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{{Diabetic foot}}
{{CMG}}; {{AE}} {{Alonso}}, {{VVS}}
 
==Overview==


{{Diabetic foot}}
{{CMG}} {{AE}} {{VVS}}
==Medical Therapy==
Foot ulcers in diabetes require multidisciplinary assessment, usually by diabetes specialists and [[surgeon]]s. Treatment consists of appropriate bandages, [[antibiotic]]s (against [[staphylococcus]], [[streptococcus]] and [[anaerobe]] strains), [[debridement]] and arterial revascularisation. It is often 500 mg to 1000 mg of [[flucloxacillin]], 1 g of [[amoxicillin]] and also [[metronidazole]] to tackle the putrid smelling bacteria. Specialists are investigating the role of [[nitric oxide]] in diabetic wound healing. Nitric oxide is a powerful vasodilator, which helps to bring nutrients to the oxygen deficient wound beds. Specialists are using forms of [[light therapy]] such as LLLT to treat diabetic ulcers.
Foot ulcers in diabetes require multidisciplinary assessment, usually by diabetes specialists and [[surgeon]]s. Treatment consists of appropriate bandages, [[antibiotic]]s (against [[staphylococcus]], [[streptococcus]] and [[anaerobe]] strains), [[debridement]] and arterial revascularisation. It is often 500 mg to 1000 mg of [[flucloxacillin]], 1 g of [[amoxicillin]] and also [[metronidazole]] to tackle the putrid smelling bacteria. Specialists are investigating the role of [[nitric oxide]] in diabetic wound healing. Nitric oxide is a powerful vasodilator, which helps to bring nutrients to the oxygen deficient wound beds. Specialists are using forms of [[light therapy]] such as LLLT to treat diabetic ulcers.
==Diabetic Foot Infection <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>==
===Principles of Therapy===
* Diabetic foot infection (DFI) is diagnosed clinically by the presence of <u>at least two</u> signs or symptoms of inflammation:
:* Local swelling or induration
:* Erythema
:* Local tenderness or pain
:* Local warmth
:* Purulent discharge (thick, opaque to white or sanguineous secretion)
* Hospitalization is appropriate for the following conditions:
:* Severe (grade 4) infections
:* Moderate (grade 3) infections with complicating features
::* Severe peripheral arterial disease or limb ischemia
::* Lack of home support
:* Patients unable to comply with the required outpatient treatment regimen for psychological or social reasons
:* Patients not responding to outpatient treatment
* Properly obtained specimens for culture prior to initiating empiric antibiotic therapy provide useful information for guiding antibiotic therapy, particularly in those with chronic or previously treated infections which are commonly caused by 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 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, coagulase-negative staphylococci, corynebacteria), but these may be true pathogens in DFIs and are often resistant to the empiric antibiotics.
* 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.
:* Consult a vascular surgeon to consider revascularization if ischemia complicates a DFI.
:* 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.
* 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, granulocyte colony-stimulating factors, hyperbaric oxygen therapy, or negative pressure wound therapy.
===Antibiotic Therapy===
* Clinically uninfected wounds should ''not'' be treated with antibiotic therapy. For all infected wounds, antibiotic therapy combined with appropriate wound care is recommended.
* For clinically infected wounds, consider the questions below:
: '''1. Is there high risk of 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
::* High local prevalence of MRSA infection or colonization (50% for a mild and 30% for a moderate soft tissue infection)
::* Clinically severe diabetic foot infection
: '''2. Has patient received antibiotics in the past month?'''
:* If so, include agents active against gram-negative bacilli in regimen.
:* If not, agents targeted against just aerobic gram-positive cocci may be sufficient.
: '''3. Are there risk factors for infection with ''Pseudomonas aeruginosa'' or extended-spectrum β-lactamase (ESBL)–producing organisms?'''
:* Anti-pseudomonal agent is usually unnecessary <u>except</u> for patients with risk factors:
::* High local prevalence of ''[[Pseudomonas aeruginosa]]'' infection
::* Frequent exposure of the foot to water
::* Warm climate
:* Coverage of ESBL-producing gram-negative organisms should be considered in countries in which they are relatively common.
: '''4. What is the infection 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]
:* Selection of empiric antimicrobial regimen should be determined by the severity of DFI and the likely etiologic agents.
::* '''Mild (grade 2) to moderate (grade 3) DFI without recent antibiotic treatment:'''
:::* Highly bioavailable oral antibiotics against aerobic gram-positive cocci may be sufficient.
::* '''Severe (grade 4) DFI:'''
:::* Broad-spectrum antibiotics are recommended while culture results and susceptibility data are pending.
{|
| style="width: 15px;"|
|
{| style="border: 2px solid #A8A8A8; font-size: 90%;"
! align="center" style="background: #A8A8A8;" | '''Clinical Manifestation'''
! align="center" style="background: #A8A8A8; padding: 0 10px;" | '''PEDIS Grade'''
! 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;" | 1
! style="background: #DCDCDC; padding: 0 10px;" | 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
* If erythema, must be >0.5 cm to ≤2 cm around the ulcer.
* Exclude other causes of an inflammatory response of the skin (eg, trauma, gout, acute Charcot neuro-osteoarthropathy, fracture, thrombosis, venous stasis).
! style="background: #F5F5F5; padding: 0 10px;" | 2
! style="background: #F5F5F5; padding: 0 10px;" | Mild
|-
| style="background: #DCDCDC; padding: 0 10px;" | '''Local infection with 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;" | 3
! 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:
* Temperature &gt;38 °C or &lt;36 °C
* Heart rate &gt;90 beats/min
* Respiratory rate &gt;20 breaths/min or PaCO2 &lt;32 mm Hg
* White blood cell count &gt;12,000 or &lt;4,000 cells/μL or ≥10% immature (band) forms
! style="background: #F5F5F5; padding: 0 10px;" | 4
! style="background: #F5F5F5; padding: 0 10px;" | Severe
|}
|}
: '''5. What is the appropriate route, setting, and duration of antibiotic therapy?'''
{|
| style="width: 15px;"|
|
{| 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;" | '''Route of Administration'''
