Table 1 Standardised clinical scenarios from survey

Scenario 1

 Part A:

  A highly functioning 63 year old lady with a history of hypertension and poorly controlled type 2 diabetes mellitus is found to have a deep heel ulcer which has been present for five weeks. She has had no previous treatment. She is afebrile with normal heart rate and blood pressure. Examination reveals a deep 2 × 3 cm ulcer with 3 cm of surrounding cellulitis and purulent discharge consistent with infection. The ulcer does not probe to bone. Peripheral pulses are present and her foot has good capillary refill, but there is evidence of peripheral neuropathy.

  Her white blood cell count is normal, ESR is 55 and a plain X-ray does not show osteomyelitis. A CT angiogram two months earlier revealed good arterial blood flow to both legs. She has no allergies, is a low anaesthetic risk and has normal renal function.

  You decide to investigate for osteomyelitis. What technique would you use (assuming all are available)?

 Part B:

  The imaging reveals no evidence of osteomyelitis, but evidence of deep soft tissue infection. Surgical debridement is undertaken but residual infection remains with non-debrided deep soft tissue samples growing fully sensitive E. coli, fully sensitive P. aeruginosa and methicillin sensitive S. aureus (MSSA) (penicillin-resistant). She is not known to be colonised by MRSA and there is a low prevalence of MRSA at your institution. Adherence is not thought likely to be an issue. What antibiotic strategy would you choose?

Scenario 2

 A highly functioning, independent 65 year old retired man with poorly controlled type 2 diabetes mellitus but no previous complications develops an ulcer overlying his 5th metatarsal head. After six weeks without treatment he attends your hospital and is found to have osteomyelitis of his 5th metatarsal head. He is afebrile with an ESR of 75. There is evidence of peripheral neuropathy and moderate peripheral arterial disease with an ankle brachial index of 0.5. A CT angiogram reveals distal small vessel disease that cannot be corrected surgically or endovascularly. He has no allergies and has normal renal function. He is not known to be colonised with MRSA and there is a low prevalence of MRSA at your institution. He has previously been adherent to oral medication and is thought to be reliable with taking medication.

 The patient is concerned amputation will impact on his golf and refuses amputation. He undergoes debridement of the ulcer and bone. Moderate growth of MSSA (penicillin resistant) is cultured from non-debrided deep tissue and direct microscopy reveals Gram-positive cocci. The surgeon says that there is some residual infected bone and tissue but the bone appears healthy. What antibiotic strategy would you choose?