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{{Diabetic foot}}
{{Diabetic foot}}
 
{{CMG}}; {{AE}} {{Alonso}} {{Anahita}}
{{CMG}}; {{AE}} {{Alonso}}


==Overview==
==Overview==
Appropriate [[wound]] care is essential for the management of all [[diabetic foot]] [[ulcers]]. [[infection|Uninfected]] [[diabetic foot|diabetic ulcers]] do not require [[antibiotic]] [[therapy]]. In the contrary for acutely [[infection|infected]] [[wounds]], [[Empiric therapy|empiric]] [[antibiotic]] [[therapy]] with coverage against [[Gram-positive bacteria|Gram-positive cocci]] should be start right after obtaining a post-[[debridement]] specimen for [[aerobic]] and [[anaerobic]] [[Tissue culture|culture]]. [[Infections]] with [[antibiotic]]-resistant [[organisms]] and those that have [[Chronic (medical)|chronic]] or severe [[ulcers]] or have been previously [[treatment|treated]] usually require broader spectrum regimens. [[Treatment]] strategies are dependent on [[ulcer]]'s grade, presence of [[infection]] and [[perfusion]]. For an effective [[treatment]] which lower the chance of the future [[diabetic foot]] [[ulcers]] control of [[blood sugar]], [[pressure]] off-loading and [[treatment]] of other [[Comorbidity|comorbidities]] are also critical. Aim of [[treatment]] should be focused on improving [[prognosis]] and decreasing [[Complication (medicine)|complications]] such as [[amputation]]. In very severe [[ulcers]] or when the [[patient]] has the history of previous [[MRSA]] [[infection]] or colonization within the past year and in regions with high [[prevalence]] of [[MRSA]] [[infection]], [[Methicillin-resistant staphylococcus aureus|MRSA]] should be also covered by [[antibiotic]] [[treatments]]. For an ideal [[treatment]] [[physicians]] should evaluate the severity of [[ulcers]] and possible [[risk factors]] of [[pseudomonas aeruginosa]] or [[Beta-lactamase|extended-spectrum β-lactamase (ESBL)–producing organisms]].


Appropriate wound care is essential for the management of all diabetic foot ulcers. Uninfected diabetic ulcers do not require antibiotic therapy. For acutely infected wounds, empiric antibiotic with efficacy against [[Gram-positive bacteria|Gram-positive cocci]] should be initiated after obtaining a post-[[debridement]] specimen for [[aerobic]] and [[anaerobic]] culture. Infections with antibiotic-resistant organisms and those that are chronic, previously treated, or severe usually require broader spectrum regimens.
==Diabetic Foot Ulcer==
The Cochrane Collaboration has reviewed hydrocolloids<ref name="pmid23922167">{{cite journal| author=Dumville JC, Deshpande S, O'Meara S, Speak K| title=Hydrocolloid dressings for healing diabetic foot ulcers. | journal=Cochrane Database Syst Rev | year= 2013 | volume=  | issue= 8 | pages= CD009099 | pmid=23922167 | doi=10.1002/14651858.CD009099.pub3 | pmc=7111300 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23922167  }} </ref>, hydrogels<ref name="pmid23846869">{{cite journal| author=Dumville JC, O'Meara S, Deshpande S, Speak K| title=Hydrogel dressings for healing diabetic foot ulcers. | journal=Cochrane Database Syst Rev | year= 2013 | volume=  | issue= 7 | pages= CD009101 | pmid=23846869 | doi=10.1002/14651858.CD009101.pub3 | pmc=6486218 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23846869  }} </ref>, and alginates<ref name="pmid23799857">{{cite journal| author=Dumville JC, O'Meara S, Deshpande S, Speak K| title=Alginate dressings for healing diabetic foot ulcers. | journal=Cochrane Database Syst Rev | year= 2013 | volume=  | issue= 6 | pages= CD009110 | pmid=23799857 | doi=10.1002/14651858.CD009110.pub3 | pmc=7111427 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23799857  }} </ref>.


==Diabetic Foot Infection==
The International Working Group on the Diabetic Foot (IWGDF) recommends<ref name="pmid32176450">{{cite journal| author=Rayman G, Vas P, Dhatariya K, Driver V, Hartemann A, Londahl M | display-authors=etal| title=Guidelines on use of interventions to enhance healing of chronic foot ulcers in diabetes (IWGDF 2019 update). | journal=Diabetes Metab Res Rev | year= 2020 | volume= 36 Suppl 1 | issue=  | pages= e3283 | pmid=32176450 | doi=10.1002/dmrr.3283 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=32176450  }} </ref>:
* "Dressings should be selected principally on the basis of exudate control, comfort, and cost"


===Principles of Therapy <small><small><small><small><small>Adapted from ''Diabetes Care. 2013;36(9):2862-71.''<ref name="pmid23970716">{{cite journal| author=Wukich DK, Armstrong DG, Attinger CE, Boulton AJ, Burns PR, Frykberg RG et al.| title=Inpatient management of diabetic foot disorders: a clinical guide. | journal=Diabetes Care | year= 2013 | volume= 36 | issue= 9 | pages= 2862-71 | pmid=23970716 | doi=10.2337/dc12-2712 | pmc=PMC3747877 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23970716  }} </ref> and ''Clin Infect Dis. 2012;54(12):e132-73.''<ref name="pmid22619242">{{cite journal| author=Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG et al.| title=2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. | journal=Clin Infect Dis | year= 2012 | volume= 54 | issue= 12 | pages= e132-73 | pmid=22619242 | doi=10.1093/cid/cis346 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22619242  }} </ref></small></small></small></small></small>===
Hydrocolloids and hydrogels are available as generic bandages.