! align="center" style="background: #A8A8A8; padding: 0 10px;" | '''Setting'''
! 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;" | Mild
| style="background: #DCDCDC; padding: 0 10px;" | Oral (or topical for superficial infections)
| style="background: #DCDCDC; padding: 0 10px;" | Outpatient
| style="background: #DCDCDC; padding: 0 10px;" | 1–2 wk; may extend to 4 wk
|-
! style="background: #DCDCDC; padding: 0 10px;" | Moderate
| style="background: #DCDCDC; padding: 0 10px;" | Oral (or initial parenteral)
| style="background: #DCDCDC; padding: 0 10px;" | Outpatient (or inpatient)
| style="background: #DCDCDC; padding: 0 10px;" | 1–3 wk
|-
! style="background: #DCDCDC; padding: 0 10px;" | Severe
| style="background: #DCDCDC; padding: 0 10px;" | Initial parenteral, switch to oral when possible
| style="background: #DCDCDC; padding: 0 10px;" | Inpatient, then outpatient
| style="background: #DCDCDC; padding: 0 10px;" | 2–4 wk
|-
! style="background: #F5F5F5; padding: 0 10px;" rowspan=4 | '''Bone or joint'''
! style="background: #F5F5F5; padding: 0 10px;" | No residual infected tissue
| style="background: #F5F5F5; padding: 0 10px;" | Parenteral or oral
| style="background: #F5F5F5; padding: 0 10px;" | Inpatient, then outpatient
| style="background: #F5F5F5; padding: 0 10px;" | 2–5 d
|-
! style="background: #F5F5F5; padding: 0 10px;" | Residual infected soft tissue
| style="background: #F5F5F5; padding: 0 10px;" | Parenteral or oral
| style="background: #F5F5F5; padding: 0 10px;" | Inpatient, then outpatient
| style="background: #F5F5F5; padding: 0 10px;" | 1–3 wk
|-
! style="background: #F5F5F5; padding: 0 10px;" | Residual infected, viable bone
| style="background: #F5F5F5; padding: 0 10px;" | Initial parenteral, switch to oral when possible
| style="background: #F5F5F5; padding: 0 10px;" | Inpatient, then outpatient
| style="background: #F5F5F5; padding: 0 10px;" | 4–6 wk
|-
! style="background: #F5F5F5; padding: 0 10px;" | 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;" | Inpatient, then outpatient
| style="background: #F5F5F5; padding: 0 10px;" | ≥3 mo
|}
|}
===Empiric Therapy===
<SMALL><font color="#FF4C4C">'''▸ Click on the following categories to expand treatment regimens.'''</font></SMALL>
{|
| valign=top |
<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: 300px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
&nbsp;&nbsp;&nbsp;&nbsp;'''Mild'''
</font>
</div>
<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: 300px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;&nbsp;&nbsp;'''''High suspicion of MRSA'''''
</font>
</div>
<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: 300px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''''Low suspicion of MRSA'''''
</font>
</div>
<div style="border-radius: 0 0 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: 300px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
&nbsp;&nbsp;&nbsp;&nbsp;'''Moderate'''
</font>
</div>
<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: 300px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''''High suspicion of MRSA'''''
</font>
</div>
<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: 300px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''''Low suspicion of MRSA'''''
</font>
</div>
<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: 300px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''''High suspicion of P. aureuginosa'''''
</font>
</div>
<div style="border-radius: 0 0 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: 300px; background: #A1BCDD; text-align: center;">
<font color="#FFF">
&nbsp;&nbsp;&nbsp;&nbsp;'''Severe'''
</font>
</div>
<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: 300px; background: #4479BA;">
<font color="#FFF">
&nbsp;&nbsp;▸&nbsp;&nbsp;'''''Broad-spectrum regimen'''''
</font>
</div>
| valign=top |
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table01" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! 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|''High suspicion of MRSA''}}
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Doxycycline]] 100 mg PO q12h'''''<br> OR <br> ▸ '''''[[TMP/SMZ]]'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table02" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! 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|''Low suspicion of MRSA''}}
|-
| 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 | ▸ '''''[[Dicloxacillin]] 250 mg PO q6h'''''<br> OR <br> ▸ '''''[[Cephalexin]] 500mg PO q12h '''''<br> OR <br> ▸ '''''[[Amoxicillin-clavulanic acid]] 850/125 mg PO q12h''''' <br> OR <br> ▸ '''''[[Clindamycin]] 300-450 mg PO q6h'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table03" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! 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|''High suspicion of 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 | High suspicion of MRSA
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Linezolid]]''''' <br> OR <br> ▸ '''''[[Daptomycin]]''''' <br> OR <br> ▸ '''''[[Vancomycin]]'''''
|-
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table04" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! 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|''Low suspicion of MRSA''}}
|-
| 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]]'''' <br> OR <br>▸  '''''[[Moxifloxacin]]'''''<br> OR <br>  ▸ '''''[[cefoxitin]]''''' <br> OR <br> ▸ '''''[[Ceftriaxone]]'''''<br> OR <br> ▸ '''''[[Tigecylin]]''''' <br> OR <br> ▸  '''''[[Imipenem-cilastatin]]'''''
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table05" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! 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|''High suspicion of P. aureuginosa''}}
|-
| 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 | ▸ '''''[[Piperacilin-tazobactam]]'''''
|}
|}
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table06" style="background: #FFFFFF;"
| valign=top |
{| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;"
! 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|''''Broad-spectrum 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 | ▸ '''''[[Vancomycin]]'''''
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS
|-
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftazidime]]''''' <br> OR <br>▸ '''''[[Cefepime]]''''' <br> OR <br>▸ '''''[[Piperacillin-Tazobactam]]''''' <br> OR <br>▸ '''''[[Aztreonam]]''''' <br> OR <br>▸ '''''[['''''
|-
|}
|}
|}


