OM and ABX

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DogSnoot

DogSnoot

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2+ Year Member
What’s your preference ? What does you hospital use? How long ? At what point do you amputate ?

Any related articles are greatly appreciated.
Here’s the IDSA guidelines. (Please keep in mind article from 2012 because that the only “free” article I could publish)


academic.oup.com

2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infectionsa

Abstract. Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a ne
academic.oup.com academic.oup.com

I will include any free resources I can find moving forward. Trying to figure out what is real world and what is textbook.
 
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If there is confirmed OM in the digits, amputate is my #1 recommendation. Stitches out in 2-3 weeks and you are back to normal. Versus 6 weeks of IV antibiotics that may not even help, just to save the 4th toe you don't need

We had great relationship with ID in residency. We had frequent meetings about protocols and such. According to the head ID doc, OM is a surgical problem and should be treated as such. Antibiotics can help with suppression, but resection should be the #1 goal
 
Foot osteo does not heal. Amp it (and the joint adjacent to it) early and often.
Distal phalanx osteo = amp at mid-prox phalanx.
Sesamoid osteo = first ray resect or TMA as appropriate
Met head osteo = ray resect or TMA as appropriate.
Tarsal osteo = BKA
Etc.
Do that asap, before it spreads to next joint/bone, causes gas, or the cellulitis damages the skin you need for closure. Get source control. 🙂

The key to amputations is them being functional. They are not to have more wounds/amp in a year. Nonsense.
Learn early that Lisfranc, Chopart, ankle Symes, etc don't work... leave that nonsense to "teaching centers" wasting ppl's time. Those contract, fail quickly, and are hard to make filler/AFO for. Skip them. Once you lose the tib anterior or pero brevis inserts, the foot is done... it's not balanced. The tendon transfers into bones or fusions adjacent to the osteo bones are for inept podiatry surgeons who don't have enough work or just want to cut. So, yeah, basically, many podiatrists dink around and dink around and do topical stuff and wound care or nibble amps or multiple debrides just to keep the cash register on. It's sad. You'll see it at meetings, on clerkships, probably in residency or in practice. That failure to get source control and amp in timely fashion will literally kill some ppl from the cardio and pulm and obesity problems from being in chair/boot... or the osteo will eventually flare to gas or sepsis. Do what's right for the pt instead.

...Do all of the IV and PO abx you like... you're just protecting the proximal tissues and bloodstream (for awhile). That should only be done for short amounts of time to let ppl come to grips with amp, to medically optimize or revasc the pt, or to try to stabilize/improve the cellulitic flap you need for TMA or whatever. The medical abx tx for osteomyelitis does not work in the foot (or most other areas). Any decent ID will tell you to get source control... then mop up with a week or two of abx, get them to filler+shoe store and on with their life.

If pt is not a surgical candidate (frail, PAD, etc), they can do lifelong abx (under med doc, not you).
If they are a surgical candidate, discharge them from your practice in short order if they refuse amp after MRI or bone biopsy confirms osteomyelitis dx. Don't ever give them the illusion it's fine with abx just because the wound "heals" or the swelling subsides. There will, unfortunately, be plenty of TFPs around you who will put a frame or wound graft or abx pellets on their calc osteomyelitis or osteomyelitis cunieforms Charcot and tell them everything will be fine. Happy day... makes ya proud to be a podiatrist sometimes. 🙁
 
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Agree with surgery. If osteo comes into my clinic I’ll talk them into an amp, book them on my next OR day (preferably within a weeks time, 2 max) and have them on oral abx til then. No need to admit if stable. Unless it’s purulent I’ll almost always do the amps outpatient and close them then and there.

My go to is usually doxy almost always. I’ll take cultures and biopsy intraop and usually keep them on oral abx a couple weeks after surgery
 
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Adam Smasher said:
as a resident you should motivate the discussion by linking articles.
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Good advice, I appreciate it. I uploaded IDSA from 2012. I will include any free resources I can find moving forward. Trying to figure out what is real world and what is textbook.
 
DogSnoot said:
Good advice, I appreciate it. I uploaded IDSA from 2012. I will include any free resources I can find moving forward. Trying to figure out what is real world and what is textbook.
Click to expand...
Oh and sorry I didn't answer your question but I pretty much amputate always, ID/IM handle antibiotic planning. I try to be a resource and make recommendations on oral vs IV if I think I have clean margins but they'll ultimately do whatever they want. Write clear op reports and they will appreciate that they have some direction to take.

