Diabetic Foot

Infections
By: Lisa Kim
Alexander Kravitz

Objectives
Review case of patient presenting with diabetic foot
infection (DFI)
Discuss the epidemiology, etiology, and clinical
presentation of DFI
Review appropriate therapies for the management of
DFI

Patient Case
KC is a 52 year old male
Was admitted to MaineGeneral on 3/5
CC: Right lower extremity leg wound on calcaneus with
foul suppurative discharge and bilateral lower extremity
swelling
Treated empirically with IV vanco + zosyn

Patient case, cont.

Vitals: Temp=99 HR=97
BP=150/83 RR=16 O2
stats=98% room air

Labs:
133

102

1.91

4.
3

24

39

8.7
355

17.6
26

116

Cultures:
No anaerobes
3+ gram (-) bacilli
2+ Beta hemoloytic
Streptococcus group G
2+ coag (-)
Staphylococcus
3+ Diphtheroid bacilli
3+ Enterococcus

Patient case, cont.

Pertinent studies:

X-ray of right foot

Tagged white blood
cell scan

PMH:

Admitted 6/20/13 for

necrotizing faciitis

Treated with IV vanco,

Flagyl, & diflucan

A1C (2/14/14): 9.6

Fhx:
Mother: T2DM
2 brothers: T2DM

Shx:
No EtOH or drugs

Allergies: none

Medications at Home

Lantus insulin: 25 units

subcutaneously QD
Centrum Mens multivitamin: 1 tab
QD
Aspirin 81 mg: 1 tab Q
Lasix 80 mg: 2 tabs BID
Carvedilol 6.25 mg: 1 tab BID
Ciprofloxacin 500 mg: 1 tab BID
Enoxaparin 40 mg: 40 mg subQ BID
Levothyroxine 25 mcg: 1 tab QD
Linezolid 600 mg: 1 tab BID

Metronidazole 500 mg: 1 tab Q 6 H

Crestor 5 mg: 1 tab QHS
Silver dressing 4X5: apply QOD
Spironolactone 25 mg: 1 tab QD
Tamsulosin 0.4 mg: 1 cap QHS
Potassium Chloride 20mEQ ER: 1
tab QD
Vitamin D 50,000 units: 1 cap once
weekly
Melatonin 3 mg: 1 tab QD
Lisinopril 5 mg: 1 tab QD

Epidemiology

Increasingly common
o In 2003: 110,000 hospital admissions for DFI

Up to 40% of patients with DFI have peripheral vascular

disease
Amputation due to DFI in the USA has decreased by almost
50% in the last decade
o Latest: 4.6 amputations per 1000 diabetics
o Most of the decrease has been in above-the-ankle amputations

Etiology

A DFI emerges when an infection occurs in an ulceration on

the foot from trauma or that is undetected because of
peripheral neuropathy
Infections can become more profound and spread to deeper
tissues, including bone
Often become complicated by vascular insufficiency
Video: http://youtu.be/ZlbanGBgecc?t=39s

Clinical Presentation

Presence of infection defined by > 2 classic findings of inflammation

or purulence
o
o
o
o
o

Redness, swelling, warmth, tenderness, pain

Presence of purulent or non-purulent secretions
Undermined wound edges
Foul odor
Discolored granulation tissue

Further classified:
o
o
o

Mild: superficial and limited in size and depth

Moderate: deeper or more extensive
Severe: accompanied by systemic signs or metabolic disturbances

Classifications of DFI

IDSA & International Working Group on Diabetic Foot

Classifications of DFI, cont.
Ischemia may increase severity of infection
Systemic infection may also manifest as hypotension,
confusion, vomiting, or evidence of metabolic
disturbances

Diagnosis, cont.

Risk factors for DFI

o
o
o
o
o
o
o
o

Positive probe-to-bone (PTB) test

Wound present for >30 days
History of recurrent ulcers
Wound caused by trauma
Presence of peripheral vascular disease in the affected limb
Loss of protective sensation
Presence of renal insufficiency
Patient known to walk barefoot

Management of infection
Classify severity of infection based on its extent,
depth, & presence of any systemic findings
Debride any wound that has necrotic tissue or
surrounding callus
o Obtain cultures prior to empiric antibiotic therapy by
performing a biopsy or curettage after wound is cleaned and
debride

Imaging: radiograph of affected foot, MRI,

radionuclide bone scan, labeled white blood cell scan

Management of Infection
Give antibiotic therapy for all infected wounds but
combine with appropriate wound care
Empiric antibiotic regimens are selected based on
severity and the likely etiologic agent

Mild-moderate infection + no recent abx therapy = target

gram (+) cocci
Severe infection = broad spectrum, pending culture results
& antibiotic susceptibility
Coverage for P. aeruginosa is not necessary

Management of Infection, cont.

