M&M presentation

1. Morbidity & Mortality
Jonathon Sargent MD
Internal Medicine Residency
April 29, 2019

2. © 2016 Virginia Mason Medical Center
Objectives:
• Case presentation (10 min)
• Overview of diabetic foot infections (15 min)
• Scope
• Pathophysiology
• Diagnosis
• Management
• Small group discussion: what went wrong (15 minutes)
• Discussion of biases and systemic errors contributing to this case
• Lessons

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Case presentation:
31 nondiabetic M with schizophrenia, ongoing tobacco use, and
peripheral neuropathy c/b osteomyelitis s/p b/l TMA, who is
transferred from an outside hospital with recurrent osteomyelitis for
advanced care in order to prevent BKA.

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Case
3/10/2016: Osteomyelitis of the left foot. Left great toe amputation
complicated by septicemia
4/9/2016: Osteomyelitis of right foot. Right partial first ray
amputation
2/2017: Chronic non healing wounds. Oral antibiotics. Care is by PCP
and HMC foot and ankle clinic

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Case
7/12/2017: ED visit with exposed necrotic bone on left foot. Admitted
for left transmetatarsal amputation at HMC. Deep tissue cultures
sent. Also, bilateral gastrocnemius recession. Superficial ulcer on
right foot debridement. Pt discharged with 10 days PO abx to
Bremerton Rehab, followed by weekly wound care at Olympic Medical
Center and f/u with PCP.
9/5/2017: Right foot with open wound. Pt missed appointment with
prosthetics and orthotics

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Case
3/6/2018: F/u with surgeon. Has been on doxycycline for past 3
weeks. Ulcer is bigger and worse, with signs of osteomyelitis.
Continue oral antibiotics, schedule right TMA.
3/15/2018: Right TMA at HMC. Level of resection was most proximal
possible. Part of first metatarsal sent for culture. “the metatarsals
themselves were nice and hard and sclerotic so I felt is was ok to
close this.” Discharge with home health on oral clindamycin (off med
list by 3/28/2018). Pt does not recall taking abx after his
hospitalization.
Bone culture grows MRSA. (R to fluoquinolones, tetracycline,
erythromycin; S to clinda).

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Case
Sometime after 4/25/2018: Pt seen ambulating in public and
discharged from home health for lack of need. Begins weekly wound
care at OMC clinic.
12/29/2018: Wound care treating left plantar non infected, non
healing ulcer. Podiatrist notes pt not well and right foot is inflamed
with no obvious ulcer. Encouraged to go to ED.

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Case
12/31/2019: Presents to ED with n/v. WBC 21.5. MRI of right foot
shows “diffuse cellulitis, multiple abscesses that tract proximally with
extensor digitorum longus tendon bundle and extends from beyond
the proximal margin of the study at the level of the talar body. There
is also osteomyelitis of cuboid, fifth metatarsal base, distal margin,
and first metatarsal, and dorsal aspect of the talus.”
12/31/2019: Started on vancomycin and cefepime. Podiatrist at local
hospital recommended BKA. Sent to VMMC for advanced care to
salvage leg (vascular surgery, podiatry, hyperbarics)

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Case continued:
January 2019: At VMMC: All the consults. Aggressive debridement in
OR. Vanc+unasyn. Deep tissue culture shows MRSA (R to clinda and
TMP-SMX). Plan for conservative therapy with IV antibiotics.
Discharge on vancomycin for 6 weeks.
February 2019: Nine days after completion of vanc, he presents to
ED with cellulitis and abscesses in the right leg. OMC tried to transfer
him to VM due to “lack of psychiatry services and need for
hyperbaric” but this was denied. We recommended a change in abx
and he improved and he was placed in a SNF.
Early March 2019 – Doing well at SNF until he experiences increased
delusions of the world ending and he left AMA to his home. No
antibiotics, no wound care.

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Case continued:
March 19, 2019 – admitted to VM with right LE cellulitis,
osteomyelitis, and fever.
March 21, 2019 – Right BKA. Discharged to home with PT/OT as SNF
placement was prohibitively difficult due to psychiatric history,
despite not needing antipsychotic medication in the hospital.