======Diagnosis of Diabetic Foot Infection======
==Diabetic Foot Infection==


* Diabetic foot infection (DFI) is diagnosed clinically by the presence of <u>at least two</u> signs or symptoms of inflammation:
===Principles of Therapy <SMALL><SMALL><SMALL><SMALL><SMALL>Adapted from ''Diabetes Care. 2013;36(9):2862-71.''<ref name="pmid23970716">{{cite journal| author=Wukich DK, Armstrong DG, Attinger CE, Boulton AJ, Burns PR, Frykberg RG et al.| title=Inpatient management of diabetic foot disorders: a clinical guide. | journal=Diabetes Care | year= 2013 | volume= 36 | issue= 9 | pages= 2862-71 | pmid=23970716 | doi=10.2337/dc12-2712 | pmc=PMC3747877 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23970716  }} </ref> and ''Clin Infect Dis. 2012;54(12):e132-73.''<ref name="pmid22619242">{{cite journal| author=Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG et al.| title=2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. | journal=Clin Infect Dis | year= 2012 | volume= 54 | issue= 12 | pages= e132-73 | pmid=22619242 | doi=10.1093/cid/cis346 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22619242  }} </ref></SMALL></SMALL></SMALL></SMALL></SMALL>===
:* Local [[swelling]] or [[induration]]
*[[Treatment]] strategies are dependent on [[ulcer]]'s grade, presence of [[infection]] and [[perfusion]].<ref name="Frykberg1998">{{cite journal|last1=Frykberg|first1=Robert G.|title=Diabetic foot ulcers: Current concepts|journal=The Journal of Foot and Ankle Surgery|volume=37|issue=5|year=1998|pages=440–446|issn=10672516|doi=10.1016/S1067-2516(98)80055-0}}</ref>
:* [[Erythema]]
*[[Treatment]] of [[diabetic foot]] should consist of intensive [[wound]] [[therapy]], [[infection]] [[treatment]], control of [[blood sugar]], [[pressure]] off-loading and [[treatment]] of [[Comorbidity|comorbidities]].<ref name="pmid18442189">{{cite journal| author=Apelqvist J, Bakker K, van Houtum WH, Schaper NC, International Working Group on the Diabetic Foot (IWGDF) Editorial Board| title=Practical guidelines on the management and prevention of the diabetic foot: based upon the International Consensus on the Diabetic Foot (2007) Prepared by the International Working Group on the Diabetic Foot. | journal=Diabetes Metab Res Rev | year= 2008 | volume= 24 Suppl 1 | issue=  | pages= S181-7 | pmid=18442189 | doi=10.1002/dmrr.848 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18442189  }} </ref>   
:* Local [[tenderness]] or pain
*Aim of [[treatment]] should be focused on improving [[prognosis]] and decreasing [[Complication (medicine)|complications]] such as [[amputation]].<ref name="pmid10097908">{{cite journal| author=Holstein PE, Sørensen S| title=Limb salvage experience in a multidisciplinary diabetic foot unit. | journal=Diabetes Care | year= 1999 | volume= 22 Suppl 2 | issue=  | pages= B97-103 | pmid=10097908 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10097908  }} </ref>
:* Local warmth
*[[Dressing (medical)|Saline wet-to-dry dressings]] are recommended for [[diabetic foot]] [[ulcers]].<ref name="pmid11280471">{{cite journal| author=Frykberg RG, Armstrong DG, Giurini J, Edwards A, Kravette M, Kravitz S | display-authors=etal| title=Diabetic foot disorders: a clinical practice guideline. American College of Foot and Ankle Surgeons. | journal=J Foot Ankle Surg | year= 2000 | volume= 39 | issue= 5 Suppl | pages= S1-60 | pmid=11280471 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11280471  }} </ref><ref name="pmid10480782">{{cite journal| author=American Diabetes Association| title=Consensus Development Conference on Diabetic Foot Wound Care: 7-8 April 1999, Boston, Massachusetts. American Diabetes Association. | journal=Diabetes Care | year= 1999 | volume= 22 | issue= 8 | pages= 1354-60 | pmid=10480782 | doi=10.2337/diacare.22.8.1354 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=10480782  }} </ref><ref name="ArmstrongHarkless2000">{{cite journal|last1=Armstrong|first1=DG|last2=Harkless|first2=LB|last3=Nguyen|first3=H|last4=Krasner|first4=D|last5=Hogge|first5=J|title=The potential benefits of advanced therapeutic modalities in the treatment of diabetic foot wounds|journal=Journal of the American Podiatric Medical Association|volume=90|issue=2|year=2000|pages=57–65|issn=8750-7315|doi=10.7547/87507315-90-2-57}}</ref>
:* [[Pus|Purulent discharge]] (thick, opaque to white or sanguineous secretion)
*[[Dressing (medical)|Dressings]] such as [[Dressing (medical)|foams]], [[Dressing (medical)|semipermeable films]], [[Dressing (medical)|hydrocolloids]], and [[Dressing (medical)|calcium alginate swabs]] are recommended since they provide a warm and moist environment that augment [[wound healing]] and prevent [[ulcer]] contamination.<ref name="ArmstrongHarkless2000">{{cite journal|last1=Armstrong|first1=DG|last2=Harkless|first2=LB|last3=Nguyen|first3=H|last4=Krasner|first4=D|last5=Hogge|first5=J|title=The potential benefits of advanced therapeutic modalities in the treatment of diabetic foot wounds|journal=Journal of the American Podiatric Medical Association|volume=90|issue=2|year=2000|pages=57–65|issn=8750-7315|doi=10.7547/87507315-90-2-57}}</ref>
*Using [[topical]] [[antiseptics]] such as [[povidone-iodine]] must be avoided due to [[toxicity|toxic effects]] of these agents on [[wound healing]].<ref name="Frykberg1998">{{cite journal|last1=Frykberg|first1=Robert G.|title=Diabetic foot ulcers: Current concepts|journal=The Journal of Foot and Ankle Surgery|volume=37|issue=5|year=1998|pages=440–446|issn=10672516|doi=10.1016/S1067-2516(98)80055-0}}</ref>


======Indications for Hospitalization======
======Indications for Hospitalization======


* [[Hospitalization]] is appropriate for the following conditions:
* [[Hospitalization]] is appropriate for the following conditions:
:* Severe (grade 4) infections
:* Severe (grade 4) [[infections]]
:* Moderate (grade 3) infections with complicating features  
:* Moderate (grade 3) [[infections]] with [[Complication (medicine)|complicating features]]
::* Severe [[peripheral arterial disease]] or limb [[ischemia]]
::* Severe [[peripheral arterial disease]] or [[Limb (anatomy)|limb]] [[ischemia]]
::* Lack of home support
::* Lack of home support
:* Patients unable to comply with the required outpatient treatment regimen for psychological or social reasons
:* [[Patients]] who are unable to comply with the required [[patient|outpatient]] [[treatment|treatment regimen]] for psychological or social reasons
:* Patients not responding to [[outpatient]] treatment
:* [[Patients]] who are not responding to [[outpatient]] [[treatments]]
 
======Obtaining Specimens======
 
* Properly obtained specimens for culture prior to initiating empiric therapy provide useful information for guiding antibiotic selection, particularly in those with chronic or previously treated infections which are commonly caused by [[Gram-negative bacilli]] or [[obligate anaerobic|obligate anaerobic organisms]].
:* Infected wounds should be cultured by obtaining tissue samples during any surgical procedure or by tissue [[biopsy]] or wound base [[curettage]].
:* Bone cultures are optimal for detecting the pathogen in [[osteomyelitis]], but blood cultures are only necessary for those with a severe (grade 4) infection.
:* Cultures may be unnecessary for mild infections in patients who have not recently received antibiotic therapy and who are at low risk for [[MRSA|methicillin-resistant ''Staphylococcus aureus'' (MRSA)]] infection; these infections are predictably caused solely by [[staphylococci]] and [[streptococci]].
:* Cultures may yield organisms that are commonly considered to be contaminants (eg, [[CoNS|coagulase-negative staphylococci]], [[corynebacteria]]), but these may be true pathogens in DFIs and are often resistant to the empiric antibiotics.


======Consultation======
======Consultation======


* Conditions to request consultation from specialists:
* Conditions to request [[consultation]] from specialists:
:* Urgent surgical intervention should be sought for DFIs accompanied by gas in the deeper tissues, an [[abscess]], or [[necrotizing fasciitis]], and less urgent surgery for DFIs with substantial nonviable tissue or extensive bone or joint involvement.
:* Urgent [[surgery|surgical intervention]] should be sought for [[diabetic foot]] [[infections]] accompanied by [[gas]] in the deeper [[Tissue (biology)|tissues]], an [[abscess]], or [[necrotizing fasciitis]], and less urgent [[surgery]] for [[diabetic foot]] [[infections]] with substantial nonviable [[Tissue (biology)|tissue]] or extensive [[bone]] or [[joint]] involvement.
:* Consult a vascular surgeon to consider [[revascularization]] if ischemia complicates a DFI.
:* Consult a [[Vascular surgery|vascular surgeon]] to consider [[revascularization]] if [[ischemia]] [[Complication (medicine)|complicates]] a [[diabetic foot]] [[infection]].
:* Infectious diseases specialists should be consulted when cultures yield multiple or antibiotic-resistant organisms, the patient has substantial [[renal impairment]], or the infection does not respond to appropriate medical or surgical therapy in a timely manner.
:* [[Infectious]] [[diseases]] specialists should be consulted when [[tissue culture|cultures]] yield multiple or [[antibiotic]]-resistant [[organisms]], the [[patient]] has substantial [[renal impairment]], or the [[infection]] does not respond to appropriate medical or [[surgery|surgical]] [[therapy]] in a timely manner.


