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Diabetic foot infection with suspected osteomyelitis — MSRA MCQ

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HardAnkle and FootDiabetic foot infection with suspected osteomyelitisMSRA

A 64-year-old woman with type 2 diabetes, established peripheral sensory neuropathy and CKD G3a presents with a 4-day history of a plantar ulcer beneath the left second metatarsal head. She is afebrile and feels well. After removal of overlying callus, there is a 9 mm ulcer with purulent discharge and erythema extending 1 cm from the ulcer edge. The wound is 8 mm deep and sterile probing reaches bone. Dorsalis pedis and posterior tibial pulses are palpable. There is no gangrene, spreading cellulitis, crepitus or pain out of proportion. CRP, white cell count and plain foot radiographs are normal. What is the most appropriate management today?

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Correct answer: A — Refer immediately to acute services and inform the multidisciplinary foot care service for suspected deep infection or osteomyelitis

This is a diabetic foot infection with clinical concern for deep infection or osteomyelitis: the ulcer is deep and probes to bone. Although the erythema is limited to 1 cm, which might otherwise suggest a mild infection, infection severity and referral urgency must not be determined by erythema extent alone when bone involvement is suspected. NICE advises immediate referral to acute services, with notification of the multidisciplinary foot care service, where there is clinical concern about deep soft-tissue or bone infection. Normal CRP, white cell count and plain radiographs do not safely exclude osteomyelitis in a diabetic foot. Further investigation, commonly MRI when radiographs are nondiagnostic, and acquisition of an appropriate deep tissue or bone specimen should occur through the acute specialist pathway; antibiotic treatment should begin promptly after sampling, or as close as possible to it. A and C would be appropriate pathways for an active diabetic foot problem without features of deep infection. B recognises the value of MRI but inappropriately substitutes outpatient imaging for immediate escalation. E delays treatment despite purulence and suspected bone involvement.

Reference: NICE NG19: Diabetic foot problems: prevention and management — Recommendations (Last updated 11 October 2019) — https://www.nice.org.uk/guidance/ng19/chapter/Recommendations NICE NG19: Diabetic foot problems: prevention and management — Investigation and treatment of diabetic foot infection (Last updated 11 October 2019) — https://www.nice.org.uk/guidance/ng19/chapter/Recommendations