What is the recommended treatment for diabetic foot?

Diabetic Foot Treatment

The recommended treatment for diabetic foot includes comprehensive wound care with appropriate debridement, infection management with targeted antibiotics, pressure offloading, and surgical intervention when necessary, all coordinated by a multidisciplinary team. 1, 2

Assessment and Classification

• Evaluate the diabetic foot at three levels: the patient as a whole, the affected foot/limb, and the infected wound 2
• Diagnose infection based on the presence of at least 2 classic symptoms or signs of inflammation (redness, warmth, swelling, pain) or purulent secretions 2, 3
• Classify infections as mild (superficial), moderate (deeper/more extensive), or severe (with systemic signs) to guide treatment decisions 3, 4
• Assess for arterial insufficiency, which significantly impacts treatment approach and outcomes 1, 2

Wound Care and Debridement

• Perform sharp debridement of necrotic tissue and surrounding callus for all diabetic foot wounds 1, 2
• Select appropriate dressings based on wound characteristics:
  • For dry/necrotic wounds: moistened saline gauze or hydrogels 1, 2
  • For exudative wounds: alginates, hydrocolloids, or foams 1, 2
• Do not use topical antimicrobials for clinically uninfected wounds 1, 2

Infection Management

• Do not treat clinically uninfected foot ulcers with systemic or local antibiotic therapy 1
• For infected wounds, obtain appropriate cultures (preferably tissue samples, not swabs) before starting antibiotics 1, 3
• Select antibiotic regimens based on infection severity:
  • Mild infections: Target Staphylococcus aureus and streptococci with a 1-2 week course 1, 3
  • Moderate infections: Consider broader coverage for 2-3 weeks, extending to 3-4 weeks if extensive or resolving slowly 1, 3
  • Severe infections: Use broad-spectrum parenteral antibiotics initially 1, 3
• For osteomyelitis: Treat for up to 3 weeks after minor amputation with positive bone margin culture, or 6 weeks without bone resection 1

Pressure Offloading

• Use non-removable knee-high offloading devices (total contact cast or irremovable walker) for plantar neuropathic ulcers 2
• When non-removable devices are contraindicated, use removable devices that best offload the ulcer 2
• Instruct patients to limit weight-bearing activities and use assistive devices as needed 2

Surgical Management

• Obtain urgent surgical consultation for severe infections or moderate infections complicated by extensive gangrene, necrotizing infection, deep abscess, compartment syndrome, or severe ischemia 1
• Consider early surgical intervention (within 24-48 hours) for moderate and severe infections to remove infected and necrotic tissue 1
• For patients with diabetes, peripheral arterial disease (PAD), and foot infection, obtain urgent consultation with both surgical and vascular specialists 1
• Consider amputation when there is extensive necrosis, life-threatening infection, recurrent ulceration despite preventive measures, or irreversible loss of foot function 1, 2

Vascular Assessment and Management

• Evaluate arterial supply in all infected limbs, especially with signs of ischemia 2, 3
• For patients with PAD and foot infection, determine the need and timing for both drainage and revascularization procedures 1
• Aim to restore direct blood flow to at least one of the foot arteries, preferably the one supplying the wound area 2

Follow-up and Monitoring

• Provide regular follow-up to ensure treatment effectiveness 2, 3
• Monitor for clinical improvement including reduction in erythema, swelling, pain, and wound size 3
• If infection has not resolved after 4 weeks of appropriate therapy, re-evaluate the patient and consider alternative treatments 1
• Use outcome at a minimum follow-up of 6 months after antibiotic therapy to diagnose remission of osteomyelitis 1

Common Pitfalls to Avoid

• Do not prescribe antibiotics for uninfected ulcers, as this promotes antimicrobial resistance 1, 2
• Do not neglect vascular assessment and potential revascularization, as inadequate blood supply prevents healing 1, 2
• Do not delay surgical intervention for severe infections or when medical therapy is failing 1
• Do not empirically target Pseudomonas aeruginosa in temperate climates unless it has been previously isolated or in patients from Asia/North Africa with moderate/severe infection 1