What is the best course of action for a 63-year-old diabetic patient with a non-healing foot ulcer and suspected osteomyelitis?

From the Guidelines

I strongly recommend continuing wound care with weekly debridement for this 63-year-old diabetic male with a chronic non-healing wound on his right second toe. The patient has a complicated history with this wound, self-treating for two years before seeking medical attention in November 2023, then intermittently refusing and restarting care. Given the previous Staphylococcus aureus infection and the chronic nature of the wound, repeating the wound culture is appropriate to guide antibiotic therapy, as suggested by the Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections 1.

The X-ray of the right foot is necessary to evaluate for osteomyelitis in the third toe, which is a common complication of diabetic foot wounds. The podiatry consultation is essential for specialized foot care and possible surgical intervention if needed. The CMP will help assess the patient's overall metabolic status, which can impact wound healing. It's critical to emphasize strict offloading with appropriate diabetic footwear to prevent pressure on the wound, as off-loading is a vital part of wound care 1.

The patient should continue using the prescribed wound care regimen with Marathon Liquid Skin Protectant after cleaning. Diabetic wounds require consistent care and monitoring due to impaired healing from poor circulation and neuropathy. The patient's history of non-compliance increases the risk of complications, so clear communication about the importance of continuous care is vital to prevent amputation, which is a significant risk in poorly managed diabetic foot wounds.

Some key points to consider in the management of this patient's wound include:

• The use of systemic antibiotic regimens that have been shown to be effective in published randomized controlled trials at standard dosing to treat diabetic foot infections 1
• The administration of antibiotic therapy for a duration of 1–2 weeks, with consideration of continuing treatment for up to 3–4 weeks if the infection is improving but is extensive and is resolving slower than expected or if the patient has severe peripheral artery disease (PAD) 1
• The importance of proper wound care, including debridement, dressing, and off-loading, as well as the consideration of adjunctive therapies such as hyperbaric oxygen or topical oxygen in certain cases 1

Overall, the management of this patient's wound requires a comprehensive approach that takes into account the patient's medical history, the severity of the wound, and the potential for complications. By following the guidelines and recommendations outlined above, we can work to promote wound healing, prevent amputation, and improve the patient's overall quality of life.

From the Research

Patient Background

• The patient is a 63-year-old male diabetic with a non-healing wound on his right second toe.
• The patient had been taking care of the wound himself for two years before reporting it to medical professionals on 11/09/2023.
• An X-ray taken in January 2024 showed no signs of osteomyelitis.

Treatment and Progress

• The patient started wound care on March 1,2024, with orders to spray wound and skin cleanser directly onto the wound surface, clean, and pat dry, and to apply Marathon Liquid Skin Protectant to the designated area.
• The patient was advised to ensure strict offloading for healing at all times and to wear an offloading shoe at all times when pressure was being applied to the foot.
• The patient refused wound care on 5/19/2025, stating that he was to receive medical shoes soon, but requested wound care again in September 2024.
• The patient has been receiving wound care since then, with weekly debridement.
• A wound culture taken last month showed heavy growth of Staphylococcus aureus, and the patient was treated with systemic antibiotics 2, 3.

Current Plan

• A repeat wound culture will be taken today to assess the effectiveness of the antibiotic treatment.
• A CMP and an X-ray of the right foot will be prescribed to rule out osteomyelitis in the third toe.
• A consult with a podiatrist will be requested to further assess and manage the patient's condition.
• The use of systemic antibiotics has been shown to be effective in reducing Staphylococcus aureus colonization and recurrent skin infection 3.
• Wound debridement is a critical component of promoting optimal healing for a wound with necrotic tissue, and the patient's weekly debridement sessions are likely to be beneficial in promoting healing 4.
• Hyperbaric oxygen therapy may be considered as an adjunctive measure in the treatment of chronic osteomyelitis, although its effectiveness in this patient's case is unclear 5.