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 ==
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==Diagnosis==
   
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* Osteomyelitis should be considered in all cases of diabetic foot infection
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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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**[[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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**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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**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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**The gold standard is still bone biopsy for histopathology and culture
   
 
==Management==
  
==Management==
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|}
  
|}
   
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=== Duration ===
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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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*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
  
 
*Osteomyelitis
  
*Osteomyelitis
 
**Traditionally, 6 weeks of parenteral therapy
  
**Traditionally, 6 weeks of parenteral therapy

Revision as of 19:09, 13 January 2021

Background

Microbiology

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

References

  1. ^  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.

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