Treating Foot Infection

Inpatient management: operative treatment of infection

L02.435/436 (abscess lower limb, right/left ), M65.171/172 (infection) or I70.261/262 (gangrene); procedure 28003 (incision and drainage) or 28820 (toe amputation).

Objectives:

1. Probe from the instigating ulcer or gangrenous area to identify abscess tracts:
2. Incision ± Penrose drain for all abscess tracts
3. Collect fluid, soft tissue or bone for microbiology in sterile container with sterile saline. Swab specimens are discouraged.
4. Removal of all obviously-necrotic tissue. Minimize resection of viable / marginal tissue
5. Pulsatile irrigation with saline solution.
6. Dress with gentamicin-impregnated 4x4 gauze in deep areas, Xeroform over shallow ulcer. Wrap with 4” inch Webril + 4” ACE from forefoot to knee to control edema.

Here is a brief (5 minute 3 second) video primer that discusses operative treatment:

Post-op orders: Continue most admission orders; saline lock IV; add diabetic diet + Glucerna BID, Iodosorb (cadexomer iodine) ointment; Do NOT order labs for POD#1

Microbiology

Because of our vascular team’s ownership of limb salvage, we have had a primarily surgical approach to the management of foot infections, including osteomyelitis. Specifically, 92% of our patients have had surgical biopsies and cultures taken as part of their operative treatment. These have been used to select an antimicrobial regimen directed to the organisms identified. Antimicrobial regimens have consisted predominately of oral antibiotics (95%) since 2011 . Finally, contrary to guidelines emphasizing the importance of Gram positive organisms, our analyses have shown that Gram negative organisms are associated treatment failure and that methicillin-resistant Staphylococcus aureus is not ; for this reason, we have focused more attention on improving outcomes in patients with these organisms. We re-biopsy if treatment failure occurs, as we have observed shifts in microbial species involved during treatment .

Goals before transitioning to outpatient management: “ABC DEF”

Letter	Item
A=	Antibiotic plan
B=	Blood flow testing
C=	Consultant follow-up (ECL wound care or Podiatry ± Infectious Disease)
D=	Discharge Destination: home, nursing facility, inpatient rehabilitation, other
E=	Equipment/supplies for advanced wound care
F=	Footwear (offloading boot) and Four point walker (both from prosthetics department)