What is the best course of action for a 63-year-old male patient with a non-healing wound on his right second toe and recent heavy growth of Staphylococcus aureus?

From the Guidelines

I strongly recommend continuing wound care with weekly debridement for this 63-year-old male patient with a chronic non-healing wound on his right second toe, as this approach is crucial for promoting healing and preventing further complications, as suggested by the Infectious Diseases Society of America guidelines 1. The wound has been present for over two years, with inconsistent treatment compliance, which highlights the need for consistent and specialized care. Given the previous heavy growth of Staphylococcus aureus, repeating the wound culture is appropriate to guide antibiotic therapy, as recommended by the guidelines for the treatment of diabetic foot infections 1. The planned CMP and right foot X-ray are necessary to evaluate for osteomyelitis, which is a concern in chronic wounds, especially since the last X-ray was in January 2024. The podiatry consultation is essential for specialized foot care management, as emphasized by the 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections 1. Strict offloading remains crucial for healing, so reinforcing the importance of wearing the prescribed medical shoes at all times when weight-bearing is vital, as highlighted by the guidelines for off-loading pressure 1. The patient's history of refusing care and then restarting treatment suggests the need for clear education about the risks of untreated chronic wounds, including infection progression, tissue necrosis, and potential amputation. The Marathon Liquid Skin Protectant should be continued as previously ordered to protect the wound edges. Regular documentation of wound measurements and appearance will help track healing progress. Patient education should emphasize the importance of consistent care, proper footwear, and regular follow-up to prevent further complications of this chronic wound. It is also essential to consider the patient's overall health and potential comorbidities, such as diabetes, and to manage these conditions accordingly to promote wound healing and prevent further complications, as suggested by the guidelines for the treatment of diabetic foot infections 1.

From the FDA Drug Label

Cephalexin is indicated for the treatment of the following infections when caused by susceptible strains of the designated microorganisms: ... Skin and skin structure infections caused by Staphylococcus aureus and/or Streptococcus pyogenes Note—Culture and susceptibility tests should be initiated prior to and during therapy. The patient has a heavy growth of Staphylococcus aureus in the wound culture, and cephalexin is indicated for the treatment of skin and skin structure infections caused by Staphylococcus aureus.

• The patient should continue with the prescribed systemic antibiotics.
• It is essential to monitor the patient's response to the treatment and adjust the therapy as needed based on the results of the culture and susceptibility tests 2.

From the Research

Patient Background

• The patient is a 63-year-old male with a non-healing wound on his right second toe, which he had been taking care of himself for two years before seeking medical attention.
• The patient started wound care on March 1,2024, and had an X-ray in January 2024 that showed no signs of osteomyelitis.
• The patient's wound care orders were changed in March 2024 to include spray wound and skin cleanser, cleaning, and patting dry, as well as applying Marathon Liquid Skin Protectant and ensuring strict offloading for healing.

Current Treatment and Diagnosis

• The patient refused wound care on May 19,2025, stating that he would be receiving medical shoes soon, but later requested wound care again in September 2024.
• The patient has been receiving wound care with weekly debridement since September 2024.
• A wound culture was taken last month, which showed heavy growth of Staphylococcus aureus, and the patient was treated with systemic antibiotics 3, 4, 5.
• A repeat wound culture will be taken, and a CMP and X-ray of the right foot will be prescribed to rule out osteomyelitis in the third toe, as well as a consult with a podiatrist.

Relevant Studies

• A study from 1985 found that vancomycin was effective in treating methicillin-resistant Staphylococcus aureus (MRSA) osteomyelitis, but the combination of vancomycin and tobramycin was potentially nephrotoxic 3.
• A 2021 review article discussed the mechanisms of antibiotic failure during Staphylococcus aureus osteomyelitis, including bacterial niche, destructive tissue remodeling, biofilm formation, and metabolically quiescent small colony variants 4.
• A 2020 minireview highlighted the importance of understanding how bacteria invade and survive within bone, and how bacterial infection triggers pathological bone remodeling, in order to develop new therapies for osteomyelitis 5.
• A 2018 systematic review found that hyperbaric oxygen therapy was effective in managing chronic osteomyelitis, especially in refractory cases 6.
• A 2000 review article found that ceftriaxone therapy was effective in treating staphylococcal osteomyelitis, although it was less active than standard antistaphylococcal agents 7.