Diabetic foot infection

Dr Paul Chadwick
Consultant Microbiologist
Salford Royal Hospital

Case History
A 76 year old man was admitted as an
emergency with a red and swollen right
foot
Apyrexial and haemodynamically stable
Diagnosed with type 2 diabetes two years
earlier
Oral hypoglycaemic therapy: blood sugar
control moderate

Investigations
X-ray of the foot showed changes
consistent with both osteomyelitis and soft
tissue infection
C-reactive protein 219 mg/l (<10mg/l)
Neutrophils 19.2 x109/l (4-11 x109/l)
Plasma glucose 24.6 mmol/l (3-6 mmo/l).

Illustration reproduced with permission from Clinical Publishing Ltd, Oxford

Diagnosis & Initial management

Moderate diabetic foot infection
limb-threatening
critical ischaemia not present

Treated empirically with IV vancomycin

and piperacillin/tazobactam

Microbiological investigation
Polymicrobial infection
Gram stain of pus showed neutrophils, Gram
positive cocci and Gram positive bacilli
Enterocoocci and alpha-haemolytic
Streptoccoci were isolated from pus
At least five different species comprising
Gram positive cocci and Enterobacteria were
cultured from superficial swabs.

Surgical Intervention
On day 4 debridement was undertaken to
remove infected bone and soft tissue
Enterococcus faecalis, Propionobacterium
sp. and Escherichia coli were isolated
from deep pus and tissue samples.

Further management
On day 7 antimicrobial therapy was
changed to oral amoxicillin plus
ciprofloxacin.
4 weeks of antimicrobial therapy were
given in total
Ongoing wound and foot care was
provided by the Podiatry team

Diabetic foot infection

Most common reason for diabetes-related
admission to hospital
High morbidity may result in amputations

Why does DFI occur?

Foot ulceration is the major factor and
occurs secondary to peripheral
neuropathy and/or vascular insufficiency
(neuro-ischaemic foot ulceration)
Hyperglycaemia and other metabolic
disturbances contribute through
immunological (e.g. neutrophil)
dysfunction and poor wound healing

Prevention of DFI
Appropriate foot care/pressure relief
Podiatry services

Good glycaemic control

Specialist diabetes services

CID 2004; 39:885-910

Multidisciplinary Foot-care Team

Physician
Podiatrist
Medical Microbiologist/ID Physician
Vascular surgeon
Foot surgeon
Radiologist

Microbiological Samples
Samples should be collected following cleansing
and debridement
Deep soft tissue samples should be obtained
from the base of an ulcer by curettage, or at
surgery
Bone biopsy (including histopathological
examination) is important in establishing a
diagnosis of osteomyelitis
Samples should be transported without delay to
the laboratory and cultured under both aerobic
and anaerobic conditions.

Microbiological pathogens
Infection is typically polymicrobial where
ulceration is present
Aerobic Gram positive cocci
Staphylococcus aureus
-haemolytic streptococci

Enterococci
Enterobacteriaceae
Obligate anaerobes
(Nonfermentative Gram negative rods)
(Candida spp.)

Diagnosis and Assessment

DFI is diagnosed clinically by signs and
symptoms of inflammation
Infections are categorized as mild, moderate or
severe, on the basis of clinical and laboratory
features
Assessment is made as to whether an episode
is life or limb threatening
Categorization helps to guide appropriate clinical
management

Mild infection
Purulent or inflamed wound present
Limited to skin and superficial soft tissues
Inflammation extends <2cm from wound
Not systemically unwell
Treatment usually by oral route
e.g. flucloxacillin, doxycycline, clindamycin
Microbiological sampling not routinely required for mild
infection unless recent antimicrobial therapy or previous
antibiotic-resistant organisms

Moderate infection
Purulent or inflamed wound present in a patient who is
systemically well and/or one of the following
inflammation extends >2cm from wound
lymphangitis
spread beneath superficial fascia
abscess formation
necrosis or gangrene
involvement of muscle, tendon, joint or bone
Treatment by oral or parenteral routes according to clinical
assessment and choice of agent

