What is the appropriate workup for a diabetic foot ulcer in the Emergency Department (ED)?

From the Guidelines

The initial workup of a diabetic foot ulcer in the emergency department should focus on assessing infection severity, vascular status, and wound characteristics, with a thorough history and physical examination, laboratory tests, wound cultures, and radiographs, as recommended by recent guidelines 1. The workup should begin with a thorough history and physical examination, noting ulcer location, size, depth, presence of necrotic tissue, and signs of infection (erythema, warmth, purulent drainage, odor).

• Obtain vital signs to assess for systemic inflammatory response.
• Laboratory tests should include complete blood count, comprehensive metabolic panel, C-reactive protein, erythrocyte sedimentation rate, and blood glucose levels.
• Wound cultures should be taken before starting antibiotics, preferably by tissue biopsy or curettage rather than superficial swabbing.
• Radiographs of the affected foot are essential to evaluate for osteomyelitis, foreign bodies, or gas in tissues. For moderate to severe infections, empiric antibiotic therapy should be initiated with agents covering gram-positive, gram-negative, and anaerobic organisms, such as ampicillin-sulbactam 3g IV every 6 hours or piperacillin-tazobactam 4.5g IV every 8 hours, as suggested by the IWGDF/IDSA guidelines 1. Vascular assessment is crucial and includes palpation of pedal pulses, ankle-brachial index measurement, and potentially vascular surgery consultation for severe ischemia, as recommended by the IWGDF guidance on peripheral artery disease in patients with foot ulcers in diabetes 1. The wound should be cleansed with normal saline, debrided of necrotic tissue if necessary, and dressed appropriately, with consideration of the IWGDF guidelines on interventions to enhance healing of foot ulcers in people with diabetes 1. Offloading pressure from the ulcer is essential, using specialized footwear or devices, as emphasized by the 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections 1. Patients with severe infections, significant ischemia, deep ulcers, or systemic symptoms should be admitted for further management, while those with mild infections can often be discharged with close follow-up, appropriate antibiotics, and wound care instructions.

From the Research

Diabetic Ulcer Workup in Emergency Department

• The initial assessment of a diabetic foot ulcer in the emergency department should include a thorough evaluation of the patient's medical history, physical examination, and laboratory tests 2.
• A critical triad of neuropathy, minor foot trauma, and foot deformity is found in more than 63% of diabetic foot ulcers (DFU), and peripheral vascular disease (PVD) is identified in 30% of foot ulcers 2.
• The treatment of DFU typically involves a combination of debridement, antibiotics, and revascularization 2.

Classification and Risk Assessment

• Classifying ulcers based on the degree of tissue loss, ischemia, and infection can help identify the risk of limb-threatening disease 3.
• The 5-year mortality rate for individuals with a diabetic foot ulcer is approximately 30%, exceeding 70% for those with a major amputation 3.

Treatment Options

• Surgical debridement, reducing pressure from weight bearing on the ulcer, and treating lower extremity ischemia and foot infection are first-line therapies for diabetic foot ulcers 3.
• Randomized clinical trials support treatments to accelerate wound healing and culture-directed oral antibiotics for localized osteomyelitis 3.
• Topical antimicrobial agents may be used to treat infected diabetic foot ulcers, although the evidence is limited by the availability of relatively few, mostly small, and often poorly designed trials 4.

Multidisciplinary Care

• Multidisciplinary care, typically consisting of podiatrists, infectious disease specialists, and vascular surgeons, in close collaboration with primary care clinicians, is associated with lower major amputation rates relative to usual care 3.
• Early referral for multidisciplinary care is recommended for patients with diabetic foot ulcers 3.

Prevention and Education

• Awareness of physicians about foot problems in diabetic patients, clinical examination, and paraclinical assessment, regular foot examination, patient education, simple hygienic practices, and provision of appropriate footwear combined with prompt treatment of minor injuries can decrease ulcer occurrence by 50% 2.
• Pressure-relieving footwear and foot skin measurements with off-loading when hot spots are found can reduce the risk of ulcers compared with usual care 3.