|
|
Should oral antibiotics be used in diabetic foot infections?
The use of systemic oral antibiotics should be initiated for all wounds, even chronic, if an active infection is felt to be invading beyond the point of local control. If there are no clinical signs of infection, oral antibiotics should be avoided.
Eaglstein W, Chronic Wounds. Surg Clin N AM. 1997;77:689.
Dow Gordon, Infection in Chronic Wounds: Controversies in Diagnosis and Treatment. Ostomy/Wound Management. 1999;45(8):23-40.)
| To top |
|
|
When are IV antibiotics indicated?
Intravenous antibiotics are generally reserved for patients that show signs of constitutional symptoms or have severe wound infections. IV antibiotics can also be used when a patient is unable to tolerate oral antibiotics or the organism is not susceptible to oral antibiotics.
Grayson ML, Diabetic foot infections. Antimicrobial Therapy. Infectious Disease Clinics of N AM. 1995;9:143-61
Lipsky Benjamin. Antibiotic therapy of Diabetic Foot Infections. Wounds 2000;12(Suppl B):55B-63B.)
| To top |
|
|
How long should patients be treated with antibiotics?
For most diabetics with a mild to moderate foot infection, it is believed that a one to two week course of antibiotics is effective. The more serious infections can be treated with 14 days of IV and then stepped down to oral antibiotics for varied time frames dependent on the the infection and patients state of health.
Lipsky BA. Outpatient Management of Uncomplicated Lower-extremity infections in Diabetic Patients. Arch Intern Med, 1990;150:790-70
Grayson ML, Use of ampicillin/sulbactam versus imipenem/cilsttatin in treatment of limb threatening foot infections in diabetic patients. Clin Infect Dis. 1994;18:683.
| To top |
|
|
What is the role of topical antibiotics?
Topical antibiotics can help lower the rate of bacterial colonization of chronic wounds. Topicals can also help to prevent wound infection or help reduce odor, exudates, inflammation, and pain.
Taddino TE, A Survey of Wound Monitoring and Topical Antimicrobial Therapy Practices in the Treatment of Burn Injury, J Burn Care Rehab, 1990;11:423-7
Eaglstein WH, Chronic Wounds, Surgical Cl N Am, june 1997, VOL. 77 Num 3, 689-700.
| To top |
|
|
Do you need to culture to determine the appropriate antibiotic?
In most cases, physicians start with empiric antibiotic therapy when infection is noted. Culturing the infected ulcer/wound is critical because it will isolate the pathogens responsible for the infection and antibiotic sensitivities will allow the physician to choose the appropriate antibiotic. Using the culture specific antibiotic will also help reduce bacterial resistance.
Lipsky BA, A Current Approach to Diabetic Foot Infections, Current Infectious Disease Reports, 1999, 1:253-260.
Levine N, The Quantitative Swab Culture and Smear: A Quick, Simple Method for Determining the Number of Viable Aerobic Bacteria on Open Wounds, J Trauma, 1976;16(2):89.
| To top |
|
|
When is surgery indicated in an infected diabetic foot ulcer?
Surgery is indicated when the ulcer/ wound shows signs of deep infection. Surgery needs to be considered in patients that have non-healing ulcerations due to an underlying osteomyelitis.
Tan J, Can Aggressive Treatment of Diabetic Foot infections Reduce the need for Above the Ankle Amputation, Clinical Infectious Disease,1996 , 23:286-91.
Bamberger DM, Osteomyelitis in the feet of Diabetic Patients: Long-term results, Prognostic Factors, and the Role of Antimicrobial and Surgical Therapy, Am J of Med, 1987 ; 83:653-60.
| To top |
|
|
How do you know how much to resect?
In an amputation, the surgeon must resect proximal to the level of infected tissue or the unsalvageable body part. A surgeon must also take into account if the patients has peripheral vascular disease and decide at what level the patient will be able to heal an amputation.
Bowker JH, Partial Foot amputations and disarticulations, Foot Ankle Clinics, 2:153, 1997.
Brodsky JW, Diabetic Foot Infections, Ortho Cl N Am, Vol.22, No. 3: 473-89, 1991.
| To top |
|
|
What labs do you obtain when you suspect infection?
Labs most physicians obtain are CBC with differential, ESR, and a HA1C.
Saltzman CL, Diabetic Foot Infections, AAOS Instructional Course Lectures, Vol. 48:317-320, 1999.
Calhoun JH, Osteomyelitis of the Diabetic Foot, Wounds, 2000;12(6suppl B):48B-54B.
| To top |
|
|
What are the criteria for hospital admission?
In most cases, patients are admitted for infection of the foot when they require parenteral antibiotics, failed course of oral antibiotics, and when a surgical procedure is planned. Patients may also be admitted if they have low compliance rates or can not care for themselves.
Eneroth M, Clinical Characteristics and Outcomes in 223 Diabetic Patients with Deep Foot Infections, Foot & Ankle International, Vol. 18, No. 11, Nov 97: 716-22.
Grayson ML, Probing to Bone in Infected Pedal Ulcers: A Clinical Sign of Underlying Osteomyelitis in Diabetic Patients, JAMA, March 1, 1995; vol. 23, No.9: 721-723.
| To top |
|
|
What are the clinical characteristics of diabetic foot infections?
The classic signs of infection are swelling, redness, pain, and odor. In diabetic patients, physicians must also look for purulent discharge and crepitus from gas forming organisms that tend to infect diabetic patients.
Boulton AJ, Diabetic Foot Ulcers: A Framework for Prevention and Care, Wound Rep Reg 1999;7:7-16.
Dow G, Infections in Chronic Wounds: Controversies in Diagnosis and Treatment, Ostomy Wound Management, 1999;45(8):23-40.
| To top |
|
|
Are elevated WBCs and temperature always present in patients with a diabetic foot infection?
In many cases, diabetic patients will lack clinical signs of infection such as chills, fever, and leukocytosis upon presentation. Physicians must be aware that patients with diabetes may not mount an inflammatory response in presence of an infection.
Bamberger DM, Osteomyelitis in the feet of diabetic patients: long-term results, prognostic factors, and the role of antimicrobial and surgical therapy, Am J Med, 83:653-660, 1987.
Grayson ML, Use of ampicillin/sulbactam versus imipenem/cilastatin in the treatment of limb-threatening foot infections in diabetic patients, Clin Infect Dis, 18:683-693, 1994.
| To top |