======Adjunctive Therapy======
======Adjunctive Therapy======
 
* No [[Adjuvant therapy|adjunctive therapy]] has been proven to improve [[infection]] resolution, but for selected [[diabetic foot]] [[wounds]] that are slow to [[wound healing|heal]], [[physicians]] might consider using [[Bioengineering|bioengineered]] [[skin]] equivalents, [[growth factors]], [[G-CSF|granulocyte colony-stimulating factors]], [[hyperbaric oxygen]] [[therapy]], or negative [[pressure]] [[wound]] [[therapy]].
* No adjunctive therapy has been proven to improve resolution of infection, but for selected diabetic foot wounds that are slow to heal, clinicians might consider using bioengineered skin equivalents, growth factors, [[G-CSF|granulocyte colony-stimulating factors]], [[hyperbaric oxygen]] therapy, or negative pressure wound therapy.
*[[Becaplermin]] is a [[human]] [[platelet]]-derived [[growth factor]] (also known as [[Becaplermin|Regranex gel]]) can be used for [[neuropathy|neuropathic]] [[diabetic foot]] [[ulcers]]. It can augment [[wound healing]] by causing [[chemotaxis]] and [[Mitosis|mitogenesis]] of [[Cell (biology)|cells]] such as [[neutrophils]], [[fibroblasts]], and [[monocytes]].<ref name="pmid9589248">{{cite journal| author=Wieman TJ, Smiell JM, Su Y| title=Efficacy and safety of a topical gel formulation of recombinant human platelet-derived growth factor-BB (becaplermin) in patients with chronic neuropathic diabetic ulcers. A phase III randomized placebo-controlled double-blind study. | journal=Diabetes Care | year= 1998 | volume= 21 | issue= 5 | pages= 822-7 | pmid=9589248 | doi=10.2337/diacare.21.5.822 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9589248  }} </ref>
*Some new types of [[biology|biologically active]] [[Implant (medicine)|implants]] such as [[Bioengineering|bioengineered]] [[skin]] (Apligraf) and [[human]] [[dermis]] (Dermagraft) (which are derived from [[Infant|neonatal]] [[foreskin]]) are recommended for faster [[wound healing]]. These [[Implant (medicine)|implants]] function as a source of [[growth factors]] and [[extracellular matrix]] which are critical for [[wound healing]].<ref name="ArmstrongHarkless2000">{{cite journal|last1=Armstrong|first1=DG|last2=Harkless|first2=LB|last3=Nguyen|first3=H|last4=Krasner|first4=D|last5=Hogge|first5=J|title=The potential benefits of advanced therapeutic modalities in the treatment of diabetic foot wounds|journal=Journal of the American Podiatric Medical Association|volume=90|issue=2|year=2000|pages=57–65|issn=8750-7315|doi=10.7547/87507315-90-2-57}}</ref><ref name="pmid11213881">{{cite journal| author=Veves A, Falanga V, Armstrong DG, Sabolinski ML, Apligraf Diabetic Foot Ulcer Study| title=Graftskin, a human skin equivalent, is effective in the management of noninfected neuropathic diabetic foot ulcers: a prospective randomized multicenter clinical trial. | journal=Diabetes Care | year= 2001 | volume= 24 | issue= 2 | pages= 290-5 | pmid=11213881 | doi=10.2337/diacare.24.2.290 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11213881  }} </ref>


===Selection of Antibiotic Regimen===
===Selection of Antibiotic Regimen===
* Clinically [[infection|uninfected]] [[wounds]] should ''not'' be [[treatment|treated]] with [[antibiotic]] [[therapy]]. For all [[infection|infected]] [[wounds]], [[antibiotic]] [[therapy]] combined with appropriate [[wound]] care is recommended.
* For clinically [[infection|infected]] [[wounds]], consider the questions below:


* Clinically uninfected wounds should ''not'' be treated with antibiotic therapy. For all infected wounds, antibiotic therapy combined with appropriate wound care is recommended.
: '''1. Is there high risk of [[Methicillin-resistant staphylococcus aureus|MRSA]]?'''
 
* For clinically infected wounds, consider the questions below:
 
: '''1. Is there high risk of MRSA?'''
:* [[MRSA|Methicillin-resistant ''Staphylococcus auerus'' (MRSA)]] coverage should be considered in the following conditions:
:* [[MRSA|Methicillin-resistant ''Staphylococcus auerus'' (MRSA)]] coverage should be considered in the following conditions:
::* Prior history of [[MRSA]] [[infection]] or colonization within the past year
::* Prior history of [[MRSA]] [[infection]] or colonization within the past year
::* High local prevalence of [[MRSA]] [[infection]] or colonization (50% for a mild and 30% for a moderate soft tissue infection)
::* High local [[prevalence]] of [[MRSA]] [[infection]] or colonization (50% for a mild and 30% for a moderate [[Tissue (biology)|soft tissue]] [[infection]])
::* Clinically severe diabetic foot infection
::* Clinically severe [[diabetic foot]] [[infection]]


: '''2. Is the infected wound chronic or treated with antibiotics in the past month?'''
: '''2. Is the [[infection|infected]] [[wound]] [[Chronic (medical)|chronic]] or [[treatment|treated]] with [[antibiotics]] in the past month?'''
:* If so, include agents active against [[aerobic]] [[gram-negative bacilli]] in regimen.
:* If so, include agents active against [[aerobic]] [[gram-negative bacilli]] in regimen.
:* If not, agents targeted against just [[aerobic]] [[Gram-positive bacteria|Gram-positive cocci]] may be sufficient.
:* If not, agents targeted against just [[aerobic]] [[Gram-positive bacteria|Gram-positive cocci]] may be sufficient.
::* [[Aerobic]] [[gram-negative bacilli]] are frequently copathogens in infections that are chronic or follow antibiotic treatment
::* [[Aerobic]] [[gram-negative bacilli]] are frequently [[Pathogen|co-pathogens]] in [[infections]] that are [[Chronic (medical)|chronic]] or follow [[antibiotic]] [[treatment]]
::* [[Obligate anaerobe]]s may be copathogens in ischemic or necrotic wounds.
::* [[Obligate anaerobe]]s may be [[Pathogen|co-pathogens]] in [[ischemia|ischemic]] or [[necrosis|necrotic]] [[wounds]].


