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Clinical guidelines for the in-patient management of diabetic

foot infections

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Central Index No 195

Medical CMT 29/08/07

Endorsing Body
CMB 16/06/07

Endorsement Date August 2007

Review Date August 2009

Dr S O Oyibo, Consultant Physician

Mr. P Taylor, Consultant Vascular Surgeon
Lead author and designation Karen Halliday, Chief Diabetes Podiatrist
Dr D Mlangeni, Consultant Microbiologist
Nikki Philimoore, Senior Pharmacist

Review led by Appendix 2 updated May 2008 Nikki Phillimore

Clinical guidelines for the in-patient management of diabetic foot infections

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Clinical guidelines for the in-patient management of diabetic

foot infections

Background
Diabetic foot infections (infected foot ulcers, gangrene and osteomyelitis) are a major
cause for admission for patients with diabetes mellitus. If not promptly treated, severe
foot infections can lead to septicaemia and death. A multidisciplinary team approach (by
podiatrists, physicians, vascular and orthopaedic surgeons, nursing staff and diabetes
nurse specialists) is required to reduce morbidity and mortality for affected patients.

Purpose of this clinical guideline

This guideline has been produced to promote consistent care of patients with diabetic
foot infections. It outlines the actions necessary for managing these conditions and
thereby reduces the risk to patients as much as possible. Whilst based on scientific
evidence or professional consensus these guidelines are not intended to replace clinical
judgement.

Scope of the guideline

The guideline should be used Trust wide by medical, surgical, podiatric and nursing staff
for the management of patients with diabetic foot infections.

Classification of infected foot ulcers

Mild: presence of markers of inflammation, erythema less than 3cm around ulcer,
infection limited to skin or subcutaneous tissues, no systemic toxicity.

Moderate: erythema more than 3cm around ulcer, lymphangitis, spread beneath
superficial fascia, deep abscess, gangrene or involvement of muscles, tendon or
bone, but no systemic toxicity.

Severe: infection as above with systemic toxicity (fever, tachycardia, tachypnoea,

leukocytosis, raised CRP).

Clinical guidelines for the in-patient management of diabetic foot infections

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Guideline recommendation
1. Diabetic foot infections
1.1. Patients with moderate to severe diabetic foot infections as described above
require urgent admission to hospital to prevent rapid deterioration (see appendix
1 & 2).
1.2. The foot ulcer/affected foot should be exposed and examined. The other
unaffected foot should also be inspected.
1.3. Assessment of circulation may be difficult. Pedal pulses may be hard to feel in
swollen feet. Diabetic neuropathy may lead to paradoxical erythema even where
ischaemia is present. Doppler examination can be difficult to interpret due to
arterial calcification. Duplex examination in the Vascular lab is often necessary. If
pedal pulses are not palpable, please refer for urgent vascular surgical
assessment (see 2.5).
1.4. A wound swab (best obtained from the debrided base of the infected ulcer)
should be sent off ideally before antibiotics are commenced. Purulent collections
should be aspirated or swabbed and sent to laboratory promptly.
1.5. Routine blood investigations should include FBC, U&E, LFT, CRP, GLU, and
Blood Cultures.
1.6. An x-ray of the affected area or foot (forefoot, mid-foot, hind-foot) should be
performed to assess for osteomyelitis, fractures, Charcot foot, etc.
1.7. All patients must be on prophylactic subcutaneous heparin.
1.8. Patients may require insulin therapy/infusion to improve their diabetes control.
1.9. A member of the diabetic foot team should be informed of any patient admitted
with a diabetic foot problem (please send a fax to Ext - 5159).

2. Infected diabetic foot ulcers

2.1. The presence of infection and ischaemia greatly increase the probability of a foot
ulcer not healing and thereby deteriorating, leading to gangrene and septicaemia.
2.2. After obtaining appropriate specimens (as in section 1.4), intravenous antibiotics
should be commenced in these patients.
2.3. You may need to cover gram-negative and anaerobic organism when there is a
deep ulcer and/or significant ischaemia, or previous antibiotic usage.
2.4. If pedal pulses are not palpable and ischaemia is suspected (see 1.3), the On
Call surgical team / vascular surgeon (see 2.5) should be informed as soon as
possible, as early vascular intervention can improve healing of foot ulcers,
prevent deterioration, and also limit the extent of necessary amputation.
2.5. The presence of osteomyelitis, deep abscess, large areas of slough/necrosis,
pre-gangrene and gangrene warrant urgent assessment by the vascular
surgeons. Please bleep the on-call surgical SpR, who will contact the vascular
surgeons or orthopaedic surgeons as necessary.
2.6. Antibiotics with good bone penetration should be used for patients with
osteomyelitis.
2.7. The presence of MRSA should prompt the swabbing of other relevant areas,
informing the Infection Control Nurse and discussion with the microbiologist.

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2.8. Debridement of neuropathic and neuro-ischaemic foot ulcers will be carried out as
necessary by the podiatric team in close collaboration with the vascular surgeons.
2.9. See appendix 2 for antibiotics usage for diabetic foot infections, and remember
that the microbiologist is there for urgent advice.

