Can a patient with a surgical wound, currently residing at a Skilled Nursing Facility (SNF), be treated with intravenous (IV) antibiotics and have a stat consult for vascular evaluation, instead of being admitted to the hospital for IV antibiotics and potential split-thickness grafts?

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Last updated: April 21, 2025 • View editorial policy

From the Guidelines

Yes, you can treat the patient at the SNF with IV antibiotics and request a stat vascular consultation, respecting her preference to avoid hospitalization, as long as she is closely monitored and meets specific criteria for outpatient treatment, as outlined in the 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections 1. To proceed with this approach, it is crucial to first obtain a thorough wound assessment and cultures before starting empiric IV antibiotics, such as vancomycin (15-20 mg/kg every 12 hours) plus either piperacillin-tazobactam (3.375g every 6 hours) or cefepime (2g every 8-12 hours), adjusting for renal function, as suggested by the guideline for managing diabetic foot infections 1. Some key points to consider in the management of this patient include:

  • Arranging for a PICC line placement and coordinating with the SNF's nursing staff for antibiotic administration to ensure continuous and appropriate antibiotic therapy.
  • Requesting an urgent vascular surgery consultation to evaluate circulation and determine if surgical intervention is necessary, given the potential need for revascularization or other vascular interventions as indicated by the patient's condition and the recommendations from the wound care team.
  • Continuing wound care as recommended by the previous provider, documenting wound measurements and appearance daily, to monitor the effectiveness of the treatment and make adjustments as necessary.
  • Temporarily holding anticoagulation as suggested, but discussing the risks with the patient, to balance the need for anticoagulation with the risk of bleeding, especially if surgical interventions are planned.
  • Ensuring the patient understands that if her condition deteriorates (increasing pain, fever, spreading erythema, or systemic symptoms), transfer to the hospital would be necessary, as hospitalization may be required for patients with severe infections or those who do not respond to outpatient treatment, as indicated by the guideline 1. This approach balances respecting patient autonomy while providing appropriate medical care, though hospital-level care may ultimately be required if the infection worsens or vascular intervention becomes necessary, highlighting the importance of close monitoring and a multidisciplinary team approach in managing diabetic foot infections, as emphasized by the guideline 1.

From the Research

Treatment Options for Patient with Surgical Wound Care

  • The patient has been recommended to be admitted to the hospital via ER for IV antibiotics and repeat vascular evaluation, but the patient is currently at a Skilled Nursing Facility (SNF) and does not want to go to the hospital.
  • The question is whether the patient can be treated at the SNF with IV antibiotics and a stat consult for vascular evaluation.

IV Antibiotics and Vascular Evaluation

  • There is no direct evidence to support or refute the treatment of the patient at the SNF with IV antibiotics and a stat consult for vascular evaluation 2, 3, 4, 5, 6.
  • However, the provided studies discuss the risk of acute kidney injury (AKI) associated with concomitant vancomycin and piperacillin-tazobactam or cefepime, which may be relevant to the patient's treatment.
  • The studies suggest that the combination of vancomycin and piperacillin-tazobactam may be associated with a higher risk of AKI compared to vancomycin and cefepime 3, 5.
  • However, other studies found no significant difference in the risk of AKI between the two combinations 2, 4, 6.

Considerations for Treatment at SNF

  • The decision to treat the patient at the SNF with IV antibiotics and a stat consult for vascular evaluation should be based on the patient's individual needs and medical condition.
  • The patient's refusal to go to the hospital should be taken into consideration, and alternative treatment options should be explored.
  • The SNF should have the necessary resources and expertise to provide the patient with the required care, including IV antibiotics and vascular evaluation.

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.