Diabetic with a foul plantar ulcer over the 1st metatarsal head for 6 weeks; probe touches bone; swollen red forefoot; T 37.9 °C (or back pain with fever — vertebral osteomyelitis)
Red flags
SIRS/sepsis
Crepitus or gas on X-ray
Absent pulses, rest pain
Neuro deficit with back pain
Differential diagnosis
Charcot neuroarthropathy (hot, swollen, no ulcer)
Soft-tissue infection only
Gout
Malignancy / metastasis (spine)
TB spine
When to admit, call ICU or discharge
Admit: Moderate/severe diabetic foot infection, osteomyelitis needing IV therapy or surgery, vertebral osteomyelitis
ICU: Septic shock, necrotising infection
Surgery: Abscess, necrosis, gas, dead bone, epidural abscess
Key points
Probe-to-bone positive in a diabetic foot ulcer strongly suggests osteomyelitis.
Up to half of diabetic foot osteomyelitis can be cured with antibiotics alone if small and well perfused — but surgery shortens treatment.
India: Pott spine (TB) must be sought in vertebral osteomyelitis — biopsy before treating.
Never
Treat on a superficial ulcer swab
Start antibiotics before a bone biopsy in a stable patient
Ignore the blood supply
Discharge without offloading and diabetes control
Common mistakes
Swab-guided treatment
Missing ischaemia
Too-long courses after complete resection
No biopsy in vertebral osteomyelitis
Disposition and follow-up
Multidisciplinary foot team; OPAT or oral step-down; podiatry follow-up.
ICU Decoded — original critical-care and internal-medicine pathways by
Dr Javed Akhtar, each cited to a current guideline. For education and quick
reference; verify every dose against local protocols before prescribing.