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ABSTRACT: Foot ulcers are a significant complication of diabetes mellitus and often precede lower-extremity amputation. The most frequent underlying etiologies are neuropathy, trauma, deformity, high plantar pressures, and peripheral arterial disease. Thorough and systematic evaluation and categorization of foot ulcers help guide appropriate treatment. The Wagner and University of Texas systems are the ones most frequently used for classification of foot ulcers, and the stage is indicative of prognosis. Pressure relief using total contact casts, removable cast walkers, or "half shoes" is the mainstay of initial treatment. Sharp debridement and management of underlying infection and ischemia are also critical in the care of foot ulcers. Prompt and aggressive treatment of diabetic foot ulcers can often prevent exacerbation of the problem and eliminate the potential for amputation. The aim of therapy should be early intervention to allow prompt healing of the lesion and prevent recurrence once it is healed. Multidisciplinary management programs that focus on prevention, education, regular foot examinations, aggressive intervention, and optimal use of therapeutic footwear have demonstrated significant reductions in the incidence of lower-extremity amputations.
Diabetic Foot Infection - Article
ABSTRACT: Foot infections are common in patients with diabetes and are associated with high morbidity and risk of lower extremity amputation. Diabetic foot infections are classified as mild, moderate, or severe. Gram-positive bacteria, such as Staphylococcus aureus and beta-hemolytic streptococci, are the most common pathogens in previously untreated mild and moderate infection. Severe, chronic, or previously treated infections are often polymicrobial. The diagnosis of diabetic foot infection is based on the clinical signs and symptoms of local inflammation. Infected wounds should be cultured after debridement. Tissue specimens obtained by scraping the base of the ulcer with a scalpel or by wound or bone biopsy are strongly preferred to wound swabs. Imaging studies are indicated for suspected deep soft tissue purulent collections or osteomyelitis. Optimal management requires aggressive surgical debridement and wound management, effective antibiotic therapy, and correction of metabolic abnormalities (mainly hyperglycemia and arterial insufficiency). Treatment with antibiotics is not required for noninfected ulcers. Mild soft tissue infection can be treated effectively with oral antibiotics, including dicloxacillin, cephalexin, and clindamycin. Severe soft tissue infection can be initially treated intravenously with ciprofloxacin plus clindamycin; piperacillin/tazobactam; or imipenem/cilastatin. The risk of methicillin-resistant S. aureus infection should be considered when choosing a regimen. Antibiotic treatment should last from one to four weeks for soft tissue infection and six to 12 weeks for osteomyelitis and should be followed by culture-guided definitive therapy.
ABSTRACT: Diabetic ulcers are the most common foot injuries leading to lower extremity amputation. Family physicians have a pivotal role in the prevention or early diagnosis of diabetic foot complications. Management of the diabetic foot requires a thorough knowledge of the major risk factors for amputation, frequent routine evaluation and meticulous preventive maintenance. The most common risk factors for ulcer formation include diabetic neuropathy, structural foot deformity and peripheral arterial occlusive disease. A careful physical examination, buttressed by monofilament testing for neuropathy and noninvasive testing for arterial insufficiency, can identify patients at risk for foot ulcers and appropriately classify patients who already have ulcers or other diabetic foot complications. Patient education regarding foot hygiene, nail care and proper footwear is crucial to reducing the risk of an injury that can lead to ulcer formation. Adherence to a systematic regimen of diagnosis and classification can improve communication between family physicians and diabetes subspecialists and facilitate appropriate treatment of complications. This team approach may ultimately lead to a reduction in lower extremity amputations related to diabetes.
Diabetic Foot Infections - Article
ABSTRACT: Diabetic foot infection, defined as soft tissue or bone infection below the malleoli, is the most common complication of diabetes mellitus leading to hospitalization and the most frequent cause of nontraumatic lower extremity amputation. Diabetic foot infections are diagnosed clinically based on the presence of at least two classic findings of inflammation or purulence. Infections are classified as mild, moderate, or severe. Most diabetic foot infections are polymicrobial. The most common pathogens are aerobic gram-positive cocci, mainly Staphylococcus species. Osteomyelitis is a serious complication of diabetic foot infection that increases the likelihood of surgical intervention. Treatment is based on the extent and severity of the infection and comorbid conditions. Mild infections are treated with oral antibiotics, wound care, and pressure off-loading in the outpatient setting. Selected patients with moderate infections and all patients with severe infections should be hospitalized, given intravenous antibiotics, and evaluated for possible surgical intervention. Peripheral arterial disease is present in up to 40% of patients with diabetic foot infections, making evaluation of the vascular supply critical. All patients with diabetes should undergo a systematic foot examination at least once a year, and more frequently if risk factors for diabetic foot ulcers exist. Preventive measures include patient education on proper foot care, glycemic and blood pressure control, smoking cessation, use of prescription footwear, intensive care from a podiatrist, and evaluation for surgical interventions as indicated.