SLR - June 2023 - Kevin Deidrick, DPM
Title: Inappropriate antibiotic administration in the setting of Charcot Arthropathy: A Case seriesReference: Shazadeh Safavi K, Janney C, Shazadeh Safavi P, Kunzler D, Jupiter D, Panchbhavi V. Inappropriate antibiotic administration in the setting of Charcot arthropathy: A case series and literature review. Prim Care Diabetes. 2022 Feb;16(1):202-206. doi: 10.1016/j.pcd.2021.11.009. Epub 2021 Dec 7. PMID: 34893452.
Level of evidence: Level 3
Scientific Literature Review
Reviewed By: Kevin Deidrick, DPM
Residency Program: Baylor Scott and White
Podiatric Relevance: Charcot arthropathy is a relatively common pathology that podiatrists encounter. Acute Charcot can be misdiagnosed in a clinical setting to other more common conditions such as an infectious process. Being able to recognize and appropriately treat acute Charcot early has direct correlation with improved patient outcomes. This article hypothesizes that unnecessarily prescribing antibiotics can contribute to overall antibiotic resistance and overall morbidity.
Methods: This is a retrospective review of electronic medical records from January 2010 to December 2017 for patients who were diagnosed with Charcot by a single foot and ankle fellowship trained orthopedic surgeon. 158 medical records were reviewed, and 55 were subsequently removed due to exclusion criteria. The diagnosis of Charcot arthropathy was based on the presence of clinical symptoms, radiographic findings, and erythema that decreased with leg elevation.
Results: Of the 103 medical records reviewed, 58 patients received antibiotics (56%) on the date or within 7 days of the referral placed to the foot and ankle specialist. There was no statically significant difference between each cohorts’ gender, age, diabetic status, or Eichenholtz progression using t -tests and Fisher’s exact/χ 2 tests, for continuous and discrete variables, respectively. The referring departments were: internal medicine 31 of 58 (53%), family medicine 13 of 58 (28%), endocrinology 8 of 58 (14%), and plastic surgery 3 of 58 (5%). At the time of diagnosis Eichenholtz Stage I was present in 2 of 58 (3%) patients and Eichenholtz Stage II was seen in 1 patient out of 58 (2%) and the remainder presented as Eichenholtz Stage 0.
Conclusions: The authors concluded that misdiagnosis of Charcot arthropathy worsens patient outcomes, healthcare expenditures, and contributes to the unnecessary prescription of antibiotics contributing to antibiotic resistance. Their literature review showed that up to 95% of non-specialist physicians misdiagnose Charcot at the time of referral, and that many physicians throughout various specialties were unaware of Charcot arthropathy. The average delay in diagnosis was found to be approximately 29 weeks, with a cited article showing that complication rates increase up to 378% when the diagnosis of Charcot was delayed at 8 weeks versus those diagnosed at 4 weeks. Overall this study highlights the importance of having awareness of early presentation of acute Charcot arthropathy within a clinical or hospital setting. Additionally, the article demonstrates the importance of reaching out to colleagues who are not specializing in the foot or ankle to ensure awareness of Charcot, with the hope to limit morbidity and unnecessary antibiotic use.