Mr. ABC was a 50-year-old man from Indore (a Tier 2 city in India) with multiple co-morbidities, which include Coronary Artery Disease (CAD), obesity, hypertension, and insulin-dependent diabetes. When on a trip to New Delhi (a Tier 1 city), he was presented to a hospital with fever and chills, along with an open wound on the bottom of his right foot. Serology results revealed a WBC 14,000 cells/mL and a serum creatinine of 3.1 mg/dL. ABC was admitted by the attending doctor for cellulitis and an infected diabetic foot ulcer.
ABC was started on intravenous vancomycin and blood cultures were drawn. A bone scan was also imaged, and the results proved negative for osteomyelitis. Blood cultures did not grow any bacteria, but a wound culture from his foot ulcer grew Klebsiella. The attending doctor consulted the in-patient podiatrist for wound debridement, but ABC apparently refused in favor of being seen by his own podiatrist as an outpatient. This was owing to the charges imposed by the hospital and the blind trust that ABC refused to place on the verbal statement given by the physician. By the next day, ABC was afebrile, eating well, and was discharged on oral antibiotics later that same day.
Two days after discharge, ABC followed up with a clinic nearby in the same Tier 1 city. ABC was again febrile and his foot ulcer looked worse. The physician recommended hospitalization with intravenous antibiotics, but ABC was reluctant to return to the same hospital. The physician referred ABC to a wound specialty clinic for intravenous vancomycin to begin the next day. ABC remained on the oral antibiotics.
Over the next 3 days, ABC received daily intravenous vancomycin at the wound clinic. However, the foot ulcer continued to drain purulent material with associated cellulitis and advancing erythema across the forefoot. Laboratory studies revealed a WBC 18,300 cells/mL and a serum creatinine of 2.2 mg/dL. ABC was informed that he needed wound debridement and was offered another podiatrist. Once again, ABC deferred in favor of his own podiatrist who apparently was on vacation. Blood and wound cultures were obtained, and ABC received a dose of intravenous amoxicillin, but because of his refusal to receive wound debridement and care at both hospitals, he was sent home that same afternoon.
ABC left the wound clinic back to his home in the Tier 2 city. After 3 days, he was immediately admitted in the hospital there and intravenous vancomycin was administered. Plain films of the foot were consistent with osteomyelitis. An MRI of the foot demonstrated cellulitis, myositis, and a forefoot abscess. Within 24 hours of admission, ABC developed chest pain and was subsequently ruled-in for a non–ST-elevation Myocardial Infarction. ABC ended up getting a left heart catheterization, and this delayed surgical debridement of his infected foot. Ultimately, ABC did have debridement of his foot, but the infection had advanced to the point that a below-the-knee amputation was required. Surgical pathology cultures were positive for methicillin-resistant Staphylococcus aureus (MRSA).