Diabetic foot medical therapy

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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]

Diabetic Foot Infection

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

Diagnosis of Diabetic Foot Infection
  • Diabetic foot infection (DFI) is diagnosed clinically by the presence of at least two signs or symptoms of inflammation:
Indications for Hospitalization
  • Severe (grade 4) infections
  • Moderate (grade 3) infections with complicating features
  • Patients unable to comply with the required outpatient treatment regimen for psychological or social reasons
  • Patients not responding to outpatient treatment
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 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.
Consultation
  • 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.
Adjunctive 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, granulocyte colony-stimulating factors, hyperbaric oxygen therapy, or negative pressure wound therapy.

Selection of Antibiotic Regimen

  • 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?
  • 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?
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 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:
  • 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?
  • The table below describes the recommended route, setting, and duration of antibiotic therapy based on the extent and severity of DFI.
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 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.

    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.