Treatment

Many aspects of the treatment of puncture wounds remain controversial.48 Uncomplicated, clean punctures presenting less than 6 h after injury require only wound cleansing and tetanus prophylaxis as indicated. Soaking of the wound has no proven benefit. Low-pressure irrigation (e.g., 0.5 psi) of wounds is recommended to assist in cleansing of the wound for better visualization of the entrance site as well as removal of visible foreign matter. The injection of irrigation fluid under high (e.g., 7 psi) pressure into a closed wound tract may lead to displacement of foreign matter secondary to hydrodissection along tissue planes and disseminate bacteria deeper into the surrounding tissue.

Debridement or "coring" of the wound tract in clean wounds is sometimes recommended, but there is no evidence that this procedure reduces the risk of infection, even for plantar puncture wounds. Large objects may produce lacerations that should be anesthetized, explored, irrigated, and debrided. The expertise, time required for the procedure, and postprocedure management may dictate referral to a surgical specialist.

There is no proven benefit to routine prophylactic antimicrobial therapy in the management of clean, nonplantar puncture wounds. In fact, it has been suggested that this practice may actually contribute to the development of secondary infections with gram-negative organisms by altering the normal flora. Puncture wounds in patients with peripheral vascular disease, diabetes mellitus, and immunocompromising disorders are associated with an increased incidence of infection and may benefit from antibiotics.6 Plantar puncture wounds, especially those in high-risk patients, those located in the forefoot, or those through athletic shoes should be treated with antibiotics.9 The ability of antibiotics to reduce the incidence of wound infections is correlated with the early achievement of antimicrobial blood levels. In the past, this required parenteral (intravenous or intramuscular) administration of both a cephalosporin and an aminoglycoside in the emergency department (ED). The development of fluoroquinolones now provides the physician with a broad-spectrum antibiotic that rapidly achieves high blood levels following an oral dose. 10 Either route is acceptable in plantar puncture wounds; the choice is up to the physician's judgment. Following the initial dose in the ED, the patient should be discharged with an oral regimen. The ideal duration of treatment is not known. A dilemma is posed by plantar puncture wounds through athletic shoes, where infection with Pseudomonas has been reported to occur in up to 25 percent. The only oral agents consistently effective against Pseudomonas are the fluoroquinolones ciprofloxacin and levofloxacin, and these agents are not approved by the FDA for use in children. The alternative would be hospital admission for intravenous antibiotics. Experience with ciprofloxacin in children with cystic fibrosis indicates a low rate of complications, particularly with short courses. A tentative recommendation can be made for the prophylactic use of ciprofloxacin in children with plantar puncture wounds either in the forefoot or through athletic shoes.

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