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Diabetic Foot Infection MAZENS.BADER,MD,MPH,Memorial University of Newfoundland School of Medicine, St

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Diabetic Foot Infection MAZENS.BADER,MD,MPH,Memorial University of Newfoundland School of Medicine, St Diabetic Foot Infection MAZENS.BADER,MD,MPH,Memorial University of Newfoundland School of Medicine, St. John’s, Newfoundland, Canada Foot infections are common in patients with diabetes and are associated with high morbidity and risk of lower extrem- ity amputation. Diabetic foot infections are classified as mild, moderate, or severe. Gram-positive bacteria, such as Staphylococcus aureus and beta-hemolytic streptococci, are the most common pathogens in previously untreated mild and moderate infection. Severe, chronic, or previously treated infections are often polymicrobial. The diag- nosis of diabetic foot infection is based on the clinical signs and symptoms of local inflammation. Infected wounds should be cultured after debridement. Tissue specimens obtained by scraping the base of the ulcer with a scalpel or by wound or bone biopsy are strongly preferred to wound swabs. Imaging studies are indicated for suspected deep soft tissue purulent collections or osteomyelitis. Optimal management requires aggressive surgical debridement and wound management, effective antibiotic therapy, and correction of metabolic abnormalities (mainly hyperglycemia and arterial insufficiency). Treatment with antibiotics is not required for noninfected ulcers. Mild soft tissue infection can be treated effectively with oral antibiotics, including dicloxacillin, cephalexin, and clindamycin. Severe soft tissue infection can be initially treated intravenously with ciprofloxacin plus clindamycin; piperacillin/tazobactam; or imi- penem/cilastatin. The risk of methicillin-resistant S. aureus infection should be considered when choosing a regimen. Antibiotic treatment should last from one to four weeks for soft tissue infection and six to 12 weeks for osteomyelitis and should be followed by culture-guided definitive therapy. (Am Fam Physician. 2008;78(1):71-79, 81-82. Copyright © 2008 American Academy of Family Physicians.) T Patient informa- npatientswithdiabetes,anyfootinfec- blistering, or penetrating foreign body. Motor tion: A handout on tion is potentially serious. Diabetic neuropathy can result in foot deformities diabetic foot infection, written by the author of foot infections range in severity from (e.g., claw toe) that contribute to local pres- this article, is provided on superficial paronychia to deep infection sure from footwear, making skin ulceration page 81. Iinvolving bone. Types of infection include even more likely. Once the skin is broken cellulitis, myositis, abscesses, necrotizing (typically on the plantar surface), the under- fasciitis, septic arthritis, tendinitis, and lying tissues are exposed to colonization by osteomyelitis. Foot infections are among the pathogenic organisms. The resulting wound most common and serious complications of infection may begin superficially, but with diabetes mellitus. They are associated with delayintreatmentandimpairedbodydefense increased frequency and length of hospital- mechanisms caused by neutrophil dysfunc- izationandriskoflowerextremityamputa- tionandvascularinsufficiency,itcanspread tion.1 Foot ulceration and infection are the to the contiguous subcutaneous tissues and to leadingriskfactorsforamputation.2 Preven- even deeper structures.3,4 tion and prompt diagnosis and treatment are Although most diabetic foot infections necessary to prevent morbidity, especially beginwithanulcer,localizedcellulitis amputation. andnecrotizingfasciitiscandevelopinthe absence of an ulcer or traumatic injury. Pathophysiology Patients with diabetes are particularly sus- Microbiology ceptible to foot infection primarily because Themostcommonpathogensinacute,pre- of neuropathy, vascular insufficiency, and viouslyuntreated,superficialinfectedfoot diminished neutrophil function.3 Peripheral wounds in patients with diabetes are aerobic neuropathy has a central role in the devel- gram-positive bacteria, particularly Staphy- opmentofafootinfectionanditoccursin lococcus aureus and beta-hemolytic strepto- about30to50percentofpatientswithdiabe- cocci (group A, B, and others).5 Infection tes. Patients with diabetes lose the protective in patients who have recently received anti- sensations for temperature and pain, impair- bioticsorwhohavedeeplimb-threatening ing awareness of trauma such as abrasions, infectionorchronicwoundsareusually Downloaded from the American Family Physician Web site at www.aafp.org/afp. Copyright © 2008 American Academy of Family Physicians. For the private, noncommercial use of one individual user of the Web site. