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DIABETIC FOOT INFECTIONS: TREATMENT

A diabetic foot is tissue damage and ulceration of the foot resulting from neuropathy and peripheral arterial
disease (PAD) in diabetes mellitus.

A foot infection (cellulitis) in a person with diabetes mellitus is not automatically a diabetic foot infection.
Diagnosing a diabetic foot infection requires an infection and pre-existing tissue damage (usually a diabetic
ulcer).

The classical signs of skin inflammation (edema, redness, warmth, pain) are less reliable in diabetic patients.
The sense of pain can be diminished due to neuropathy, and redness and warmth can be reduced due to
peripheral arterial disease. This is why you should carefully examine the feet of every febrile patient with
diabetes.

Do NOT take superficial swabs of diabetic ulcers (infected or uninfected). This type of microbiological sample
is useless. Ulcers are always contaminated or colonized by multiple species of bacteria, but this does not mean
that all (or any) of these bacteria cause the current infection.

To obtain a proper microbiological sample, first, it is necessary to do a debridement and then scrape the base
of the ulcer.

In addition to antibiotics, timely surgical debridement is the mainstay of treatment. Antibiotics cannot
penetrate dead tissue.

Besides necrotic tissue, always look for abscesses and osteomyelitis.

Findings that make osteomyelitis more probable:

a) Large ulcers (>2cm2)

b) Visible bone
c) Reaching the bone by probing the infected ulcer with a dull metal object

Osteomyelitis also requires surgical debridement and microbiological sampling.

Tips for choosing the right antibiotic:

1. For mild infections with no need for surgical debridement, we can use the same antistaphylococcal
antibiotics that we use for uncomplicated cellulitis (antistaphylococcal penicillins, first-generation
cephalosporins, clindamycin).
2. For more severe infections that require surgical debridement, in addition to covering staphylococci
and streptococci, we should also cover Gram-negative rods and anaerobes.
3. In Europe and North America, routine coverage of Pseudomonas aeruginosa is rarely necessary unless
the patient is severely ill or has risk factors for infection with P.aeruginosa.
4. In North America, for purulent infections, it's necessary to cover CA-MRSA.
5. HA-MRSA coverage is necessary if there are risk factors for HA-MRSA infection (recent hospitalization,
recent exposure to antibiotics, nursing home residence, previous infection, or colonization with
MRSA) or if the patient is severely ill.
6. The duration of treatment is longer than for uncomplicated cellulitis. For mild infections, it's 1-2
weeks. For more severe infections, it's 2-4weeks, and for osteomyelitis 4-6 weeks.

When in doubt, consult an infectious diseases specialist!!!

On the next page, there are some (but not all) options for antimicrobial treatment of moderately severe and
severe diabetic foot infections:

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GPB: Gram-positive bacteria, GNRs: Gram-negative rods

If MRSA coverage is also necessary:

Piperacillin/tazobactam, meropenem, imipenem, and ciprofloxacin might cover P.aeruginosa, but the
resistance rates vary widely between countries and regions.

REFERENCES & RECOMMENDED READING:

1. Chastain CA, Klopfenstein N, Serezani CH, Aronoff DM. A Clinical Review of Diabetic Foot Infections. Clin
Podiatr Med Surg. 2019 Jul;36(3):381–95.

2. Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJG, Armstrong DG, et al. 2012 Infectious Diseases Society
of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect
Dis. 2012 Jun;54(12):e132-173.

3. Pitocco D, Spanu T, Di Leo M, Vitiello R, Rizzi A, Tartaglione L, et al. Diabetic foot infections: a
comprehensive overview. Eur Rev Med Pharmacol Sci. 2019 Apr;23(2 Suppl):26–37.

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