: '''3. Are there risk factors for infection with ''Pseudomonas aeruginosa'' or extended-spectrum β-lactamase (ESBL)–producing organisms?'''
: '''3. Are there [[risk factors]] for [[infection]] with ''[[Pseudomonas aeruginosa]]'' or [[Beta-lactamase|extended-spectrum β-lactamase (ESBL)–producing organisms]]?'''
:* Anti-pseudomonal agent is usually unnecessary <u>except</u> for patients with risk factors:
:* [[[[Pseudomonas aeruginosa|Anti-pseudomonal agent]] is usually unnecessary <u>except</u> for [[patients]] with [[risk factors]]:
::* High local prevalence of ''[[Pseudomonas aeruginosa]]'' infection
::* High local [[prevalence]] of ''[[Pseudomonas aeruginosa]]'' [[infection]]
::* Frequent exposure of the foot to water
::* Frequent exposure of the [[foot]] to water
::* Warm climate
::* Warm climate
:* Coverage of [[ESBL|ESBL]]-producing gram-negative organisms should be considered in countries in which they are relatively common.
:* Coverage of [[ESBL|ESBL]]-producing [[Gram-negative|gram-negative organisms]] should be considered in countries in which they are relatively common.


: '''4. What is the severity status?'''
: '''4. What is the severity status?'''
:* DFI is classified based on its severity according to the Infectious Diseases Society of America (IDSA) guideline or the PEDIS grade developed by International Working Group on the Diabetic Foot (IWGDF). (see Table below)
:* [[Diabetic foot]] [[infection]] is classified based on its severity according to the Infectious Diseases Society of America (IDSA) guideline or the PEDIS grade developed by International Working Group on the Diabetic Foot (IWGDF). (see Table below)
:* Selection of empiric antimicrobial regimen should be determined by the severity of DFI and the likely etiologic agents.
:* Selection of [[Empiric therapy|empiric]] [[antibiotic|antimicrobial regimen]] should be determined by the severity of [[diabetic foot]] [[infection]] and the likely [[etiology|etiologic agents]].
::* '''Mild (grade 2) to moderate (grade 3) DFI without recent antibiotic treatment:'''
::* '''Mild (grade 2) to moderate (grade 3) [[diabetic foot]] [[infection]] without recent [[antibiotic]] [[treatment]]:'''
:::* Highly bioavailable oral antibiotics against [[aerobic]] [[Gram-positive bacteria|Gram-positive cocci]] may be sufficient.
:::* Highly [[Bioavailability|bioavailable]] [[mouth|oral]] [[antibiotics]] against [[aerobic]] [[Gram-positive bacteria|Gram-positive cocci]] may be sufficient.
::* '''Severe (grade 4) DFI:'''
::* '''Severe (grade 4) [[diabetic foot]] [[infection]]:'''
:::* Broad-spectrum antibiotics are recommended while culture results and susceptibility data are pending.
:::* [[antibiotic|Broad-spectrum antibiotics]] are recommended while [[tissue culture|culture]] results and susceptibility data are pending.


{|
{|
Line 92: Line 87:
! align="center" style="background: #A8A8A8; padding: 0 10px;" | '''IDSA Severity'''
! align="center" style="background: #A8A8A8; padding: 0 10px;" | '''IDSA Severity'''
|-
|-
| style="background: #DCDCDC; padding: 0 10px;" | '''No symptoms or signs of infection'''
| style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" | [[Wound]] lacking [[purulent|purulence]] or any manifestations of [[inflammation]]
! style="background: #DCDCDC; padding: 0 10px;" | 1
! style="background: #DCDCDC; padding: 0 10px;" | 1
! style="background: #DCDCDC; padding: 0 10px;" | Uninfected
! style="background: #DCDCDC; padding: 0 10px;" | [[infection|Uninfected]]
|-
|-
| style="background: #F5F5F5; padding: 0 10px;" | '''Local infection involving only the [[skin]] and the [[subcutaneous tissue]]''' <u>without</u> involvement of deeper tissues and <u>without</u> signs of SIRS
| style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" |  
* If erythema, must be >0.5 cm to ≤2 cm around the ulcer.
* Presence of ≥2 manifestations of [[inflammation]] ([[purulent|purulence]], or [[erythema]], [[pain]], [[tenderness]], [[calor|warmth]], or [[induration]])
* Exclude other causes of an inflammatory response of the skin (eg, trauma, gout, acute Charcot neuro-osteoarthropathy, fracture, thrombosis, venous stasis).
* Any [[cellulitis]] or [[erythema]] extends ≤2 cm around the [[ulcer]]
* Limited to the [[skin]] or superficial [[subcutaneous tissue]]s
* <u>No</u> other local [[complication]]s (eg, [[trauma]], [[gout]], [[Neuropathic joint disease|acute Charcot neuro-osteoarthropathy]], [[fracture]], [[thrombosis]], [[venous stasis]]) or systemic [[illness]]
! style="background: #F5F5F5; padding: 0 10px;" | 2
! style="background: #F5F5F5; padding: 0 10px;" | 2
! style="background: #F5F5F5; padding: 0 10px;" | Mild
! style="background: #F5F5F5; padding: 0 10px;" | Mild
|-
|-
| style="background: #DCDCDC; padding: 0 10px;" | '''Local infection with [[erythema|erythema >2 cm]] or involving structures deeper than skin and subcutaneous tissues (eg, [[abscess]], [[osteomyelitis]], [[septic arthritis]], [[fasciitis]])''' <u>without</u> signs of SIRS
| style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" | [[Infection]] in a [[patient]] who is [[Metabolism|metabolically stable]] and systemically well, but with ≥1 of the following characterisitics:
* [[Cellulitis]] extending more than 2 cm
* [[Lymphangitis|Lymphangitic streaking]]
* Spread beneath the superficial [[fascia]]
* Deep-[[Tissue (biology)|tissue]] [[abscess]]
* [[Gangrene]]
* Involvement of [[muscle]], [[tendon]], [[joint]], or [[bone]]
! style="background: #DCDCDC; padding: 0 10px;" | 3
! style="background: #DCDCDC; padding: 0 10px;" | 3
! style="background: #DCDCDC; padding: 0 10px;" | Moderate
! style="background: #DCDCDC; padding: 0 10px;" | Moderate
|-
|-
| style="background: #F5F5F5; padding: 0 10px;" | '''Local infection with the signs of [[SIRS]]''', as manifested by ≥2 of the following:
| style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" | [[Infection]] in a [[patient]] with [[Metabolism|metabolic instability]] (eg, [[acidosis]], severe [[hyperglycemia]], or [[azotemia]]) or systemic [[toxicity]] as manifested by ≥2 of the following:
* Temperature &gt;38 °C or &lt;36 °C
* [[Fever|Temperature &gt;38 °C]] or [[Hypothermia|&lt;36 °C]]
* Heart rate &gt;90 beats/min
* [[Tachycardia|Heart rate &gt;90 beats/min]]
* Respiratory rate &gt;20 breaths/min or PaCO2 &lt;32 mm Hg
* [[Tachypnea|Respiratory rate &gt;20 breaths/min]] or [[Respiratory alkalosis|PaCO2 &lt;32 mm Hg]]
* White blood cell count &gt;12,000 or &lt;4,000 cells/μL or ≥10% immature (band) forms
* [[Leukocytosis|White blood cell count &gt;12,000]] or [[Leukopenia|&lt;4,000 cells/μL]] or [[bandemia|≥10% immature (band) forms]]
! style="background: #F5F5F5; padding: 0 10px;" | 4
! style="background: #F5F5F5; padding: 0 10px;" | 4
! style="background: #F5F5F5; padding: 0 10px;" | Severe
! style="background: #F5F5F5; padding: 0 10px;" | Severe
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|}
|}


: '''5. What is the appropriate route, setting, and duration of antibiotic therapy?'''
: '''5. What is the appropriate route, setting, and duration of [[antibiotic]] [[therapy]]?'''