==References==
==References==
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[[Category:Endocrinology]]
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Revision as of 01:48, 3 June 2014

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

Overview

Foot ulcers in diabetes require multidisciplinary assessment, usually by diabetes specialists and surgeons. Treatment consists of appropriate bandages, antibiotics (against staphylococcus, streptococcus and anaerobe strains), debridement and arterial revascularisation. It is often 500 mg to 1000 mg of flucloxacillin, 1 g of amoxicillin and also metronidazole to tackle the putrid smelling bacteria. Specialists are investigating the role of nitric oxide in diabetic wound healing. Nitric oxide is a powerful vasodilator, which helps to bring nutrients to the oxygen deficient wound beds. Specialists are using forms of light therapy such as LLLT to treat diabetic ulcers.

Diabetic Foot Infection Adapted from Diabetes Care. 2013;36(9):2862-71.[1] and Clin Infect Dis. 2012;54(12):e132-73.[2]

Principles of Therapy

  • Diabetic foot infection (DFI) is diagnosed clinically by the presence of at least two signs or symptoms of inflammation:
  • Local swelling or induration
  • Erythema
  • Local tenderness or pain
  • Local warmth
  • Purulent discharge (thick, opaque to white or sanguineous secretion)
  • Hospitalization is appropriate for the following conditions:
  • Severe (grade 4) infections
  • Moderate (grade 3) infections with complicating features
  • Severe peripheral arterial disease or limb ischemia
  • Lack of home support
  • Patients unable to comply with the required outpatient treatment regimen for psychological or social reasons
  • Patients not responding to outpatient treatment
  • Properly obtained specimens for culture prior to initiating empiric antibiotic therapy provide useful information for guiding antibiotic therapy, particularly in those with chronic or previously treated infections which are commonly caused by 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 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, coagulase-negative staphylococci, corynebacteria), but these may be true pathogens in DFIs and are often resistant to the empiric antibiotics.
  • 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.
  • Consult a vascular surgeon to consider revascularization if ischemia complicates a DFI.
  • 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.
  • 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, granulocyte colony-stimulating factors, hyperbaric oxygen therapy, or negative pressure wound therapy.

