diabetic%20foot%20infection
DIABETIC FOOT INFECTION

Diabetic foot infection occurs in patients with diabetes as they are prone to microorganism invasion and multiplication in the soft tissue or bone (anywhere below the malleoli) that leads to host inflammatory response that usually results to tissue destruction.

Staphylococci and streptococci are the most common causative organisms although most diabetic foot infections are polymicrobial.

Most infections usually start with a break in the protective cutaneous envelope of the skin that resulted from trauma or neuropathic ulceration.

Management of diabetic foot ulcer in patients with diabetes needs an interdisciplinary approach to address glycemic control, infection, offloading of high-pressure areas, lower extremity vascular status and local wound care.

Prevention

Foot Care

  • Educate patient on proper foot care
    • Foot ulcers should be detected & treated early; encourage daily foot inspection
  • Have a regular foot examination & evaluation of amputation risk at intervals of 1-3 months
  • The IWGDF recommends the following frequency of clinic visits for the prevention of foot ulcers based on ulcer risk:
    • Very low: Annually
    • Low: Every 6-12 months
    • Moderate: Every 3-6 months
    • High: Every 1-3 months
  • Have a regular callus debridement
  • The use of professionally fitted therapeutic footwear is recommended for the following:
    • High-risk patients w/ diabetes
    • Diabetic patients w/ severe neuropathy, foot deformities or amputation history
    • Patients w/ healed diabetic foot ulcer
  • Pressure-relief devices that cannot be removed are associated w/ faster healing ulcers than are removable devices as per clinical trials 
  • If indicated, consider referring patients to foot care specialists for preventive care & further vascular evaluation

Lifestyle Modification

  • Glycemic & blood pressure control
  • Smoking cessation

Further Assessment

  • Evaluate surgical interventions as indicated
  • In selected patients w/ an active foot ulcer that has not responded to nonsurgical treatment, foot surgery can effectively reduce the risk of recurrent plantar & nonplantar ulcers
  • Specialist referral should be considered in patients needing further management of deformities, peripheral artery disease & neuropathy

Prognosis

  • Mild diabetic foot infections’ signs & symptoms that have been given appropriate treatment almost always resolve without the need for amputation
    • In >80% of cases, long-term control of infection is achieved
  • Infections involving deep soft tissue structures or bone often have less favorable outcome & many require surgical debridement, bone resection or partial amputation
  • Lower extremity amputation rates may reach 50-60% in patients w/ extensive infection or in medical centers w/ limited expertise or resources
  • For hospitalized patients, even in expert centers, almost half of the patients have poor outcomes or will have amputations
  • Most amputations can be foot sparing (ie below the malleoli) in the hands of any experienced surgeon
  • Presence of limb or foot ischemia can synergize w/ infection that worsen prognosis
  • For a patient w/ diabetic foot ulcer, the risk of death at 5 years is 2.5 times as high as the risk for a patient who does not have a foot ulcer
  • There is a high likelihood that having had one foot infection can also infect the other
    • There is a 20-30% recurrence of diabetic foot infection especially in those w/ underlying osteomyelitis
  • Evidence of remissions includes a decrease in the erythrocyte sedimentation rate, destroyed bone reconstitution on plain radiograph & healing of any overlying soft tissue wound
  • Early signs of skin damage, ie abundant callus, blistering or hemorrhage, are among the strongest predictors of ulcer recurrence
  • Within a year after ulcer healing, there is roughly 40% chance of having recurrence, almost 60% in 3 years & 65% within 5 years
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