a cause of hand infections, coverage with appropriate antibiotics is important. [12, 13] In this era, cephalexin alone is inappropriate coverage for hand infections, and coverage for all infections should include MRSA coverage.
Antibiotics
Class Summary
Therapy must cover all likely pathogens in the context of the clinical setting.
Cephalexin (Keflex)
First-generation cephalosporin that inhibits bacterial growth by inhibiting bacterial cell wall synthesis. Bactericidal and effective against rapidly growing organisms forming cell walls. Primarily active against skin flora. Typically used for skin structure coverage and as prophylaxis in minor procedures. DOC for immunocompromised patients with paronychia.
Clindamycin (Cleocin)
Lincosamide useful as treatment against serious skin and soft tissue infections caused by most staphylococcal strains. Also effective against aerobic and anaerobic streptococci, except enterococci. Inhibits bacterial protein synthesis by inhibiting peptide chain initiation at bacterial ribosome where it preferentially binds to 50S ribosomal subunit, causing bacterial growth inhibition. DOC for paronychia in children and those who wash dishes.
Ampicillin-sulbactam (Unasyn)
Combination antimicrobial agent that uses a beta-lactamase inhibitor with ampicillin. Covers skin, enteric flora, and anaerobes. DOC for infectious tenosynovitis and deep fascial space infections.
Cefazolin (Ancef, Kefzol, Zolicef)
First-generation semisynthetic cephalosporin, which, by binding to 1 or more penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial growth. Primarily active against skin flora, including S aureus. Typically used alone for skin and skin-structure coverage. An alternate DOC for infectious tenosynovitis and deep fascial space infections.
Vancomycin (Vancocin)
Potent antibiotic directed against gram-positive organisms and active against Enterococcus species. Useful in treatment of septicemia and skin structure infections. Indicated for patients who cannot receive or whose conditions have not responded to penicillins and cephalosporins or for those who have infections with resistant staphylococci. For abdominal penetrating injuries, combine with agent active against enteric flora and/or anaerobes. DOC (in conjunction with gentamicin) for infectious tenosynovitis and deep fascial space infections in patients who are allergic to penicillin. To avoid toxicity, current recommendation is to assay vancomycin trough levels after third dose drawn 0.5 h prior to next dosing. Use CrCl to adjust dose in patients with renal impairment.
Gentamicin (Garamycin, Gentacidin)
Aminoglycoside antibiotic used for gram-negative bacterial coverage. Used commonly in combination with both an agent against gram-positive organisms and an agent that covers anaerobes. DOC (in conjunction with vancomycin) for infectious tenosynovitis and deep fascial space infections in patients who are allergic to penicillin. Dosing regimens are numerous and are adjusted based on CrCl and changes in volume of distribution.
Toxoids
Class Summary
These agents are used to induce and boost active immunity.
Tetanus toxoid adsorbed or fluid
Used to induce active immunity against tetanus in selected patients. Immunizing agents of choice for most adults and children >7 y are tetanus and diphtheria toxoids. Necessary to administer booster doses to maintain tetanus immunity throughout life.
Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product.
In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is mid thigh laterally.
Topical steroids
Class Summary
These agents are used in the treatment of chronic paronychia. They have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.
Hydrocortisone topical (CortaGel, Cortaid, Dermacort, Westcort)
An adrenocorticosteroid derivative suitable for application to skin or external mucous membranes. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing increased capillary permeability.
Topical antifungal
Class Summary
These agents are used in the treatment of chronic paronychia.
Clotrimazole (Lotrimin, Mycelex)
Broad-spectrum antifungal agent that inhibits yeast growth by altering cell membrane permeability, causing death of fungal cells. Reevaluate diagnosis if no clinical improvement after 4 wk.
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A paronychia can progress to a felon if left untreated.
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A herpetic whitlow. Image courtesy of Glen Vaughn, MD.
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Paronychia incision and drainage.
