Foot Infection/Infected Ulcers

Diagnosis

Non-antimicrobial treatment

Antimicrobial therapy

General principles

Specific choices

Therapy of osteomyelitis

DIAGNOSIS

Diagnose wound care infections clinically, (recognising that the inflammatory response may be mitigated by diabetic complications), by the presence of purulent secretions or local evidence of inflammation, or occasionally systemic toxicity.

Laboratory tests,including cultures, may suggest but do not establish the presence of infection, with the exceptions of reliably obtained deep bone cultures in suspected osteomyelitis.

NON-ANTIMICROBIAL TREATMENT 

• Consult a diabetic foot care team or specialist where available
• Correct any metabolic derangements, optimise wound care and assess vascular status
• Hospitalise patients with a severe infection, needing multiple or complex diagnostic or surgical procedures ; having critical foot ischemia ; needing intravenous therapy or unlikely to comply with therapy
• In case if severe infection, consult appropriate specialists promptly for any necessary invasive diagnostic or surgical procedures

ANTIMICROBIAL THERAPY

GENERAL PRINCIPLES  

• Prescribed for all clinically infected wounds immediately but not for uninfected wounds
• Select the narrowest spectrum therapy possible for mild or moderate infections
• Choose initial therapy based on the commonest pathogens are know local antibiotic sensitivity data
• Adjust (broaden or constrain) empiric therapy based on the culture results and clinical response to the initial regimen

SPECIFIC CHOICES 

• Cover staphylococci and streptococco in almost all cases
• Broaden the spectrum if necessary based on the clinical picture, or previous culture or current Gram-stained  smear results
• Tropical therapy for mild superficial infections have not been adequately studied; oral therapy is effective for the most mild to moderate infections; parenteral therapy ( at least initially) is advisable for severe infections
• Choose agents that have demonstrated efficacy in treating complication skin and soft tissue infections. These include semi- synthetic-penicillins, cephalosporins, penicillin- β - lactamase inhibitors, clindamycin, fluoroquinolones, carbapenems and oxazolidinones
• Treat soft tissue infections for 1-2 weeks if mild infections, and about 2-4 weeks for most that are moderate and severe. When the clinical evidence of infection has been resolved, antibiotics therapy can be stopped

THERAPY OF OSTEOMYELITIS

• Consider surgically removing any infected and necrotic bone, if possible.
• Unless all infected and necrotic bone is resected, provide antibiotic treatment (with parenteral therapy at least initially) for at least 4 weeks
• Treating for several months with highly bioavailable oral agents (especially fluoroquinolones) without surgical resection may be effective in selected patients.