I think we all have anecdotal stories of patients who refuse amputation, do the 6 weeks of IV abx plus wound care, and heal up, however.
 
Some open source crap journals on the topic:

Meta-Analysis: Outcomes of Surgical and Medical Management of Diabetic Foot Osteomyelitis - PMC

The aim of this study was to evaluate clinical outcomes in the published literature on medical and surgical management of diabetic foot osteomyelitis (DFO). A PubMed and Google Scholar search of articles relating to DFO was performed over the dates ...
www.ncbi.nlm.nih.gov www.ncbi.nlm.nih.gov

Consensus statements on the surgical management of diabetic foot osteomyelitis - DiabetesontheNet

Foot ulcers occur in about 6% of people with diabetes in the US who are covered by Medicare insurance for older people (Margolis et al, 2011) and there is a
diabetesonthenet.com diabetesonthenet.com
 
Ive had good success with 6 weeks oral abx for distal phalanx osteo (esp adding rifampin QD or m-w-f). If it fails, partial toe amp.

Definitely prefer surgery though.
 
The wound healing center blasts my patients with abx before I swoop in to save the day. 😉

Just had a patient close an ulcer with abx - he has active cancer and oncology preferred to see him treated medically. We'll see how it does.
 
If acute antibiotics work well.

T2 changes only then ABX works great in my experience.

If there is dead/necrotic bone (T1 changes) then its surgical as ive never had good results with dead infected bone.

Confident to say i've cured quite a few acute osteomyelitis patients.

IV is still king but PO levaquin also works quite well if the sensitivities allow.
 
GreenHousePub said:
Really? I have never had them heal. Ever. All of them I sent for long term iv abx.
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They "heal" despite the underlying osteomyelitis... then open up... or drain... or blow up bad with abscess or gas.
It might be a few months, some times a year or more... but they crap out, sometimes in grand fashion.
They usually just come back with that bone worse and the next one(s) having osteo as well.

Ppl are only kidding themselves when they think they've healed MRI osteo wounds (or bone bx or probe to bone). It's usually the wound care "providers" who are non-op and like to think the HBO and unna boots cured the would... only to be a BKA a few months later. They always tell the pts, "aww, too bad, we had that all healed just a month ago." Mularkey.

I tell ppl foot osteomyelitis is like fire coals you can't put out. All it takes is a random wind (illness, off abx, time, etc) for it to blaze up again and do even more damage.

...Follow-up is the back-breaker for any osteomyelitis "healed" wound... or unstable amps like Chopart or multiple rays, etc. If you don't get true source control, it's screwed. That darn follow-up.
 
I have practiced the last 5 years without infection disease. Sure I may send them there eventually after surgery but bone infection is excisional surgery. Antibiotics are to clean up the soft tissues. ID consult ok city slicker.
 
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The International Working Group on the Diabetic Foot has the best UTD reference/guideline on DFI.

In general ...

Forefoot: soft tissue loss/infection/gangrene in the forefoot dictates the necessity for amputation more than the bone involvement. In toes, abx alone have shown to be effective.

Foot and ankle: Combination surgery and medical treatment

Which abx: Always culture directed

Length of therapy: if resected with clean margins, just treat for soft tissue 5-7 days. If residual OM, no evidence on length of therapy, but the usual practice/recommendation is 6-8 weeks.
 
It is best to review the evidence yourself instead of asking an online forum. There is a lot of misinformation here.
 
air bud said:
You cut bone infection out. Antibiotics are for the soft tissue. End of story.
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Now sir, how are they gonna have enough ring frames and Chopart subtalar fusions and tendon transfer cases and TTC nails through infected calc osteo for the crummy residencies to get their RRA numbers by doing your simple "cut bone infection out" method?

It doesn't matter if it gets BKA by the end of the year... gotta get those numberzzz!
 
diabeticfootdr said:
@DogSnoot

Sorry for the rude responses above to a legitimate question.

Lesson here is:

Don't ask any questions unless it deals with RVUs, making money, crying about not making enough money, oversaturation, ROI, why not to do a fellowship, etc ... SDN has a lot of experts for that.
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Just wanted to let you know that I reported your annoying post for violating TOS (deliberate thread derailing)

Sure will be a shame when your summer pus camp has unfilled seats as the student enrollment continues to dwindle in this massively over saturated profession.
 
I haven't read the new guidelines so I will this weekend. My problem with any sort of "how do you cure osteomyelitis question" is that in my practice the question is actually "how do you resolve the ulcer and resolve osteomyelitis". I'll be curious to see how the guidelines approach this distinction.
 
diabeticfootdr said:
The International Working Group on the Diabetic Foot has the best UTD reference/guideline on DFI.