Moderate infection
Treatment options include
amoxicillin/clavulanate
clindamycin + ciprofloxacin
rifampicin + levofloxacin
piperacillin/tazobactam
ertapenem
NB. Choices influenced by local policy with consideration of
local issues such as C. difficile and MRSA incidence
Add glycopeptide, linezolid or daptomycin if MRSA infection
is suspected or infection is life/limb-threatening

Severe infection
Infection in a patient with evidence of systemic
inflammatory response syndrome
IV treatment, at least initially, as an inpatient, e.g.
clindamycin + ciprofloxacin
piperacillin/tazobactam
meropenem or imipenem/cilastatin
Add glycopeptide, linezolid or daptomycin if MRSA infection
is suspected or infection is life/limb-threatening

Duration of Antimicrobial Therapy

Continued until the signs and symptoms of
infection have resolved (ulcer may persist)
Mild soft tissue infections 1-2 weeks
Moderate-severe soft tissue 3-4 weeks
Osteomyelitis typically 6 weeks, unless all
affected bone is completely removed by surgery
(1-2 weeks)
Therapy 3 months sometimes required for
extensive bone infection e.g. calcaneum
NB. Courses may need to be longer than for
non-diabetic patients with cellulitis

Antibiotics in DFI
Antimicrobial therapy can be challenging!
Consider patient factors (e.g. age, renal
function, peripheral vascular disease)
Side effects are common
Gastrointestinal intolerance of oral antibiotics,
often to multiple agents
Hypersensitivity reactions (typically skin
rashes)

Deterioration in renal function may occur

Does the patient require surgery?

Surgical intervention is often required. Urgent
assessment is needed by a surgeon with
expertise in foot surgery where the infection is
life- or limb-threatening. Vascular surgery may be
needed where there is critical ischaemia.
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Excision & drainage

Debridement
Resection +/- reconstruction
Revascularisation
Amputation

Wound Care Issues

Ongoing debridement of non-viable
tissue as required
Dressings to allow daily inspection of
wound and to encourage a moist
wound-healing environment
Remove pressure from the wound
(off-loading)

Glucose Control
Good blood glucose control should be
achieved
To manage the acute infection
To reduce the risk of future foot problems

Diagnostic Imaging 1
Imaging should always be considered to identify
soft tissue abscesses or osteomyelitis
Osteomyelitis is present in 30% DFI
It is important to identify underlying osteomyelitis
as this influences the choice, dose, route and
duration of antimicrobial therapy, however
There is no single, non-invasive, highly sensitive
and specific test for osteomyelitis

Diagnostic Imaging 2
If osteomyelitis is suspected and initial Xray does not confirm the presence of
osteomyelitis, use magnetic resonance
imaging (MRI).
If MRI is contraindicated, white blood cell
(WBC) scanning may be performed
instead
NICE clinical guideline 119

Clinical signs of osteomyelitis

The following are associated with
osteomyelitis
Inflamed, swollen (sausage) toe
Presence of exposed bone
Positive probe-to-bone test

Sausage toe

Osteomyelitis of hallux
Probe to bone?

X-rays and DFI

Plain X-rays can be negative during the first 2-3
weeks of osteomyelitis
Charcot neuroarthropathy & gout may produce
similar appearances
Pragmatic approach where osteomyelitis is
suspected but X-rays are negative
treat for osteomyelitis for two weeks then re-Xray
extend the course of therapy if new changes become
apparent.

Osteomyelitis distal phalanx

MR imaging and DFI

Marrow oedema
Cortical discontinuity
periosteal reaction
debris
sequestra
soft tissue oedema/induration
joint involvement
ulceration
sinus formation
abscess collection

Osteomyelitis of calcaneum, T1 image

Marrow oedema

Sinus
Image courtesy of Dr J Harris, Radiology Department, Salford Royal Hospital

Osteomyelitis of 1st metatarsal head, STIR image

Soft tissue oedema

Marrow oedema

Image courtesy of Dr J Harris, Radiology Department, Salford Royal Hospital

OPAT and DFI

Outpatient (or home) parenteral
antimicrobial therapy may be appropriate
as prolonged IV therapy often needed for
Severe infection
Osteomyelitis
MRSA infection
Intolerance of oral agents
No response to oral agents

Patient eligibility for OPAT

Medically stable
Appropriate IV access
Home circumstances appropriate
Support
Communications
Facilities

PICC lines