Diabetic foot ulcer and poor compliance: How would you treat?
TABLE 4
Clinical classification of diabetic foot infections
| CLINICAL APPEARANCE | CLASSIFICATION |
|---|---|
| Wound lacking purulence or any manifestations of inflammation | Uninfected |
| Presence of 2 or more manifestations of inflammation (purulence, erythema, pain, tenderness, warmth, or induration). Any cellulitis/erythema extends 2 or more cm around the ulcer, and infection is limited to the skin or superficial subcutaneous tissues. No other local complications or systemic illness. | Mild |
| Infection (as above) in a patient who is systematically well and metabolically stable but which has 1 or more of the following characteristics: cellulites extending >2 cm, lymphagitic streaking, spread beneath the superficial fascia, deep-tissue abcess, gangrene, and involvement of muscle, tender, joint or bone | Moderate |
| Infection in a patient with systemic toxicity or metabolic instability (eg, fever, chills, tachycardia, hypotension, confusion, vomiting, leukocytosis, acidosis, severe hyperglycemia, or azotemia) | Severe |
| Source: Lipsky et al, 2004.2 | |
Case resolution
The family physician and M.N. discuss the options. The specialist recommends surgery, but the patient does not want to undergo this procedure. As his physician explains his concerns about the chronic, nonhealing ulcer and osteomyelitis, M.N. says he will negotiate a change in his work situation that would allow him to decrease the time spent on his feet and thus improve healing.
The patient has small clinical improvement of his ulcer while hospitalized, and a peripherally inserted central catheter (PICC) line is placed to administer long-term antibiotics on an outpatient basis. The ulcer heals gradually in coming weeks and months. Laboratory results show improvement as well, with normalization of the ESR and CRP. Given the clinical improvement and a steady decrease in inflammatory markers, a bone scan is not repeated. The patient now has a job that allows him to sit instead of being on his feet all day.
