Diabetic foot infections

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Foot infections in persons with diabetes are a common, complex, and costly problem.
In addition to causing severe morbidities, they now account for the largest number of diabetes related hospital bed days and are the most common proximate, nontraumatic cause of amputations.
Diabetic foot infections require careful attention and coordinated management, preferably by a multidisciplinary foot-care team.

Illness, drug, dose,frequency and duration information

Diabetic Foot Ulcer Referral Guideline

  • only use antibiotics if clinical signs of infection.
  • send microbiological samples early in infection – tissue, aspirates are preferable to wound swabs.
  • continue therapy until the infection has resolved, not until the wound has healed.
  • treatment plan should include wound care and pressure relief – see Wound Formulary
  • osteomyelitis
    • suspect if able to touch bone through the wound with a sterile probe
    • suspect in a non-healing diabetic ulcer with adequate blood supply
    • refer to Combined Diabetic Foot Clinic
    • deep swab or tissue samples are essential for diagnosis. Delay therapy pending microbiology results in chronic cases
    • treat for 6 weeks minimum.
  • typical pathogens (antibiotic-naïve = no antimicrobials in last 3 months)
    • antibiotic-naïve: Staph aureus and β-haemolytic streptococci
    • not antibiotic-naïve or chronic: as above plus Gram-negative bacilli, enterococci, anaerobes.
  • all doses are for adults with normal renal function or mild renal impairment.
  • IDSA grading of severity of diabetic foot infection - see Lipsky, B. A. et al., 2004. Diagnosis and Treatment of Diabetic Foot Infections. Clinical Infectious Diseases, 39, pp. 885-910.
Clinical classification of a diabetic foot infection (from reference above)
Clinical manifestations of infection

Infection severity

PEDIS grade

Wound lacking purulence or any manifestations of inflammation
Presence of ≥ 2 manifestations of inflammation (purulence, or erythema, pain, tenderness, warmth, or induration), but any cellulitis/erythema extends ≤2 cm around the ulcer, and infection is limited to the skin or superficial subcutaneous tissues; no other local complications or systemic illness.
Infection (as above) in a patient who is systemically well and metabolically stable but which has 1 of the following characteristics: cellulitis extending 12cm, lymphangitic streaking, spread beneath the superficial fascia, deep-tissue abscess, gangrene, and involvement of muscle, tendon, joint or bone.
Infection in a patient with systemic toxicity or metabolic instability (eg, fever, chills, tachycardia, hypotension, confusion, vomiting, leukocytosis, acidosis, severe hyperglycaemia, or azotaemia).

Foot ischaemia may increase the severity of any infection, and the presence of critical ischaemia often makes the infection severe.
PEDIS: Perfusion, Extent/size, Depth/tissue loss, Infection, and Sensation.
Editorial Information

Last reviewed: 30 April 2016

Next review: 30 April 2018

Version: 1

Approved By: high-uhb.tam@nhs.net

Reviewer Name(s): Prof MacRury

Document Id: TAM151