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Diabetic Foot Infection SORT: KEY RECOMMENDATIONS FOR PRACTICE Evidence Clinical recommendation rating References The existence, severity, and extent of infection, as well as vascular status, neuropathy, and glycemic C 3, 9 control should be assessed in patients with a diabetic foot infection. Visible bone and palpable bone on probing are suggestive of underlying osteomyelitis in patients with C13, 14 a diabetic foot infection. Before an infected wound of a diabetic foot infection is cultured, any overlying necrotic debris should C3, 17 be removed to eliminate surface contamination and to provide more accurate results. Routine wound swabs and cultures of material from sinus tracts are unreliable and strongly discouraged B17-19 in the management of diabetic foot infection. The empiric antibiotic regimen for diabetic foot infection should always include an agent active against A 3, 5, 7, 8 Staphylococcus aureus, including methicillin-resistant S. aureus if necessary, and streptococci. A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease- oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, see http://www.aafp. org/afpsort.xml. causedbyamixtureofaerobicgram-positive,aerobic It can clinically mimic cellulitis and presents as erythema, gram-negative (e.g., Escherichia coli, Proteusspecies, edema,andelevatedtemperatureofthefoot.Mostpatients Klebsiella species), and anaerobic organisms (e.g., Bacte- with diabetic foot infection do not have systemic features roides species, Clostridium species, Peptococcus and Pep- such as fever or chills. The presence of systemic signs or tostreptococcus species).5 Anaerobic bacteria are usually symptoms indicates a severe deep infection.12 partofmixedinfectionsinpatientswithfootischemia or gangrene.6 Methicillin-resistant S. aureus (MRSA) is ESTABLISHING EXTENT OF INFECTION amorecommonpathogeninpatientswhohavebeen Earlyrecognitionoftheareaofinvolvedtissuecanfacili- previously hospitalized or who have recently received tate appropriate management and prevent progression of antibiotictherapy.MRSA infectioncanalsooccurinthe the infection (Figure 3).Thewoundshouldbecleansed absence of risk factors because of the increasing preva- and debrided carefully to remove foreign bodies or lenceofMRSA inthecommunity.7,8 necroticmaterialandshouldbeprobedwithasterile metalinstrumenttoidentifyanysinustracts,abscesses, Clinical Evaluation or involvement of bones or joints. Key elements for evaluating and treating diabetic foot Osteomyelitis is a common and serious complication of infection are summarized in Figure 1.9 diabetic foot infection that poses a diagnostic challenge. A delay in diagnosis increases the risk of amputation.13 CONFIRMING THE DIAGNOSIS Risk factors associated with osteomyelitis are summa- Diabetic foot infection must be diagnosed clinically rather rized in Table 1.3,13-16 Visible bone and palpable bone by than bacteriologically because all skin ulcers harbor micro- probing are suggestive of underlying osteomyelitis in organisms (Figure 2).Theclinicaldiagnosisoffootinfec- patients with a diabetic foot infection.13-14 Laboratory tionisbasedonthepresenceofpurulentdischargefroman studies, such as white blood cell count and the erythrocyte ulcerortheclassicsignsofinflammation(i.e.,erythema, sedimentation rate (ESR), have limited sensitivity for the pain,tenderness,warmth,orinduration).Othersugges- diagnosis of osteomyelitis. Osteomyelitis is unlikely with tive features of infection include foul odor, the presence normal ESR values; however, an ESR of more than 70 mm of necrosis, and failure of wound healing despite optimal perhoursupportsaclinicalsuspicionofosteomyelitis.13 management.10 Local inflammatory findings may be less Definitive diagnosis requires percutaneous or open bone prominent or absent in some diabetic foot infections. For biopsy.Bonebiopsyisrecommendedifthediagnosisof example, pain and tenderness may be reduced or absent osteomyelitis remains in doubt after imaging.3 in patients who have neuropathy, whereas erythema may be absent in those with vascular disease.11 Acute Char- ESTABLISHING SEVERITY OF INFECTION cot’s foot is characterized by a progressive deterioration The severity of the infection determines the appropriate of weight-bearing joints, usually in the foot or ankle. antibiotic regimen and route of administration. It also is 72 American Family Physician www.aafp.org/afp Volume 78, Number 1 V July 1, 2008 Evaluation and Treatment of Diabetic Foot Infection Cleanse, debride, probe wound Assess for signs of inflammation Assess neurologic and vascular status of foot Consider plain radiography of the foot Is the wound clinically infected? Yes No Assess severity of infection Prescribe appropriate wound care and metabolic status Off-load local pressure Assess medical and Consider wound-healing
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