The patient is a 63-year-old man with a 5-year history of type 2 diabetes who has had left DFUs for three years. He is also a retired employee of the education department with a middle level of socioeconomic status. So far, he has been hospitalized three times for the routine treatment of DFU (normal saline wound dressing and antibiotic therapy). He shows poor glycemic control and has a history of hypertension and iron deficiency anemia. The patient also has a family history of diabetes and high blood pressure. He is not a smoker and denies a history of drug and alcohol abuse.
The patient had referred to Imam Reza Hospital in Urmia on 8 June 2019 with a chief complaint of ulceration on the left foot. In history-taking and physical examination, it was found that the patient had antibiotic-resistant DFUs (the organisms of Staphylococcus aureus and Pseudomonas aeruginosa has been reported responsible for the infection in patient culture-antibiogram) on three sites of the left external ankle in the form of two deep, circular ulcers with sizes of 6×4 cm and 6×8 cm, the sole as a superficial ulcer with a size of 6×3 cm, and the left heel as a deep skin groove (Fig. 1). Moreover, the left hallux was completely gangrenous (Fig. 1). Some of the patient's laboratory data on admission were as follows:
Hemoglobin A1C = 7/5%
Blood Sugar = 550 mg/dl
High-density lipoprotein 38 mg/dl
Low-density lipoprotein 75 mg/dl
Cholesterol 182 mg/dl
Triglycerides 79 mg/dl
Blood urea = 19.1 mg/dl
Blood creatinine = 0.83 mg/dl
Hemoglobin = 8/9 g/dl
Hematocrit = 32%
During the hospital stay, the patient first received Amp Ciprofloxacin 400 mg Intravenous (IV) q12h (BID) and Amp Clindamycin 900 mg IV q8h (TDS) for four days, and then he received Amp Meropenem 1 g IV TDS and Amp Vancomycin 1 g IV BID for two weeks. In addition, to control blood sugar, he was on Novorapid insulin six units TDS and Lantus Insulin 25 units at night before bedtime. To control blood pressure, he was taking Tab Captopril 25mg BID.
The patient underwent an initial examination, Color Flow Doppler, and Magnetic Resonance Imaging (MRI). The findings did not show any abnormalities in the left foot’s circulatory system, although the results of the MRI confirmed the diagnosis of osteomyelitis of the left hallux. Moreover, due to a low hemoglobin level on admission, a single unit of packed red blood cells was injected into the patient. The patient's DFU also had an annoying odor, so that other patients complained of an unpleasant odor. The severity of diabetic foot infection was such that the patient suffered from sepsis symptoms (fever, chills, tachycardia, and hypotension). The patient's vital signs on admission were as follows: Temperature: 38.3°C, Respiration Rate: 19 bpm, Pulse Rate: 103 bpm, Blood Pressure: 150/85 mmHg. During the hospital stay, the patient received the routine DFU care (normal saline dressing twice a day and intravenous antibiotic therapy). However, she did not recover from DFU using routine wound care, so she was referred to our wound management team.
2.1. Management
First, St. Lucilia Sericata (L1 larvae) medicinal maggots were provided from the laboratory of medical entomology of the School of Public Health, Tehran University of Medical Sciences, Iran. Then on 11 June 2019, the MT was begun to conduct debridement and bacterial disinfection. For this case, the MT included preparing the wound, putting the larvae on DFUs, and finally dressing and removing the larvae after 48 hours (Fig. 2). After beginning the MT, the odor of the infection completely ended, and the MT continued for four weeks [see Additional file 1].
Furthermore, after the completion of MT, the patient's DFUs were stimulated by mechanical debridement and saline irrigation so that the whole necrotic tissue was completely removed and granulation tissue formed on the surface of the DFUs (Fig. 3). After completing the MT on 12 July 2019, the patient was discharged from the hospital with good general condition, and the treatment process was continued as home care by the wound management team. After completing the MT, to accelerate the treatment process and speed up recovery, the NPWT (applying a pressure of 125 mmHg intermittently) was used for five four-day sessions. After each session, foam dressings of the DFUs were changed until the next session (Fig. 4). All deep parts of the DFUs, especially the deep heel ulcer, were recovered due to the rapid granulation tissue growth.
Moreover, after completing the MT, silver dressing was used once every three days for two months to completely heal the DFUs (Fig. 5). The patient was finally able to walk on his left foot. Another essential part of the DFU treatment was offloading, in which the patients were instructed to avoid excessive pressure on the granulation tissue throughout the treatment period. They were also educated to use the crutch and wheelchair to transfer until the completion of the treatment. The patient's DFUs were completely healed after three months and ten days, and the patient was discharged from our service with a good and stable general condition (Fig. 5).