:* The table below describes the recommended route, setting, and duration of antibiotic therapy based on the extent and severity of DFI.
:* The table below describes the recommended route, setting, and duration of [[antibiotic]] [[therapy]] based on the extent and severity of [[diabetic foot]] [[infection]].


{|
{|
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|  
|  
{| style="border: 2px solid #A8A8A8; font-size: 90%;"
{| style="border: 2px solid #A8A8A8; font-size: 90%;"
! align="center" style="background: #A8A8A8; padding: 0 10px;" colspan=2 | '''Site of Infection, by Severity or Extent'''
! align="center" style="background: #A8A8A8; padding: 0 10px;" colspan=2 | '''Site of [[Infection]], by Severity or Extent'''
! align="center" style="background: #A8A8A8; padding: 0 10px;" | '''Route of Administration'''
! align="center" style="background: #A8A8A8; padding: 0 10px;" | '''[[Route of Administration]]'''
! align="center" style="background: #A8A8A8; padding: 0 10px;" | '''Setting'''
! align="center" style="background: #A8A8A8; padding: 0 10px;" | '''Setting'''
! align="center" style="background: #A8A8A8; padding: 0 10px;" | '''Duration of Therapy'''
! align="center" style="background: #A8A8A8; padding: 0 10px;" | '''Duration of [[Therapy]]'''
|-
|-
! style="background: #DCDCDC; padding: 0 10px;" rowspan=3 | '''Soft-tissue only'''
! style="background: #DCDCDC; padding: 0 10px;" rowspan=3 | '''Soft-[[tissue (biology)|tissue]] only'''
| style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" | Mild (Grade 2)
| style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" | Mild (Grade 2)
| style="background: #DCDCDC; padding: 0 10px;" | Oral (or topical for superficial infections)
| style="background: #DCDCDC; padding: 0 10px;" | [[mouth|Oral]] (or [[topical]] for superficial [[infections]])
| style="background: #DCDCDC; padding: 0 10px;" | Outpatient
| style="background: #DCDCDC; padding: 0 10px;" | [[patient|Outpatient]]
| style="background: #DCDCDC; padding: 0 10px; text-align: center;" | 1–2 wk
| style="background: #DCDCDC; padding: 0 10px; text-align: center;" | 1–2 wk
|-
|-
| style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" | Moderate (Grade 3)
| style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" | Moderate (Grade 3)
| style="background: #DCDCDC; padding: 0 10px;" | Oral (or initial parenteral)
| style="background: #DCDCDC; padding: 0 10px;" | [[mouth|Oral]] (or initial Route of administration|parenteral]])
| style="background: #DCDCDC; padding: 0 10px;" | Outpatient (or inpatient)
| style="background: #DCDCDC; padding: 0 10px;" | [[patient|Outpatient]] (or [[patient|inpatient]])
| style="background: #DCDCDC; padding: 0 10px; text-align: center;" | 1–3 wk
| style="background: #DCDCDC; padding: 0 10px; text-align: center;" | 1–3 wk
|-
|-
| style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" | Severe (Grade 4)
| style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" | Severe (Grade 4)
| style="background: #DCDCDC; padding: 0 10px;" | Initial parenteral, switch to oral when possible
| style="background: #DCDCDC; padding: 0 10px;" | Initial [[Route of administration|parenteral]], switch to [[mouth|oral]] when possible
| style="background: #DCDCDC; padding: 0 10px;" | Inpatient, then outpatient
| style="background: #DCDCDC; padding: 0 10px;" | [[patient|Inpatient]], then [[patient|outpatient]]
| style="background: #DCDCDC; padding: 0 10px; text-align: center;" | 2–4 wk
| style="background: #DCDCDC; padding: 0 10px; text-align: center;" | 2–4 wk
|-
|-
! style="background: #F5F5F5; padding: 0 10px;" rowspan=4 | '''Bone or joint'''
! style="background: #F5F5F5; padding: 0 10px;" rowspan=4 | '''[[Bone]] or [[joint]]'''
| style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" | No residual infected tissue
| style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" | No residual [[infection|infected]] [[tissue (biology)|tissue]]
| style="background: #F5F5F5; padding: 0 10px;" | Parenteral or oral
| style="background: #F5F5F5; padding: 0 10px;" | Parenteral or oral
| style="background: #F5F5F5; padding: 0 10px;" | Inpatient, then outpatient
| style="background: #F5F5F5; padding: 0 10px;" | [[patient|Inpatient]], then [[patient|outpatient]]
| style="background: #F5F5F5; padding: 0 10px; text-align: center;" | 2–5 d
| style="background: #F5F5F5; padding: 0 10px; text-align: center;" | 2–5 d
|-
|-
| style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" | Residual infected soft tissue
| style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" | Residual [[infection|infected]] [[tissue (biology)|soft tissue]]
| style="background: #F5F5F5; padding: 0 10px;" | Parenteral or oral
| style="background: #F5F5F5; padding: 0 10px;" | [[Route of administration|Parenteral]] or [[mouth|oral]]
| style="background: #F5F5F5; padding: 0 10px;" | Inpatient, then outpatient
| style="background: #F5F5F5; padding: 0 10px;" | [[patient|Inpatient]], then [[patient|outpatient]]
| style="background: #F5F5F5; padding: 0 10px; text-align: center;" | 1–3 wk
| style="background: #F5F5F5; padding: 0 10px; text-align: center;" | 1–3 wk
|-
|-
| style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" | Residual infected, viable bone
| style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" | Residual [[infection|infected]], viable [[bone]]
| style="background: #F5F5F5; padding: 0 10px;" | Initial parenteral, switch to oral when possible
| style="background: #F5F5F5; padding: 0 10px;" | Initial [[Route of administration|parenteral]], switch to [[mouth|oral]] when possible
| style="background: #F5F5F5; padding: 0 10px;" | Inpatient, then outpatient
| style="background: #F5F5F5; padding: 0 10px;" | [[patient|Inpatient]], then [[patient|outpatient]]
| style="background: #F5F5F5; padding: 0 10px; text-align: center;" | 4–6 wk
| style="background: #F5F5F5; padding: 0 10px; text-align: center;" | 4–6 wk
|-
|-
| style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" | Residual dead bone or no surgery
| style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" | Residual dead [[bone]] or no [[surgery]]
| style="background: #F5F5F5; padding: 0 10px;" | Initial parenteral, switch to oral when possible
| style="background: #F5F5F5; padding: 0 10px;" | Initial [[Route of administration|parenteral]], switch to [[mouth|oral]] when possible
| style="background: #F5F5F5; padding: 0 10px;" | Inpatient, then outpatient
| style="background: #F5F5F5; padding: 0 10px;" | [[patient|Inpatient]], then [[patient|outpatient]]
| style="background: #F5F5F5; padding: 0 10px; text-align: center;" | ≥3 mo
| style="background: #F5F5F5; padding: 0 10px; text-align: center;" | ≥3 mo
|}
|}
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===Empiric Therapy===
===Empiric Therapy===


