How would you manage an infected foot ulcer in a 60-year-old diabetic man?

Assessment and Management of Infected Diabetic Foot Ulcer

For a 60-year-old diabetic man with an infected foot ulcer, comprehensive assessment followed by aggressive multidisciplinary management is essential to prevent limb loss and reduce mortality. 1

Initial Assessment

Severity Classification

• Assess for signs of infection (erythema, warmth, tenderness, purulent discharge) and determine severity (mild, moderate, or severe) 1, 2
• Evaluate depth of ulcer and presence of exposed bone or joint involvement 1
• Assess for peripheral neuropathy using 10g monofilament test and/or 128 Hz tuning fork 1
• Screen for peripheral arterial disease (PAD) by checking foot pulses and ankle-brachial index 1

Diagnostic Tests

• Obtain wound cultures before starting antibiotics to guide therapy 2
• Order complete blood count, C-reactive protein, and blood glucose levels 1
• Perform plain radiography to assess for osteomyelitis or foot deformities 1
• Consider advanced imaging (MRI) if osteomyelitis is suspected but not evident on X-ray 2

Management Approach

Infection Control

• For mild infections: Start empiric oral antibiotics targeting Staphylococcus aureus and streptococci 1, 2
• For moderate to severe infections: Initiate broad-spectrum parenteral antibiotics covering gram-positive, gram-negative, and anaerobic bacteria 1, 2
• Adjust antibiotic regimen based on culture results and clinical response 1
• Treatment duration: 1-2 weeks for soft tissue infections; 6 weeks for osteomyelitis 2

Wound Care

• Perform sharp debridement of necrotic tissue and surrounding callus 1, 3
• Select appropriate dressings to control exudate and maintain moist wound environment 1
• Consider negative pressure wound therapy for post-operative wounds 1
• Avoid foot soaking as it causes skin maceration 1

Pressure Offloading

• The preferred treatment for neuropathic plantar ulcers is a non-removable knee-high offloading device, such as total contact cast or irremovable walker 1, 4
• When non-removable devices are contraindicated, use removable offloading devices 1
• For non-plantar ulcers, consider shoe modifications, temporary footwear, or orthoses 1
• Instruct patient to limit standing and walking, using assistive devices if necessary 1

Vascular Assessment and Management

• If ankle pressure <50 mmHg or ABI <0.5, consider urgent vascular imaging and revascularization 1
• When ulcers fail to show healing signs within 6 weeks despite optimal management, consider revascularization regardless of initial vascular assessment 1
• The goal of revascularization is to restore direct blood flow to at least one foot artery 1

Metabolic Control

• Optimize blood glucose control 1, 5
• Address cardiovascular risk factors (smoking cessation, control of hypertension and dyslipidemia) 1

Prevention of Recurrence

• Include patient in integrated foot-care program with regular follow-up 1
• Provide structured education about foot self-care 1
• Prescribe appropriate therapeutic footwear 1
• For healed plantar ulcers, prescribe footwear with demonstrated plantar pressure-relieving effect 1
• Educate patient to examine feet daily and contact healthcare provider promptly if new lesions develop 1

Follow-up Schedule Based on Risk

• For patients with loss of protective sensation or PAD (IWGDF risk 1): Follow-up every 6-12 months 1
• For patients with deformity or pre-ulcerative lesions (IWGDF risk 2): Follow-up every 3-6 months 1
• For patients with history of foot ulceration or amputation (IWGDF risk 3): Follow-up every 1-3 months 1

Common Pitfalls to Avoid

• Delaying treatment of infection, which can lead to rapid progression and limb loss 6
• Failing to offload pressure from the ulcer site, which prevents healing 4, 3
• Neglecting to assess vascular status before aggressive debridement 1
• Using antibiotics for uninfected wounds, which contributes to antimicrobial resistance 2
• Inadequate patient education about foot care and early warning signs 1