What is the management of a diabetic patient with erythema and swelling of the foot, normal Complete Blood Count (CBC) and normal erythrocyte sedimentation rate (ESR)?

From the Guidelines

The management of a diabetic patient with erythema and swelling of the foot, despite normal CBC and ESR, should focus on prompt treatment for possible diabetic foot infection, with empiric antibiotic therapy and urgent evaluation by a multidisciplinary team. The initial management includes empiric antibiotic therapy with amoxicillin-clavulanate 875/125 mg twice daily or clindamycin 300-450 mg four times daily for mild to moderate infections, pending culture results, as recommended by the 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections 1. The foot should be elevated, and the patient should avoid weight-bearing on the affected limb. Regular wound care with gentle cleansing and dressing changes is essential. Blood glucose control should be optimized, aiming for levels between 140-180 mg/dL during this acute phase. Despite normal inflammatory markers, diabetic patients may not mount typical inflammatory responses due to neuropathy and vascular disease, making clinical assessment crucial, as noted in the 2012 guidelines 1. The patient requires urgent evaluation by a multidisciplinary team including endocrinology, infectious disease, and possibly vascular surgery. Imaging studies such as plain radiographs, MRI, or ultrasound may be necessary to assess for osteomyelitis or deep tissue infection, as suggested by the guidelines 1. Close follow-up within 48-72 hours is mandatory to assess treatment response, with hospitalization indicated if symptoms worsen or if the patient has significant comorbidities or poor social support. Recent guidelines also emphasize the importance of prevention and management of foot problems in diabetes, including identification of the at-risk foot, regular inspection and examination, education, and routine wearing of appropriate footwear 1. However, in the context of an acute presentation like this, the immediate focus should be on treating the potential infection and preventing further complications. Given the most recent and highest quality evidence available, the 2024 guidelines on the prevention of foot ulcers in persons with diabetes 1 support a strong approach to preventive measures, but the immediate management of a potentially infected foot ulcer should follow the principles outlined for acute infection management.

From the Research

Management of Diabetic Patient with Erythema and Swelling of Foot

• The management of a diabetic patient with erythema and swelling of the foot, normal Complete Blood Count (CBC) and normal erythrocyte sedimentation rate (ESR) involves a comprehensive approach 2, 3, 4.
• Initial assessment should include evaluation of the foot for signs of infection, neuropathy, and vascular perfusion 4.
• Proper cleansing, debridement, and local wound care are essential in managing diabetic foot infections 2.
• Antibiotic therapy should be carefully selected, taking into account the potential for polymicrobial infection and the need for broad-spectrum coverage 2, 5.
• The duration of antibiotic therapy ranges from a week for mild soft tissue infections to over 6 weeks for osteomyelitis 2.

Role of Laboratory Tests

• A normal white blood cell count should not deter one from taking appropriate action to mitigate the propagation of a potentially limb-threatening foot infection 3.
• Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) can be used to monitor treatment outcomes in diabetic foot osteomyelitis 6.
• Trajectories of ESR and CRP during follow-up can predict clinical outcomes, with stagnating values associated with poor outcomes 6.

Vascular Evaluation and Revascularization

• Vascular evaluation is crucial in managing diabetic foot infections, as impaired arterial perfusion can contribute to ulceration and infection 4.
• Revascularization may be necessary to promote wound healing and prevent further complications 4.
• Early aggressive drainage, debridement, and local foot amputations combined with liberal use of revascularization can result in cumulative limb salvage of 74% at 5 years in high-risk groups 4.