<SMALL><font color="#FF4C4C"> ▸ '''Click on the following categories to expand treatment regimens.'''</font></SMALL>
<SMALL><font color="#FF4C4C"> ▸ '''Click on the following categories to expand [[treatment]] regimens.'''</font></SMALL>


{|
{|
| valign=top |
| valign=top style="font-size: 80%;" |


<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #A1BCDD; text-align: center;">
<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
<font color="#FFF">
&nbsp;&nbsp;&nbsp;&nbsp;'''Uninfected (Grade 1)'''
&nbsp;&nbsp;&nbsp;&nbsp;'''[[infection|Uninfected]] (Grade 1)'''
</font>
</font>
</div>
</div>
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<div class="mw-customtoggle-table00" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;">
<div class="mw-customtoggle-table00" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;">
<font color="#FFF">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''No Evidence of Infection'''
&nbsp;&nbsp;▸&nbsp;&nbsp;'''No Evidence of [[Infection]]'''
</font>
</font>
</div>
</div>
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<div class="mw-customtoggle-table01" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;">
<div class="mw-customtoggle-table01" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;">
<font color="#FFF">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Acute Infection Without Recent Antibiotic Use'''
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Acute [[Infection]] Without Recent [[Antibiotic]] Use'''
</font>
</font>
</div>
</div>
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<div class="mw-customtoggle-table02" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;">
<div class="mw-customtoggle-table02" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;">
<font color="#FFF">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''High Risk for MRSA'''
&nbsp;&nbsp;▸&nbsp;&nbsp;'''High Risk for [[Methicillin-resistant staphylococcus aureus|MRSA]]'''


</font>
</font>
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<div class="mw-customtoggle-table03" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;">
<div class="mw-customtoggle-table03" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;">
<font color="#FFF">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Chronic Infection or Recent Antibiotic Use'''
&nbsp;&nbsp;▸&nbsp;&nbsp;'''[[Chronic (medical)|Chronic]] [[Infection]] or Recent [[Antibiotic]] Use'''
</font>
</font>
</div>
</div>
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<div class="mw-customtoggle-table04" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;">
<div class="mw-customtoggle-table04" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;">
<font color="#FFF">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''High Risk for MRSA'''
&nbsp;&nbsp;▸&nbsp;&nbsp;'''High Risk for [[Methicillin-resistant staphylococcus aureus|MRSA]]'''
</font>
</font>
</div>
</div>
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<div class="mw-customtoggle-table05" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;">
<div class="mw-customtoggle-table05" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;">
<font color="#FFF">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''High Risk for ''Pseudomonas aureuginosa'''''
&nbsp;&nbsp;▸&nbsp;&nbsp;'''High Risk for ''[[Pseudomonas aureuginosa]]'''''
</font>
</font>
</div>
</div>
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<div class="mw-customtoggle-table06" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;">
<div class="mw-customtoggle-table06" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;">
<font color="#FFF">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Polymicrobial Infection'''
&nbsp;&nbsp;▸&nbsp;&nbsp;'''Polymicrobial [[Infection]]'''
</font>
</font>
</div>
</div>
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| valign=top |
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 425px;"
{| style="float: left; cellpadding=0; cellspacing= 0; width: 425px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Uninfected Wound, No Evidence of Infection}}
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|[[infection|Uninfected]] [[Wound]], No Evidence of [[Infection]]}}
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''Uninfected wounds should be managed with appropriate wound care.'''''<BR> ▸ '''''Antibiotic therapy is <u>not</u> recommended.'''''
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[infection|Uninfected]] [[wounds]] should be managed with appropriate [[wound]] care.'''''<BR> ▸ '''''[[Antibiotic]] [[therapy]] is <u>not</u> recommended.'''''
|}
|}
|}
|}
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| valign=top |
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 425px;"
{| style="float: left; cellpadding=0; cellspacing= 0; width: 425px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Mild DFI, Acute Infection Without Recent Antibiotic Use}}
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Mild DFI, Acute [[Infection]] Without Recent [[Antibiotic]] Use}}
|-
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
Line 256: Line 259:
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Dicloxacillin]] 125–250 mg PO qid'''''<BR> OR <BR> ▸ '''''[[Clindamycin]] 150–300 mg PO qid''''' <sup>†</sup><BR> OR <BR> ▸ '''''[[Cephalexin]] 500 mg PO qid'''''<BR> OR <BR> ▸ '''''[[Levofloxacin]] 750 mg PO qd'''''<BR> OR <BR> ▸ '''''[[Amoxicillin-Clavulanate]] 500 mg PO bid (or 250 mg PO tid)''''' <sup>‡</sup>
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Dicloxacillin]] 125–250 mg PO qid'''''<BR> OR <BR> ▸ '''''[[Clindamycin]] 150–300 mg PO qid''''' <sup>†</sup><BR> OR <BR> ▸ '''''[[Cephalexin]] 500 mg PO qid'''''<BR> OR <BR> ▸ '''''[[Levofloxacin]] 750 mg PO qd'''''<BR> OR <BR> ▸ '''''[[Amoxicillin-Clavulanate]] 500 mg PO bid (or 250 mg PO tid)''''' <sup>‡</sup>
|-
|-
| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" | <sup>†</sup> Usually active against community-associated MRSA, but check macrolide sensitivity and consider ordering a D-test before using for MRSA.<BR><sup>‡</sup> Relatively broad-spectrum oral agent that includes anaerobic coverage.
| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" | <sup>†</sup> Usually active against community-associated [[Methicillin-resistant staphylococcus aureus|MRSA]], but check [[macrolide]] [[sensitivity]] and consider ordering a D-test before using for [[Methicillin-resistant staphylococcus aureus|MRSA]].<BR><sup>‡</sup> Relatively broad-spectrum [[mouth|oral]] agent that includes anaerobic coverage.
|}
|}
|}
|}
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| valign=top |
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 425px;"
{| style="float: left; cellpadding=0; cellspacing= 0; width: 425px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Mild DFI, High Risk for MRSA}}
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Mild [[diabetic foot|DFI]], High Risk for [[Methicillin-resistant staphylococcus aureus|MRSA]]}}
|-
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
Line 269: Line 272:
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Doxycycline]] 100 mg PO q12h''''' <sup>†</sup><BR> OR <BR> ▸ '''''[[TMP-SMX|TMP–SMX]] 80-160 mg/400-800 mg PO q12h''''' <sup>†</sup>
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Doxycycline]] 100 mg PO q12h''''' <sup>†</sup><BR> OR <BR> ▸ '''''[[TMP-SMX|TMP–SMX]] 80-160 mg/400-800 mg PO q12h''''' <sup>†</sup>
|-
|-
| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" | <sup>†</sup> Active against many MRSA & some gram-negatives; uncertain against streptococci.
| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" | <sup>†</sup> Active against many [[Methicillin-resistant staphylococcus aureus|MRSA]] & some [[gram-negatives]]; uncertain against [[Streptococcus|streptococci]].
|}
|}
|}
|}
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| valign=top |
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 425px;"
{| style="float: left; cellpadding=0; cellspacing= 0; width: 425px;"
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Moderate to Severe DFI, Chronic Infection or Recent Antibiotic Use}}
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Moderate to Severe [[diabetic foot|DFI]], [[Chronic (medical)|Chronic]] [[Infection]] or Recent [[Antibiotic]] Use}}
|-
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen
|-
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Levofloxacin]] 750 mg IV/PO q24h'''''<BR> OR <BR> ▸ '''''[[Cefoxitin]] 1 g IV q4h (or 2 g IV q6–8h)'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 1–2 g/day IV/IM q12–24h'''''<BR> OR <BR> ▸ '''''[[Ampicillin-Sulbactam|Ampicillin–Sulbactam]] 1.5–3 g IV/IM q6h'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 400 mg IV/PO q24h'''''<BR> OR <BR> ▸ '''''[[Ertapenem]] 1 g IV/IM q24h'''''<BR> OR <BR> ▸ '''''[[Tigecycline]] 100 mg IV, then 50 mg IV q12h''''' <sup>†</sup><BR> OR <BR> ▸ '''''[[Imipenem-Cilastatin|Imipenem–Cilastatin]] 0.5–1 g IV q6–8h''''' <sup>‡</sup>
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Levofloxacin]] 750 mg IV/PO q24h'''''<BR> OR <BR> ▸ '''''[[Cefoxitin]] 1 g [[intravenous|IV]] q4h (or 2 g IV q6–8h)'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 1–2 g/day IV/IM q12–24h'''''<BR> OR <BR> ▸ '''''[[Ampicillin-Sulbactam|Ampicillin–Sulbactam]] 1.5–3 g IV/IM q6h'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 400 mg IV/PO q24h'''''<BR> OR <BR> ▸ '''''[[Ertapenem]] 1 g IV/IM q24h'''''<BR> OR <BR> ▸ '''''[[Tigecycline]] 100 mg IV, then 50 mg IV q12h''''' <sup>†</sup><BR> OR <BR> ▸ '''''[[Imipenem-Cilastatin|Imipenem–Cilastatin]] 0.5–1 g IV q6–8h''''' <sup>‡</sup>
|-
|-
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen
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==References==
==References==
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[[Category:Aging-associated diseases]]
[[Category:Diabetes]]
[[Category:Disease]]
[[Category:Emergency medicine]]
[[Category:Emergency medicine]]
[[Category:Endocrinology]]
[[Category:Endocrinology]]
[[Category:Infectious disease]]
[[Category:Intensive care medicine]]
[[Category:Medical conditions related to obesity]]
[[Category:Medicine]]
[[Category:Primary care]]

