Patient Develops Sepsis Due to Allegedly Negligent Treatment of Diabetic Ulcer

Case Overview

This case involves a middle-aged patient with a past medical history of diabetes who presented to a podiatrist with an open callous on the bottom of her right foot. The doctor trimmed off the loose skin and noted signs of infection. The doctor put the patient on an antibiotic and recommended that she keep it covered with a band-aid or gauze. The patient continued to return to the podiatrist on a regular basis for treatment of the ulcer, during which time debridements were performed, dressings applied, and antibiotics prescribed. The patient presented to the podiatrist and reported the ulcer had gotten worse. There was no odor, but significant drainage, and her left foot and leg were warm and swollen. Nevertheless, the patient was not admitted to the hospital and was given a prescription for antibiotics. The patient eventually presented to ER because she didn’t feel well and her foot had swelled significantly. She was diagnosed with sepsis and her foot and part of her lower leg were amputated.

Questions to the Infectious Disease and Communicable Disease expert and their responses

Please elaborate on your experience in the management of foot infections such as the one described above.

Foot infections in diabetics are common and I have seen dozens of them. The chronicity of this wound is a concern and its progression despite local wound care suggests that there is poor circulation. After several months of non-healing, a diabetic should be referred to a vascular specialist, be that person a cardiologist or surgeon. However, I think the real errors, in this case, is failure to recognize cellulitis that requires intravenous antibiotics, failure to obtain cultures of purulent drainage from the dorsal foot abscess, and failure to recognize osteomyelitis (drainage from a wound with exposed bone indicates osteomyelitis, and an x-ray is less sensitive than an MRI to make that diagnosis). Purulent drainage from an open wound may reveal cultures that are misleading, but they should be sent and an antibiotic regimen selected that at a minimum includes the bacteria isolated from the culture. I suspect that this patient had a cellulitis associated with the dorsal foot abscess and this required intravenous antibiotics in a patient with diabetes who is demonstrating poor wound healing and persistent foot infection.

About the expert

This expert has over 30 years of experience in the field of infectious disease. He earned his BA from Dartmouth University and his MD from Dartmouth Medical School. After completing his internship at St. Joseph Hospital at the University of Texas and his residency at the University of Pennsylvania, he remained there to complete a prestigious fellowship in infectious diseases. Today, this expert is board certified in internal medicine and infectious disease and is active in his field as a member of the American Society of Microbiology and the Infectious Disease Society of America. In addition, he has published over 120 peer-reviewed journal articles and 20 book chapters related to his field. Previously, he held multiple positions at the University of Pennsylvania, including an associate professor of medicine, the associate director of clinical care and therapeutics, and the director of the immunodeficiency program clinic and the outpatient infectious diseases program. Currently, he is an attending physician at a university-affiliated hospital, the director of the clinical and therapeutics program for an AIDS research center, a professor of medicine, and the director of the HIV Vaccine Trials Unit at an Ivy League medical school in Pennsylvania.

E-070114

Specialties:

Infectious Disease and Communicable Disease