This case involves a middle-aged patient with a past medical history of diabetes who presented to a podiatrist with an open callous on the bottom of her right foot. The doctor trimmed off the loose skin and noted signs of infection. The doctor put the patient on an antibiotic and recommended that she keep it covered with a band-aid or gauze. The patient continued to return to the podiatrist on a regular basis for treatment of the ulcer, during which time debridements were performed, dressings applied, and antibiotics prescribed. The patient presented to the podiatrist and reported the ulcer had gotten worse. There was no odor, but significant drainage, and her left foot and leg were warm and swollen. Nevertheless, the patient was not admitted to the hospital and was given a prescription for antibiotics. The patient eventually presented to ER because she didn’t feel well and her foot had swelled significantly. She was diagnosed with sepsis and her foot and part of her lower leg were amputated.
Question(s) For Expert Witness
- 1. Please elaborate on your experience in the management of foot infections such as the one described above.
Expert Witness Response E-070114
Foot infections in diabetics are common and I have seen dozens of them. The chronicity of this wound is a concern and its progression despite local wound care suggests that there is poor circulation. After several months of non-healing, a diabetic should be referred to a vascular specialist, be that person a cardiologist or surgeon. However, I think the real errors, in this case, is failure to recognize cellulitis that requires intravenous antibiotics, failure to obtain cultures of purulent drainage from the dorsal foot abscess, and failure to recognize osteomyelitis (drainage from a wound with exposed bone indicates osteomyelitis, and an x-ray is less sensitive than an MRI to make that diagnosis). Purulent drainage from an open wound may reveal cultures that are misleading, but they should be sent and an antibiotic regimen selected that at a minimum includes the bacteria isolated from the culture. I suspect that this patient had a cellulitis associated with the dorsal foot abscess and this required intravenous antibiotics in a patient with diabetes who is demonstrating poor wound healing and persistent foot infection.