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Health care for the homeless is a major public health concern. With the rise in antibiotic-resistant tuberculosis, the increase of human immunodeficiency virus (HIV) diseases, and other health risks, the medical community has begun to recognize the urgency of taking a proactive role in providing care for this population. Lower extremity pathology can result in limb-threatening and, in some cases, life-threatening sequelae for homeless populations. This patient group has limited access to regular hygiene, appropriate shoes, and podiatric medical care. Participation in the "Stand Down for the Homeless" projects provided an opportunity to evaluate the podiatric needs of a homeless population and to project a response to those needs. The authors define and compare this homeless population with the national homeless population, compare the podiatric needs of this homeless populations versus the general population, and respond to those needs.
This retrospective study reviewed the culture results of 112 admissions to a multidisciplinary diabetic foot care team with a primary diagnosis of infected diabetic pedal ulceration. An average of 1.5 +/- 0.9 species per patient (P < 0.0001) were isolated. Eighty-nine percent of wounds cultured grew two or fewer organisms. Anaerobic species were isolated in only 5% of all cultures. Of these isolates, the distinction between anaerobic colonization and true anaerobic infection is made. Results suggest that aggressive early hospitalization, coupled with aggressive intraoperative debridement, may yield less microbiologically complex infections that may be controlled with less expensive narrow spectrum antibiotic therapy. Diagnosis of the infected pedal ulceration of a patient with diabetes is a clinical one. If this diagnosis is combined with appropriate surgical intervention, microbiologic correlation, and antimicrobial therapy, the result may be a less complex hospital course and improved outcome.
The authors report on 20 patients who were admitted to the University of Texas Health Science Center at San Antonio during a recent 4-month period with foot infections caused predominantly by non-group A streptococci. This number of patients was significantly greater than the number admitted to the same institution with the same diagnosis during the preceding 3 years. All patients had type 2 diabetes mellitus. In each case, a rapidly spreading cellulitis followed trauma to the foot, which necessitated emergent incision and drainage. Five patients required extensive fascial and skin debridement because of soft-tissue destruction, and two patients needed below-the-knee amputation because of uncontrolled infection. These cases suggest that non-group A streptococci, like group A streptococci, can cause serious skin and soft-tissue infections in patients with diabetes that may require aggressive surgical debridement despite appropriate antibiotic therapy.
A. rabbit model of Staphylococcus aureus osteomyelitis was used to compare 3 weeks of clindamycin-impregnated polymethylmethacralate (PMMA) bead treatment with 3 weeks of gentamicin-impregnated polymethylmethacralate bead treatment, 4 weeks of parenteral clindamycin treatment, and surgical debridement without any antibiotic treatment. The animals were weighed throughout the course of the experiment and cortical bone and marrow flush specimens were obtained for bacterial culture at the end of therapy. The cortical specimens were bacteria free in 100% (6/6) of the animals receiving parenteral clindamycin, 83% (5/6) of the animals in the clindamycin PMMA group and, none of the animals in the gentamicin PMMA group. The marrow flush specimens were bacteria free in 83% (5/6) of the animals in the parenteral clindamycin group, 67% (4/6) of the animals in the clindamycin PMMA group, and 40% (2/5) of the animals in the gentamicin PMMA group. While these findings are preliminary and further studies with larger numbers of animals are needed, the authors suggest that when PMMA bead therapy is being contemplated, serious consideration should be given to replacing gentamicin with clindamycin in treatment of gram-positive osteomyelitis. Furthermore, incorporation of clindamycin with gentamicin (or tobramycin) should be considered when treating mixed gram-positive and gram-negative osteomyelitis.
INTRODUCTION AND OBJECTIVES: Corynebacterium striatum (C. striatum) is known to colonize the skin and mucous membranes of most normal human hosts. While it is frequently isolated in clinical laboratories, the clinical significance of C. striatum is often unknown with respect to diabetic foot infections with osteomyelitis. There have been very few studies published on this topic, and even fewer that report on treatment courses. To our knowledge, there has been no study published reporting diabetic foot osteomyelitis with isolation of C. striatum from bone culture.
METHODS: Four patients were known to have been treated at our facility for C. striatum diabetic foot osteomyelitis. The medical records for each patient were thoroughly reviewed with close attention directed towards the past medical history, wound duration, wound and bone cultures, antimicrobial therapy and clinical outcomes.
RESULTS: Bone cultures of all 4 patients were notable for C. striatum. Diphtheroids were also noted on wound cultures for 3 patients which were not speciated. All bone cultures were obtained during surgical treatment of the diabetic foot infection. All patients were type II diabetics but varied with respect to age and gender. All patients were treated with an extended course of antibiotics and/or surgical resection of osteomyelitis. Patients were followed until complete wound closure.
CONCLUSIONS: We report four cases of diabetic foot osteomyelitis in which C. striatum was noted and treated as a pathogen. Diphtheroids are often overlooked as a potential pathogen in diabetic foot infections and rarely treated as such. However, our findings suggest that clinicians should consider C. striatum as a possible cause of osteomyelitis, especially when patients fail to completely heal wounds in a timely manner that have previously and repeatedly displayed Diphtheroids from cultures.
The management guidelines of gunshot wound (GSW) injuries to the lower extremities have primarily been described more recently in the literature. A navicular fracture with adjacent joint involvement is presented from a GSW with initial external fixation management to prevent loss of anatomical alignment and successful staged definitive treatment with internal fixation. Based on previous experiences with rearfoot joint involvement from GSW injuries, we were able to direct definitive treatment with arthrodesis of violated joints. After a 1-year follow-up, the patient has returned to normal activities without any limitations. This case report demonstrates a stepwise approach to management of an open navicular fracture secondary to a GSW.
Fluoroquinolones have been associated with tendinopathies. The authors present three cases of Achilles tendinopathy in which the patients’ symptoms were preceded by treatment for unrelated bacterial infections with ciprofloxacin. Although the exact mechanism of the relationship is not understood, those who engage in sports or exercise should be advised of the risk of quinolone-induced tendinopathy. (J Am Podiatr Med Assoc 93(4): 333-335, 2003)
