A pediatrician received a telephone call from a local physician regarding a 10-year-old male who came to his office with a puncture wound to his bare foot that occurred a couple hours ago. The child had been wading in a river and did not know what had been stepped on. The child was previously healthy. No other history was available as the physician was hurried and wanted to know if Ciprofloxacin could be given to a 10 year old. The pediatrician answered yes that it could be given but that other antibiotics were probably more appropriate. The physician stated that he was very concerned about possible Pseudomonas, even when the pediatrician pointed out that the child had been barefoot and that the injury had just occurred. She noted that Staphylococcus and Streptococcus were the more likely organisms. He insisted that he was going to give Ciprofloxacin as the pediatrician had said that it could be used in children. The pediatrician helped the physician choose an appropriate dosing regimen for the Ciprofloxacin and also reminded the physician that the child should receive a tetanus shot as the child was 10 years old and most likely 5 years or more probably had elapsed since his last tetanus vaccination.
Ciprofloxacin and other fluoroquinolones have demonstrated cartilage and joint toxicity when administered to immature laboratory animals. Therefore health care providers have been reluctant to use fluoroquinolones in young children and voluntarily have avoided them. However in 2002, more than 182,000 courses of fluoroquinolones were administered to children. Research data is limited but the pediatric safety profile appears to be similar to the adult safety profile. Current indications for fluoroquinolones include complicated urinary tract infections, treatment of opportunistic infections in immunocompromised patients such as patients with cancer, patients with cystic fibrosis and certain Shigella and Salmonella infections, and for inhalational anthrax. Fluoroquinolones are often considered second line antibiotics for specific indications and should be used only when indicated.
Puncture wounds of the foot are common presentations to the office or emergency room. Punctures are caused by a variety of objects including nails, needles, plastic, metal, organic materials and glass. The foot has an increased risk of secondary infection owning to the structure of the foot and its increased cartilage. There is a higher risk of infection the deeper the puncture is and the more distal on the foot (i.e. a deep puncture around the metatarsalphalayngeal joint). Most infections actually are relatively superficial with Staphylococcus and Streptococcus predominating, particularly in the first 24 hours after injury. Pseudomonas aeruginosa is a frequent cause of deep seated infections such as osteochondritis or osteomyelitis. Pseudomonas is a known contaminate of the soft inner foam lining of tennis shoes. One study found Pseudomonas only occurred in patients wearing foot gear when the trauma occurred. Other organisms include Bacteroids, E. coli, Klebsiella and Serratia.
Patients who present with a puncture wound should have the wound thoroughly examined, possibly explored, and debrided. A retained foreign body is a possibility even with thorough examination. Standard radiographs and possibly ultrasound or magnetic resonance imaging may be indicated if a retained foreign body is suspected. Some physicians use providine-iodine solutions as part of the thorough cleaning of the wound. Hexachlorophene should not be used as open bottles may become colonized with Pseudomonas. Tetanus prophylaxis should also be assessed for any patient and given if appropriate.
Children who present within 24 hours with a clean wound, and with low suspicion for a retained foreign body often can be treated conservatively. These children usually do well with few complications. Prophylactic oral antibiotics against Streptococcus and Staphylococcus are usually given to patients who are high risk (such as diabetics), or with wounds at the metatarsalphalangeal joint to distal to it. Patients should be re-examined in 1-2 days. For patients not improving, a retained foreign body must be considered and the patient usually needs parental antibiotics. Again the antibiotic choice usually is against Streptococcus and Staphylococcus, but Pseudomonas should be considered if foot gear was worn during the trauma.
For patients presenting 24-72 hours after injury, prophylactic oral antibiotics against Streptococcus and Staphylococcus is usually begun empirically, with appropriate initial management and followup. Patients presenting > 72 hours after injury with pain, erythema, swelling etc, should be started on parental antibiotics against Streptococcus and Staphylococcus, and also against Pseudomonas if foot gear had been worn. Patients presenting after 72 hours usually have a high rate of complications.
Questions for Further Discussion
1. As the treating physician, how would you have treated the patient presented above?
2. As the consulting physician, how would you have handled this telephone call?
3. What is a common organism found in animal puncture bites?
4. How would you treat a puncture wound to another body site?
- Symptom/Presentation: Lower Extremity Trauma
- Specialty: Emergency Medicine | General Pediatrics | Infectious Diseases | Pharmacology / Toxicology
- Age: School Ager
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Eidelman M, Bialik V, Miller Y, Kassis I. Plantar puncture wounds in children: analysis of 80 hospitalized patients and late sequelae.
Isr Med Assoc J. 2003 Apr;5(4):268-71.
Chachad S, Kamat D. Management of plantar puncture wounds in children.
Clin Pediatr (Phila). 2004 Apr;43(3):213-6.
Grady RW. Systemic quinolone antibiotics in children: a review of the use and safety.
Expert Opin Drug Saf. 2005 Jul;4(4):623-30.
ACGME Competencies Highlighted by Case
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
16. Learning of students and other health care professionals is facilitated.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital