Osteomyelitis/Diabetic Foot Infection Consult Note

Date/Time: [Date and time of note entry]

Service: [Infectious Diseases / Multidisciplinary Wound / Other]

Location: [ED / inpatient unit / outpatient]

Requesting Service/Clinician: [Service and clinician name]

Primary Team: [Inpatient primary team] (Omit if outpatient.)

Other Involved Services: [Podiatry, vascular surgery, wound care, endocrinology, PT/OT, case management] (List all actively involved services.)

Information Sources: [Patient / family / chart review / outside records]

Limitations: [Specific information or exam limitations and reasons] (Only include if applicable; e.g., language barrier, altered mental status, dressing not removable.)

Consult Request

[Reason for consultation and specific clinical question(s)] (One to three lines. If unclear, note how clarification was obtained or remaining ambiguity.)

Brief Summary

[Patient age, diabetes status/control, ulcer location and depth, key severity modifiers (systemic illness, PAD, prior amputations, immunosuppression, renal function), current antibiotics with start date, whether deep cultures have been obtained] (One to three sentences.)

History

Wound and Infection History

[Index wound onset date, precipitant (trauma, blister, callus, foreign body), and course (stable vs progressive). Changes in drainage, odor, size, surrounding erythema. Systemic symptoms (fever, chills, malaise) or explicit absence. Prior ulcer at this site, prior osteomyelitis or amputations, Charcot history. Prior wound care and offloading practices, adherence barriers. Prior microbiology (deep/bone cultures), MRSA colonization, prior resistant organisms. Prior imaging with dates. Antibiotic exposure in past 90 days with response/failure and adverse reactions.]

Vascular History

[Claudication, rest pain, prior revascularization procedures, prior vascular studies and results. Smoking status and cessation efforts. Antiplatelet/anticoagulant therapy.]

Diabetes and Neuropathy

[Most recent HbA1c with date. Neuropathy symptoms and prior loss of protective sensation testing. Foot deformities, Charcot changes, limited joint mobility. Current footwear or offloading devices.]

Relevant Comorbidities

[Renal disease or dialysis status, hepatic disease, immunosuppression (steroids, transplant, biologics), malnutrition, history of C. difficile. Cardiac history relevant to surgical candidacy or OPAT feasibility.]

Medications and Allergies

• Current antimicrobials: [Agent, dose, route, frequency, start date, time of last dose]
• Diabetes medications: [List] (Include if relevant to inpatient glycemic management.)
• Anticoagulants/Antiplatelets: [List with indications]
• Allergies: [Agent, reaction type, timing, severity] (Differentiate intolerance vs immune-mediated reaction.)

Social and Disposition Factors

[Living situation, ability to perform wound care, caregiver support, mobility and offloading compliance capacity, transportation barriers to follow-up, substance use relevant to OPAT safety and line care.]

Review of Systems

• Constitutional: [Fever, chills, malaise]
• Musculoskeletal: [Foot pain, weight-bearing difficulty]
• Skin: [Spreading erythema, bullae, drainage/odor changes]
• Neurologic: [Neuropathy symptoms, numbness/tingling]
• Vascular: [Rest pain, color changes, cold extremity]
• GI: [Diarrhea] (Note if recent antibiotics.)

Physical Examination

Vitals and General

• Vitals: [T, HR, BP, RR, SpO2 with date/time] (Include trends if clinically meaningful.)
• General appearance: [Toxic / non-toxic]; Mentation: [Normal / altered]
• Sepsis/hemodynamic instability: [Present / absent] (Specify findings if present.)

Lower Extremity Examination

(Document both legs when comparison is relevant.)

Wound Description:

• Side/Location: [Right / Left; anatomic location and surface]
• Wound type: [Neuropathic ulcer / traumatic / surgical / ischemic / other]
• Measurements: [Length × width × depth with method and date]
• Depth to structures: [Dermis / subcutaneous / tendon / joint / bone] (Note if tendon or bone exposed.)
• Probe-to-bone: [Positive / negative / not performed] (If not performed, state reason.)
• Wound bed: [Granulation %, slough %, eschar %]
• Drainage: [Amount, character, odor]
• Periwound skin: [Maceration, callus, margins]
• Inflammation: [Erythema extent in cm from edge, warmth, tenderness, induration, fluctuance]
• Undermining/tunneling/sinus tracts: [Presence, direction, depth]
• Concerning features: [Crepitus, bullae, skin discoloration suggesting necrotizing infection] (Include only if present.)
• Foreign material/hardware: [Visible / palpable / none]

Vascular Examination:

• Pulses: Dorsalis pedis [present / diminished / absent]; Posterior tibial [present / diminished / absent] (Note if Doppler used.)
• Perfusion signs: [Capillary refill, skin temperature, dependent rubor/pallor, edema]
• Noninvasive testing: [ABI, TBI, toe pressures, TcPO2, skin perfusion pressure with dates/results] (If ABI unreliable, document why and alternative measure used.)

Neurologic Examination:

• Loss of protective sensation: [Monofilament and additional modality results with sites tested] (Include if performed.)
• Motor function: [Findings relevant to deformity and gait]
• Pain assessment: [Findings] (Note that neuropathy may blunt symptoms.)

Musculoskeletal:

• Deformities: [Hammer toes, prominent metatarsal heads, Charcot findings]
• Range of motion: [Limitations]
• Weight-bearing ability: [Full / partial / non-weight-bearing; device used]

(If any element cannot be assessed, document the specific reason.)

Diagnostics

Laboratory Data

• CBC with differential: [Values with date; trend if applicable]
• BMP: [Creatinine and electrolytes with date]
• Inflammatory markers: [ESR, CRP with dates; trends]
• HbA1c: [Value with date]
• Albumin/Prealbumin: [Value] (Include if nutrition concern.)
• Blood cultures: [Collection times, results]
• Lactate: [Value] (Include if systemic illness suspected.)

Imaging

• Plain radiographs: [Body part, laterality, date, key findings, impression]
• MRI: [Body part, laterality, date, marrow signal changes, abscess, sinus tracts, hardware] (Include if performed.)
• Nuclear medicine/PET: [Study type, date, findings] (Include if MRI contraindicated or diagnosis uncertain.)

Microbiology and Pathology

(Separate by specimen type. Prioritize deep tissue and bone cultures over superficial swabs.)

• Superficial swab: [Collection date, cleansing/debridement prior, organisms, susceptibilities, polymicrobial status] (Note limited diagnostic value.)
• Deep tissue: [Collection date, method, antibiotics at time, organisms with susceptibilities]
• Bone culture: [Percutaneous / intraoperative; date; antibiotics at time; organisms with susceptibilities]
• Bone histopathology: [Acute vs chronic osteomyelitis, necrosis]
• Resection/Amputation margins: [Margin status; evaluation method (culture, histology)]
• Blood cultures: [Results with dates]

Assessment

Infection Classification

Status: [Not infected / Infected: mild / moderate / severe per IWGDF/IDSA]

Supporting findings: [Local signs, systemic toxicity, SIRS criteria] (List specific findings supporting classification.)

Osteomyelitis Assessment

Suspicion level: [Unlikely / possible / probable / confirmed]

Supporting evidence: [Probe-to-bone result; imaging findings; ESR/CRP; bone culture/histology]

Alternative explanations: [Charcot neuroarthropathy, gout, fracture, post-surgical changes] (Include if relevant.)

Vascular and Healing Assessment

Perfusion: [Adequate / inadequate / uncertain for healing]

Ischemia as barrier: [Yes / no]

Urgent vascular evaluation: [Emergent / urgent / routine / not needed]

Pathogen Risk Assessment

• MRSA risk: [Low / moderate / high] (Based on prior MRSA, colonization, local prevalence, severity.)
• Pseudomonas risk: [Low / elevated] (Provide rationale if coverage included.)
• Resistant gram-negative risk: [Low / moderate / high]
• Anaerobes risk: [Low / elevated] (Consider ischemic/necrotic tissue, foul odor, deep chronic wounds.)
• Empiric rationale: [If no cultures, state empiric coverage choices and de-escalation triggers.]

Plan

Source Control and Surgical Coordination

• Surgical evaluation urgency: [Emergent / urgent within 24–48 hours / routine / not indicated]
• Indications: [Necrotizing infection / abscess / compartment syndrome / extensive gangrene / severe ischemia] (Include if applicable.)
• Debridement plan: [Bedside / OR]; anticipated extent: [Soft tissue debridement / bone resection / amputation level]
• Specimens requested: [Deep tissue and bone for culture and histology; label proximal margin separately]
• Peri-procedural antibiotics: [Continue / hold / modify] (State timing relative to specimen collection.)
• Responsible service: [Podiatry / vascular surgery / orthopedics / primary team]

Deep Culture Strategy

• Preferred approach: [Aseptically collected deep tissue after cleansing/debridement]
• Bone specimen: [Percutaneous / intraoperative] (Obtain when osteomyelitis suspected.)
• Antibiotic hold: [Can hold safely / cannot hold]; antibiotic-free interval: [Duration or N/A] (State rationale.)
• Studies: [Gram stain, aerobic and anaerobic cultures, histopathology for bone] (Request fungal/AFB only with risk factors.)
• Constraints: [If deep culture cannot be obtained, document reason and impact on diagnosis/stewardship.]

Antimicrobial Therapy

Empiric Regimen:

• Agents: [Drug(s), dose, route, frequency]
• Targets: [Gram-positive ± MRSA / Gram-negative ± Pseudomonas / anaerobes]
• Rationale: [Severity, prior cultures, epidemiology, exposure risks]
• Dose adjustments: [Renal/hepatic considerations]

Definitive Regimen:

• De-escalation plan: [Based on culture/susceptibility results and clinical response]
• Selected agent(s): [Drug(s), dose, route, frequency]

Route:

• Clinical stability: [Stable / unstable]; GI absorption: [Intact / impaired]
• Route decision: [Oral step-down appropriate / IV therapy required]
• OPAT: [Required / not required] (If required: line type, insertion plan.)

Duration:

• Start date anchor: [Date or event, e.g., adequate source control]
• Soft tissue infection: [Duration] (Extend if slow response or severe.)
• Osteomyelitis without resection: [Duration and remission assessment plan]
• Post-resection/amputation: [If margins negative: duration; if margins positive: duration]
• Planned stop date: [Explicit date or conditional criteria]

Monitoring:

• Toxicity labs: [Renal, hepatic, CBC; frequency; responsible reviewer]
• Therapeutic drug monitoring: [Agent, target levels, timing] (Include if indicated.)
• C. difficile risk mitigation: [Strategies; avoid duplicate anaerobic coverage]

Vascular Management

• Vascular surgery consult: [Emergent / urgent / routine / not needed]
• Noninvasive testing: [Ordered / reviewed / not indicated]
• Revascularization: [Needed / not needed / pending evaluation] (Coordinate timing with source control.)

Wound Care and Offloading

• Cleansing: [Method and frequency]
• Dressing: [Goals: exudate management, moist environment, antimicrobial if indicated]
• Debridement frequency: [Bedside vs clinic schedule]
• Offloading: [Device: TCC, removable cast walker, postoperative shoe, other]
• Weight-bearing: [Full / partial / non-weight-bearing]; PT/OT involvement: [Yes / no]

Glycemic and Comorbidity Management

• Glycemic targets: [Targets and adjustments; coordinating service]
• Nutrition support: [Plan] (Include if indicated.)
• Edema management: [Plan] (Include if venous component present.)

Disposition and Follow-Up

• Wound clinic/Podiatry: [Timing]
• Infectious Diseases: [Timing]
• Vascular surgery: [Timing] (Include if indicated.)
• Outpatient antibiotics: [Regimen, route, stop date]
• OPAT monitoring: [Line type, lab frequency, responsible reviewer, contingency plan] (Include if OPAT required.)
• Home wound care: [Dressing change frequency, supplies, home health involvement]
• Discharge offloading: [Device, weight-bearing status, footwear instructions]
• Return precautions: [Worsening erythema, new fever, increased drainage/odor, pain out of proportion, black discoloration, inability to bear weight]
• Pending items: [What is pending and responsible party]

Communication

• Recommendations communicated to: [Primary team/consultants; names or services] at [time]
• Pending results for reassessment: [Cultures, MRI, vascular studies, other]