What is the best way to prevent diabetic foot infection?

Best Practices to Mitigate Risk for Diabetic Foot Infection

The best way to mitigate risk for diabetic foot infection is through regular screening for risk factors, structured patient education on proper foot care, appropriate footwear, and prompt treatment of pre-ulcerative lesions. 1

Risk Assessment and Screening

• Screen all people with diabetes annually for signs of peripheral neuropathy and peripheral arterial disease (PAD) to determine risk of foot ulceration using the IWGDF risk stratification system 1
• For patients with loss of protective sensation or PAD, extend screening to assess for:
  • History of foot ulceration or amputation
  • End-stage renal disease
  • Foot deformity
  • Limited joint mobility
  • Excess callus
  • Pre-ulcerative lesions 1
• Adjust screening frequency based on risk level:
  • IWGDF risk 1: every 6-12 months
  • IWGDF risk 2: every 3-6 months
  • IWGDF risk 3: every 1-3 months 1

Patient Education and Self-Care

• Educate patients at risk of foot ulceration (IWGDF risk 1-3) to:
  • Never walk barefoot, in socks without shoes, or in thin-soled slippers 1
  • Wash feet daily with careful drying, particularly between toes 1
  • Use emollients to moisturize dry skin 1
  • Cut toenails straight across 1
  • Examine feet daily for any changes or lesions 1
  • Contact healthcare professionals immediately if pre-ulcerative lesions are detected 1
• Provide structured education about appropriate foot self-care 1
• For moderate to high-risk patients (IWGDF risk 2-3), consider coaching on daily foot temperature monitoring:
  • Temperature difference >2.2°C between corresponding regions of left and right foot for two consecutive days requires reduced activity and professional consultation 1, 2

Appropriate Footwear

• For patients with no/limited foot deformity (IWGDF risk 1-3): Educate on wearing properly fitting footwear that accommodates foot shape 1
• For patients with foot deformity or pre-ulcerative lesions (IWGDF risk 2-3): Consider prescribing extra-depth shoes, custom-made footwear, insoles, or toe orthoses 1
• For patients with healed plantar foot ulcers (IWGDF risk 3): Prescribe therapeutic footwear with demonstrated plantar pressure-relieving effect during walking 1
• Ensure patients never return to the same shoes that caused previous ulcers 1

Treatment of Pre-Ulcerative Lesions

• Provide appropriate treatment for:
  • Pre-ulcerative lesions
  • Excess callus
  • Ingrown toenails
  • Fungal infections 1
• For non-rigid hammertoe with pre-ulcerative lesion, consider flexor tendon tenotomy 1
• Avoid footbaths that soak the feet as they induce skin maceration 1

Physical Activity Considerations

• For low-to-moderate risk patients, consider recommending a supervised foot-ankle exercise program to reduce ulcer risk factors 1
• An increase in weight-bearing activity of 1000 steps/day is likely safe regarding ulceration risk 1
• Instruct patients with active lesions to limit standing and walking, using mobility aids if necessary 1

Multidisciplinary Approach

• Implement a multidisciplinary foot care team approach, which has been shown to reduce diabetes-related lower extremity amputations 1
• Organize care at appropriate levels:
  • Level 1: General practitioner, podiatrist, diabetic nurse
  • Level 2: Diabetologist, surgeon, vascular specialist, podiatrist, diabetic nurse, shoe-maker/orthotist
  • Level 3: Specialized diabetic foot care center with multiple experts 1

Infection Management When Prevention Fails

• Determine if a foot ulcer is infected before starting antibiotics, as uninfected ulcers should not receive antibiotic therapy 2, 3
• For mild infections: Cleanse, debride necrotic tissue and callus, start empiric oral antibiotics targeting Staphylococcus aureus and streptococci 1, 2
• For moderate to severe infections: Consider surgical intervention, assess for PAD, initiate broad-spectrum antibiotics covering gram-positive, gram-negative, and anaerobic bacteria 1, 2
• Adjust antibiotic regimen based on clinical response and culture results 1, 2

Special Considerations

• Peripheral arterial disease is present in up to 40% of patients with diabetic foot infections, making vascular assessment critical 3, 4
• Patients with uncontrolled diabetes, poor vascular perfusion, or comorbid illness require more intensive monitoring and intervention 4, 5
• Prevention strategies should be tailored to the patient's risk level, with more intensive interventions for high-risk individuals 5, 6