Latest revision as of 22:13, 21 March 2022

Diabetic foot Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

Pathophysiology

Causes

Differentiating Diabetic foot from other Diseases

Epidemiology and Demographics

Risk Factors

Screening

Natural History, Complications and Prognosis

Diagnosis

History and Symptoms

Physical Examination

Laboratory Findings

Electrocardiogram

X Ray

CT

MRI

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Other Imaging Findings

Other Diagnostic Studies

Treatment

Medical Therapy

Surgery

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Diabetic foot medical therapy On the Web

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Risk calculators and risk factors for Diabetic foot medical therapy

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Alonso Alvarado, M.D. [2] Anahita Deylamsalehi, M.D.[3]

Overview

Appropriate wound care is essential for the management of all diabetic foot ulcers. Uninfected diabetic ulcers do not require antibiotic therapy. In the contrary for acutely infected wounds, empiric antibiotic therapy with coverage against Gram-positive cocci should be start right after obtaining a post-debridement specimen for aerobic and anaerobic culture. Infections with antibiotic-resistant organisms and those that have chronic or severe ulcers or have been previously treated usually require broader spectrum regimens. Treatment strategies are dependent on ulcer's grade, presence of infection and perfusion. For an effective treatment which lower the chance of the future diabetic foot ulcers control of blood sugar, pressure off-loading and treatment of other comorbidities are also critical. Aim of treatment should be focused on improving prognosis and decreasing complications such as amputation. In very severe ulcers or when the patient has the history of previous MRSA infection or colonization within the past year and in regions with high prevalence of MRSA infection, MRSA should be also covered by antibiotic treatments. For an ideal treatment physicians should evaluate the severity of ulcers and possible risk factors of pseudomonas aeruginosa or extended-spectrum β-lactamase (ESBL)–producing organisms.

Diabetic Foot Ulcer

The Cochrane Collaboration has reviewed hydrocolloids[1], hydrogels[2], and alginates[3].

The International Working Group on the Diabetic Foot (IWGDF) recommends[4]:

  • "Dressings should be selected principally on the basis of exudate control, comfort, and cost"

Hydrocolloids and hydrogels are available as generic bandages.

Diabetic Foot Infection

Principles of Therapy Adapted from Diabetes Care. 2013;36(9):2862-71.[5] and Clin Infect Dis. 2012;54(12):e132-73.[6]


Indications for Hospitalization
Consultation
Adjunctive Therapy

Selection of Antibiotic Regimen

1. Is there high risk of MRSA?
2. Is the infected wound chronic or treated with antibiotics in the past month?
3. Are there risk factors for infection with Pseudomonas aeruginosa or extended-spectrum β-lactamase (ESBL)–producing organisms?
4. What is the severity status?
Clinical Manifestation PEDIS Grade IDSA Severity
Wound lacking purulence or any manifestations of inflammation 1 Uninfected
2 Mild
Infection in a patient who is metabolically stable and systemically well, but with ≥1 of the following characterisitics: 3 Moderate
Infection in a patient with metabolic instability (eg, acidosis, severe hyperglycemia, or azotemia) or systemic toxicity as manifested by ≥2 of the following: 4 Severe
5. What is the appropriate route, setting, and duration of antibiotic therapy?
Site of Infection, by Severity or Extent Route of Administration Setting Duration of Therapy
Soft-tissue only Mild (Grade 2) Oral (or topical for superficial infections) Outpatient 1–2 wk
Moderate (Grade 3) Oral (or initial Route of administration|parenteral]]) Outpatient (or inpatient) 1–3 wk
Severe (Grade 4) Initial parenteral, switch to oral when possible Inpatient, then outpatient 2–4 wk
Bone or joint No residual infected tissue Parenteral or oral Inpatient, then outpatient 2–5 d
Residual infected soft tissue Parenteral or oral Inpatient, then outpatient 1–3 wk
Residual infected, viable bone Initial parenteral, switch to oral when possible Inpatient, then outpatient 4–6 wk
Residual dead bone or no surgery Initial parenteral, switch to oral when possible Inpatient, then outpatient ≥3 mo

Empiric Therapy

Click on the following categories to expand treatment regimens.

