What is the detailed treatment for diabetic foot?

Detailed Treatment for Diabetic Foot

The treatment of diabetic foot requires a multidisciplinary approach focusing on infection control, wound care, pressure offloading, vascular assessment, and glycemic management to prevent amputation and reduce mortality. 1, 2

Classification and Assessment

Infection Classification

• Mild: Superficial infection limited to skin and subcutaneous tissue
• Moderate: Deeper or more extensive infection
• Severe: Infection with systemic signs or metabolic disturbances 1

Diagnostic Workup

• Obtain deep tissue cultures (not swabs) after wound cleansing and debridement 2
• Plain radiographs for initial screening for osteomyelitis 1
• Consider MRI when osteomyelitis is suspected or soft tissue abscess is present 1
• Probe-to-bone test to help diagnose osteomyelitis 1
• Vascular assessment (ankle pressure, ABI, toe pressure, TcpO2) 1

Treatment Algorithm

1. Infection Management

For Mild Infections:

• Oral antibiotics targeting Staphylococcus aureus and streptococci 1, 2
  • Doxycycline 100 mg twice daily
  • Clindamycin 300-450 mg three times daily
  • For penicillin allergy: Cefalexin 500 mg four times daily

For Moderate to Severe Infections:

• Parenteral broad-spectrum antibiotics 1, 2
  • Vancomycin IV + piperacillin-tazobactam IV (covers MRSA, streptococci, gram-negatives, anaerobes)
  • Vancomycin IV + imipenem-cilastatin IV
  • Consider anti-pseudomonal coverage for patients who have soaked feet, live in warm climates, or have severe infections 2
• Adjust antibiotics based on culture results and clinical response 2
• Continue antibiotics until infection resolves, not through complete healing 2

2. Surgical Management

• Urgent surgical debridement for:
  • Necrotic tissue removal
  • Abscess drainage
  • Infected bone removal 1, 2
• Sharp debridement of all necrotic tissue and surrounding callus 1
• Consider bone biopsy for definitive diagnosis of osteomyelitis 1

3. Pressure Offloading

For Plantar Ulcers:

• Non-removable knee-high offloading device (first choice) 1
  • Total contact cast
  • Removable walker rendered irremovable
• When non-removable devices are contraindicated, use removable devices 1
• For non-plantar ulcers: shoe modifications, temporary footwear, toe-spacers, or orthoses 1
• Instruct patients to limit standing/walking and use crutches if necessary 1

4. Vascular Assessment and Management

• For ankle pressure <50 mmHg or ABI <0.5: urgent vascular imaging and revascularization 1
• Consider revascularization when:
  • Toe pressure <30 mmHg or TcpO2 <25 mmHg
  • Ulcer not showing signs of healing within 6 weeks despite optimal management
  • Before considering major amputation 1
• Aim to restore direct flow to at least one foot artery, preferably supplying the wound area 1

5. Local Wound Care

• Frequent inspection and debridement of the ulcer 1
• Select dressings to control excess exudation and maintain moist environment 1
• Consider negative pressure wound therapy for post-operative wounds 1
• Do not use footbaths (causes skin maceration) 1
• Consider hyperbaric oxygen therapy for poorly healing wounds 1

6. Glycemic Control

• Optimize diabetes management to promote healing and prevent recurrence 2

Prevention of Recurrence

Once healed, implement:

• Lifelong observation and professional foot treatment 1
• Appropriate footwear (never return to shoes that caused the ulcer) 1
• Patient education on self-care 1, 2
• Daily foot inspection and washing with careful drying 2
• Applying emollients to dry skin (not between toes) 2
• Avoiding walking barefoot 2

Common Pitfalls to Avoid

• Inadequate sampling for cultures before starting antibiotics 2
• Insufficient debridement of necrotic tissue 2
• Inappropriate antibiotic selection or insufficient duration 2
• Neglecting glycemic control during infection 2
• Treating uninfected wounds with antibiotics 2
• Premature discontinuation of antibiotics, especially with deep infections 2

Monitoring and Follow-up

• Frequent monitoring (every 2-5 days initially) to assess response to therapy 2
• Follow-up for at least 6 months after completion of antibiotic therapy 2
• Regular wound assessment until complete healing 2

Implementing this comprehensive approach can significantly reduce the risk of amputation, which affects up to 80% of diabetic patients with foot ulcers, and decrease the 5-year mortality rate, which is approximately 30% for individuals with diabetic foot ulcers 3.