Diabetic foot infection: Difference between revisions

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*Typically polymicrobial, including:
  
*Typically polymicrobial, including:
−
**[[Staphylococcus species]]
 +
**[[Staphylococcus aureus]], which is by far the most common cause of monomicrobial infections
  +
**[[Coagulase-negative staphylococci]]
−
**[[Streptococcus species]]
  
  +
**[[Streptococcus]]
−
**[[Proteobacteria]] (Gram-negative bacterial genus that includes enterics)
  
−
**[[Anaerobes]]
 +
**[[Enterococcus]]
  +
**[[Enterobacteriaceae]]
  +
**[[Pseudomonas aeruginosa]]
  +
**[[Anaerobes]], including [[Bacteroides fragilis]]
 
*Anaerobes are more likely to be involved in deeper, more chronic ulcers
  
*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==
  
==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
  
*Osteomyelitis

Latest revision as of 00:02, 28 January 2022

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 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

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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