Antibiotic Therapy

  • Clinically uninfected wounds should not be treated with antibiotic therapy. For all infected wounds, antibiotic therapy combined with appropriate wound care is recommended.
  • For clinically infected wounds, consider the questions below:
1. Is there high risk of 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
  • High local prevalence of MRSA infection or colonization (50% for a mild and 30% for a moderate soft tissue infection)
  • Clinically severe diabetic foot infection
2. Has patient received antibiotics in the past month?
  • If so, include agents active against gram-negative bacilli in regimen.
  • If not, agents targeted against just aerobic gram-positive cocci may be sufficient.
3. Are there risk factors for infection with Pseudomonas aeruginosa or extended-spectrum β-lactamase (ESBL)–producing organisms?
  • Anti-pseudomonal agent is usually unnecessary except for patients with risk factors:
  • Coverage of ESBL-producing gram-negative organisms should be considered in countries in which they are relatively common.
4. What is the infection 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]
  • Selection of empiric antimicrobial regimen should be determined by the severity of DFI and the likely etiologic agents.
  • Mild (grade 2) to moderate (grade 3) DFI without recent antibiotic treatment:
  • Highly bioavailable oral antibiotics against aerobic gram-positive cocci may be sufficient.
  • Severe (grade 4) DFI:
  • Broad-spectrum antibiotics are recommended while culture results and susceptibility data are pending.
Clinical Manifestation PEDIS Grade IDSA Severity
No symptoms or signs of infection 1 Uninfected
Local infection involving only the skin and the subcutaneous tissue without involvement of deeper tissues and without signs of SIRS
  • If erythema, must be >0.5 cm to ≤2 cm around the ulcer.
  • Exclude other causes of an inflammatory response of the skin (eg, trauma, gout, acute Charcot neuro-osteoarthropathy, fracture, thrombosis, venous stasis).
2 Mild
Local infection with erythema >2 cm or involving structures deeper than skin and subcutaneous tissues (eg, abscess, osteomyelitis, septic arthritis, fasciitis) without signs of SIRS 3 Moderate
Local infection with the signs of SIRS, as manifested by ≥2 of the following:
  • Temperature >38 °C or <36 °C
  • Heart rate >90 beats/min
  • Respiratory rate >20 breaths/min or PaCO2 <32 mm Hg
  • White blood cell count >12,000 or <4,000 cells/μL or ≥10% immature (band) forms
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 Oral (or topical for superficial infections) Outpatient 1–2 wk; may extend to 4 wk
Moderate Oral (or initial parenteral) Outpatient (or inpatient) 1–3 wk
Severe 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.

    Mild

    High suspicion of MRSA

  ▸  Low suspicion of MRSA

    Moderate

  ▸  High suspicion of MRSA

  ▸  Low suspicion of MRSA

  ▸  High suspicion of P. aureuginosa

    Severe

  ▸  Broad-spectrum regimen

High suspicion of MRSA
Doxycycline 100 mg PO q12h
OR
TMP/SMZ
Low suspicion of MRSA
Preferred Regimen
Dicloxacillin 250 mg PO q6h
OR
Cephalexin 500mg PO q12h
OR
Amoxicillin-clavulanic acid 850/125 mg PO q12h
OR
Clindamycin 300-450 mg PO q6h
High suspicion of MRSA
Preferred Regimen
High suspicion of MRSA
Linezolid
OR
Daptomycin
OR
Vancomycin
Low suspicion of MRSA
Preferred Regimen
Levofloxacin'
OR
Moxifloxacin
OR
cefoxitin
OR
Ceftriaxone
OR
Tigecylin
OR
Imipenem-cilastatin
High suspicion of P. aureuginosa
Preferred Regimen
Piperacilin-tazobactam
'Broad-spectrum regimen
Preferred Regimen
Vancomycin
PLUS
Ceftazidime
OR
Cefepime
OR
Piperacillin-Tazobactam
OR
Aztreonam
OR
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References

  1. 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.
  2. 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.