What is the treatment for a patient with an arterial ulcer infection, possibly with underlying conditions such as diabetes, hypertension, and hyperlipidemia?

Treatment of Arterial Ulcer Infection

Patients with arterial ulcer infection require emergency vascular intervention combined with systemic antibiotics, as this combination represents a particularly high-risk scenario for major limb amputation. 1

Immediate Emergency Management

Patients with signs of peripheral artery disease (PAD) and foot infection require emergency treatment due to exceptionally high amputation risk. 1 This is a time-critical situation that demands urgent action within hours, not days.

Urgent Vascular Assessment

• Measure ankle-brachial index (ABI), toe pressures, and transcutaneous oxygen pressure (TcPO2) immediately to quantify ischemia severity 2
• Obtain vascular imaging urgently (color Doppler ultrasound, CT angiography, MR angiography, or digital subtraction angiography) to define arterial anatomy 1, 2
• Consider emergency revascularization if:
  • Toe pressure <30 mmHg 1, 2
  • TcPO2 <25 mmHg 1, 2
  • Ankle pressure <50 mmHg 2
  • ABI <0.5 2

The IWGDF guidelines emphasize that infection in the setting of PAD creates a vicious cycle where infection increases metabolic demand while ischemia prevents adequate perfusion for healing and infection resolution. 1

Antibiotic Therapy

Initiate broad-spectrum systemic antibiotics empirically before culture results are available. 1 The infection component cannot wait for revascularization completion.

• For deep infections with PAD: urgent surgical drainage and debridement of necrotic tissue must accompany parenteral antibiotics 2
• Empiric antibiotic selection should cover gram-positive, gram-negative, and anaerobic organisms pending culture results 1

Revascularization Strategy

The primary goal is restoring direct arterial flow to at least one foot artery, preferably the artery supplying the ulcer region, achieving minimum toe pressure ≥30 mmHg or TcPO2 ≥25 mmHg. 1, 2

Revascularization Approach

• Evaluate the entire lower extremity arterial circulation with detailed visualization of below-the-knee and pedal arteries 1
• Both endovascular techniques and bypass surgery should be available, with decisions made by a multidisciplinary team based on PAD morphology, vein availability, patient comorbidities, and local expertise 1
• Endovascular treatment (balloon angioplasty) is often preferred in patients with open infected ulcers due to graft infection risk with open surgical reconstruction 3

The evidence shows that after revascularization, limb salvage rates reach 80-85% with ulcer healing in >60% at 12 months, compared to only 50% limb salvage without revascularization. 2

Wound Management

Perform sharp surgical debridement immediately to remove all necrotic tissue and surrounding callus, as continuing necrotic tissue prevents healing and perpetuates infection. 2, 4

• Discontinue antiseptic-only treatments (like betadine alone) and implement proper wound care with appropriate dressings based on exudate control 2
• Repeat debridement as needed since necrotic tissue accumulates in ischemic wounds 2, 4

Multidisciplinary Team Approach

Treatment must involve a multidisciplinary team including vascular surgery, infectious disease, endocrinology (if diabetic), and wound care specialists. 1

• The center treating these patients must have expertise and rapid access to facilities for diagnosing and treating PAD 1
• After revascularization, continue comprehensive care as part of an integrated treatment plan 1

Aggressive Cardiovascular Risk Management

All patients require aggressive cardiovascular risk management including smoking cessation support, hypertension treatment, statin therapy, and antiplatelet therapy (aspirin or clopidogrel). 1, 2, 4

• Optimize glycemic control targeting blood glucose <140 mg/dL in diabetic patients, as hyperglycemia impairs wound healing and increases infection risk 2, 4
• Well-controlled blood glucose may delay progression of complications 1

Critical Pitfalls to Avoid

• Never delay revascularization consultation while attempting medical management alone in infected ischemic ulcers—this combination is a surgical emergency 1
• Do not rely on ABI alone in diabetic patients due to arterial calcification causing falsely elevated readings; always obtain toe pressures and TcPO2 2
• Avoid revascularization only when the risk-benefit ratio is clearly unfavorable from the patient perspective (severe comorbidities, limited life expectancy, patient preferences) 1

Prognosis

Most arterial ischemic ulcers will progress to healing if adequate blood supply is reestablished, unless complicating factors persist. 3, 5 However, without revascularization in the setting of infection, the amputation risk is extremely high and outcomes are poor. 1, 2