Diabetic Foot Infection:

A challenge for primary and secondary care?

Thomas Erwin C J Huwae

SMF Orthopaedi dan Traumatologi
RSUD Dr Saiful Anwar Malang/FK UB
 Infection and Healing
Healing

Infection
ReplaceLose
footwear
footwear
Off-
loading

Amputation
Wound
 Learning objectives

• Be able to discuss the epidemiological

importance of DFI
• Know how to assess risk of diabetic foot
ulceration and infection
• Be able to assess a patient with a diabetic foot
infection, in the context of published
guidelines, and make rational antibiotic choices

Epidemiology Pathophysiology Microbiology Assessment Biomechanics

 General epidemiology
 252 million diabetics worldwide

Epidemiology Pathophysiology Microbiology Assessment Biomechanics

 General epidemiology
 252 million diabetics worldwide
 Foot problems account for largest number of
hospital bed days used for diabetic patients
 1-4% of diabetics develop foot ulcer annually, 25%
in lifetime
 45-75% of all lower extremity amputations are in
diabetics
 85% of these preceded by foot ulcer
 Two-thirds of elderly patients undergoing
amputation do not return to independent life
 Studies have shown less costs for saving a limb cf.
amputation
Epidemiology Pathophysiology Microbiology Assessment Biomechanics
Pathophysiology: diabetic foot ulceration
Neuropathy
 Pathophysiology: diabetic foot ulceration
Neuropathy

Motor Sensory Autonomic

Abnormal foot Loss of protective Reduced skin
biomechanics sensation compliance and
lubrication

Ulceration

Vascular
insufficiency
Infection
 30-second foot examination

• Any previous diabetes related foot problems?

• Are both foot pulses palpable?
• Is protective sensation intact?
• Is there evidence of significant foot deformity?
 Two-minute foot examination

• Examine feet for ulcers, callus, blisters,

maceration, skin breaks, infection
• Examine the toenails
• Identify nature of any foot deformity
• Examine the shoes
• Observe patient’s ability to perform foot care
and examination (by observing them replace
socks and shoes)
• Establish need for patient education
 Standard ulcer care

 Evaluate for infection

 Debride ulcer, remove callosities
 Check for sensation (monofilament)
 Check for circulation (pulses, Dopplers)
 Probe to bone?
 Adequate offloading
 Antibiotics if infected
 Secondary prevention of ulcer and of major
diabetes related events
Epidemiology Pathophysiology Microbiology Assessment Biomechanics
 Microbiology

• Popular mythology = all infections are

polymicrobial

Epidemiology Pathophysiology Microbiology Assessment Biomechanics

Microbial complexity
Microbial burden
Clinical risk

Anaerobes

Aerobic Gram-negative rods

Gram positive cocci

Severity
1 2 3 4 Depth
Necrosis
Prior Rx
 Treatment: myths

• Treat uninfected ulcers to promote healing

• Treat infected ulcers until the ulcer is healed
• Treat all the organisms isolated from the
microbiological specimens
• Hospitalise all infections
• Give lots of intravenous therapy
 Timeline of Staphylococcal antibiotic
resistance
Penicillin-resistance

Sporadic MRSA Epidemic MRSA

GISA

CA-MRSA

VRSA

1940 1950 1960 1970 1980 1990 2000 2010

 Evaluating the Patient with a DFI
• Patient
– Systemic response
• Fever, chills, sweats, cardiovascular status
– Metabolic status
• Hyperglycaemia, electrolyte imbalance,
hyperosmolality, renal impairment
– Cognitive function
• Delirium, depression, dementia, psychosis
– Social situation
• Support, self-neglect
· Limb/Foot
· Wound
Epidemiology Pathophysiology Microbiology Assessment Biomechanics
 Evaluating the Patient with a DFI
• Patient
• Limb or Foot
– Biomechanics
– Vascular
• Ischaemia
• Venous insufficiency
– Neuropathy
– Infection
• Wound
– Size, depth
– Necrosis, gangrene
– Infection
Epidemiology Pathophysiology Microbiology Assessment Biomechanics
 Clinical Classification of Diabetic Foot Infection
Clinical Manifestations of Infection (Wagner Classification)
Wound without purulence or other evidence of
inflammation (Wagner 0) Uninfected 1

