Peer Review Case Summary: Telephone Management of Diabetic Patient with Leg Cellulitis
Case Details and Timeline
The patient, with documented history of diabetes and cellulitis, contacted the clinic regarding redness and soreness on his leg. He reported self-treating with a 10-day course of cephalexin (from home supply) that had been completed 2 days prior to the call. The provider prescribed Augmentin without an in-person evaluation and advised the patient to call if symptoms changed or worsened.
Determination of Care Appropriateness
The care provided was inappropriate and represents a significant deviation from standard practice for diabetic foot/leg infections, as this patient required immediate in-person evaluation rather than empiric telephone-based antibiotic escalation.
Critical Deficiencies in Clinical Management
Failure to Perform Required In-Person Assessment
The IWGDF/IDSA 2023 guidelines emphasize that proper assessment of diabetic foot/leg infections requires direct examination to classify infection severity, evaluate for deep tissue involvement, assess vascular status, and determine if surgical intervention is needed 1.
Diabetic patients with cellulitis require immediate evaluation because approximately 20% of necrotizing fasciitis cases present without visible skin lesions, and clinical examination is essential to detect warning signs such as wooden-hard subcutaneous tissues, skin discoloration, gangrene, or anesthesia of involved skin 2.
The IDSA guidelines specify that patients with severe infections require immediate hospitalization, and determining severity requires physical examination—something impossible via telephone 1, 3.
Peripheral neuropathy in diabetic patients masks pain and allows infections to progress unrecognized, making visual and tactile examination mandatory 1, 2.
Inappropriate Antibiotic Selection Without Clinical Data
Augmentin (amoxicillin-clavulanate) is not recommended as empiric therapy for diabetic cellulitis that has failed initial cephalexin treatment 1.
The IWGDF/IDSA 2023 guidelines state that antibiotic selection should be based on infection severity classification, likely pathogens, local resistance patterns, and clinical examination findings—none of which were obtained in this case 1.
For mild diabetic soft tissue infections, gram-positive coverage (beta-hemolytic streptococci and S. aureus) is appropriate, but treatment failure after 10 days of cephalexin suggests either: (1) incorrect diagnosis, (2) resistant organisms, (3) inadequate source control, (4) progression to deeper infection, or (5) non-infectious etiology 1.
Switching antibiotics without cultures or examination risks masking progressive infection while providing false reassurance 1.
Inadequate Response to Treatment Failure
The patient had completed a full 10-day course of cephalexin with persistent symptoms—this represents treatment failure requiring diagnostic re-evaluation, not empiric escalation 1.
IDSA guidelines specify that if infection has not resolved after appropriate therapy, the patient should be re-evaluated with consideration for further diagnostic studies including deep tissue cultures, imaging, and assessment for osteomyelitis 1.
The provider missed the opportunity to obtain crucial diagnostic information: wound cultures from debrided tissue, assessment for abscess or deeper infection, probe-to-bone testing if ulceration present, and evaluation of vascular status 1.
Documentation Deficiencies
- No documentation of infection severity classification (mild, moderate, or severe) 1.
- No assessment of systemic signs (fever, tachycardia, hypotension) that would indicate need for urgent evaluation 1, 2, 3.
- No documentation of wound characteristics: size, depth, drainage, odor, or surrounding tissue quality 1.
- No vascular assessment documented (pulses, capillary refill, skin temperature) 1.
- No assessment for bone involvement, which occurs commonly in diabetic foot infections 1.
- No documentation of glycemic control status, which directly impacts infection outcomes 1, 3.
Evidence-Based Management That Should Have Occurred
Immediate In-Person Evaluation Required
All diabetic patients with persistent or worsening skin/soft tissue infection after completing antibiotic therapy require same-day clinical evaluation 1, 3.
Physical examination should assess: extent of erythema (measure and mark borders), presence of warmth/swelling/tenderness, skin integrity, presence of purulence or necrosis, lymphangitis, systemic toxicity signs, peripheral pulses, and probe-to-bone if ulcer present 1, 2.
Appropriate Diagnostic Workup
Deep tissue cultures should be obtained via curettage or biopsy of debrided wound base, not superficial swabs 1, 3.
Plain radiographs to evaluate for gas, foreign body, or osteomyelitis (though early osteomyelitis may not be visible) 1.
Laboratory assessment including CBC, metabolic panel, and hemoglobin A1c 3.
Correct Antibiotic Approach
For treatment failure after cephalexin in a diabetic patient, empiric escalation should cover MRSA, gram-negatives, and anaerobes pending culture results 1, 4.
However, research shows that among diabetic patients with cellulitis and positive cultures, gram-negative pathogens are not significantly more common than in non-diabetics (7% vs 12%), and gram-positive organisms predominate (90% of cases) 4.
The key issue is that antibiotic selection should follow, not precede, proper clinical assessment and culture acquisition 1.
Common Pitfalls Demonstrated in This Case
Telephone management of diabetic infections: Diabetic patients have impaired inflammatory responses and neuropathy that mask infection severity, making remote assessment unreliable 1, 2.
Antibiotic escalation without source control: Many diabetic infections require debridement, drainage, or surgical intervention that antibiotics alone cannot address 1.
Assuming treatment failure equals antibiotic resistance: Treatment failure may indicate abscess, osteomyelitis, ischemia, or non-infectious diagnosis rather than resistant organisms 1.
Missing the window for limb salvage: Delays in proper evaluation and surgical consultation contribute to progression requiring amputation 1, 3.
Risk Stratification Implications
This patient's risk factors place him in a high-risk category requiring aggressive management:
Diabetes with history of cellulitis indicates recurrent infection risk and possible underlying vascular or neuropathic complications 1, 2.
Treatment failure after 10 days of antibiotics is a red flag for complicated infection 1.
Self-medication with leftover antibiotics suggests possible non-adherence or access barriers requiring social work evaluation 1.
Recommendations for System Improvement
Implement triage protocols requiring same-day evaluation for diabetic patients reporting skin/soft tissue infections, especially with treatment failure 1, 3.
Provide staff education on diabetic foot infection red flags that mandate immediate in-person assessment 1, 2, 3.
Establish clear documentation templates for infection assessment including severity classification, wound characteristics, and vascular status 1.
Create pathways for urgent multidisciplinary consultation (infectious disease, surgery, podiatry) for complex diabetic infections 1.