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  #1  
Old 06-02-2012
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Question treating diabetic foot ulcer...

A 75-year-old man with type 2 diabetes mellitus is evaluated in the emergency department for a draining chronic ulcer on the left foot, erythema, and fever. Drainage initially began 3 weeks ago. Current medications include metformin and glyburide. On physical examination, he does not appear ill. Temperature is 37.9C (100.2F); other vital signs are normal. The left foot is slightly warm and erythematous. A plantar ulcer that is draining purulent material is present over the fourth metatarsal joint. A metal probe makes contact with bone. The remainder of the examination is normal.
The leukocyte count is normal, and an erythrocyte sedimentation rate is 70 mm/h. A plain radiograph of the foot is
normal. Gram stain of the purulent drainage at the ulcer base shows numerous leukocytes, gram-positive cocci in clusters, and gramnegative rods.

Which of the following is the most appropriate management now?

(A) Begin imipenem
(B) Begin vancomycin and ceftazidime
(C) Begin vancomycin and metronidazole
(D) Perform bone biopsy
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Old 06-02-2012
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Quote:
Originally Posted by tyagee View Post
A 75-year-old man with type 2 diabetes mellitus is evaluated in the emergency department for a draining chronic ulcer on the left foot, erythema, and fever. Drainage initially began 3 weeks ago. Current medications include metformin and glyburide. On physical examination, he does not appear ill. Temperature is 37.9C (100.2F); other vital signs are normal. The left foot is slightly warm and erythematous. A plantar ulcer that is draining purulent material is present over the fourth metatarsal joint. A metal probe makes contact with bone. The remainder of the examination is normal.
The leukocyte count is normal, and an erythrocyte sedimentation rate is 70 mm/h. A plain radiograph of the foot is
normal.
Gram stain of the purulent drainage at the ulcer base shows numerous leukocytes, gram-positive cocci in clusters, and gramnegative rods.

Which of the following is the most appropriate management now?

(A) Begin imipenem
(B) Begin vancomycin and ceftazidime
(C) Begin vancomycin and metronidazole
(D) Perform bone biopsy
cuz the Rx though include Abx but its primarily dependent on debridement (right), though X-ray is nl, but i dont know if that's enough to rule out bone infection (not very sensitive i think)
the rule is Pt who have associated cellulitis, osteomyelitis, or abscess formation need to be started on IV antibiotics after obtaining cultures from deep ulcer & bone biopsy in addition to surgical debridement, Abx need to cover both Anaerobes & Gram negative.
Antibiotics alone do not cure diabetic ulcers.
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Old 06-02-2012
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(A) Begin imipenem
(B) Begin vancomycin and ceftazidime
(C) Begin vancomycin and metronidazole
(D) Perform bone biopsy
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Old 06-02-2012
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I agree with B)

I think best screen test for osteomyelitis is xray, and in this case was normal so we can rule out involvement of bone.. so better to start abx.
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Quote:
Originally Posted by tyagee View Post
A 75-year-old man with type 2 diabetes mellitus is evaluated in the emergency department for a draining chronic ulcer on the left foot, erythema, and fever. Drainage initially began 3 weeks ago. Current medications include metformin and glyburide. On physical examination, he does not appear ill. Temperature is 37.9C (100.2F); other vital signs are normal. The left foot is slightly warm and erythematous. A plantar ulcer that is draining purulent material is present over the fourth metatarsal joint. A metal probe makes contact with bone. The remainder of the examination is normal.
The leukocyte count is normal, and an erythrocyte sedimentation rate is 70 mm/h. A plain radiograph of the foot is
normal. Gram stain of the purulent drainage at the ulcer base shows numerous leukocytes, gram-positive cocci in clusters, and gramnegative rods.

Which of the following is the most appropriate management now?

(A) Begin imipenem
(B) Begin vancomycin and ceftazidime
(C) Begin vancomycin and metronidazole
(D) Perform bone biopsy
I think B.......on the basis of result of gm stain....???
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Quote:
Originally Posted by bisho View Post
cuz the Rx though include Abx but its primarily dependent on debridement (right), though X-ray is nl, but i dont know if that's enough to rule out bone infection (not very sensitive i think)
the rule is Pt who have associated cellulitis, osteomyelitis, or abscess formation need to be started on IV antibiotics after obtaining cultures from deep ulcer & bone biopsy in addition to surgical debridement, Abx need to cover both Anaerobes & Gram negative.
Antibiotics alone do not cure diabetic ulcers.
ans is B.

