Inappropriate Treatment of Infected Wound Leads to Amputation

This case involves a middle-aged female patient in Kansaswho suffered from morbid obesity as well as diabetes, who was being followed by a vascular surgeon for a wound on her hallux. The wound was initially managed as an outpatient with antibiotics, however, it continued to worsen and x-ray imaging showed signs of possible osteomyelitis. The plan was made for surgical debridement and treatment with broad-spectrum antibiotics. However, this plan was changed after the completion of the case and the patient was discharged home that day and instructed to continue with the same regimen of antibiotics. She returned to her surgeon’s office several days later complaining of worsening of the wound despite the previous surgical debridement. It was then noted that testing of the patient’s wound had revealed the presence of antibiotic resistant bacteria, however, her medication regimen was never adjusted. She was eventually admitted to the hospital, where she underwent an amputation of her foot.

Question(s) For Expert Witness

1. How frequently do you evaluate and treat patients with similar problems?

2. What would be an appropriate reason to forgo inpatient broad spectrum antibiotics in a patient with a history similar to this patient?

Expert Witness Response E-026099

I frequently evaluate patients with forefoot gangrene and toe infections. I treat patients similar to the one in this case approximately 2-5 times per month. An appropriate reason to forgo inpatient broad spectrum antibiotics would be if the operating surgeon felt that during the initial debridement and amputation all the infected tissue had been removed. Inpatient admission is not always required. When the cultures of the wound become known and there is the concern for residual infection the antibiotics should be modified immediately in order to more specifically target the offending bacterial organisms. This is not an uncommon scenario, especially in patients with diabetes mellitus and peripheral vascular disease. Multiple debridements may be required and limb loss may occur with aggressive infections.