What is the preferred timing of surgery for hospitalized patients with severe, deep Diabetes-Related Foot Infection (DFI) with or without osteomyelitis?

Timing of Surgery for Severe, Deep Diabetes-Related Foot Infections

Early surgery (within 72 hours after presentation) is preferred for hospitalized patients with severe, deep diabetes-related foot infections because it is associated with lower rates of major lower extremity amputation and higher rates of wound healing. 1

Evidence Supporting Early Surgical Intervention

The 2024 IWGDF/IDSA guidelines on diabetes-related foot infections (DFIs) provide clear evidence supporting early surgical intervention. Retrospective studies comparing early surgery (within 72 hours of presentation) versus delayed surgery (3-6 days after admission) in hospitalized patients with severe, deep DFIs have demonstrated:

• Lower rates of major lower extremity amputation
• Higher rates of wound healing 1

The guidelines specifically recommend considering early surgery (within 24-48 hours) combined with antibiotics for moderate and severe DFIs to remove infected and necrotic tissue (Conditional recommendation; Low quality evidence). 1

Surgical Consultation Timing

For patients with severe infections or moderate DFIs complicated by:

• Extensive gangrene
• Necrotizing infection
• Deep (below fascia) abscess
• Compartment syndrome
• Severe lower limb ischemia

An urgent surgical consultation should be obtained. 1

Approach to Different Types of Diabetic Foot Infections

The approach varies based on infection severity:

Severe DFIs

• Require urgent surgical consultation
• Early surgery (within 24-48 hours) is recommended
• Combined with appropriate antibiotic therapy

Moderate DFIs with Complications

• Urgent surgical consultation needed if complicated by:
  • Extensive gangrene
  • Necrotizing infection
  • Deep abscess
  • Compartment syndrome
  • Severe limb ischemia

Diabetic Foot Osteomyelitis (DFO)

• Patients with DFO who have concomitant soft tissue infection generally require more urgent and extensive surgery 1
• These patients typically have:
  • Longer hospital stays
  • Worse outcomes

Risks of Delayed Surgical Intervention

Delayed admission to specialized foot centers is associated with higher likelihood of requiring major amputation. 1 This underscores the importance of early surgical intervention when indicated.

Special Considerations

For patients with diabetes, peripheral arterial disease (PAD), and foot ulcer/gangrene with infection:

• Obtain urgent consultation with both surgical and vascular specialists
• Determine appropriate timing for drainage and/or revascularization procedures 1

Pitfalls to Avoid

1. Delaying surgical consultation when indicated can worsen outcomes and increase amputation risk
2. Underestimating infection severity - clinical assessment can be unreliable, especially in patients with neuropathy
3. Failing to assess vascular status - PAD combined with infection significantly worsens outcomes
4. Relying solely on clinical appearance - deep infections may not have obvious external signs

Antibiotic Considerations

While early surgery is crucial, appropriate antibiotic therapy remains essential:

• For severe infections, begin with parenteral therapy
• Duration typically 1-2 weeks for soft tissue infections, up to 6 weeks for osteomyelitis without bone resection 1, 2
• Re-evaluate if infection hasn't resolved after 4 weeks of appropriate therapy 1

In summary, the evidence clearly supports early surgical intervention (within 72 hours) for hospitalized patients with severe, deep diabetes-related foot infections to reduce the risk of major lower extremity amputation and improve wound healing outcomes.