What is the management plan for a 62-year-old male with diabetic (on metformin and gliclazide, insulin) bilateral leg ulcers/cellulitis, presenting with maggots, foul odor, and pain, with lab results showing leukocytosis, anemia, elevated C-reactive protein (CRP), neutrophilia, and hypocalcemia?

Management Plan for Diabetic Foot Infection with Maggot Infestation

This patient requires immediate hospitalization for aggressive wound debridement, intravenous antibiotics, and comprehensive wound care to prevent amputation and manage his moderate to severe diabetic foot infection.

Assessment of Infection Severity

Based on the clinical presentation, this patient has a moderate to severe diabetic foot infection according to the IWGDF/IDSA classification system 1:

• Bilateral lower leg ulcers with maggots and surrounding cellulitis
• Elevated inflammatory markers (WBC 22, CRP 77, neutrophilia 90%)
• Foul odor from wounds
• Pain (though limited sensation due to neuropathy)

Initial Management Steps

1. Hospitalization

   • The patient meets multiple criteria for hospitalization 1, 2:
     • Extensive bilateral cellulitis
     • Need for surgical debridement
     • Elevated inflammatory markers
     • Social factors (homelessness, poor wound care)
     • Uncontrolled diabetes requiring insulin adjustment

2. Medical Stabilization

   • Address hyperglycemia with insulin therapy (continue current regimen with adjustments)
   • Correct hypocalcemia (Ca 1.79)
   • Monitor fluid and electrolyte status
   • Continue to monitor inflammatory markers

Wound Management

1. Urgent Surgical Debridement

   • Perform thorough sharp debridement to:
     • Remove all maggots
     • Excise necrotic tissue
     • Drain any purulent collections
     • Explore wound depth and extent 1, 2

2. Wound Assessment

   • After debridement, probe the wound with a sterile metal probe to:
     • Determine depth and extent
     • Assess for bone involvement (probe-to-bone test)
     • Evaluate for joint or tendon involvement 1
   • Document wound size, depth, and characteristics

3. Specimen Collection

   • Obtain deep tissue specimens during debridement (not superficial swabs)
   • Send for aerobic and anaerobic culture and sensitivity testing
   • Consider bone biopsy if osteomyelitis is suspected 1, 2

Antimicrobial Therapy

1. Initial Empiric Therapy

   • Start broad-spectrum intravenous antibiotics immediately after obtaining cultures:
     • Piperacillin-tazobactam OR
     • Amoxicillin-clavulanate IV 1, 2

2. Adjust Based on Culture Results

   • Narrow spectrum once culture results are available
   • Duration: 1-2 weeks for soft tissue infection; 3-4 weeks if infection is extensive 2

Vascular Assessment

1. Peripheral Vascular Evaluation
   • Assess peripheral pulses (noted as present on initial exam)
   • Consider non-invasive vascular studies (ABI, toe pressures)
   • Vascular surgery consultation if signs of critical limb ischemia develop 1, 2

Ongoing Wound Care

1. Appropriate Dressing Selection

   • For exudative wounds: alginates or foam dressings
   • For necrotic areas post-debridement: hydrogels
   • Change frequency based on exudate amount 2

2. Pressure Offloading

   • Complete offloading of affected areas
   • Appropriate assistive devices for mobility while protecting wounds 2

Metabolic Management

1. Glycemic Control

   • Optimize insulin regimen to achieve target blood glucose
   • Poor glycemic control increases risk of cellulitis (12% increased odds for every 1% rise in HbA1c) 3
   • Continue metformin and gliclazide if no contraindications

2. Nutritional Support

   • Assess nutritional status
   • Protein supplementation to support wound healing

Monitoring and Follow-up

1. Daily Wound Assessment

   • Monitor for:
     • Increasing drainage
     • Changes in drainage color/character
     • Increased erythema
     • Development of systemic symptoms 2

2. Laboratory Monitoring

   • Serial WBC counts and CRP to assess response
   • Note that normal WBC does not exclude osteomyelitis in diabetic patients 4
   • Monitor calcium levels and correct as needed

Discharge Planning

1. Social Support

   • Coordinate with social services for appropriate discharge placement
   • Homeless shelter may not be appropriate for wound care needs
   • Consider skilled nursing facility if wounds not healed at discharge

2. Patient Education

   • Proper foot care
   • Recognition of infection signs
   • Importance of regular dressing changes
   • Medication adherence 2

3. Follow-up Arrangements

   • Outpatient wound care within 2-3 days of discharge
   • Endocrinology follow-up for diabetes management
   • Consider home health services if returning to community

Pitfalls and Caveats

1. Do not underestimate infection severity in diabetic patients - neutrophil function is impaired in diabetes, potentially masking typical inflammatory responses 5

2. Do not rely solely on normal WBC count to exclude osteomyelitis - 54% of patients with acute osteomyelitis have normal WBC counts 4

3. Do not delay debridement - prompt and thorough debridement is essential for infection control and wound healing 1, 2

4. Do not neglect deep infection assessment - infection can spread rapidly through fascial planes without obvious surface signs 2

5. Do not discharge prematurely - ensure adequate wound healing progress and appropriate discharge placement to prevent readmission