From the Guidelines
For an infected wound to the great toe in a person with diabetes, empiric antibiotic therapy should typically include coverage for both gram-positive and gram-negative organisms, including MRSA, with a recommended duration of 1-2 weeks, as stated in the most recent guidelines 1.
Key Considerations
- The choice of antibiotics should be based on the likely or proven causative pathogens, their antibiotic susceptibilities, the clinical severity of the infection, evidence of efficacy for DFI, and costs, as recommended by the IWGDF guidance 1.
- A reasonable first-line oral regimen would be amoxicillin-clavulanate 875/125 mg twice daily plus trimethoprim-sulfamethoxazole (TMP-SMX) DS 1-2 tablets twice daily for 7-14 days, depending on infection severity.
- Alternatively, doxycycline 100 mg twice daily or clindamycin 300-450 mg four times daily could be used if the patient has penicillin allergy.
- For more severe infections requiring intravenous therapy, options include vancomycin 15-20 mg/kg every 12 hours plus either piperacillin-tazobactam 4.5 g every 6-8 hours or a carbapenem.
Essential Components of Management
- Proper wound care
- Glycemic control
- Pressure offloading
- Regular follow-up
Reassessment and Adjustment
- The choice of antibiotics should be reassessed and potentially narrowed once culture results are available.
- Consider continuing treatment, perhaps for up to 3-4 weeks, if the infection is improving but is extensive and is resolving slower than expected or if the patient has severe PAD, as recommended by the IWGDF/IDSA guidelines 1.
From the FDA Drug Label
1 INDICATIONS AND USAGE
Daptomycin for injection is a cyclic lipopeptide antibacterial agent indicated for the treatment of
- Complicated skin and skin structure infections (cSSSI) caused by susceptible isolates of Gram-positive bacteria, including
- Staphylococcus aureus (including methicillin-resistant isolates)
- Streptococcus pyogenes
- Streptococcus agalactiae
- Streptococcus dysgalactiae subspecies equisimilis
- Enterococcus faecalis (vancomycin-susceptible isolates only)
The antibiotic daptomycin is indicated for the treatment of complicated skin and skin structure infections (cSSSI) caused by susceptible isolates of Gram-positive bacteria, which may be applicable for a diabetic patient with an infected wound to the hallux (great toe) if the infection is caused by a Gram-positive bacterium. 2
From the Research
Antibiotic Options for Diabetic Patients with Infected Wounds
- The choice of antibiotic for a diabetic patient with an infected wound to the hallux (great toe) depends on the severity of the infection and the local prevalence of microbial causal agents 3, 4, 5.
- For mild infections, antibiotic therapy can often be directed at just staphylococci and streptococci 6.
- For moderate to severe infections, empiric therapy should usually be more broad spectrum, covering a range of bacteria including Gram-positive and Gram-negative bacteria 7, 4, 5.
- Piperacillin/tazobactam is a suitable option for empiric antibiotic therapy in diabetic foot infections, as it covers Pseudomonas aeruginosa and has a broad spectrum of activity 7, 4.
- Amoxicillin-clavulanate plus ciprofloxacin is also a recommended combination therapy for soft tissue infections in diabetic foot, especially in areas where Gram-negative bacteria are prevalent 5.
- Vancomycin may be added to the empiric antibiotic regimen if there is a risk of methicillin-resistant Staphylococcus aureus (MRSA) 7, 4.
Considerations for Antibiotic Selection
- The Infectious Diseases Society of America (IDSA) 2012 guidelines are widely followed for the management of infected wounds in diabetic patients 3.
- Regular microbiological updates are essential to ensure optimal antibiotic coverage and to guide empiric antibiotic therapy 4, 5.
- The choice of antibiotic should be based on the severity of the infection, the local prevalence of microbial causal agents, and the results of microbiological cultures and antibiotic sensitivity tests 3, 4, 5.