How to manage a 59-year-old female with a history of complex pyoderma gangrenosum (PG) infection, polysubstance use disorder on methadone (opioid analgesic), presenting with worsening pain, erythema, and drainage from a chronic ulcer on the left lower extremity (LLE) with underlying osteomyelitis and myonecrosis?

From the Guidelines

The patient should be admitted for inpatient management with IV antibiotics targeting Pseudomonas, such as piperacillin-tazobactam 4.5g IV q6h or cefepime 2g IV q8h, based on previous culture results, pending new cultures. Management of this complex case of pyoderma gangrenosum with underlying osteomyelitis and myonecrosis requires a multidisciplinary approach, considering the patient's history of polysubstance use disorder and methadone maintenance 1. The patient's worsening symptoms, including pain, redness, drainage, and new black tissue in the wound, suggest a need for urgent reassessment and adjustment of the treatment plan.

Current Situation

The patient has a history of complex pyoderma gangrenosum infection, polysubstance use disorder, and a chronic, nonhealing ulcer on the left lower extremity (LLE) with underlying osteomyelitis and myonecrosis. The patient has been seen by orthopedic and infectious disease specialists, who have recommended below-knee amputation (BKA), but the patient has refused this option in the past.

Treatment Approach

The treatment approach should prioritize controlling the infection, managing the patient's pain, and addressing the underlying pyoderma gangrenosum inflammation. This can be achieved through:

• IV antibiotics targeting Pseudomonas, based on previous culture results, pending new cultures 1
• Wound care, including gentle cleansing, application of topical corticosteroids (clobetasol 0.05% ointment) to wound edges, and non-adherent dressings
• Systemic immunosuppression with prednisone (40-60mg daily) and cyclosporine (3-5mg/kg/day in divided doses) to control the pyoderma gangrenosum inflammation
• Pain management with appropriate analgesics, while continuing methadone maintenance

Multidisciplinary Approach

The patient needs urgent reassessment by dermatology, infectious disease, and orthopedic surgery specialists to discuss the worsening condition, risks of sepsis, and limited alternatives. While respecting the patient's previous refusal of BKA, a frank discussion about the potential need for surgery is necessary. If the patient continues to decline surgery, palliative approaches focusing on symptom management and infection control should be implemented.

Monitoring and Follow-up

Close monitoring for signs of systemic infection is essential, as the new wound characteristics (black tissue, changed smell) suggest worsening necrosis that could lead to sepsis. The patient should be closely followed up by the multidisciplinary team to adjust the treatment plan as needed and to address any concerns or changes in the patient's condition.

From the Research

Patient Management

• The patient has a history of complex pyoderma gangrenosum infection, polysubstance use disorder, and a chronic, nonhealing ulcer on the left lower extremity (LLE) with osteomyelitis and myonecrosis 2, 3.
• The patient has been treated with various antibiotics, including vancomycin, and has developed pseudomonas infection, which is a common nosocomial pathogen 3.
• The patient's current symptoms include worsening pain, itchiness, erythema, and drainage from the wound edges, with new skin growth and black coloration in the wound 4, 5.
• The patient has appointments with ortho and dermatology next week, and an MRI shows underlying osteomyelitis and myonecrosis, making debridement complicated 6.

Antibiotic Treatment

• The combination of vancomycin and piperacillin/tazobactam has been associated with an increased risk of acute kidney injury (AKI) 2, 6.
• Cefepime is a potential alternative to piperacillin/tazobactam, with a lower risk of AKI 3, 6.
• The patient's pseudomonas infection may require treatment with novel fluoroquinolones or combinations of β-lactams/β-lactamase inhibitors 3.

History Taking and Clinical Examination

• Taking a comprehensive patient history is fundamental for accurate diagnosis and effective management of health conditions 4, 5.
• The patient's history of polysubstance use disorder and chronic ulceration should be considered when developing a treatment plan 4, 5.
• A thorough clinical examination, including assessment of the wound and surrounding tissue, is essential for guiding treatment decisions 4, 5.

Treatment Considerations

• The patient's refusal of below-knee amputation (BKA) should be respected, and alternative treatment options should be explored 6.
• The patient's worsening symptoms and new skin growth may indicate a need for adjusted wound care and antibiotic treatment 4, 5.
• The patient's appointments with ortho and dermatology should be used to discuss treatment options and develop a comprehensive plan for managing the patient's condition 6.