Diabetes is the leading cause of non-traumatic lower limb amputations which are preventable with education, early recognition and  appropriate therapy.

We would like to share the  course  of the disease of a type 2 diabetic patient with huge wounds infected with multidrug resistant Gram negative bacteria on the lower limbs.

S.A. was admitted to the hospital with very wide lesions on both legs. They were Wagner stage 3 lesions with longest diameter of 20 cm on right , 30 cm on left lower limb.  Fever, leucocytosis,  high CRP were compatible with an infection. Infected tissue was sent to the Department of Clinical Microbiology. Klebsiella pneumoniae and Morganella morganii  were cultured from the infected tissue. Both of the bacteria were multidrug resistant and even K. pneumoniae had carbapenemase. Eradication was succeeded by daily wound care with debridement (when needed) and tigecycline infusion.  He was discharged from the hospital at the end of four months with improved and clean but still open wounds. 

After 8 months, patient was readmitted to the hospital with widened and infected wounds and positive acute phase reactants. This time, Alcaligenes faecalis was cultured from the infected tissue. It was sensitive to cefepime, amikacin,  trimethoprim / sulfamethoxazole and ciprofloxacin and was eradicated with combination of cefepime and ciprofloxacin  in 38 days.  After eradicating the infection, intralesional epidermal growth factor (Heberprot-P 75 mcg) have been used to help the epithelisation and reduction of the wound size.

This is a case with recurrent mixed infections on diabetic wounds that are too wide to heal up without getting complicated by multipl infective agents; occurring repetitively in spite of good care.