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Mrs. J. is a 66 yrs. old woman with diabetes mellitus. She presents with an oozing erythematous area on her left lower leg that began 2 weeks ago as an insect bite. The area was itchy but not painful-until recently it is becoming more painful. She has had an intermittent, low grade fever for the past week but otherwise feels well. She states the redness has gotten worse and the lesion is oozing purulent fluid approx. one week ago. Also noted mild swelling in her lower leg near the lesion and erythema tracking. Her medication is insulin and Lisinopril and she has no allergies. Post your discussion on what drug therapy would you prescribe for how long and why?

 

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Before prescribing antibiotics, we must first debride the wound. Sharp debridement, with the use of a scalpel or scissors to shear off necrotic tissue, is the preferred method to remove callus and nonviable tissue. Such debridement promotes wound healing and removes pathogens that are present in nonviable tissues.

In prescribing antibiotics, agents with activity against methicillin-resistant S. aureus (MRSA) should be used in patients with purulent infections and those at risk for MRSA infection, since it is a common pathogen in diabetic foot infections, particularly in those who have had previous MRSA infections or known colonization. Other risk factors for MRSA infection include prior antibiotic use, previous hospitalization, and residence in a long-term care facility. Also considering that this patient already had a systemic manifestation such as fever, it is crucial to admit her and give her IV antibiotics rather than oral.

We should give her Piperacillin-Tazobactam 3.375 g every 6 hours (to cover for Pseudomonas aeruginosa which is also a common isolate in diabetic foot infections) PLUS Vancomycin 15 to 20 mg/kg every 8 to 12 hours (to cover for Methicillin-Resistant Staphylococcus aureus). Duration of therapy must be at least 2 weeks. From then on, reassess the patient if he or she can step down to oral antibiotics and be discharged and tailor antibiotic regimen once culture results are available.

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