What is the recommended treatment for diabetic foot?

Comprehensive Management of Diabetic Foot

The recommended treatment for diabetic foot requires a multidisciplinary approach focusing on wound care, infection management, pressure offloading, vascular assessment, and appropriate antimicrobial therapy based on infection severity. 1

Assessment and Classification

• Evaluate the diabetic foot at three levels: the patient as a whole, the affected foot/limb, and the infected wound 1
• Diagnose infection based on the presence of at least 2 classic symptoms or signs of inflammation (erythema, warmth, tenderness, pain, or induration) or purulent secretions 1
• Classify infections as mild (superficial), moderate (deeper or more extensive), or severe (with systemic signs or metabolic perturbations) to guide treatment decisions 2, 3
• Assess for arterial ischemia, venous insufficiency, protective sensation loss, and biomechanical problems 1

Wound Care and Debridement

• Debride any wound with necrotic tissue or surrounding callus; sharp (surgical) methods are generally preferred 1
• For dry or necrotic wounds, use continuously moistened saline gauze or hydrogels 1
• For exudative wounds, use alginates, hydrocolloids, or foams 1
• Do not use topical antimicrobials for treating most clinically uninfected wounds 1

Pressure Offloading

• For neuropathic plantar ulcers, use a non-removable knee-high offloading device, either total contact cast or removable walker rendered irremovable 1
• When non-removable devices are contraindicated, use removable devices or footwear that best offloads the ulcer 1
• For non-plantar ulcers, consider shoe modifications, temporary footwear, toe-spacers, or orthoses 1
• Instruct patients to limit standing and walking, and to use crutches if necessary 1

Infection Management

Mild Infections:

• Cleanse and debride all necrotic tissue and surrounding callus 1
• Start empiric oral antibiotic therapy targeted at Staphylococcus aureus and streptococci 1, 2
• Typical antibiotics include dicloxacillin, cephalexin, or clindamycin for 1-2 weeks 2

Moderate Infections:

• May require broader coverage with oral or initial parenteral therapy for 2-4 weeks 2
• Consider hospitalization based on infection extent, patient factors, and need for surgical intervention 1

Severe Infections:

• Requires hospitalization, prompt initiation of broad-spectrum parenteral antibiotics 1, 2
• Options include ciprofloxacin plus clindamycin, piperacillin/tazobactam, or imipenem/cilastatin 2
• Duration typically 2-4 weeks for soft tissue infections or 4-6+ weeks for osteomyelitis 2

Surgical Management

• Seek surgical consultation for infections with deep abscess, extensive bone/joint involvement, crepitus, substantial necrosis/gangrene, or necrotizing fasciitis 1, 2
• Urgent surgical intervention is required for deep abscesses, compartment syndrome, and necrotizing soft tissue infections 2
• For patients with severe infection and ischemia, perform revascularization early rather than delaying for prolonged antibiotic therapy 1
• Consider amputation when there is extensive necrosis, life-threatening infection, recurrent ulceration despite maximal preventive measures, or irreversible loss of foot function 1

Vascular Assessment and Management

• Evaluate arterial supply in all infected limbs, especially with signs of ischemia 2
• Consider revascularization when toe pressure <30 mmHg or TcpO2 <25 mmHg 1
• When an ulcer is not showing signs of healing within 6 weeks despite optimal management, consider revascularization 1
• The aim of revascularization is to restore direct flow to at least one of the foot arteries, preferably the artery that supplies the anatomical region of the wound 1

Osteomyelitis Management

• Consider osteomyelitis as a potential complication of any infected, deep, or large foot ulcer, especially one that is chronic or overlies a bony prominence 1
• Perform probe-to-bone test for any diabetic foot infection with an open wound 1
• Obtain plain radiographs of the foot, though they have relatively low sensitivity and specificity 1
• For definitive diagnosis, MRI is recommended when available 1
• Treat with antibiotics for at least 4-6 weeks, unless all infected bone is surgically removed 1, 2

Follow-up and Monitoring

• Provide early and careful follow-up to ensure that treatment is appropriate and effective 1, 2
• Monitor for clinical improvement, including reduction in erythema, swelling, pain, and wound size 2
• Re-evaluate antimicrobial regimen based on clinical response and culture results 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics for uninfected ulcerations, as this may encourage antimicrobial resistance 1
• Do not rely on superficial swabs for culture; obtain tissue specimens from the debrided base by curettage or biopsy 1
• Do not delay surgical intervention when there is evidence of deep infection, abscess, or advancing infection despite optimal medical therapy 4
• Do not neglect vascular assessment and potential revascularization, as inadequate blood supply will prevent healing 1