Diabetic Foot Infection

Diabetic Foot Infection – VASP

Evaluation

  • Plain radiograph for all pts; MRI w/contrast if abscess/osteo suspected
  • BCx (prior to antibiotics) if systemic signs of infection, or severe infection
    • Do not culture swab of lesions, as these generally only grow colonizing organisms.
  • Consult podiatry if osteomyelitis present for bone specimen culture and pathology (either from debridement specimen or bone biopsy) prior to starting antibiotics.
  • Consult surgery if c/f abscess, gas in tissue, joint involvement
  • Assess peripheral vasculature, consider arterial flow studies/vascular surgery consult

 

Management

  • Assess Severity:
    • Mild: Local infxn, skin/subQ tissue only, erythema >0.5 cm but ≤2cm from ulcer
    • Moderate: Local infxn w/erythema > 2 cm from ulcer or deeper structures included without SIRS
    • Severe: Local infxn with systemic inflammation as evidenced by ≥ 2 SIRS criteria

 

 

Non-purulent, no MRSA risk factors

Purulent, MRSA risk factors

Mild

Cephalexin 500 QID OR

Amoxicillin-clavulanate 875/125 BID

TMP-SMX DS 1-2 tabs BID OR

Doxycycline 100 BID

Moderate

Amoxicillin-clavulanate 875/125 BID OR

Ampicillin-sulbactam 3g q6h OR

Piperacillin-tazobactam 3.375g q8h ext infusion

Levofloxacin 500 daily

TMP-SMX DS 1-2 tabs BID + cephalexin 500 QID OR Amoxicillin-clavulanate 875/125 BID

Vancomycin 15-20mg/kg q8-12h + ampicillin-sulbactam 3g q6h (anaerobic but NO Pseudomonas cvg*) OR cefepime 2g q8h (Pseudomonas cvg) + metronidazole 500 q8h (anaerobic cvg)

Severe

Vancomycin 15-20 mg/kg q8-12h + cefepime 2g q8h + metronidazole 500 q8h

*Consider anti-pseudomonal coverage if at risk for Pseudomonas aeruginosa infection (e.g. wet; failure of prior antibiotic therapy; chronic wound). Consider anaerobic coverage with metronidazole if foul-smelling and/or necrotic.

 

Additional Information

  • If pt HDS, hold abx until deep tissue/operative cultures obtained.
  • Most diabetic foot infections are polymicrobial in nature.
  • Many wounds colonized with MRSA and/or Pseudomonas improve even when antibiotic treatment not directed at those pathogens are administered.
  • Culture results may guide therapy, but all pathogens identified may not require treatment. Do not swab superficial swabs of the lesion.
  • Treatment is multidisciplinary and may require orthopedics, vascular, and/or endocrinology assessment and intervention.