The Infectious Diseases Society of America has issued updated guidelines
for the diagnosis and treatment of diabetic foot infections. Most infections
can be cured if properly managed, but some patients with diabetes often undergo
amputations because they were not diagnosed or treated promptly or effectively.
The guidelines include recommendations to help orthotists and prosthetists
determine when to refer to another specialist.
According to The Infectious Disease Society of America (IDSA),
infections should be defined clinically and then classified by severity, which
helps clinicians decide which patients to hospitalize, to send for imaging
procedures or to recommend surgical interventions.
The organization issued several recommendations for managing diabetic
foot infections:
· Clinicians should look for evidence of
infection, including inflammation, purulent secretions, other secretions or
discolored tissue and foul odor. Factors that increase the risk for infection
include a wound for which the probe to bone test is positive; ulceration
present for more than 30 days; history of recurrent foot ulcers; traumatic foot
wound; presence of peripheral vascular disease; previous lower extremity
amputation; loss of protective sensation; presence of renal insufficiency, and;
a history of walking barefoot. Clinicians should use a validated classification
system to help define the variety and severity of their cases and their
outcomes.
- Clinicians should evaluate the patient, the affected limb and the
infected wound. Diagnosis should be based on presence of at least two classic
symptoms or signs of inflammation or purulent secretions. Assess the affected
limb and foot for arterial ischemia and debride any wound that has necrotic
tissue or surrounding callus.
- Clinicians should seek a multidisciplinary diabetic footcare team for
specialized input. This may include consultation with an infectious disease or
clinical microbiology specialist and a surgeon experienced in managing
infections.
- Patients with severe infection, moderate infection with complicating
features and patients who are treatment noncompliant should be hospitalized.
- For infected wounds, clinicians should obtain a deep tissue specimen
for culture after wound has been cleaned and debrided, before starting
antibiotic therapy. An antibiotic regimen should be based on the severity of
the infection and likely etiologic agent, and administered in conjunction with
appropriate wound care. Parenteral therapy is preferred for all severe and some
moderate infections initially; oral agents can be given when the patient is
systemically well and culture results are obtained. Antibiotic therapy should
continue until there is evidence of healing, but not through complete healing.
- New patients with diabetic foot infections should have radiographs of
the affected foot to note bony abnormalities. Magnetic resonance imaging should
be used for patients who require further imaging, particularly those with soft
tissue abscess or in whom the diagnosis of osteomyelitis is uncertain.
- Clinicians should perform a probe to bone test for a diabetic foot
infection with an open wound to help diagnose or exclude osteomyelitis. Serial
radiographs can help diagnose or monitor suspected osteomyelitis. Magnetic
resonance imaging may be used, but if contraindicated, clinicians may use a
leukocyte or antigranulocyte scan combined with a bone scan. A diagnostic bone
biopsy may be obtained under specific circumstances. After radical resection of
infected tissue, antibiotic therapy may be given for 2 to 5 days; with
persistent infected or necrotic bone, longer treatment is warranted.
- Non-surgical clinicians should request an assessment by a surgeon for
patients with moderate or severe diabetic foot infection.
- Diabetic foot patients with a foot wound should receive appropriate
wound care, consisting of debridement; redistributing pressure of the wound to
the weight bearing surface of the foot; and dressings that allow for moist
wound healing and control excess exudation. Treating uninfected wounds with
topical antimicrobials is not recommended.
— by Carey Cowles
References:
Lipskey B et al. 2012 Infectious Diseases Society of America Clinical
Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections.
Clin Infect Dis. 2012:54. Available at:
http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/2012%20Diabetic%20Foot%20Infections%20Guideline.pdf#search=%22diabetes%22.
Accessed May 3, 2012.