What is the best approach to manage diabetic foot disease in an adult or elderly patient with diabetes mellitus and comorbid hypertension and hyperlipidemia?

Management of Diabetic Foot Disease

The gold standard management of diabetic foot disease requires immediate involvement of a multidisciplinary foot care team, which has been proven to reduce diabetes-related lower extremity amputations. 1

Immediate Assessment and Risk Stratification

Clinical Evaluation

• Assess for infection severity using clinical signs: fever, tachycardia, elevated inflammatory markers (WBC, CRP), and extent of erythema surrounding the ulcer 1
• Evaluate for loss of protective sensation (LOPS) using 10-g monofilament testing at three plantar sites on each foot, with loss of sensation indicating high amputation risk 1, 2
• Screen for peripheral arterial disease (PAD) by palpating pedal pulses and measuring ankle-brachial index (ABI); note that ABI >1.4 suggests arterial calcification and requires alternative vascular assessment 1, 2
• Probe to bone test should be performed on all new ulcers to assess depth and potential osteomyelitis 1, 3
• Plain radiographs are mandatory initially, followed by MRI if soft tissue abscess or osteomyelitis is suspected 3

Infection Classification and Antibiotic Management

For mild/superficial infections:

• Cleanse and debride necrotic tissue and callus 1, 2
• Start empiric oral antibiotics targeting Staphylococcus aureus and streptococci (e.g., flucloxacillin, cephalexin) 1, 2

For moderate-to-severe/deep infections (as in the case presented):

• Urgently evaluate for surgical intervention to remove necrotic tissue, drain abscesses, and debride infected bone 1, 2
• Initiate empiric parenteral broad-spectrum antibiotics covering gram-positive, gram-negative, and anaerobic bacteria 1, 2
• Assess for PAD and consider urgent revascularization if ischemia is present 1, 2
• Adjust antibiotic regimen based on culture results and clinical response 1

Glycemic Control

• Optimize blood glucose control immediately with insulin infusion for acute hyperglycemia (as demonstrated in the case with glucose 17.2 mmol/L and HbA1c 10.2%) 1
• Poor glycemic control is a major risk factor for ulceration and amputation 1

Wound Care Protocol

Debridement and Dressings

• Perform sharp debridement with scalpel and repeat as needed to remove necrotic tissue 1
• Select dressings to control exudation and maintain moist environment 1
• Avoid footbaths as they induce skin maceration 1
• Silver-containing or antimicrobial dressings are not well-supported for routine use 1

Advanced Therapies

• Consider negative pressure wound therapy for post-operative wounds 1
• Consider hyperbaric oxygen therapy for poorly healing wounds after 4 weeks of standard therapy, though evidence is mixed 1, 3
• Biologically active products (growth factors, bio-engineered tissue) lack strong evidence for routine use 1

Off-Loading Strategy

For plantar diabetic foot ulcers, use total contact cast or irremovable fixed ankle walking boot as the primary off-loading method 3. This is critical but often challenging in elderly patients with comorbidities 4.

• Custom therapeutic footwear with demonstrated plantar pressure-relieving effect is essential for patients with healed plantar ulcers 2, 3
• Patients should never walk barefoot, in socks without shoes, or in thin-soled slippers 2

Vascular Assessment and Revascularization

• For ulcers with PAD that fail to improve, perform revascularization via surgical bypass or endovascular therapy 3
• Missing posterior tibial pulse and ABI >1.4 (suggesting calcification) warrant urgent vascular surgery consultation 1

Multidisciplinary Team Structure

Establish care at the appropriate level:

• Level 1: General practitioner, podiatrist, diabetic nurse 1
• Level 2: Diabetologist, surgeon (general/orthopedic/foot), vascular surgeon, interventional radiologist, podiatrist, diabetic nurse, orthotist 1
• Level 3: Specialized diabetic foot care center with multiple experts acting as tertiary reference center 1

This case requires immediate Level 2 or 3 care given the moderate-to-severe infection with systemic signs 1, 5, 6

Management of Comorbidities

Hypertension

• Blood pressure of 150/95 mmHg requires optimization 1
• Treat hypertension aggressively as part of PAD prevention 4

Hyperlipidemia

• Manage dyslipidemia to prevent PAD progression 4

Smoking Cessation

• Mandatory smoking cessation (patient smokes 20 cigarettes/day for 40 years) as smoking is a major risk factor for amputation 1

Patient and Family Education

• Instruct on daily foot inspection using mirrors if needed for visual impairment 1, 2
• Teach recognition of infection signs: fever, wound changes, worsening hyperglycemia 1
• Emphasize medication adherence (patient admitted to forgetting flucloxacillin) 1
• Prevent contralateral foot ulceration during bed rest 1

Follow-Up and Prevention of Recurrence

• Screen high-risk patients (IWGDF risk 3) every 1-3 months after healing 2
• Lifelong integrated foot-care program with professional foot treatment and appropriate footwear 1
• The foot should never return to the same shoe that caused the ulcer 1
• Treat pre-ulcerative lesions including callus, ingrown toenails, and fungal infections promptly 2

Critical Pitfalls to Avoid

• Do not delay surgical consultation for moderate-to-severe infections with systemic signs 1, 2
• Do not rely on ABI alone when >1.4 due to arterial calcification; use alternative vascular studies 1
• Do not use oral antibiotics alone for deep infections requiring parenteral broad-spectrum coverage 1, 2
• Do not overlook Charcot neuroarthropathy when patients present with acute red, hot, swollen foot (note the "flattened" midfoot in this case) 1
• Do not discharge without ensuring multidisciplinary follow-up and patient understanding of self-care 1, 2