    Uninfected (Grade 1)

  ▸  No Evidence of Infection

    Mild (Grade 2)

  ▸  Acute Infection Without Recent Antibiotic Use

  ▸  High Risk for MRSA

    Moderate to Severe (Grade 3–4)

  ▸  Chronic Infection or Recent Antibiotic Use

  ▸  High Risk for MRSA

  ▸  High Risk for Pseudomonas aureuginosa

  ▸  Polymicrobial Infection

Uninfected Wound, No Evidence of Infection
Uninfected wounds should be managed with appropriate wound care.
Antibiotic therapy is not recommended.
Mild DFI, Acute Infection Without Recent Antibiotic Use
Preferred Regimen
Dicloxacillin 125–250 mg PO qid
OR
Clindamycin 150–300 mg PO qid
OR
Cephalexin 500 mg PO qid
OR
Levofloxacin 750 mg PO qd
OR
Amoxicillin-Clavulanate 500 mg PO bid (or 250 mg PO tid)
Usually active against community-associated MRSA, but check macrolide sensitivity and consider ordering a D-test before using for MRSA.
Relatively broad-spectrum oral agent that includes anaerobic coverage.
Mild DFI, High Risk for MRSA
Preferred Regimen
Doxycycline 100 mg PO q12h
OR
TMP–SMX 80-160 mg/400-800 mg PO q12h
Active against many MRSA & some gram-negatives; uncertain against streptococci.
Moderate to Severe DFI, Chronic Infection or Recent Antibiotic Use
Preferred Regimen
Levofloxacin 750 mg IV/PO q24h
OR
Cefoxitin 1 g IV q4h (or 2 g IV q6–8h)
OR
Ceftriaxone 1–2 g/day IV/IM q12–24h
OR
Ampicillin–Sulbactam 1.5–3 g IV/IM q6h
OR
Moxifloxacin 400 mg IV/PO q24h
OR
Ertapenem 1 g IV/IM q24h
OR
Tigecycline 100 mg IV, then 50 mg IV q12h
OR
Imipenem–Cilastatin 0.5–1 g IV q6–8h
Alternative Regimen
Levofloxacin 750 mg IV/PO q24h
OR
Ciprofloxacin 600–1200 mg/day IV q6–12h
OR
Ciprofloxacin 1200–2700 mg IV q6–12h (for more severe cases)
PLUS
Clindamycin 150–300 mg PO qid
Active against MRSA.
Not active against MRSA; consider when ESBL-producing pathogens suspected.
Moderate to Severe DFI, High Risk for MRSA
Preferred Regimen
Linezolid 600 mg IV/PO q12h
OR
Daptomycin 4 mg/kg IV q24h
OR
Vancomycin 15–20 mg/kg IV q8–12h (trough: 10–20 mg/L)
Moderate to Severe DFI, High Risk for Pseudomonas aeruginosa
Preferred Regimen
Piperacillin–Tazobactam 3.375 g IV q6–8h
Moderate to Severe DFI, Polymicrobial Infection
Preferred Regimen
Vancomycin 15–20 mg/kg IV q8–12h (trough: 10–20 mg/L)
OR
Linezolid 600 mg IV/PO q12h
OR
Daptomycin 4 mg/kg IV q24h
PLUS
Piperacillin–Tazobactam 3.375 g IV q6–8h
OR
Imipenem–Cilastatin 0.5–1 g IV q6–8h
OR
Ertapenem 1 g IV/IM q24h
OR
Meropenem 1 g IV q8h
Alternative Regimen
Vancomycin 15–20 mg/kg IV q8–12h (trough: 10–20 mg/L)
OR
Linezolid 600 mg IV/PO q12h
OR
Daptomycin 4 mg/kg IV q24h
PLUS
Ceftazidime 2 g IV q8h
OR
Cefepime 2 g IV q8h
OR
Aztreonam 2 g IV q6–8h
PLUS
Metronidazole 15 mg/kg IV, then 7.5 mg/kg IV q6h


References

  1. Dumville JC, Deshpande S, O'Meara S, Speak K (2013). "Hydrocolloid dressings for healing diabetic foot ulcers". Cochrane Database Syst Rev (8): CD009099. doi:10.1002/14651858.CD009099.pub3. PMC 7111300 Check |pmc= value (help). PMID 23922167.
  2. Dumville JC, O'Meara S, Deshpande S, Speak K (2013). "Hydrogel dressings for healing diabetic foot ulcers". Cochrane Database Syst Rev (7): CD009101. doi:10.1002/14651858.CD009101.pub3. PMC 6486218. PMID 23846869.
  3. Dumville JC, O'Meara S, Deshpande S, Speak K (2013). "Alginate dressings for healing diabetic foot ulcers". Cochrane Database Syst Rev (6): CD009110. doi:10.1002/14651858.CD009110.pub3. PMC 7111427 Check |pmc= value (help). PMID 23799857.
  4. Rayman G, Vas P, Dhatariya K, Driver V, Hartemann A, Londahl M; et al. (2020). "Guidelines on use of interventions to enhance healing of chronic foot ulcers in diabetes (IWGDF 2019 update)". Diabetes Metab Res Rev. 36 Suppl 1: e3283. doi:10.1002/dmrr.3283. PMID 32176450 Check |pmid= value (help).
  5. Wukich DK, Armstrong DG, Attinger CE, Boulton AJ, Burns PR, Frykberg RG; et al. (2013). "Inpatient management of diabetic foot disorders: a clinical guide". Diabetes Care. 36 (9): 2862–71. doi:10.2337/dc12-2712. PMC 3747877. PMID 23970716.
  6. Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG; et al. (2012). "2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections". Clin Infect Dis. 54 (12): e132–73. doi:10.1093/cid/cis346. PMID 22619242.
  7. 7.0 7.1 Frykberg, Robert G. (1998). "Diabetic foot ulcers: Current concepts". The Journal of Foot and Ankle Surgery. 37 (5): 440–446. doi:10.1016/S1067-2516(98)80055-0. ISSN 1067-2516.
  8. Apelqvist J, Bakker K, van Houtum WH, Schaper NC, International Working Group on the Diabetic Foot (IWGDF) Editorial Board (2008). "Practical guidelines on the management and prevention of the diabetic foot: based upon the International Consensus on the Diabetic Foot (2007) Prepared by the International Working Group on the Diabetic Foot". Diabetes Metab Res Rev. 24 Suppl 1: S181–7. doi:10.1002/dmrr.848. PMID 18442189.
  9. Holstein PE, Sørensen S (1999). "Limb salvage experience in a multidisciplinary diabetic foot unit". Diabetes Care. 22 Suppl 2: B97–103. PMID 10097908.
  10. Frykberg RG, Armstrong DG, Giurini J, Edwards A, Kravette M, Kravitz S; et al. (2000). "Diabetic foot disorders: a clinical practice guideline. American College of Foot and Ankle Surgeons". J Foot Ankle Surg. 39 (5 Suppl): S1–60. PMID 11280471.
  11. American Diabetes Association (1999). "Consensus Development Conference on Diabetic Foot Wound Care: 7-8 April 1999, Boston, Massachusetts. American Diabetes Association". Diabetes Care. 22 (8): 1354–60. doi:10.2337/diacare.22.8.1354. PMID 10480782.
  12. 12.0 12.1 12.2 Armstrong, DG; Harkless, LB; Nguyen, H; Krasner, D; Hogge, J (2000). "The potential benefits of advanced therapeutic modalities in the treatment of diabetic foot wounds". Journal of the American Podiatric Medical Association. 90 (2): 57–65. doi:10.7547/87507315-90-2-57. ISSN 8750-7315.
  13. Wieman TJ, Smiell JM, Su Y (1998). "Efficacy and safety of a topical gel formulation of recombinant human platelet-derived growth factor-BB (becaplermin) in patients with chronic neuropathic diabetic ulcers. A phase III randomized placebo-controlled double-blind study". Diabetes Care. 21 (5): 822–7. doi:10.2337/diacare.21.5.822. PMID 9589248.
  14. Veves A, Falanga V, Armstrong DG, Sabolinski ML, Apligraf Diabetic Foot Ulcer Study (2001). "Graftskin, a human skin equivalent, is effective in the management of noninfected neuropathic diabetic foot ulcers: a prospective randomized multicenter clinical trial". Diabetes Care. 24 (2): 290–5. doi:10.2337/diacare.24.2.290. PMID 11213881.


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