Diabetic Foot Infection:
A challenge for primary and secondary care?
Dr Tony Berendt
Consultant Physician
Bone Infection Unit
NOC NHS Trust, Oxford
Disclosure of Potential
Conflicts of Interest
Has received honoraria, travel expenses and
hospitality for serving on speakers bureaux and
advisory boards for RPR (Synercid), Pfizer (Linezolid)
MSD (Ertapenem) and MacroChem (Pexiganin)
Vice-Chair of IDSA Clinical Practice Guidelines
Committee for Diabetic Foot Infections; Chair of
IWGDF Osteomyelitis Sub-group
Member of Oxfordshire Priorities Forum and ORHNOC Medicines Advisory Committee
DIPC at NOC, Chair of TV (South Central) CHAIN
and Steering Group for pan-Oxfordshire C. difficile
intervention project
Infection and Healing
Healing
Infection
Replace
Lose
footwear
footwear
Offloading
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
Abnormal foot Loss of
biomechanics protective
sensation
Autonomic
Reduced skin
compliance
and
lubrication
Ulceration
Vascular
insufficienc
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 patients 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
Overview of Diabetic Foot Infections
7 % o f P o p u la t io n
D ia b e t ic
1 5 - 2 5 % D e v e lo p F o o t U lc e r
4 0 -8 0 % In fe c te d
(o r s u s p e c te d )
4 0 % M i ld
3 0 -4 0 % M o d e r a te
2 0 -3 0 % S e v e re
Slide courtesy of Ben Lipsky, Puget Sound VA, Seattle
Independent Risk Factors* for Foot
Infection:
Diabetex Prospective Trial
Variable
Risk Ratio (95%CI) p Value
Wound depth to bone
6.7 (2.319.9) 0.001
Wound duration >30 days 4.7 (1.613.4) 0.004
Recurrent foot wound
2.4 (1.34.5)
0.006
Traumatic wound etiology 2.4 (1.15.0)
0.02
Peripheral vascular disease 1.9 (1.03.6)
0.04
*stepwise logistic regression model, excluding ulceration
Lavery, Armstrong, Lipsky et al, Diabetes Care 2006;29:1288
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
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
194
195
196
197
198
199
200
201
www.idsociety.org
Clinical Infectious Diseases 2004;39:885-910
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
Wound without purulence or other evidence of
inflammation
Uninfected
More than 2 of purulence, erythema, pain,
tenderness, warmth or induration. Any
cellulitis/erythema extends 2 cm around ulcer and
infection is limited to skin/superficial subcut tissues.
No local complications or systemic illness
Mild
Moderate
Severe
Infection in patient who is systemically well &
metabolically stable but has any of: cellulitis
extending >2 cm; lymphangitis; spread beneath
fascia; deep tissue abscess; gangrene; muscle,
tendon, joint or bone involved
Infection in a patient with systemic toxicity or
metabolic instability
Epidemiology Pathophysiology Microbiology Assessment Biomechanics
Outcomes By IDSA DFI Severity Classification
100%
90%
80%
100%
1666 patients enrolled in prospective
diabetic foot study
89%
90%
Hospitalization
X2 trend = 118.6, <0.0001
80%
X2 trend = 108, p < 0.0001
78%
70%
70%
60%
54%
60%
50%
50%
40%
40%
30%
30%
20%
20%
10%
LE Amputation
10%
46%
10%
6%
3%
0%
3%
0%
No infection
None
Mild
Moderate
Severe
Mild Moderate Severe
No infection
None
Mild
Mild
Moderate
Severe
Moderate
Severe
Armstrong, Lavery, Peters, Lipsky. Clin Infect Dis 2007
Table 8: Suggested Antibiotic Regimens: DFI
Agent(s)
Mild
Advised Route
Moderate
Oral for Most
Severe
Oral or IV
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
Parenteral
Site
Severity
Route
Location
Duration
Soft
tissue
only
Mild
Topical or oral
Outpatient
7-14 days;
Moderate
Oral (or initial
parenteral)
Outpatient/
inpatient
2-4 weeks
Severe
Initial IV, switch to
oral when
possible
Inpatient,
to
outpatient
2-4 weeks
Extent of
surgery
No residual
infected tissue
(e.g. post
amputation)
Residual
infected soft
tissue only
Residual
infected (but
viable) bone
No surgery, or
residual dead
bone post-op.
Route
Duration
Parenteral or oral
2-5 days
Parenteral or oral
2-4 weeks
Initial IV, then
consider oral
switch
Initial IV, then
consider oral
switch
4-6 weeks
Bone
or joint
extend up
to 28 d if
slow to
resolve
>3 months
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 wont 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)