In general ...

Forefoot: soft tissue loss/infection/gangrene in the forefoot dictates the necessity for amputation more than the bone involvement. In toes, abx alone have shown to be effective.

Foot and ankle: Combination surgery and medical treatment

Which abx: Always culture directed

Length of therapy: if resected with clean margins, just treat for soft tissue 5-7 days. If residual OM, no evidence on length of therapy, but the usual practice/recommendation is 6-8 weeks.
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This.

Always clean margins. Bone biopsy if necessary. Not to "bill"bill for it, but to guide treatment. Jamshiddi in clinic works great....
 
JustAPedicurist said:
A lot of times oral antibiotics are just as effective as IV depending on the bioavailability. But I bet you guys aren’t ready for that discussion
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Thanks for the info. I will put this in parenthesis next to the part that says consult ID in my note.
 
Pronation said:
Thanks for the info. I will put this in parenthesis next to the part that says consult ID in my note.
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Do you consult ID for onychomycosis? Interested to hear your thoughts. Also how likely is total toenail replacement failure in a patient with previous mycotic nail? Thank you
 
JustAPedicurist said:
Do you consult ID for onychomycosis? Interested to hear your thoughts. Also how likely is total toenail replacement failure in a patient with previous mycotic nail? Thank you
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I have tried to consult them for this as well but they refuse these consults. Even when I write the note as consult to INFECTious diseases for onychomycosis INFECTION.

The stakes are extremely high in total toenail replacement surgery.
 
JustAPedicurist said:
A lot of times oral antibiotics are just as effective as IV depending on the bioavailability. But I bet you guys aren’t ready for that discussion
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I thought most of the research has been suggesting this? I would say maybe 1 in 100 of my infection cases has needed IV abx over orals in practice. I don’t see train wrecks really though, mostly toe osteo
 
Pronation said:
I have tried to consult them for this as well but they refuse these consults. Even when I write the note as consult to INFECTious diseases for onychomycosis INFECTION.

The stakes are extremely high in total toenail replacement surgery.
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I respect your opinion and expert matter in this sub specialty within podiatric medicine and surgery. I am a little more old school.

I will perform a staged approach when planning these cases.

I first perform a matrixectomy, and send the nail to pathology right away to make sure the margin is clear. Then I usually allow the nail bed to epithelialize.

Once this is done, I perform a Keryflex procedure to help restore the nail. During the procedure, I will have the contralateral limb present for comparison to make sure the nail is the same height/width as the corresponding digit on the other foot. After this is completed, I will paint the Keryflex nail if requested by the patient, and only under special circumstances where I use an off-label technique. It's my personal touch to the procedure at hand.

I have not felt the need to consult infectious disease in all of my years of doing this. They are not the experts when it comes to Onychomycosis. My president would agree.

I am thinking of publishing this procedure. Maybe we can collaborate?

Thank you.
 
BubbaWub said:
I respect your opinion and expert matter in this sub specialty within podiatric medicine and surgery. I am a little more old school.

I will perform a staged approach when planning these cases.

I first perform a matrixectomy, and send the nail to pathology right away to make sure the margin is clear. Then I usually allow the nail bed to epithelialize.

Once this is done, I perform a Keryflex procedure to help restore the nail. During the procedure, I will have the contralateral limb present for comparison to make sure the nail is the same height/width as the corresponding digit on the other foot. After this is completed, I will paint the Keryflex nail if requested by the patient, and only under special circumstances where I use an off-label technique. It's my personal touch to the procedure at hand.

I have not felt the need to consult infectious disease in all of my years of doing this. They are not the experts when it comes to Onychomycosis. My president would agree.

I am thinking of publishing this procedure. Maybe we can collaborate?

Thank you.
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I will glady collaborate.

You’re welcome.
 
JustAPedicurist said:
A lot of times oral antibiotics are just as effective as IV depending on the bioavailability. But I bet you guys aren’t ready for that discussion
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Well every person I operate on these days has significant PVD.....so throw that in there and poof mind blown.
 
DYK343 said:
I really dislike beads. They have their place in my practice but they drain and drain and drain. They can be detrimental to wound closure. I rarely use them.
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DYK343 said:
I really dislike beads. They have their place in my practice but they drain and drain and drain. They can be detrimental to wound closure. I rarely use them.
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This is only true if you use those silly “absorbable” beads. Staged amp with PMMA beads, which are removed upon DPC work great.
 
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