More than 2 of purulence, erythema, pain,

tenderness, warmth or induration. Any Mild 2
cellulitis/erythema extends ≤2 cm around ulcer and
infection is limited to skin/superficial . No local
complications or systemic illness (Wagner 1-2

Infection in patient who is systemically well &

Moderate 3
metabolically stable but has any of: cellulitis
extending >2 cm; lymphangitis; spread beneath
fascia; deep tissue abscess; gangrene; muscle,
tendon, joint or bone involved (Wagner 3-4)

Infection in a patient with systemic toxicity or Severe 4

metabolic instability (Wagner 5)
WAGNER CLASSIFICATION
Outcomes By IDSA DFI Severity Classification
100%
1666 patients enrolled in prospective
100%
diabetic foot study
89%
90% 90%

80%
Hospitalization 80%
LE Amputation 78%
X2 trend = 118.6, <0.0001 X2 trend = 108, p < 0.0001
70% 70%

60% 60%
54%

50% 50% 46%

40% 40%

30% 30%

20% 20%

10%
10% 6% 10%
3% 3%
0% 0%
None
No infection Mild
Mild Moderate
Moderate Severe
Severe None
No infection Mild
Mild Moderate
Moderate Severe
Severe

Armstrong, Lavery, Peters, Lipsky. Clin Infect Dis 2007

 Table 8: Suggested Antibiotic Regimens: DFI
Agent(s) Mild Moderate Severe
Advised Route Oral for Most Oral or IV Parenteral
Dicloxacillin Yes
Clindamycin Yes
Cephalexin Yes
TMP/SMX Yes Yes
Amoxicillin/clavulanate Yes Yes
Levofloxacin Yes Yes
Cefoxitin Yes
Ceftriaxone Yes
Ampicillin/sulbactam Yes
Linezolid (± aztreonam) Yes
Daptomycin (± aztreonam) Yes
Ertapenem Yes
Cefuroxime (± metronidazole) Yes
Ticarcillin/clavulanate Yes
Piperacillin/tazobactam Yes Yes
Levo- or Cipro- floxacin + Clindamycin Yes Yes
Imipenem-cilastatin Yes
Vanco + Ceftazidime ± metronidazole Yes
Site Severity Route Location Duration

Soft Mild Topical or oral Outpatient 7-14 days;

tissue extend up
to 28 d if
only slow to
resolve
Moderate Oral (or initial Outpatient/ 2-4 weeks
parenteral) inpatient

Severe Initial IV, switch to Inpatient, 2-4 weeks

oral when to
possible outpatient
Bone Extent of Route Duration
or joint surgery
No residual Parenteral or oral 2-5 days
infected tissue
(e.g. post
amputation)
Residual Parenteral or oral 2-4 weeks
infected soft
tissue only
Residual Initial IV, then 4-6 weeks
infected (but consider oral
viable) bone switch
No surgery, or Initial IV, then >3
residual dead consider oral months
bone post-op. switch
The diabetic foot: Charcot foot with
“rocker bottom” deformity
• Charcot foot
– grossly disordered
architecture and
biomechanics
– midfoot ulceration
– instability of midfoot
– note previous minor
amputations
– still well-vascularised
Bone resorption and destruction
Bone regeneration on antibiotic therapy
 Conclusions

• Ulceration is a common consequence of diabetic

neuropathy
• To understand and treat ulceration, understand the
pathophysiology and biomechanics
• Infection (DFI) is a common and frequently serious
consequence of diabetic foot ulceration (DFU)
• A structured approach to assessment and
treatment, using international or local guidelines,
provides a means to rationalise care and improve
outcomes
• Care must be multidisciplinary to achieve this;
agreed pathways, health service management and
audit are required
 Does it need
antibiotics, doctor?

Besides, they won’t be

discovered for another 300
years!

You must be joking mate!

Debridement and offloading
more like it!

Doctor treating a patient in his surgery: 17th Century, after Teniers the
younger (by kind permission of National Gallery, London)