What is the treatment for diabetic foot?

Treatment of Diabetic Foot

Diabetic foot treatment requires a coordinated multidisciplinary approach prioritizing wound debridement, infection control with appropriate antibiotics, pressure off-loading, vascular assessment with revascularization when needed, and optimal wound care—all while avoiding antibiotics for uninfected ulcers. 1, 2

Initial Assessment and Classification

Evaluate the patient at three levels: the patient systemically (metabolic stability, systemic toxicity), the affected limb (vascular status, neuropathy), and the specific wound (depth, infection, tissue involvement). 2

• Assess for signs of infection including erythema, warmth, tenderness, purulent drainage, or systemic symptoms—infection requires at least 2 classic inflammatory signs. 2
• Classify infection severity: mild (superficial, limited cellulitis <2cm), moderate (deeper structures or extensive cellulitis >2cm), or severe (systemic toxicity or metabolic instability). 3, 1
• Check arterial perfusion by palpating dorsalis pedis and posterior tibial pulses; if absent, obtain ankle-brachial index or vascular imaging. 4
• Test for neuropathy using 10-g Semmes-Weinstein monofilament at plantar heel, metatarsal heads, arch, and toe tips. 4
• Probe the wound with sterile blunt metal probe to assess depth, detect bone involvement, abscesses, or foreign bodies. 4

Wound Debridement

Sharp debridement is the preferred method and should be performed on all wounds with necrotic tissue or surrounding callus. 2, 4

• Remove all hyperkeratotic, infected, and nonviable tissue to reduce bacterial burden and allow proper wound assessment. 4, 5
• Obtain tissue specimens from the debrided wound base for culture before starting antibiotics (via curettage, biopsy, or aspiration—never superficial swabs of undebrided wounds). 3, 2
• Warn patients that bleeding is expected and the wound will appear larger after debridement. 4
• Caution: Avoid aggressive debridement in primarily ischemic wounds without first assessing revascularization options. 4

Infection Management

When to Use Antibiotics

Do NOT prescribe antibiotics for clinically uninfected ulcers—this promotes antimicrobial resistance without benefit. 3, 2

• Antibiotics are indicated only when infection is clinically evident (inflammation, purulence, systemic signs). 1, 2

Antibiotic Selection

For mild infections: Use oral antibiotics targeting Staphylococcus aureus and streptococci (e.g., cephalexin, clindamycin, or amoxicillin-clavulanate). 3, 2

For moderate to severe infections: Initiate broad-spectrum parenteral antibiotics covering gram-positive cocci (including MRSA if prevalent locally), gram-negative rods, and anaerobes. 3, 6

• Adjust therapy based on culture results, susceptibility data, and clinical response. 3
• Consider MRSA coverage if patient recently received antibiotics or local prevalence is high. 3

Duration of Antibiotic Therapy

• Mild infections: 1-2 weeks, occasionally extending to 3-4 weeks. 3
• Moderate/severe infections: 2-4 weeks depending on tissue involvement, debridement adequacy, and vascularity. 3
• Osteomyelitis: Minimum 4-6 weeks, but shorter if all infected bone is surgically removed; longer if infected bone remains. 3, 2
• Continue antibiotics until infection resolves, NOT until wound heals. 3

Pressure Off-Loading

Off-loading is vital for healing and should use non-removable knee-high devices as first-line therapy. 1, 2

• Preferred: Total contact cast or removable walker rendered irremovable for neuropathic plantar ulcers. 1, 2
• Use removable devices only when non-removable options are contraindicated (severe ischemia, active deep infection). 2, 4
• Instruct patients to limit standing/walking and use crutches if necessary. 2

Wound Care and Dressings

Select dressings based on wound moisture level, prioritizing exudate control, comfort, and cost. 4

• Dry/necrotic wounds: Continuously moistened saline gauze or hydrogels to facilitate autolysis. 2, 4
• Exudative wounds: Alginates, hydrocolloids, or foams to absorb drainage. 2, 4
• Avoid topical antimicrobials for clinically uninfected wounds. 2, 4
• Change dressings based on exudate level and manufacturer recommendations. 4

Surgical Management

Seek urgent surgical consultation for: deep abscess, extensive bone/joint involvement, crepitus, substantial necrosis/gangrene, necrotizing fasciitis, or compartment syndrome. 3, 2

• Surgery is required for retained purulence or advancing infection despite optimal medical therapy. 7
• Procedures include incision and drainage, extensive debridement, removal of infected bone, or amputation when necessary. 2, 7
• Most plantar ulcers require plantar incisions for adequate drainage. 7

Vascular Assessment and Revascularization

Evaluate arterial supply in ALL infected limbs, especially with signs of ischemia (rest pain, dependent rubor, tissue loss). 3, 2

• Consider revascularization when toe pressure <30 mmHg or transcutaneous oxygen pressure (TcpO2) <25 mmHg. 2
• Goal is to restore direct flow to at least one foot artery, preferably the vessel supplying the wound region. 2
• Critical: Inadequate blood supply will prevent healing regardless of other interventions. 2

Hospitalization Criteria

Hospitalize if ANY of the following are present: 3

• Systemic toxicity (fever, leukocytosis)
• Metabolic instability (severe hypoglycemia, acidosis)
• Rapidly progressive or deep-tissue infection
• Substantial necrosis, gangrene, or critical ischemia
• Need for urgent diagnostic/therapeutic interventions
• Inability to perform self-care or inadequate home support

Adjunctive Therapies

Consider for severe infections or wounds failing standard therapy after correcting all adverse factors: 3, 1

• Granulocyte colony-stimulating factors may help prevent amputations. 3, 1
• Systemic hyperbaric oxygen therapy may reduce amputation risk in selected cases. 3, 1
• Negative pressure wound therapy for post-operative diabetic foot wounds. 1, 4

Follow-Up and Monitoring

Provide early and careful follow-up (within 3-5 days initially, or sooner if worsening) to ensure treatment effectiveness. 3

• Monitor for reduction in erythema, swelling, pain, and wound size. 1
• Measure and document wound dimensions regularly to track healing progress. 4
• If infection fails to respond to one antibiotic course in a stable patient, discontinue all antimicrobials for a few days, then obtain optimal culture specimens. 3

Critical Pitfalls to Avoid

• Never treat uninfected wounds with antibiotics—this encourages resistance without benefit. 3, 2
• Never neglect vascular assessment—ischemia prevents healing regardless of other interventions. 2
• Never obtain cultures from undebrided wounds—swabs of superficial drainage yield contaminating flora, not pathogens. 3
• Never delay surgical consultation for deep or severe infections—retained purulence requires drainage. 1, 7
• Never use footbaths—these induce skin maceration and worsen outcomes. 1
• Never perform aggressive debridement without first assessing arterial supply in ischemic limbs. 1, 4