Case Presentation: Diabetic Foot Infection and Failed Oral Antibiotics

In this video, Robert J. Klein, DPM, FACFAS, CWS, discusses a case that involves a 51-year-old male with a diabetic foot infection (dog bite) and failed outpatient therapy with oral antibiotics. The patient was then admitted IVABx and for OR debridement and NPWT. Watch the video to learn more about the patient's outcome.

Transcript:

Hello, I'm Robert Klein. I serve as the division chair for Prisma Health Upstate, located in Greenville, South Carolina. We're the largest not-for-profit healthcare center in South Carolina.

I also serve as the medical director for the Vascular Health Alliance and Wound Healing Center in Greenville, South Carolina. I'm a clinical assistant professor of surgery at the University of South Carolina School of Medicine in Greenville, South Carolina.

We're going to be talking today about an interesting case presentation that was ultimately closed with negative pressure wound therapy and a split-thickness skin graft.

This is a 51-year-old Hispanic male who, according to the patient's history, was possibly bitten by a dog and developed an infection, and failed outpatient therapy. He was placed on Bactrim and Augmentin, failed oral antibiotics and was seen in the clinic in a follow-up visit, and still had an extensive infection.

It looks much worse, as you'll see in the upcoming slides, than what we saw in the office. Ultimately, he was admitted to the hospital for IV antibiotics and was taken to the OR for debridement. His past medical history was significant for diabetes mellitus and pancreatitis.

These are the photos that were taken intraoperatively. In the photo on the left, you can see the patient had an extensive soft tissue infection and necrotizing type of infection. This culture is ultimately Group B with Strep. He underwent an excess debridement, losing most of the skin on the dorsal aspect of his foot.

He has exposed deeper structures, including muscle and tendon, and bone. He wound up requiring a fifth re-amputation, as you can see on the photo on the left. This is the patient a few days later in the hospital, still receiving local wound care and antibiotics.

The patient was ultimately discharged with a wound VAC. We placed adapted gauze over the exposed deeper structures, muscle, and tendon and then used negative pressure wound therapy.

You can see on the photo on the left; we're starting to get very nice, robust, healthy granulation tissue covering most of the muscle and most of the extensor tendons. Post-op six weeks, on the photo on the right, you can see that the patient has developed very healthy, robust granulation tissue.

This is a wound that we need to think about; what can we do to get this to close? The patient was interested in getting this wound as closed as quickly as possible. I had suggested a split-thickness skin graft. In most instances, the patient could be basically one and done with a split-thickness skin graft. That's ultimately what we chose to do for this patient.

The photo on the left is an intraoperative photo. One of our vascular surgeons, a colleague that I work with at Prisma Health, harvest this split-thickness skin graft for me. You can see the split-thickness skin graft applied onto the patient's right foot intraoperatively.

The photo on the right is a wound VAC placed intraoperatively. The patient was admitted to the hospital for five days. We kept the VAC on for five days to allow that split-thickness skin graft to help heal the wound. This is the patient five days after application of a split-thickness skin graft.

The photo on the left is a VAC that you saw interactively. The photo on the right is the VAC taken down. You can see that the patient has nearly 100 percent take of his split-thickness skin graft. Post-op care at this point was applying adapted gauze and just a gauze dressing over the split-thickness skin graft.

This is the patient 14 weeks from their original surgery. The patient had a limb-threatening infection. He had a necrotizing infection. He lost most of the skin on the dorsal aspect of his right foot.

Through negative pressure wound therapy, a wound VAC in combination with a split-thickness skin graft and negative pressure wound therapy again were able to salvage his foot and get his wound closed roughly 14 weeks from the original surgery. The patient now is in a diabetic shoe and an insole and back at work and has closed this chapter out in his life.

Thank you for listening to my presentation regarding this interesting case for a necrotizing soft-tissue infection requiring negative pressure wound therapy, split-thickness skin grafting, followed by negative pressure wound therapy to take the patient onto closure.