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- EXECUTIVE SUMMARY
- RECOMMENDATIONS FOR MANAGING DIABETIC FOOT INFECTIONS
- I. In which diabetic patients with a foot wound should I suspect infection, and how should I classify it?
- II. How should I assess a diabetic patient presenting with a foot infection?
- III. When and from whom should I request a consultation for a patient with a diabetic foot infection?
- IV. Which patients with a diabetic foot infection should I hospitalize, and what criteria should they meet before I discharge them?
- V. When and how should I obtain specimen(s) for culture from a patient with a diabetic foot wound?
- VI. How should I initially select and when should I modify, an antibiotic regimen for a diabetic foot infection? (See question VIII for recommendations for antibiotic treatment of osteomyelitis)
- VII. When should I consider imaging studies to evaluate a diabetic foot infection, and which should I select?
- VIII. How should I diagnose and treat osteomyelitis of the foot in a patient with diabetes?
- IX. In which patients with a diabetic foot infection should I consider surgical intervention, and what type of procedure may be appropriate?
- X. What types of wound care techniques and dressings are appropriate for diabetic foot wounds?
- PubMed Citation
- Article by Benjamin A. Lipsky
- Article by Anthony R. Berendt
- Article by Paul B. Cornia
- Article by James C. Pile
- Article by Edgar J. G. Peters
- Article by David G. Armstrong
- Article by H. Gunner Deery
- Article by John M. Embil
- Article by Warren S. Joseph
- Article by Adolf W. Karchmer
- Article by Michael S. Pinzur
- Article by Eric Senneville
- Similar articles in PubMed
2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infectionsa
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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.
