Diabetic foot ulcer

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Patient is an 83-year-old female with past medical history of hypertension, diabetes, hyperlipidemia, neuropathy, and CVA. Patient developed bilateral foot cellulitis due to diabetic ulcers 2 years ago. Patient underwent an MRI and osteomyelitis was ruled out. The wound was MRSA positive. Patient was placed on IV antibiotics 3 months ago. Recent culture, done one week ago, showed K. pneumoniae infection. Patient placed on Levaquin 750 mg times seven days.
Patient has had stem cell treatment and cadaver grafts placed all of which have failed. Current treatment includes Levaquin, 750 mg times seven days and ultra misting. Xeroform on the left plantar wound, as well as frequent debridement. Treatment for the right heel consist of offloading, silver, alginate, dressing, and foam heal padding. Treatment for the right plantar consist of light debridement, silver, alginate, and foam dressing. Patient is under consideration for allograft for the right planter foot.

Jan 11, 2023 by Brenda Baker ,

1 replies

Elaine Horibe Song
MD, PhD, MBA

Hi Brenda

Thanks for sharing this case. Scott Robinson MD, Kye Evans DO FACEP, and I talked about it and here are some thoughts:

Healable DFUs that fail to reach a 50% decrease in size after 4 weeks of treatment with standard therapy should be reassessed. Re-evaluation of the patient and ulcer should be performed and underlying etiologies or factors impeding healing should be addressed before use of adjuvant therapies. Re-evaluation should include assessment of adequate offloading, any ongoing soft tissue infection or osteomyelitis, need for debridement, excessive exudate, impaired extremity vascular flow, uncontrolled glycemia and malnourishment.
- For a checklist for reassessment of refractory DFUs, please see: https://woundreference.com/app/topic?id=diabetic-foot-ulcer&find=diabetic+foot#plan-reassessment
- For an algorithm for management of refractory DFUs, please see page 3 : https://woundreference.com/files/1622.pdf

Some other thoughts:
- In regards to offloading the DFU on the heel while sleeping and while on a wheelchair, a Podus boot can be a cost-effective offloading device (https://woundreference.com/app/search?q=podus%20boot&searchType=product)
- One option to help prepare the wound bed prior to the use of cellular and/or tissue products is purified native collagen matrix with PHMB (e.g. Puraply)

And here are some links for further reading:
- Algorithm for DFU Assessment https://woundreference.com/files/1616.pdf
- 'Peripheral Artery Disease (PAD) in patients with DFU' : https://woundreference.com/app/topic?id=diabetic-foot-ulcer-introduction-and-assess#-peripheral-artery-disease-(pad)-in-patients-with-dfu
- 'Diabetic Foot Infection': https://woundreference.com/app/topic?id=diabetic-foot-ulcer-introduction-and-assess#diabetic-foot-infection

Jan 12, 2023

* Information provided without clinical evaluation and is not intended as a replacement for in-person consultation with a medical professional. The information provided through Curbside Consult is not a substitute for proper training, experience, and exercising of professional judgment. While every effort has been made to ensure the accuracy of the contents, neither the authors nor the Wound Reference, Inc. give any guarantee as to the accuracy of the information contained in them nor accept any liability, with respect to loss, damage, injury or expense arising from any such errors or omissions in the contents of the work.

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