Consider MRSA coverage in patients with prior history
or if infection is clinically severe
Continue antibiotic therapy until, but not beyond the
resolution of the infection
o Mild:1-2 weeks
o Moderate-severe: 2-3 weeks

Management of Infection, cont.

Anaerobes are isolated from chronic, previously treated,
or severe infections
o Not major pathogens in most mild to moderate infections
o Little evidence to support to cover for anaerobes in adequately
debrided DFIs

Empiric Antibiotic Therapy Based

on Clinical Severity
Infx severity

Pathogens

Abx agent

Pearls

Mild

MSSA;
Streptococcus spp

-Dicloxacillin

-QID dosing;
inexpensive
-covers CA-MRSA
(TSS)
-QID; inexpensive
-QD; suboptimal S.
aureus
-anaerobic
coverage + broad
spectrum

-Clindamycin
-Cephalexin
-Levofloxacin
-Amoxicillinclavulanate

MRSA

-Doxycycline
Trimethoprim/sulfa
methoxazole

-some gram (-);

uncertain against
streptococcus spp.
-QD suboptimal S.
aureus

Infx severity

Pathogens

Abx agent

Pearls

Moderate-Severe

MSSA; Streptococcus
spp;
Enterobacteriaceae;
obligate anaerobes

-Levofloxacin
-Cefoxitin
-Ceftriaxone
-Ampicillinsulbactam
-Moxifloxacin
-Ertapenem
-Imipenem-cilastatin

-QD
-covers anaerobes
-QD
-if low suspicion P.
aeruginosa
-covers anaerobes

Linezolid

-$$$; increased risk >2

weeks
-monitor CPK
-check MICs

MRSA
-Daptomycin
-Vancomycin

-Use only when required

TID-QID dosing

P. aeruginosa

Piperacillintazobactam

MRSA,
Enterobacteriaceae,
Pseudomonas,
anaerobes

-Vanco +
ceftazidime,
cefpime, pip/taz,
aztreonam or
carbapenem

-Very broad spectrum

coverage, only used for
empiric therapy of
severe infx

Reasons to Avoid Amputation

Reduced mobility, very low quality of life

5-year mortality estimated similar to that of some of the most
deadly cancers

Signs of Possible Imminently LimbThreatening Infection

Evidence of systemic inflammatory response

Rapid progression of infection
Extensive gangrene or necrosis
Tissue gas on imaging
Hemorrhagic bullae
Pain out of proportion to clinical findings
Extensive tissue loss
Failure to improve despite appropriate abx therapy

Clinical Pearls
Tenderness on palpation may be absent if sufficient
neuropathy is present
Crepitus can indicate gas and therefore anaerobes
When developing a plan for the patients treatment,
consider the patients ability to comply with antibiotics
o Support network
o Comorbid conditions (e.g. psych)
o Tolerability of medication

Patient case-Home visit (4/2/14)

Vitals:
BP=128/82 mmHg, Temperature= 97.4, HR=94 BPM

Findings:

Not compliant on current antibiotic regimen

o Complaining about recurrent diarrhea, nausea, and vomiting

Patient did not have proper sleeping patterns

o Underlying signs of depression
Patient was dividing lantus dose: 12 units BID
o Learned from hospital
o Complained of bloating

Patient case-Home visit (4/2/14),

cont.

Consultation for medical marijuana

Didnt know the exact dates of future doctors appointments
Delay in wound dressing change to overworked home health nurse
Multitude of symptoms..

Patient follow-up
Called patient 4/9/14 @ 9:40 am
KC had two appointments on 4/8 regarding the status
of his foot
o 1 appointment cancelled due to MD performing emergency
surgery
o Patient taking antibiotics again: wants to get better
o No change in sleeping patterns
o Overall impression: KC did not want to communicate

Patient follow-up, cont.

Follow-up note:
o Right leg wound = full of thickness, and unchanged from
previous are
o Left leg = decubitus ulcer
o Severe malodor on right foot

Cultures with susceptibility performed

o 4+ Morganella morganii
o 2+ VRE

Prognosis after home visit, cont.

MD states that patient was delusional as to what
effects these wounds can have
o Refused readmission
o Refused VAC dressing

Questions????

References
Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of
America clinical practice guideline for the diagnosis and treatment of
diabetic foot infections. Clin Infect Dis. 2012;54(12):e132-73.
Sabatine M. Pocket Medicine, The Massachusetts General Hospital Handbook
of Internal Medicine. Lippincott Williams & Wilkins; 2013.