Management of Skin Infections in Diabetic Patients
Diabetic skin infections require prompt classification by severity, with treatment including appropriate antibiotics, glycemic control, and multidisciplinary care to reduce morbidity and mortality.
Classification of Skin Infections in Diabetics
Proper classification guides management decisions:
- Mild infections: Limited to skin and superficial subcutaneous tissue without systemic signs 1
- Moderate infections: Involving deeper tissues but without systemic toxicity 1
- Severe infections: Presenting with systemic signs of infection or metabolic instability 1
Treatment Approach by Severity
Mild Infections
- Antibiotic therapy: Oral antibiotics targeting aerobic gram-positive cocci for 7-10 days 1
- First-line options: Amoxicillin-clavulanate, cephalexin
- If MRSA suspected: Trimethoprim-sulfamethoxazole or doxycycline
- Local wound care: Frequent debridement of necrotic tissue and callus with scalpel 2
- Offloading: Reduce pressure on affected area, especially for plantar ulcers 2
Moderate Infections
- Antibiotic therapy: Oral options for 10-14 days 1
- Amoxicillin-clavulanate
- Fluoroquinolone plus clindamycin
- Consider initial parenteral therapy followed by oral therapy
- Wound care: More aggressive debridement, consider specialized dressings 2
- Offloading: Total contact casting or other casting techniques for plantar ulcers 2
Severe Infections
- Hospitalization required 2
- Parenteral broad-spectrum antibiotics for 14-21 days 1
- Vancomycin IV plus piperacillin-tazobactam IV
- Vancomycin IV plus imipenem-cilastatin IV
- Include MRSA coverage if risk factors present
- Surgical intervention: Urgent evaluation for surgical drainage, removal of necrotic tissue 2
- Vascular assessment: Consider need for arterial revascularization 2
Microbiological Considerations
- Obtain proper cultures before starting antibiotics 2
- Deep tissue specimens via biopsy or curettage after wound cleansing
- Avoid swab specimens which may only capture surface colonization
- Common pathogens 3:
- Staphylococcus aureus (28%)
- Escherichia coli (19%)
- Staphylococcus epidermidis (14%)
- Polymicrobial infections are common in moderate to severe cases 2
Glycemic Control
- Optimize blood glucose levels to promote healing and infection resolution 1
- Target: Blood glucose <8 mmol/L or <140 mg/dL 2
- Consider intensified insulin regimen during active infection 1
Multidisciplinary Approach
The IDSA guidelines strongly recommend a multidisciplinary team approach 2:
- Rapid-response teams for initial evaluation and care recommendations
- Specialty teams including:
- Foot specialist
- Vascular surgeon
- Wound care specialist
- Infectious disease specialist or clinical microbiologist
- Diabetes specialist
- Pharmacist
Duration of Therapy
- Mild infections: 7-10 days 1
- Moderate infections: 10-14 days 1
- Severe infections: 14-21 days 1
- Important: Antibiotics can usually be discontinued once clinical signs and symptoms of infection have resolved. There is no evidence supporting continuing antibiotics until the wound is completely healed 2
Common Pitfalls to Avoid
- Inadequate sampling for cultures before starting antibiotics 1
- Insufficient debridement of necrotic tissue 1
- Inappropriate antibiotic selection or duration 1
- Neglecting glycemic control during infection 1
- Treating uninfected wounds with antibiotics 2
- Premature discontinuation of antibiotics, especially with deep infections 1
- Using footbaths (contraindicated as they induce maceration of the skin) 2
Prevention of Recurrence
- Determine the cause of infection to reduce chance of recurrence 2
- Include patient in comprehensive foot care program with lifelong observation 2
- Provide education on appropriate self-care and recognition of early infection signs 2
- Regular foot inspection and proper skin care can help prevent skin problems 4
By following this systematic approach to diabetic skin infections, clinicians can improve outcomes and reduce the risk of complications including amputation.