Diabetic Foot Infections

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Diabetic Foot Infections
Definition Signs/ Symptoms Management
Initial Empirical Therapy Comment
Infection of a foot wound located below the malleoli (IDSA/IWGDF) definition. "Erythema, warmth , swelling, tenderness, and/or pus in an ulcer. Osteomyelitis may be also present."
Mild infection:

Select one of the following antibiotics:

  • Clindamycin 300 - 450 mg oral every 6 - 8 hours
  • Levofloxacin 750 mg IV every 24 hours
  • Amoxicillin/Clavulanate 1 g every 12 hours
  • Ampicillin/Sulbactam 3 g IV every 6 hours
  • Linezolid (if high risk of MRSA)
Mild Infection:
Infected: At least two of these items are present:
  • Local swelling or induration
  • Erythema > 0.5 but < 2 cm around the wound
  • Local tenderness or pain
  • Local increased warmth
  • Purulent discharge
Moderate or Severe infection:

Select one of the following antibiotics:

  • Ceftriaxone 1 - 2 g IV every 24 hours
  • Piperacillin/Tazobactam 4.5 g IV every 6 - 8 hours
  • Ertapenem 1 g IV every 24 hours

Plus:

(Only IF MRSA Risk factors)

  • Vancomycin 15- 20mg/kg IV every 8 to 12 hours
  • Linezolid 600 mg IV every 12 hours
Moderate Infection:
Infection with no systemic manifestations and involving:
  • Erythema extending ≥ 2 cm from the wound margin, and/or
  • Tissue deeper than skin and subcutaneous tissues (e.g., tendon, muscle, joint, and bone)
Moderate or Severe infection with: Macerated ulcer or warm climate or Ischemic limb/necrosis/ gas forming or risk factor for MDR:

Select one of the following antibiotics:

  • Piperacillin/Tazobactam 4.5 g IV every 6 - 8 hours
  • Meropenem 1 g IV every 8 hours
  • Imipenem/Cil 500 mg IV every 6 hours

Plus:

(Only IF MRSA Risk factors)

  • Vancomycin 15- 20mg/kg IV every 8 to 12 hours
  • Linezolid 600 mg IV every 12 hours
Severe infection:
Any foot infection with associated systemic manifestations (of the systemic inflammatory response syndrome [SIRS]), as manifested by ≥2 of the following:
  • Temperature, > 38°C or < 36°C
  • Heart rate, > 90 beats/min
  • Respiratory rate, > 20 breaths/min, or PaCO₂ < 4.3 kPa (32 mmHg)
  • White blood cell count > 12,000/mm³, or < 4 G/L, or > 10% immature (band) forms
Duration: 1 - 2 weeks , up to 4 weeks in severe infection.
MRSA Risk Factors
  • Prolonged hospitalization
  • Intensive care admission
  • Recent hospitalization
  • Recent antibiotic use
  • Invasive procedures
  • HIV infection
  • Admission to nursing homes
  • Open wounds
  • Hemodialysis
  • Discharge with long-term central venous access
References:

Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections