University of Iowa
Department of Family Medicine

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DFM Info

Inpatient management of diabetic foot ulcers


1.       The intent of this protocol is to obtain a bone biopsy on all suspected osteomyelitis cases and avoid long term empiric antibiotics management and minimize overuse of vancomycin.

2.       If on admission there is a reasonable probability of osteomyelitis clinically and there is no other reason for antibiotics then we should not order antibiotics and should discontinue antibiotics already ordered.

3.       If your examining finger or probe can go deep through the ulcer to or near the bone it has a reasonable likelihood of osteomyelitis.

4.       A normal plain film does not rule out osteomyelitis.

5.       If osteomyelitis is suspected then from 8 to 5 every day the team calls MSK Radiology Fellow on call (call MSK Reading Room at 3-7721 or look on Smart Web call schedule). If it is a weekend or holiday they will consider accommodating us but have limited staffing.

6.       The fellow will instruct us on which EPIC MSK order to do. They will biopsy the bone within 24 hours.

7.       Consult ID and Ortho on admission. ID will recommend post biopsy empiric antibiotic to use based on the following guidelines:

 HIGH RISK FOR MRSA (MRSA nasal swab + is NOT a risk factor):

a) Prisoners

b) HemoDialysis pts

c) Ho inpt. hospitalisation in past 30days

d) Homeless pts

e) H/o MRSA in SAME WOUND (irrespec.of time of isolation) -- a (+) hx often compels ID to use an MRSA active drug.

HIGH RISK FOR MRSA/ Pseudomonas: Chronic ulcer > 4wks, deep ulcer, h/o prior heavy abx usage).

8.       Once cultures are back ID will assist with selection and confer with Ortho on surgical management

9.       On nights we will hold antibiotics until the next morning and then call (see #5 above)

10.   If it is a Saturday and the MSK fellow cannot do the biopsy the team will order antibiotics per the guidelines above. On Sunday antibiotics would be held until the biopsy the next morning.