Non-surgical, out-patient management of osteomyelitis of the foot in diabetes.
Sanjeev Mehta1 Gaytree Todd2 Guduru Gopal Rao3 Anthony Chambers4 Tina Beaconsfield4 David Greenstein5 Daniel Darko1 Wing May Kong1
Departments of 1Diabetes & Endocrinology, 2Podiatry, 3Microbiology, 4Radiology and 5Vascular Surgery, Central Middlesex Hospital, North West London Hospitals NHS Trust, London, UK.
Background Bone infection (osteomyelitis) is a common complication of foot ulceration in patients with diabetes and presents a considerable therapeutic challenge. If the infection is not managed appropriately amputation may be required. To avoid this, a targeted multidisciplinary team approach is essential.
Case A 79 year old gentleman with Type 2 diabetes, hypertension, renal impairment and established peripheral vascular disease (with a previous left sided femoral popliteal bypass graft) was referred to the foot clinic with a long-standing ulcer on his left great toe. On examination the ulcer was sloughy, malodourous and probed to bone, suggesting underlying osteomyelitis. His forefoot was erythematous, swollen and warm, indicating cellulitis. A bone sample was taken for culture and grew coliforms. He was admitted for intravenous antibiotics and bed rest. Plain x-ray showed evidence of bony destruction in the distal phalanx of his left great toe and istope bone scan confirmed osteomyelitis. He was reviewed by the vascular surgeons. Hand held dopplers showed a strong biphasic signal in the posterior tibial artery and a moderate biphasic signal in the dorsalis pedis artery. A duplex scan of his lower limbs showed good flow throughout the left leg. On discharge from hospital his antibiotics were changed to intramuscular ceftriaxome (administered in his home by the Community Care Team) and oral metronidazole. In view of his established peripheral vascular disease he was commenced on a statin, and a thiazide diuretic was commenced for his hypertension. He initially responded well, but when his ulcer became static culture of a bony sequestrum was repeated twice and on both occasions grew pseudomonas which was sensitive to ceftazidime but resistant to ciprofloxacin. Microbiology advice was sought, and it was suggested that he received a prolonged course of intravenous ceftazidime for his pseudomonas osteomyelitis. He required 3 months of intravenous ceftazidime, administered in his home by the Community Care Team via a PICC line (peripherally inserted central catheter), with fortnightly review in the multidisciplinary foot clinic He tolerated this well, his ulcer healed, and a 12 week interval isotope bone scan was entirely normal indicating resolution of the osteomyelitis.
Conclusion Osteomyelitis complicating foot ulceration in patients with diabetes can be successfully treated without need for amputation. Patients should be managed by a multidisciplinary foot care team and attention paid to eradication of infection, treatment of vascular insufficiency and adequate off-loading, while optimising glycaemic control and addressing co-morbiditities. Prolonged courses of parenteral antibiotics may be necessary but can be successfully administered in the community.