GUIDELINES FOR DIABETIC FOOT INFECTION

Clinical Setting Diabetic foot1,2 (Usually Polymicrobial) Empiric Therapy Zosyn Likely Pathogens Subsequent Therapy Usual Duration 6 weeks4

Staphylococcus aureus, Zosyn3 Streptococci, Gram-negative bacilli, Cefepime + Anaerobes Metronidazole3 Fluoroquinolone + Metronidazole3 Meropenem3 Addition of vancomycin5

1. 2. 3. 4. 5.

Prior to confirmation of pathogen. Final choice depends upon confirmation of specific pathogen. May require prolonged therapy depending on clinical situation. Debridement and culture of deep devitalized tissue, including bone, should be performed prior to initiating antibiotics in many settings (see Addendum II). If organism from biopsy of bone prior to antibiotics reveals susceptible organism. May consider ertapenem at discharge for dosing convenience if pseudomonas not likely. Duration may be shortened if amputation performed. For patients in whom MRSA is proven or likely

ADDENDUM II: Guidelines for the Management of Diabetic Foot Infections with Evidence of Osteomyelitis It is ideal to obtain deep soft tissue or bone in order to determine the microbiology of the foot infection prior to initiating antibiotics in order to permit the administration of the proper antibiotic agent and to determine whether an organism resistant to the usual empirical agent. Organisms isolated from superficial swabs of foot ulcers often do not reflect the organisms causing osteomyelitis. Thus, a swab culture can not reliably be used to identify the organisms responsible for osteomyelitis. The following are general guidelines for the indications for surgical debridement of involved bone prior to initiation of antibiotics in diabetic foot infections: I. Indications for surgical debridement of involved bone prior to initiating antibiotics ONLY IF A AND B are present: A. Adequate blood supply as documented by ankle pressures (ABI) or toe pressures (TBI) 1. Preserved perfusion required for proper wound healing and prevention of osteonecrosis

B. Chronic draining sinus tract or ulcer without surrounding cellulitis. II. Surgical debridement and biopsy of infected bone contraindicated if A OR B Present: A. Blood supply is inadequate by ABI or TBI B. Extensive cellulitis overlying exposed bone 1. Surgical intervention could result in introduction of infection into bone that is not already infected.

Guidelines for Antimicrobial Use

III. Ordering TBI and ABI In selected clinical circumstances, toe pressures can be used to detect an occlusive lesion between the level of the ankle and digital arteries. Additionally, TBI's may be used to predict healing capabilities in foot ulcers. The systolic toe blood pressure measurement is a simple, reliable and readily reproducible method. This non-invasive diagnostic study is especially useful in the diabetic patient. Diabetic patients are particularly prone to medial calcification, which can cause artifactual elevation of ankle pressures (ABI). Accurate measurements of arterial pressure, using pneumatic cuffs, require pressure to be transmitted through the arterial wall to the flow stream. Occasionally, it is impossible to eliminate the flow signal with maximum inflation pressures, suggesting evidence of medial calcification. The presence of medial calcification in the arterial wall results in varying degrees of incompressibility and the recording of falsely high pressures. Medial calcification seldom occurs at the toe level, therefore toe pressures are particularly valuable for evaluating diabetics. The normal TBI is 70% or greater of the brachial pressure. A toe systolic pressure which is 30 to 40 mm Hg or greater indicates that healing in the foot from a vascular perspective will likely occur. Currently, in the Diagnostic Vascular Unit, when a TBI is performed, the temperature of the toe is taken prior to obtaining a toe pressure. Toe temperature varies from 24C to 33C. This can cause an average change of 10 mm Hg in a toe systolic pressure. Therefore, warming the foot to above 30C can increase the pressure significantly, particularly in patients with moderate to severe arterial disease. If a non-invasive vascular study is needed, the Diagnostic Vascular Unit is available to assist in scheduling an appointment between the hours of 7:00 a.m. to 5:00 p.m. The telephone number for elective scheduling is 936-5937. A technologist is available from 7AM to 11 PM. IV. Antibiotic choice A. Initial: see Guidelines for Diabetic Foot Infection B. Subsequent: Guided by isolation of bacteria from deep soft tissue or bone. Note that up to 40% of isolates may be resistant to the standard empirically chosen antibiotic, Zosyn. Examples of Zosyn resistant organisms: methicillin-resistant Staphylococcus aureus, Pseudomonas spp, Enterobacter. spp, Citrobacter spp, ampicillin-resistant enterococci, VRE, etc. C. Antibiotic therapy should not be guided by bacteria isolated from superficial surfaces (surface of ulcer, draining sinus tracts) as the bacteria isolated from these areas are not reflective of those isolated from bone.

Guidelines for Antimicrobial Use