What is the management of cellulitis of the great toe in a 60-year-old patient with type 2 diabetes mellitus (DM)?

From the Guidelines

For cellulitis in the big toe of a 60-year-old with type 2 diabetes mellitus, prompt treatment with antibiotics is essential, and I recommend starting with oral antibiotics such as cephalexin 500 mg four times daily or amoxicillin-clavulanate 875/125 mg twice daily for 7-10 days, as suggested by the most recent guidelines 1. The selection of an antibiotic agent should be based on the likely or proven causative pathogen(s) and their antibiotic susceptibilities, as well as the clinical severity of the infection, and the risk of adverse events, including collateral damage to the commensal flora 1. Careful wound care is critical, including gentle cleansing with saline, keeping the area clean and dry, and elevating the affected foot when possible. Blood glucose control should be optimized during treatment, as hyperglycemia impairs immune function and wound healing 1. The patient should be evaluated within 48-72 hours to ensure improvement, and if the infection doesn't improve within 48 hours of antibiotic therapy, consider broadening antibiotic coverage or obtaining wound cultures. Prevention of future episodes includes daily foot inspection, proper footwear, regular podiatry care, and maintaining good glycemic control. Some key points to consider in the management of diabetes-related foot infections include:

• The importance of prompt treatment with antibiotics to prevent complications and improve outcomes
• The need for careful wound care and optimization of blood glucose control
• The importance of regular evaluation and follow-up to ensure improvement and prevent complications
• The consideration of broadening antibiotic coverage or obtaining wound cultures if the infection does not improve within 48 hours of treatment. It is also important to note that diabetic patients are at higher risk for severe infections and complications due to impaired circulation, neuropathy, and immune dysfunction, and therefore require close monitoring and aggressive treatment 1.

From the Research

Cellulitis in a 60-year-old with Type 2 Diabetes

• Cellulitis is an acute infection of the dermal and subcutaneous layers of the skin, often occurring after a local skin trauma 2.
• The condition classically presents with erythema, swelling, warmth, and tenderness over the affected area, which in this case is the big toe 2, 3.
• Given the patient's age and Type 2 diabetes, it is essential to consider a broad differential diagnosis, including venous stasis dermatitis, contact dermatitis, deep vein thrombosis, and panniculitis 2, 3.

Management of Cellulitis

• Most patients can be treated as outpatients with oral antibiotics, with dicloxacillin or cephalexin being the oral therapy of choice when methicillin-resistant Staphylococcus aureus is not a concern 2.
• However, the rise in community-onset methicillin-resistant Staphylococcus aureus infections may complicate the empiric management of cellulitis, and alternative treatments such as clindamycin and trimethoprim/sulfamethoxazole may be considered 4.
• The choice of antibiotic therapy should be guided by the likelihood of infection due to MRSA, as well as the patient's individual characteristics and medical history 4.

Considerations for Patients with Type 2 Diabetes

• Patients with Type 2 diabetes, particularly those over 60 years of age, require special considerations in their management, including individualized glycemic targets and treatment strategies 5, 6.
• The use of certain hypoglycemic agents, such as sulfonylureas and insulin regimens, should be used with caution due to the high risk of hypoglycemia in older adults 6.
• Alternative treatments, such as dipeptidyl peptidase-4 inhibitors and glucagon-like peptide-1 receptor agonists, may be more suitable for older patients with Type 2 diabetes 6.