Key Insights On Managing Infected Diabetic Ulcers

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Here is a severe polymicrobial diabetic foot infection with MRSA as the primary pathogenic organism. Anthony F. Cutrona, MD, says MRSA accounts for 65 percent of Staph aureus cases at his facility.
For the majority of pedal osteomyelitis, Lawrence Karlock, DPM, says he usually relies on standard radiographs as well as probe to bone tests. (Photo courtesy of Dr. Karlock.)
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Author(s): 
Clinical Editor: Lawrence Karlock, DPM

All patients who require deep surgical debridement are admitted for IV antibiotics, wound care and offloading, according to Dr. Brill. Dr. Karlock says he will admit patients whom he suspects of having osteomyelitis. He adds that whether the patient needs an I&D is another factor influencing a possible admission. When assessing the foot wound, one should take into account the odor, cellulitis, the possibility of expressing purulence, findings of gangrene of the skin and soft tissue, and the depth of the wound and whether you can probe to bone. Dr. Cutrona says all of these factors would influence admission to the hospital. Dr. Brill concurs, noting that rapidly progressing cellulitis would warrant hospital admission.
One should also consider the possibility of a vascular problem as a comorbid concern, notes Dr. Cutrona. Dr. Karlock says the general health status of the patient also comes into play. For example, he would want to admit patients who are on renal dialysis for more aggressive treatment.
The patient’s social structure (specifically the availability of a caregiver) plays a role in making the decision to treat patients as outpatients or admitting them to the hospital.
“If the patient has a good support system at home to treat this wound, we’ll try to treat on an outpatient basis,” explains Dr. Karlock. “However, if the patient has a poor social structure at home, admission into the hospital is usually more appropriate.”

Q: How do you approach the MRSA infected wound?
A:
Dr. Brill says MRSA and vancomycin resistant Staph aureus (VRSA) are becoming “alarmingly increasing” problems in the community he serves. More specifically, Dr. Karlock says MRSA accounts for upward of 40 percent of all Staph aureus isolates at one of the local hospitals in his area. Dr. Cutrona says 65 percent of the Staph aureus cases at his facility are MRSA.
Dr. Brill says one should have a strong index of suspicion for MRSA when assessing patients who have diabetic wounds of long duration and a long history of single or multiple oral and/or topical antibiotic use. For these patients, Dr. Brill will pursue empiric treatment with vancomycin in the hospital and trimethoprim/sulphamethoxazole for outpatients. If the patients are allergic to sulphamethoxazole, Dr. Brill says he will substitute a tetracycline instead. Due to increasing resistance, Dr. Brill says he reserves daptomycin and linezolid for resistant cases. In these cases, he always obtains an infectious disease consult.
MRSA strains are more prevalent in the hospital, according to Dr. Cutrona. He says these strains are resistant to most oral antibiotics and are sensitive to vancomycin, linezolid and rifampin. Dr. Cutrona says outpatient MRSA tends to be sensitive to the aforementioned antibiotics as well as doxycycline, clindamycin and trimethoprimsulfa.
He emphasizes that treating MRSA is no different than treating penicillin- or methicillin-sensitive Staph aureus. If the wound involves deep structures, such as tendon, ligament or bone, Dr. Cutrona says IV antibiotics are necessary as well as aggressive surgical debridement. He emphasizes that clean surgical margins are key to facilitating the effectiveness of the antibiotics. The length of antibiotic therapy depends upon the depth of the wound infection, notes Dr. Cutrona. When there is extension to the bone, he says one will need to proceed with six to eight weeks of IV antibiotics.

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