What is the management approach for a 63-year-old male diabetic patient with a non-healing toe ulcer and signs of fungal infection, presenting with diabetes mellitus (DM) and potential complications?

From the Guidelines

For a 63-year-old male diabetic patient with a non-healing toe ulcer and signs of fungal infection, I strongly recommend starting with wound care including daily gentle cleansing with saline solution and debridement of necrotic tissue by a healthcare professional, as well as treating the fungal infection with topical antifungal medication. The patient's wound care should include daily gentle cleansing with saline solution, debridement of necrotic tissue by a healthcare professional, and application of an appropriate dressing such as hydrocolloid or alginate depending on wound exudate, as recommended by the guidelines on interventions to enhance healing of foot ulcers in people with diabetes 1. For the fungal infection, prescribe topical antifungal medication such as clotrimazole 1% cream applied twice daily for 2-4 weeks, as fungal infections are a common complication of diabetic foot ulcers 1. If the infection appears extensive, consider oral terbinafine 250 mg daily for 6-12 weeks. Blood glucose control is crucial, with a target HbA1c below 7%, as poor glycemic control can impede wound healing 1. Offloading pressure from the affected toe using a specialized diabetic shoe, walker boot, or total contact cast is essential, as pressure can exacerbate the wound and impede healing 1. The patient should receive antibiotics if signs of bacterial infection are present, such as amoxicillin-clavulanate 875/125 mg twice daily for 7-14 days, as bacterial infections are a common complication of diabetic foot ulcers 1. Regular follow-up every 1-2 weeks is necessary to monitor healing progress, as diabetic foot ulcers can be challenging to treat and require close monitoring. This comprehensive approach addresses both the fungal infection and the underlying factors contributing to poor wound healing in diabetic patients, including vascular insufficiency, neuropathy, and immunocompromise that make diabetic foot ulcers particularly challenging to treat. Some key points to consider in the treatment of diabetic foot ulcers include:

• Debridement of necrotic tissue to promote wound healing
• Use of topical antifungal medication to treat fungal infections
• Blood glucose control to promote wound healing
• Offloading pressure from the affected area to prevent further injury
• Use of antibiotics to treat bacterial infections
• Regular follow-up to monitor healing progress.

From the FDA Drug Label

The FDA drug label does not answer the question.

From the Research

Diabetic Foot Ulcers and Fungal Infections

• Diabetic foot ulcers (DFU) and diabetic foot infections (DFI) are significant complications of diabetes mellitus, which can lead to lower limb amputation and potentially death 2.
• The prevalence of common superficial fungal infections, such as tinea pedis and onychomycosis, can directly increase a diabetic patient's risk of developing both DFU and DFI 2.

Management of Diabetic Foot Infections

• Early surgical intervention should be considered to improve patients' quality of life, as managing diabetic dry toe gangrene by waiting for autoamputation may lead to worse clinical outcomes 3.
• Antibiotic therapy is a crucial aspect of treating diabetic foot infections, with third-generation cephalosporines and chinolones being effective options 4.
• Prompt identification of clinical infection with appropriate tissue sampling is essential to limit the use of broad-spectrum empirical antibiotics and improve antibiotic stewardship 5.

Treatment of Fungal Infections in Diabetic Patients

• Terbinafine has a proven safety record and no significant drug interactions, making it a suitable option for treating superficial fungal infections in diabetic patients 6.
• Reducing the burden of fungal infections in diabetic patients can help reduce the risk of developing DFU and DFI complications and their associated morbidity and mortality 2.

Antibiotic Therapy Recommendations

• Staphylococcus aureus is the most common infecting organism, and high-dose flucloxacillin remains the empirical antibiotic of choice for antibiotic-naive patients 5.
• Narrow-spectrum, high-dose, short-duration antimicrobial therapy is ideal, and recommendations for empirical therapy, including the choice of alternative oral agents and use of outpatient antibiotics, can support clinicians in the management of diabetic foot infection 5.