14. Diabetic Foot Infections

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Diabetic foot infection (DFI) scope
• Ulcers develop in 9.1-26 million people with DM world wide,
annually.
• >50% become infected
• Risk of death from DFI is 2.5x higher compared to a pt with DM
and no DFI.
• ~20% of moderate to severe DFI leads to some level of amputation
• Mortality after DM related amputation is increased 70% at 5 years.
• Every year ~1 million people with DM loose a leg

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Diabetic foot infection (DFI) scope
• DM and DFI are major driving factors for ER visits and hospital
admissions
• ~$176 billion is spent of DM care and 1/3 of that is for the lower
extremity.

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Diabetic Foot Ulcers

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Diabetic Foot Ulcers
Recurrence is common:
–40% recur in 1 year
–60% recur within 3 years
–Maybe a healed ulcer should be thought of as “in remission”
rather than healed.

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Diabetic Foot Ulcers

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Diabetic Foot Ulcers
Methods to prevent foot ulcers:
• Pt education – important, maybe
• Self management:
• Measure temp differences
• Always wear footwear
• Foot surgery
• Adherence
• Pressure release devices that cannot be removed are superior
• Not just patient responsibility
• Comprehensive multidisciplinary foot care programs

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Diagnosing DFI and Osteomyelitis
• Many bacteria may colonize an ulcer, but inflammatory reactions
defines an infection
• 2 local findings to suggest infection
• Red
• Warm
• Pain and tenderness
• Induration
• Purulent secretions
• Most common bacteria: Staph aureus. MDRO are common
• Hospitalizations, surgery, and prolonged abx induce MDRO

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Diagnosing DFI and Osteomyelitis
• Diabetic osteo mostly from STI  bone (cortex first, then marrow)
• Detecting osteo
• Probe to bone
• Crp and esr
• Deep tissue culture (superficial does not correlate
• MRI (most sn and sp) but tagged WBC scan can be used.
• Bone biopsy is gold standard

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Management of DFI and Osteomyelitis
Primary treatment modalities are:
–Debridement
–Special dressings
–Offloading
–Antibiotics
–Regimented follow up
–Vascular evaluation

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Management of DFI and Osteomyelitis
• Not standardized
• Prolonged antibiotic therapy (6 wks) promotes wound healing,
reduces amputations and ulcer recurrence.
• IDSA defines 4 clinical patterns where abx without surgery should be
considered
• May induce MDRO, has side effects.
• Conservative surgery reduces amputations and hosp LOS.
• IWGDF recommends no more than 1 wk abx with this.
• Amputation: Mortality rate is substantially higher with a major
amputation (BKA) compared to minor (TMA).
• Minor: 80% alive at 2 yrs; 64% fully ambulatory
• Major: 48 alive at 2 yrs, 64% ambulatory

26. What went wrong?
What could have gone better?

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Fishbone
Technical Systemic Patient
Outcome
Cognitive Other

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Examples of errors
Technical
• No bone culture
• No long term Abx
• Removable orthotics
• TMA vs BKA
Systemic
• Fragmented system
• Lack of providers/resources
• Poor communication
• Lack of time
• Home health
Other
Patient
Medical literacy
Continued smoking
Follow up
Behavior modification
Psychiatric stability
Cognitive
Framing effect
Fundamental attribution error
Hawthorne effect
Psych out error
Search satisficing

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Lessons
• DFI are common and have a high morbidity and mortality
• Multidisciplinary care and a team based approach is needed.
• Patients in rural areas with limited resources face additional
challenges.
• Practices vary and treatment and approach are not standardized.
• Patient adherence is not solely the responsibility of the patient.
• Bone biopsy of margin before closing

31. © 2016 Virginia Mason Medical Center
Thank you
Uma Malhotra, MD
Pilar Almy, DPM

32. © 2016 Virginia Mason Medical Center
References
• Armstong, Boulton, and Buss. Diabetic foot ulcers and their recurrence. N Engl J Med
2017; 376:2367-75
• Sagray et al. Current therapies for diabetic foot infection and osteomyelitis. Clin Podiatry
Med Surg 31 (2014) 57-70.
• Hingorani, et. Al. Management of diabetic foot: A clinical practice guideline by the society
for vascular surgery in collaboration with the American Podiatric Medical Association and
the society for vascular medicine. J vasc surg 2016;63:3S-21S.
• Brocco, et. Al. Diabetic foot management: multidisciplinary approach for advanced lesion
rescue. J Cardiovasc Surg 2018;59:670-84.
• World Journal of Diabetes 2017 April 15; 8(4):120-171