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Clinical Case 047: Not so sweet feet

This week a classic Australian remote area case.  There is so much to discuss on this case!  But I have isolated a few key points to put under the microscope, and get your input / expertise.

47 yo. Aboriginal woman has returned to the ED complaining of painless purulent lesions on her left foot.  She was seen a week ago by the nice city locum who diagnosed cellulitis and commenced her on a week of oral flucloxacillin.  She has been taking this for 6 days, but it aint working!

Not so good.  She reports increasing ooze, and the occasional maggot escaping from her improvised dressing.

Here is the background info:

PMHx:  Diabetic (type 2 – is there any other kind?)

  • Hypertensive
  • Nephropathy with significant proteinuria, Cr 100 last visit
  • Retinopathy requiring laser last year
  • No documented ischemic heart disease, CVA or PVD

Meds:  metformin 2 g/day SR, Gliclazide 120 mg MR,  Quinapril 20 mg, aspirin 150 mg/d.  No Allergies

She is overweight with a BMI of 39.  Central adiposity.  Malodourous slough coming off the foot.  She has a good dorsalis pedis and posterior tibial pulse to feel

Obs: T = 38.4,  pulse = 98 SR, BP = 166/102,  RR 14, Sats 97% RA.  Her BSL is 29 mmol (~ 520 in USA)

This is bread and butter for the remote area docs, so i am going to ask 3 questions for you to ponder and comment upon…

Q1:  Antibiotics in this scenario – what are you going to use? Any particular pathogens to keep in mind?

Q2:  Imaging – what do you do?  Are plain films worthwhile?

Q3:  Management of her hyperglycemia (assume she is admitted) – what targets and what to use to achieve this?

….. OK, bonus question… #4 :  Maggots…. good, bad or indifferent?

Get your thinking caps on.  Especially you Dr Dorr – I am gonna quiz you on this this week!

Casey

 

Comments

  1. Nice one casey!

    diabetic foot infection

    1) AB’s Yes-> we would be treating ?staph/strep/bacteroides/pseudomonas is the slough is green/ enteric nasties as well

    -> so based on the fact there isn’t significant inflammation but a bit of a smell, i’d start with Augmentin or ciprofloxacin + clindamycin
    -> bony involvement on X-ray? then i’d start IV stuff like cephazolin 2gm TDS then direct therapy if we got a culture back

    2) X-ray: YES -> poorly controlled diabetic with a smelly foot infection, I would strongly suspect osteomyelitis

    3) I would try to keep anything less than 10mmol/L and would consider your Basal Bolus Insulin regime.

    4) in a quick Pubmed search I uncovered some suprising results!
    -> Medical maggot therapy can successfully debride wounds and help to eradicate bacterial infections

    There you go!

  2. 1. Abs:
    Tazocin IV for your average multi-organism diabetic foot. Pseudomonas can be the tricky one to clear as well as MRSA plus almost anything else!
    2. Imaging:
    My “rule of thumb is:” If you can probe to bone, assume osteomyelitis!
    Plain films are pretty rubbish to rule osteomyelitis out, but can rule it in. My guess is there isn’t a heap of access to MR or bone scans up in Broome!
    So: I’d go on clinical likelihood, plus do an XR (but ignore the XR and treat as osteomyelitis if XR shows no signs of osteomyelitis).
    Even in tertiary centres my experience is: I think clinically it is osteo. Gets admitted, cultured, commenced on IV Taz. ID get involved. pt gets XR which is negative. Gets equivocal CT. Gets a bone scan which may or may not show a hot spot. Gets an MR which confirms osteomyelitis. All the tertiary approach adds is time and money. End result -- it is, as we thought, osteomyelitis!
    3. From the hyperglycaemia point of view, it is tricky! Ideally it’d be great to get her in and use your basal bolus insulin regime (which I love) to get her sugars down to a realistic 6-10 as her sepsis settles.
    4. Maggots -- yummmm! Dunno if I’d be letting any old fly lay its eggs in there, but medical maggotry may be of benefit in terms of time to “clean” wound, but probably no overall healing benefit. It may save you having to debride it yourself. Sounds like this lady has already declared that she can tolerate it, which can be the main stumbling block! Ref. http://www.reuters.com/article/2011/12/19/us-maggots-wounds-idUSTRE7BI24B20111219?feedType=RSS&feedName=healthNews&utm_source=twitterfeed&utm_medium=twitter&utm_campaign=Feed%3A+reuters%2FhealthNews+%28News+%2F+US+%2F+Health+News%29
    http://www.reuters.com/article/2011/09/23/us-diabetes-wounds-idUSTRE78M6SD20110923?feedType=RSS&feedName=healthNews&utm_source=feedburner&utm_medium=feed&utm_campaign=Feed:+reuters/healthNews+(News+/+US+/+Health+News)&utm_content=Google+Reader

    • Casey Parker says:

      Ah DR Brannigan -- always probing into the underneath of things (check out the blog http://dreapadoir.wordpress.com/ )

      Nice clinical pearls -- the bug I was hoping would get a mention is Burkholderia pseudomallei -- not much of that in Hobart I caution to guess!

      I think in Broome we opt for surgical eploration once the Xray is normal -- probably as good as a series of irradiating events which reach no firm conclusion -- with the added benefit of a cure being possible!

      I will have to post on maggot-related war stories some time -- always gets a chat started!

      Anybody doing Basal bolus in Tassie?
      Casey

  3. Wondered about melioidosis having spent some time up in QLD, and I guess it would definitely change your ABs a bit! It would be in my answer in the ED fellowship exam! Like you say though, very different managing this issue here vs. there! So, do you stick with tazocin for this case, or do you use timentin or a carbapenem?

  4. Hi mate
    We tend to throw a bit of mero at em of we reckon they fit the bill for melioidosis
    Diabetic, wet season, spent some time in contact with the dirt , alcohol -- so pretty much most customers!!
    C

  5. Just checked out the epidemiological piece on the melioidosis spike in Darwin associated with the wetter than wet 2009-10 season. (MJA VOL 196 no.5 19 March 2012) Interesting stuff! Also just read Adelaide article on basal bolus insulin in MJA VOL 196 no.4 5 March 2012 which says basal bolus probably superior to sliding scale.

  6. BB the way to go
    But then again, I am close to Adelaide
    Great blog Dr Brannigan -- how’s Hobart?
    That Edi Albert chap still running around in ED?

  7. working in darwin now, everything looks like melioid, so throw some mero at them (but there are other agents for melioid- bactrim, ceftazidime, even ceftriazone can work if they are not too sick)
    just a thought though for the nice locum doctor: QID fluclox not so good for compliance!
    There is also a lot of community acquired MRSA round our neck of the woods…
    as for the maggots…sterile maggots good, but i bet these particular maggots have seen things that clean, urban, hospital maggots would be shocked by!

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