Keys To Addressing MRSA In The Diabetic Foot

Suhad Hadi, DPM, FACFAS, and Randy Garr, DPM

   Cultures were positive for MSSA. We reviewed the case with the infectious disease team and followed recommendations for the initiation of therapy with dicloxacillin (Diclocil, Bristol-Myers Squibb). Treatment also included aggressive offloading and wound care management with Iodosorb (Smith and Nephew) dressings daily with aggressive irrigation of the wound tract. The patient refused incision and drainage with operative debridement due to needing to care for his wife and father.

   Due to the death of his father and his mother-in-law within the same two-week period, the patient was absent to follow up in the clinic for one month. Upon his return, he had a full blown abscess and fluctuance encompassing the entire fifth metatarsal region. The patient had a new onset of pain to his foot at the fifth metatarsal and along the peroneals just distal to the lateral malleolus. He had nausea and complained of not being able to keep his food down. The patient was febrile with a 101º temperature and had an elevated white blood cell count of 16, findings that were concerning for systemic inflammatory response syndrome.

   We hospitalized the patient and started him on vancomycin and piperacillin/tazobactam (Zosyn, Pfizer) due to concern for MRSA and polymicrobial infection, given the wound’s chronicity and progression to a severe diabetic foot infection.
After two days on an intravenous antibiotic, the patient developed a localized fluctuant abscess in the region of the fifth metatarsal base extending dorsal and lateral. He then went to the operating room for a formal incision and drainage.

   Intraoperative findings were consistent with thick purulent drainage. The fifth metatarsal was gray and fragmented along the midshaft to the level of the base. The peroneus brevis tendon was shredded from the insertion to the distal lateral malleolus and there was hemorrhagic tissue along the sheath of the longus tendon proximal to the lateral malleolus. We resected the respective portion of the brevis and debrided the sheath of the longus.

   The cuboid had a dorsal erosion and cartilage was intact. The intraoperative biopsy and culture were consistent with osteomyelitis and new cultures revealed E. coli, Proteus and MRSA. Once the patient was stable postoperatively, the patient was discharged. He remained on the same antibiotic coverage (vancomycin 1,500 mg q12h and Zosyn 3 gm q8h) per the infectious disease team via PICC line placement and home nursing assistance. Due to the severity of his infection and required revascularization, antibiotic use continued for seven weeks without evidence of toxicity. Serial radiographs were without evidence of progressed osseous changes to the cuboid with full granulation of the wound.

   Therefore, we decided to discontinue the antibiotics after consulting with the infectious disease team. The wound continued to improve and the patient progressed to weightbearing activities with prescription shoe gear and bracing.

Case Study Two: When A Patient With Diabetes Presents With One Week Of Pain, Redness And Swelling To Her Left Foot

A 57-year-old female with a history of diabetes for 12 years presented with complaints of pain, redness and swelling of her left foot for a one-week duration. She noticed the foot starting to blister on top and presented to the clinic. The patient denies any trauma or puncture, and states she wears socks around the house. She does have numbness to her feet and does not always feel well. The patient has had a history of a “sore” to the foot before but it healed after she put an antibiotic ointment on it. She tried the same ointment with this episode but the foot has not responded. The patient noted that she soaks the foot in warm, soapy water and applies the antibiotic ointment each day. She admits her blood glucose levels fluctuate and are usually more on the high end, around 200 mg/dL.

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