Diabetic foot infection: Difference between revisions
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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== |
− | * |
+ | *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== |
==Management== |
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− | === |
+ | ===Duration=== |
+ | {| 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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− | *After amputation or resection |
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− | **If good source control, only 2 to 5 days is recommended |
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− | **If there is persistent infection or necrotic bone, 4 or more weeks |
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*Osteomyelitis |
*Osteomyelitis |
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**Traditionally, 6 weeks of parenteral therapy |
**Traditionally, 6 weeks of parenteral therapy |
Revision as of 19:09, 13 January 2021
Background
Microbiology
- Typically polymicrobial, including:
- Staphylococcus aureus, which is by far the most common cause of monomicrobial infections
- Coagulase-negative staphylococci
- Streptococcus species
- ENterococcus species
- 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 species | 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 species, 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.