Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections

2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infectionsa

1. Benjamin A. Lipsky1,
2. Anthony R. Berendt2,
3. Paul B. Cornia3,
4. James C. Pile4,
5. Edgar J. G. Peters5,
6. David G. Armstrong6,
7. H. Gunner Deery7,
8. John M. Embil8,
9. Warren S. Joseph9,
10. Adolf W. Karchmer10,
11. Michael S. Pinzur11 and
12. Eric Senneville12

+ Author Affiliations

1. ¹Department of Medicine, University of Washington, Veterans Affairs Puget Sound Health Care System, Seattle
2. ²Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Oxford
3. ³Department of Medicine, University of Washington, Veteran Affairs Puget Sound Health Care System, Seattle
4. ⁴Divisions of Hospital Medicine and Infectious Diseases, MetroHealth Medical Center, Cleveland, Ohio
5. ⁵Department of Internal Medicine, VU University Medical Center, Amsterdam, The Netherlands
6. ⁶Southern Arizona Limb Salvage Alliance, Department of Surgery, University of Arizona, Tucson
7. ⁷Northern Michigan Infectious Diseases, Petoskey
8. ⁸Department of Medicine, University of Manitoba, Winnipeg, Canada
9. ⁹Division of Podiatric Surgery, Department of Surgery, Roxborough Memorial Hospital, Philadelphia, Pennsylvania
10. ¹⁰Department of Medicine, Division of Infectious Diseases, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
11. ¹¹Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois
12. ¹²Department of Infectious Diseases, Dron Hospital, Tourcoing, France

1. Correspondence: Benjamin A. Lipsky, MD, University of Washington, VA Puget Sound Health Care System, 1660 S Columbian Way, Seattle, WA 98108 (balipsky@uw.edu).

Abstract

Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds.

Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.

JAPMA January/February 2013 vol. 103 no. 1 2-7

enlace abstract: http://www.japmaonline.org/content/103/1/2.abstract