Soft Tissue & Bone Infections

Case 3:

Princess Leia is a 64 year old woman who was diagnosed with type II diabetes two years ago and is now seeing you for the first time in your primary care clinic. She admits that she has yet to start therapy for her diabetes as she has been too preoccupied with work. Her A1c is 9.8% and on monofilament testing of her feet, she decreased sensation distally. You note a small, 0.5 cm ulcer on the tip of her right 2nd toe that is non-purulent and without surrounding erythema. She noticed this ulcer just last week. Which of the following is true?

a.       She likely has an uninfected ulcer, and treatment should involve pressure off-loading and local wound care.

b.       She likely has a mild diabetic foot infection and should be treated with a short course of oral antibiotic therapy targeting Streptococci spp. and Staph.

c.       She likely has a mild diabetic foot infection and should be treated with a short course of oral antibiotic therapy targeting Pseudomonas.

d.       Imaging should be performed to evaluate for possible osteomyelitis.

Explanation:

Luckily, Princess Leia’s ulcer does not have any classic findings of inflammation (purulence, warmth, pain, swelling, or erythema) so her wound is uninfected. She should be educated in regular wound care, and ideally, referred to a podiatrist for regular foot exams and debridement if needed. Taking care of diabetic foot infections properly involves a multidisciplinary approach, including surgical debridement, assessment of possible arterial insufficiency, glycemic control and routine follow-up. The correct answer here is A.

(Also, empiric therapy for Pseudomonas is generally not recommended for diabetic foot infections!)

Let’s discuss diabetic foot infections in a bit more detail…