Cultures obtained from a sinus tract or ulcer base often do not
reflect the bacterial etiology of an underlying osteomyelitis;

bone biopsy is indicated to identify the causative pathogens and
guide antibiotic therapy.


btw, even if antibiotic cover was given,,, vanco and ceftazidime was inadequate...where worry is MRSA,Pseudomonas and ANEROBES

Quote:
vancomycin and ceftazidime will not adequately
cover anaerobic bacteria

@ bisho
i dont think for cellulitis and abscess formation we cant treat emperically and we need culture report. are you sure ? source ?
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Quote:
Originally Posted by tyagee View Post
ans is B.

Cultures obtained from a sinus tract or ulcer base often do not
reflect the bacterial etiology of an underlying osteomyelitis;

bone biopsy is indicated to identify the causative pathogens and
guide antibiotic therapy.


btw, even if antibiotic cover was given,,, vanco and ceftazidime was inadequate...where worry is MRSA,Pseudomonas and ANEROBES




@ bisho
i dont think for cellulitis and abscess formation we cant treat emperically and we need culture report. are you sure ? source ?
Treatment of diabetic foot ulcer (Uptodate)
-Adequate debridement, proper local wound care, and control of infection (when present).
-culture of material obtained from deep in the ulcer and bone biopsy, is often helpful in choosing antibiotic therapy
-The diagnosis is clear if osteomyelitis is visible on plain radiographs. However, radiologic changes occur late in the course of osteomyelitis and negative radiographs do not exclude it. Other imaging techniques that may be useful in selective cases include radionuclide bone imaging, magnetic resonance imaging and imaging with indium-labeled leukocytes.
-Cultures of the ulcer base are taken after debridement and prior to initiation of empiric antibiotic therapy. Abx treatment depend on Culture
-empiric abx: (activity against streptococci, MRSA, aerobic gram negative bacilli and anaerobes)
Trimethoprim-sulfamethoxazole PLUS Amoxicillin-clavulanate, Clindamycin PLUS Ciprofloxacin or levofloxacin or moxifloxacin

so if u wanna pick an answer from this informatiion u will be confused what to choose
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Quote:
Originally Posted by tyagee View Post
ans is B.

Cultures obtained from a sinus tract or ulcer base often do not
reflect the bacterial etiology of an underlying osteomyelitis;

bone biopsy is indicated to identify the causative pathogens and
guide antibiotic therapy.


btw, even if antibiotic cover was given,,, vanco and ceftazidime was inadequate...where worry is MRSA,Pseudomonas and ANEROBES
Did you mean that answer is D ?

According to MTB 3 Page 7:

X-ray is the best initial test for osteomyelitis. However, it is only positive when there is more than 50% calcium loss and takes two weeks to become positive.
Bone biopsy (and culture) is the most accurate test and is required to identify/confirm the organism(s) for specific therapy.
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Quote:
Originally Posted by bisho View Post
Treatment of diabetic foot ulcer (Uptodate)
-Adequate debridement, proper local wound care, and control of infection (when present).
-culture of material obtained from deep in the ulcer and bone biopsy, is often helpful in choosing antibiotic therapy
-The diagnosis is clear if osteomyelitis is visible on plain radiographs. However, radiologic changes occur late in the course of osteomyelitis and negative radiographs do not exclude it. Other imaging techniques that may be useful in selective cases include radionuclide bone imaging, magnetic resonance imaging and imaging with indium-labeled leukocytes.
-Cultures of the ulcer base are taken after debridement and prior to initiation of empiric antibiotic therapy. Abx treatment depend on Culture
-empiric abx: (activity against streptococci, MRSA, aerobic gram negative bacilli and anaerobes)
Trimethoprim-sulfamethoxazole PLUS Amoxicillin-clavulanate, Clindamycin PLUS Ciprofloxacin or levofloxacin or moxifloxacin

so if u wanna pick an answer from this informatiion u will be confused what to choose
That's the reason why you should go with MTB.
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