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Diabetic Foot Infection

Management of Diabetic Foot Infection Adapted from Diabetes Care. 2013;36(9):2862-71.

• 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)

• 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).

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

• 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

• 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.

• Surgical consultation should be sought for when DFIs are deep, extensive, accompanied by osteomyelitis, limb ischemia, crepitus, bullae, ecchymosis, or skin necrosis. 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.

Antibiotic Therapy Adapted from Clin Infect Dis. 2012;54(12):e132-73.

• Clinically uninfected wounds should not be treated with antibiotic therapy. For all infected wounds, antibiotic therapy combined with appropriate wound care is recommended.

• Selection of empiric antimicrobial regimen should be based on the severity of DFI and the likely etiologic agents.

• Mild to moderate with no recent antibiotic treatment: cover gram-positive cocci
• Severe infections: broad-spectrum regimen (after a sample is send for culture)
• Cover for Pseudomona aeuruginosa is unnecessary in the empiric treatment.

• Consider MRSA coverage in patients with risk factors:

• Recent previous hospitalization
• Recent antibiotic treatment
• Prior history of MRSA infection
• High local prevalence of MRSA or severe infection

• Antibiotic regimen should be adjusted according to culture ans susceptibility results

• Route of therapy should be decided according to infection severity.

• Severe infections: parenteral therapy with future change to oral therapy
• Mild to moderate: oral regimen

• Antibiotics should be discontinued when infection is resolved. Do not continue antibiotics till the wound is totally healed
• Recommended time of treatment

• Mild infections: 1-2 weeks
• Moderate to severe: 2-3 weeks

• A broad-spectrum antibiotic regimen is recommended for severe infections, covering staphylococci, streptococci and commonly reported gram-negative pathogens.

• Initial therapy must usually be parenteral and empiric, based on the likeliest pathogens and their probable antibiotic susceptibility patterns.

• Where the likelihood is more than minimal of infection with methicillin-resistant Staphylococcus aureus, Pseudomonas aeruginosa, extended-spectrum beta-lactamase–producing gram-negatives, or obligately anaerobic bacteria, antibiotics effective against these organisms should be considered.

• No one agent or regimen has shown superiority in treating DFIs.

▸ 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 OR ▸ TMP/SMZ Low suspicion of MRSA Preferred Regimen ▸ Dicloxacilin OR ▸ Cephalexine OR ▸ Amoxicillin-clavulanic acid OR ▸ Clindamycin High suspicion of MRSA Preferred Regimen High suspicion of MRSA ▸ [[ PLUS ▸ [[ Low suspicion of MRSA ▸ [[ OR ▸ [[ PLUS ▸ [[ Alternative Regimen (For low suspicion of MRSA) ▸ [[ Low suspicion of MRSA Preferred Regimen ▸ [[ PLUS ▸ [[ Alternative Regimen ▸ [[ OR ▸ [[ PLUS ▸ [[ High suspicion of P. aureuginosa Preferred Regimen At risk for Gonococcal infection ▸ [[ OR ▸ [[ OR ▸ [[ Not at risk for Gonococcal infection ▸ [[ PLUS ▸ [[ OR ▸ [[ Alternative Regimen (If not at risk for Gonococcal infection) ▸ [[ PLUS ▸ [[ OR ▸ [[ 'Broad-spectrum regimen Preferred Regimen ▸ [[