Diabetic foot infection: Difference between revisions
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*Typically polymicrobial, including: |
*Typically polymicrobial, including: |
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**[[Staphylococcus |
**[[Staphylococcus aureus]], which is by far the most common cause of monomicrobial infections |
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**[[Coagulase-negative staphylococci]] |
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**[[Streptococcus species]] |
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**[[Streptococcus]] |
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**[[Proteobacteria]] (Gram-negative bacterial genus that includes enterics) |
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**[[ |
**[[Enterococcus]] |
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**[[Enterobacteriaceae]] |
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**[[Pseudomonas aeruginosa]] |
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**[[Anaerobes]], including [[Bacteroides fragilis]] |
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*Anaerobes are more likely to be involved in deeper, more chronic ulcers |
*Anaerobes are more likely to be involved in deeper, more chronic ulcers |
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==Diagnosis== |
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*Osteomyelitis should be considered in all cases of diabetic foot infection |
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**[[Probe-to-bone test]] should be done routinely |
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**Plain film X-ray can be helpful, though not sensitive |
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**MRI is the preferred diagnostic test, followed by bone and white cell scan |
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**The gold standard is still bone biopsy for histopathology and culture |
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==Management== |
==Management== |
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{| class="wikitable" |
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!Severity |
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!Common Pathogens |
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!Antibiotics |
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!Notes |
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|- |
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| rowspan="7" |Mild |
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| rowspan="5" |methicillin-susceptible [[Staphylococcus aureus]], [[Streptococcus]] |
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|[[dicloxacillin]] |
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|qid dosing and very narrow-spectrum |
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|- |
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|[[clindamycin]] |
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|active against MRSA but higher risk of [[CDAD]] |
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|- |
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|[[cephalexin]] |
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|qid dosing |
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|- |
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|[[levofloxacin]] |
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|not as effective against [[Staphylococcus aureus]] |
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|- |
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|[[amoxicillin-clavulanic acid]] |
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|broad-spectrum, includes anaerobic coverage |
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|- |
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| rowspan="2" |methicillin-resistant [[Staphylococcus aureus]] |
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|[[doxycycline]] |
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|uncertain activity against streptococci |
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|- |
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|[[TMP-SMX]] |
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|uncertain activity against streptococci |
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|- |
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| rowspan="13" |moderate or severe |
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| rowspan="9" |[[MSSA]], [[Streptococcus]], [[Enterobacteriaceae]], [[anaerobes]] |
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|[[levofloxacin]] |
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|suboptimal against MSSA |
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|- |
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|[[cefoxitin]] |
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| |
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|- |
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|[[ceftriaxone]] |
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| |
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|- |
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|[[ampicillin-sulbactam]] |
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| |
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|- |
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|[[moxifloxacin]] |
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| |
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|- |
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|[[ertapenem]] |
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| |
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|- |
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|[[tigecycline]] |
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| |
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|- |
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|[[Fluoroquinolones|fluoroquinolone]] with [[clindamycin]] |
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|- |
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|[[imipenem-cilastatin]] |
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| |
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|- |
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| rowspan="3" |MRSA |
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|[[linezolid]] |
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| |
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|- |
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|[[daptomycin]] |
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| |
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|- |
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|[[vancomycin]] |
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| |
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|- |
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|[[Pseudomonas aeruginosa]] |
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|[[piperacillin-tazobactam]] |
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|} |
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===Duration=== |
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{| class="wikitable" |
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!Site of Infection |
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!Severity |
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!Duration |
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|- |
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| rowspan="3" |soft tissue only |
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|mild |
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|1 to 2 weeks; up to 4 weeks if slow-to-resolve |
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|- |
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|moderate |
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|1 to 3 weeks |
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|- |
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|severe |
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|2 to 4 weeks |
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|- |
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| rowspan="4" |bone and joint infection |
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|postamputation, with no residual infection |
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|2 to 5 days |
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|- |
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|postamputation, with residual soft tissue infection |
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|1 to 3 weeks |
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|- |
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|postamputation, with residual bone infection |
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|4 to 6 weeks |
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|- |
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|no surgery |
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|≥3 months |
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|} |
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*Osteomyelitis |
*Osteomyelitis |
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Latest revision as of 04:02, 28 January 2022
Background
Microbiology
- Typically polymicrobial, including:
- Staphylococcus aureus, which is by far the most common cause of monomicrobial infections
- Coagulase-negative staphylococci
- Streptococcus
- Enterococcus
- Enterobacteriaceae
- Pseudomonas aeruginosa
- Anaerobes, including Bacteroides fragilis
- Anaerobes are more likely to be involved in deeper, more chronic ulcers
Diagnosis
- Osteomyelitis should be considered in all cases of diabetic foot infection
- Probe-to-bone test should be done routinely
- Plain film X-ray can be helpful, though not sensitive
- MRI is the preferred diagnostic test, followed by bone and white cell scan
- The gold standard is still bone biopsy for histopathology and culture
Management
| Severity | Common Pathogens | Antibiotics | Notes |
|---|---|---|---|
| Mild | methicillin-susceptible Staphylococcus aureus, Streptococcus | dicloxacillin | qid dosing and very narrow-spectrum |
| clindamycin | active against MRSA but higher risk of CDAD | ||
| cephalexin | qid dosing | ||
| levofloxacin | not as effective against Staphylococcus aureus | ||
| amoxicillin-clavulanic acid | broad-spectrum, includes anaerobic coverage | ||
| methicillin-resistant Staphylococcus aureus | doxycycline | uncertain activity against streptococci | |
| TMP-SMX | uncertain activity against streptococci | ||
| moderate or severe | MSSA, Streptococcus, Enterobacteriaceae, anaerobes | levofloxacin | suboptimal against MSSA |
| cefoxitin | |||
| ceftriaxone | |||
| ampicillin-sulbactam | |||
| moxifloxacin | |||
| ertapenem | |||
| tigecycline | |||
| fluoroquinolone with clindamycin | |||
| imipenem-cilastatin | |||
| MRSA | linezolid | ||
| daptomycin | |||
| vancomycin | |||
| Pseudomonas aeruginosa | piperacillin-tazobactam |
Duration
| Site of Infection | Severity | Duration |
|---|---|---|
| soft tissue only | mild | 1 to 2 weeks; up to 4 weeks if slow-to-resolve |
| moderate | 1 to 3 weeks | |
| severe | 2 to 4 weeks | |
| bone and joint infection | postamputation, with no residual infection | 2 to 5 days |
| postamputation, with residual soft tissue infection | 1 to 3 weeks | |
| postamputation, with residual bone infection | 4 to 6 weeks | |
| no surgery | ≥3 months |
- Osteomyelitis
- Traditionally, 6 weeks of parenteral therapy
- May be able to shorten to 3 weeks if adequately debrided, based on more recent evidence1
Further Reading
- The Neuropathic Diabetic Foot Ulcer Microbiome IsAssociated With Clinical Factors. Diabetes. 2013;62:923-930.
References
- ^ Karim Gariani, Truong-Thanh Pham, Benjamin Kressmann, François R Jornayvaz, Giacomo Gastaldi, Dimitrios Stafylakis, Jacques Philippe, Benjamin A Lipsky, İlker Uçkay. Three versus six weeks of antibiotic therapy for diabetic foot osteomyelitis: A prospective, randomized, non-inferiority pilot trial. Clinical Infectious Diseases. 2020. doi:10.1093/cid/ciaa1758.
