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

Benjamin A. Lipsky Department of Medicine, University of Washington, Veterans Affairs Puget Sound Health Care System, Seattle

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Anthony R. Berendt Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford

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Paul B. Cornia Department of Medicine, University of Washington, Veteran Affairs Puget Sound Health Care System, Seattle

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James C. Pile Divisions of Hospital Medicine and Infectious Diseases, MetroHealth Medical Center, Cleveland, Ohio

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Edgar J. G. Peters Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands

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David G. Armstrong Southern Arizona Limb Salvage Alliance, Department of Surgery, University of Arizona, Tucson

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H. Gunner Deery Northern Michigan Infectious Diseases, Petoskey

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John M. Embil Department of Medicine, University of Manitoba, Winnipeg, Canada

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Warren S. Joseph Division of Podiatric Surgery, Department of Surgery, Roxborough Memorial Hospital, Philadelphia, Pennsylvania

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Adolf W. Karchmer Department of Medicine, Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts

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Michael S. Pinzur Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois

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Eric Senneville Department of Infectious Diseases, Dron Hospital, Tourcoing, France

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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.

Correspondence: Benjamin A. Lipsky, MD, University of Washington, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108 (balipsky@uw.edu).