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Diabetic foot infection

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Updated 2023 IWGDF/IDSA guidelines for the diagnosis and management of diabetic foot infection.

Background

Overview

Definition
DFI is a microvascular complication characterized by soft tissue or bone infection below the malleoli in a diabetic.
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Pathophysiology
DFI is caused by an amalgamation of neuropathy, vasculopathy, immunopathy, and foot ulcer infected with microbes (S. aureus, Proteus species, E. coli, Peptostreptococcus, Veilonella, and Bacteroides species).
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Disease course
Clinical manifestations include longstanding ulceration of a foot, constitutional symptoms (fever, tachycardia, tachypnea) of infection, wound erythema, hyperkeratosis, anhidrosis, fissures, blisters, nail disorders, and necrosis. Chronic infection may lead to osteomyelitis, gangrene, metabolic instability, and septic shock.
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Prognosis and risk of recurrence
The all-cause mortality associated with lower extremity amputation is 86.80 per 1,000 person-years.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of diabetic foot infection are prepared by our editorial team based on guidelines from the Infectious Diseases Society of America (IDSA/IWGDF 2024), the Society for Vascular Medicine (SVM/SVS/APMA 2016), and the Infectious Diseases Society of America (IDSA 2012). ...
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Screening and diagnosis

Diagnostic criteria: as per IDSA/IWGDF 2024 guidelines, diagnose diabetes-related soft tissue infection clinically based on local or systemic signs and symptoms of inflammation.
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Classification and risk stratification

Severity assessment: as per IDSA/IWGDF 2024 guidelines, use the IWGDF/IDSA classification scheme to assess the severity of any DFI.
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Diagnostic investigations

General principles: as per IDSA 2012 guidelines, assess patients with diabetes presenting with a foot wound at 3 levels: the patient as a whole, the affected foot or limb, and the infected wound.
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  • Physical examination

  • Inflammatory markers

  • Radiography

  • MRI

  • Tagged WBC and bone scans

  • Other imaging modalities

  • Wound culture

Diagnostic procedures

Bone culture and histology: as per IDSA/IWGDF 2024 guidelines, consider obtaining bone (rather than soft tissue) samples for culture, either intraoperatively or percutaneously, in patients with suspected diabetic foot osteomyelitis (before or after treatment).
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Medical management

General principles: as per IDSA 2012 guidelines, consider offering either primarily surgical or primarily medical strategies for the treatment of diabetic foot osteomyelitis in properly selected patients.
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  • Setting of care

  • Empiric antibiotic therapy (DFI)

  • Empiric antibiotic therapy (diabetic foot osteomyelitis)

  • Definitive antibiotic therapy

  • Duration of treatment (DFI)

  • Duration of treatment (diabetic foot osteomyelitis)

  • Topical antimicrobials

  • Glycemic control

Therapeutic procedures

Adjunctive therapies, DFI
As per IDSA/IWGDF 2024 guidelines:
Avoid offering the following adjunctive therapies for the management of DFIs:
G-CSFs
topical antiseptics or silver preparations
honey
bacteriophage therapy
negative pressure wound therapy (with or without instillation)
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Avoid offering hyperbaric oxygen therapy or topical oxygen therapy as an adjunctive treatment for the sole indication of treating a DFI.
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  • Adjunctive therapies (diabetic foot osteomyelitis)

Surgical interventions

Wound care: as per IDSA 2012 guidelines, provide appropriate wound care in patients with diabetic foot ulcers.
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  • Indications for surgeon consultation

  • Wound debridement

  • Surgical interventions

Follow-up and surveillance

Discharge criteria: as per IDSA 2012 guidelines, discharge patients with DFI meeting the following criteria:
patient is clinically stable, and acceptable glycemic control has been attained
patient has undergone any urgently needed surgery
patient is able to manage on his/her own or with help at the designated discharge location
patient has a well-defined plan that includes an appropriate antibiotic regimen to which he/she will adhere, an off-loading scheme if needed, specific wound care instructions, and appropriate outpatient follow-up.
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