Diabetic foot infection: Difference between revisions
From IDWiki
No edit summary |
m (Text replacement - " species]]" to "]]") |
||
(6 intermediate revisions by the same user not shown) | |||
Line 1: | Line 1: | ||
− | == |
+ | ==Background== |
+ | ===Microbiology=== |
||
− | * Typically involve a combination of ''Staphylococci'', ''Streptococci'', Proteobacteria (Gram-negative bacterial genus that includes enterics), and anaerobes |
||
− | * Anaerobes are more likely to be involved in deeper, more chronic ulcers |
||
+ | *Typically polymicrobial, including: |
||
− | == Further Reading == |
||
+ | **[[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== |
||
− | * [https://doi.org/10.2337/db12-0771 The Neuropathic Diabetic Foot Ulcer Microbiome IsAssociated With Clinical Factors]. ''Diabetes''. 2013;62:923-930. |
||
+ | |||
+ | *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== |
||
+ | {| class="wikitable" |
||
+ | !Severity |
||
+ | !Common Pathogens |
||
+ | !Antibiotics |
||
+ | !Notes |
||
+ | |- |
||
+ | | rowspan="7" |Mild |
||
+ | | rowspan="5" |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 |
||
+ | |- |
||
+ | | rowspan="2" |methicillin-resistant [[Staphylococcus aureus]] |
||
+ | |[[doxycycline]] |
||
+ | |uncertain activity against streptococci |
||
+ | |- |
||
+ | |[[TMP-SMX]] |
||
+ | |uncertain activity against streptococci |
||
+ | |- |
||
+ | | rowspan="13" |moderate or severe |
||
+ | | rowspan="9" |[[MSSA]], [[Streptococcus]], [[Enterobacteriaceae]], [[anaerobes]] |
||
+ | |[[levofloxacin]] |
||
+ | |suboptimal against MSSA |
||
+ | |- |
||
+ | |[[cefoxitin]] |
||
+ | | |
||
+ | |- |
||
+ | |[[ceftriaxone]] |
||
+ | | |
||
+ | |- |
||
+ | |[[ampicillin-sulbactam]] |
||
+ | | |
||
+ | |- |
||
+ | |[[moxifloxacin]] |
||
+ | | |
||
+ | |- |
||
+ | |[[ertapenem]] |
||
+ | | |
||
+ | |- |
||
+ | |[[tigecycline]] |
||
+ | | |
||
+ | |- |
||
+ | |[[Fluoroquinolones|fluoroquinolone]] with [[clindamycin]] |
||
+ | | |
||
+ | |- |
||
+ | |[[imipenem-cilastatin]] |
||
+ | | |
||
+ | |- |
||
+ | | rowspan="3" |MRSA |
||
+ | |[[linezolid]] |
||
+ | | |
||
+ | |- |
||
+ | |[[daptomycin]] |
||
+ | | |
||
+ | |- |
||
+ | |[[vancomycin]] |
||
+ | | |
||
+ | |- |
||
+ | |[[Pseudomonas aeruginosa]] |
||
+ | |[[piperacillin-tazobactam]] |
||
+ | | |
||
+ | |} |
||
+ | |||
+ | ===Duration=== |
||
+ | {| class="wikitable" |
||
+ | !Site of Infection |
||
+ | !Severity |
||
+ | !Duration |
||
+ | |- |
||
+ | | rowspan="3" |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 |
||
+ | |- |
||
+ | | rowspan="4" |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 evidence[[CiteRef::gariani2020th]] |
||
+ | |||
+ | ==Further Reading== |
||
+ | |||
+ | *[https://doi.org/10.2337/db12-0771 The Neuropathic Diabetic Foot Ulcer Microbiome IsAssociated With Clinical Factors]. ''Diabetes''. 2013;62:923-930. |
||
[[Category:Skin and soft tissue infections]] |
[[Category:Skin and soft tissue infections]] |
Latest revision as of 00:02, 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.