2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infectionsa

Abstract

Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds. Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.

Aerobic bacterial profile and antibiotic resistance in patients with diabetic foot infections

“…Patients with diabetic foot infections are usually hospitalized multiple times and are often exposed to multiple courses of antibiotics (46) , which may infl uence antibiotic resistance. Therefore, the potential presence of such resistant strains emphasizes the importance of obtaining optimal specimens from diabetic foot infections for culture and sensitivity testing (47) (48) as well as the need to avoid excessive antibiotic therapy that promotes this resistance.…”

Prognosis of the infected diabetic foot ulcer: a 12‐month prospective observational study

“…Participants were recruited from community podiatry‐led and multi‐disciplinary diabetic foot ulcer clinics. Eligibility criteria were: diagnosis of diabetes mellitus; foot ulcer suspected of being infected based on clinical signs and symptoms using Infectious Diseases Society of America/International Working Group on the Diabetic Foot 16, 20 criteria and clinical judgement; plan to treat with antibiotics for their infected ulcer; and age ≥ 18 years with written consent provided.…”

“…The European Study Group on Diabetes and the Lower Extremity (Eurodiale) study 5, 15 in people with a new diabetic foot ulcer presenting to one of 14 diabetic foot ulcer clinics, and for whom there was a 1‐year follow‐up, identified independent predictors of delayed healing as: older age;, male sex; larger ulcer size; heart failure; inability to stand or walk without help; end‐stage renal disease; peripheral neuropathy; and peripheral arterial disease 15. Current guidelines for the management of infected diabetic foot ulcer 16, 17, 18, 19, 20 highlight the importance of prevention, early diagnosis and appropriate therapy delivered by a multidisciplinary team.…”

Clinical and surgical characteristics of infected diabetic foot ulcers in a tertiary hospital of Mexico

“…Patients with neuropathy and insufficient peripheral artery flow have a greater risk of developing ulcers than those that only have peripheral diseases [6,7]. On the other hand, patients with neuropathy have more possibilities of healing an ulcer than those with an artery disease [10–12]. …”