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I have a very challenging case- I was wondering if anyone has seen anything similar and could offer some help.
She was referred to me for her diabetic foot ulcer, present intermittently for approximately 3 years. She has a history of end-stage kidney disease, stage 3/4; uncontrolled NIDDM, neuropathy, and gouty arthropathy. Peripheral circulation has been deemed adequate by vascular surgeons. She has had two partial amputations/osteomyelitic debridements over the past 2-3 years (4th, 5th digits). Limited clinical notes and history show simultaneous history of uncontrolled DM, Charcot neuroarthropathy, ESRD, gouty arthropathy. The present ulcer has been stable, but we are dealing with issues regarding her renal status- we cannot give her recommended doses of antibiotics or gout medication due to ESRD. After the last wound culture, I gave her Cipro and Clindamycin at reduced doses, as per nephrologist. The drainage and local signs of infection have subsided, but we continue to see serous drainage and I have found what appear to be gouty tophi in the wound. She is receiving excellent wound care and off-loading, but we appear to be stuck in a cycle, from treating the wound, to struggling to control DM, to dealing with ESRD. I have omitted specific details in an attempt to be more brief. Including all her relevant data and findings would not be practical. Has anyone managed a similar patient in the past? All contributions would be appreciated. Thank you-

 

OK...challenging for sure. So...I'll just throw out some options and we can bounce off each other. So: take her to the OR, open debridement of boney prominences, necrotic tissue, tophi, etc., pulse lavage and VAC or primary closure if neg intra-op gram stain or cultures negative.....

 

she is scheduled for next Friday---

 

you da man

 

If the antibiotics are too much, after debridement, try cleaning with Microcyn wound care, followed by Hydrogel. This will kill off 99.99% of pathogens. Cleanse and change dressings daily at first until under control. Please see oculusis.com/us and read the clinicals. Has been working amazingly in cases where nothing else works. Inexpensive, and covered by medicare and medicaid. Call for samples, they can drop them off to you or ship them.