Amputation does not only happen in DM foot ulcers, but also in cases where the wound is not treated properly and it develops infection recurrently.

1. Case study on Antibiotic coated nail
infection in left lower limb with a sinus
formation
J. Anisha Ebens
Pharm D IV yr

2. Case study:
Mrs. G, 27 yr old female patient was admitted in the
hospital on 21.1.17,
C/O: Left knee sinus formation with seropurulent
discharge.
H/O: Fever x 1 day prior to the onset of left knee sinus.

3. H/O: Old C/O custom mega prosthesis of left femur operated
for aggressive GCT of distal femur. Patient underwent
removal of CMP and Antibiotic nail insertion in the same
hospital on 07.09.2016. Patient was normal and then
developed a sinus over anteromedial aspect of left knee x 10
days.

4. Past medical history: Operated for GCT 4 yrs back.
Personal history: No allergy to any drugs.
Physical and systemicexamination:
Pulse: 113 beats/min RR: 17 breaths /min BP: 110/60mmHg
O/E: Ambulant with walker support
Multiple surgical tear in left thigh
Active SLR not possible on left leg
Left knee sinus seenon the anteromedial aspect with
seropurulent discharge.

5. Lab report:
Hematological parameter: Lab values Normal values
Hb 9.2 12-16 g/dl
ESR 31 1-25 mm/hr
PCV 30.1 36-46 %
MCV 64.7 78-102 Fl
MCH 19.8 25-35 Pg
MCHC 30.7 31-37 g/dl
RDW 19.1 11.5-14.5 %
PT Control:
Test:
12.4
38.1 9.5-13.5 Sec
ISI 0.98 0.9-1.2
INR 3.00 <1.3
RFT parameters: Lab value Normal value
21.1 22.3
Urea 5 6 8-25 mg/dl
Creatinine 0.56 0.47 0.6-1.5 mg/dl

6. LFT parameters: Lab value Normal values
21.1 24.3
T. Bilirubin 0.3 0.8 0.0- 1.0 mg/dl
D. Bilirubin 0.06 0.13 0.0-0.4 mg/dl
T. Protein 5.8 3.5 6-8 g/dl
SGOT/AST 18 65 5-40 U/L
SGPT/ALT 24 49 7-30 U/L
ALP 72 51 45-115 U/L
Albumin 2.6 1.9 3.1-4.1 g/dl
Globulin 3.2 1.6 2.6-4.1 g/dl
GGT 14 12 15-85 U/L
A/G Ratio 0.8 : 1 1.19 : 1.04 g/dl
Urine Examination:
pH: 6 Specific gravity: 1.010 Epi. Cells: 2-3 cells

7. Other investigation:
X-Ray- left femur AP
Lat
left knee AP
Lat
Diagnosis: Antibioticcoatednail left LL with sinus on the
anterior aspectof knee
Plan: Implant exit with wound debridement and high above
the knee amputation
Infective organism: 21.1.17- scanty growthof Staphylococcus aureus
Susceptibility test: antimicrobial susceptibility report-
Resistantto Erythromycin, Penicillin.
Antibiotic coated nail
seen in shaft of femur
and shaft of tibia across
knee joint

8. Pre operative treatment on 23.3.17
• NPO– 12 midnight
• Inj. Xylo – test dose
• Inj. TT 1/2ccIM
Consent for surgery:
Failed infected femur reconstruction with custuming
prosthesis following GCT, excision; now persistent infection-
anitibioticcoated nail loosening and bone loss.
Wound debriment metal exit & LRS (Lengthening
ReconstructionSurgery)/ above knee amputation.
Surgery carried out on 24.3.17- Antibiotic coated nail loosening and
above knee amputation/ LRS.

9. Drug Dose ROA Freq. No. of days
15.2 5-16.3 17-22.3
T. Rantac 150mg P/O BD   
T. Anxit (Alprazolam(0.5
mg),Sertraline(25 mg))
0.25mg P/O BD 
T. Paracetamol 500mg P/O SOS  
T. Healvit 1tab P/O 1-0-0  
T. Zolpidem 10mg P/O 0-0-1  
Inj. Diclofenac 1ml IM SOS  
Cap. Pregabalin 75mg P/O HS 
Drug chart:

10. Drug Dose ROA Freq. No. of days
24 25 26 27 28 29 30 31
Inj. Ondansetron 4mg IV OD    
Inj. Cefazolin 1g IV TDS        
Inj. Pantoprazole 40mg IV BD      
Inj. Tramadol 50mg IV BD      
Inj. Clindamycin 600mg IV TDS   
Inj. Diclofenac 75mg IV SOS  
Inj. Paracetamol 1g IV SOS  
T. Azithromycin 2mg P/O OD     
T. Zerodol P 1tab P/O 1-0-1  
T. Pantoprazole 40mg P/O 1-0-1  

11. Pharmacist intervention:
• In this case Drug-Drug interaction wasfound to be with
Tramadol and Ondansetron, where Ondansetron reduce the
effect of Tramadol. So Tramadol dose must be increased.
• Acetaminophen interactswith foodand cabbage which reduces
the effect of Acetaminophen. So the drug must be taken one
hour after the food and shouldavoidcabbage.
• The patientskidney and liver functions shouldbe closely
monitored.
• The patient has to be treatedfor anaemia.
• The patient has to increase the dietary intake of proteins.