3. Wound dressing and diabetic foot ulcers

3.1. Patients should be kept off their feet for as much as possible to aid healing of
their ulcers.
3.2. The foot team should inspect their shoes for foreign bodies, as shoes are the
commonest culprits in the pathogenesis of foot ulceration.
3.3. Sterile, non-adhesive dressings should be used to cover ulcers to protect them
from trauma, absorb exudates, reduce infection and promote healing.
3.4. Please liase with podiatrist and the tissue viability nurse.

4. Osteomyelitis (and the acute Charcot foot)

Osteomyelitis is suspected if there is a red, swollen, sometimes painful joint or toe
(sausage toe) in the presence of a nearby infected ulcer. The underlying bone is
usually exposed. An x-ray may be normal in the early stages, but later may reveal
cortical destruction, periostal reaction, reduced bone density or sclerosis.

Charcot foot is suspected if there is a red, swollen, sometimes painful joint

(commonest in the mid-foot) in the absence of infection in patients with severe diabetic
neuropathy. However, this could co-exist with infection. An x-ray could be normal
initially, but later reveal destructive bony changes and the typical disorganised joint.

All patients with suspected osteomyelitis should have:

4.1. A specimen from the ulcer or discharge (best done after cleaning/debridment)
should be sent for culture and sensitivity.
4.2. Antibiotics as for moderate/severe foot infection to target most likely pathogens
(see appendix 2).
4.3. An x-ray of the affected site. Patients may require a magnetic resonance imaging
test (MRI) to differentiate osteomyelitis from the acute Charcot foot.
4.4. Review by the vascular surgeons as soon as possible, especially if there is
associated ischaemia, pre-gangrene, gangrene or deep abscess. The vascular
surgeons will liaise with the orthopaedic surgeons as appropriate.
4.5. The acute Charcot foot is usually treated by casting, stabilisation and non-weight
bearing (this could be done on an out-patient basis). Please inform the diabetic
foot team.
5. Discharge from hospital and out-patient follow-up
5.1. No patient should be discharge with either moderate or severe infection. Patients
with mild infection can be discharged on oral antibiotics (1-2 weeks course for
mild foot infections; 8-12 weeks for unresolved osteomyelitis).

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5.2. Foot ulcers do not necessary need to be healed before patients can be
discharged from hospital.
5.3. All foot lesions must be inspected on the day of discharge.
5.4. All patients on discharge must be referred to the diabetic foot clinic for out-patient
follow-up, using appropriate referral forms (patients need to be seen within two
weeks of discharge).

Suggested areas for audit

1. Foot ulcers swabs/sample sent for microbiological examination before antibiotics
commenced. (100%)
2. Vascular assessment done for all patients. (100%)
3. Patients referred to the diabetic foot clinic on discharge. (100%)

References
Edmonds ME, Foster AVM (2000) Managing stage 4: The cellulitic foot. In Managing the
diabetic foot. Blackwell Science: Oxford, pp 77-98.

Edmonds ME, Foster AVM (2000) Managing stage 5: The necrotic foot. In Managing the
diabetic foot. Blackwell Science: Oxford, pp 99-112.

International Working Group on the Diabetic Foot (2003) International consensus on the
diabetic foot [CD-ROM]. Brussels: International Diabetes Foundation.

Kings College Hospital (2003) Guidelines for the microbiological management of diabetic
foot infections.

Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, LeFrock JL,
Lew DP, Mader JT, Norden C, Tan JS, Infectious Disease Society of America (2004)
Diagnosis and treatment of diabetic foot infections. Clin Infect Dis 39: 885-910.

National Institute for Clinical Excellence (2004) Type 2 diabetes: prevention and
management of foot problems. NICE Technology Appraisal Guidance No. 10. London:
National Institute for Clinical Excellence. Available at: www.nice.org.uk. Accessed Nov
17, 2006.

North West Podiatry Services Diabetes Clinical Effectiveness Group (2005) Guidelines
for the prevention and management of foot problems for people with diabetes.

Oyibo SO (2004) Studies on the management of diabetic foot problems. A thesis

accepted by the University of Manchester.

Appendix 1
Flow chart showing guidelines for in-patient management of diabetic foot infections

Appendix 2
Flow chart showing guidelines for use of antibiotics for diabetic foot infections

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Appendix 1

Guidelines for in-patient management of diabetic foot infections

Examine foot lesion

Moderate/severely infected FBC, U&E, LFT, CRP, GLU, B/C
diabetic foot ulcers Swab/curettage/aspirate ulcer for
microbiology
Vascular assessment
X-ray of affected foot
Inform Diabetic Foot Team

Intravenous antibiotics to cover Osteomyelitis

gram-positive, gram-negative and suspected, but not
anaerobic organism (see appendix 2) confirmed,
S.C. Clexane consider MRI scan
Wound dressing
Improve diabetes control

Presence of severe ischaemia, large

areas of slough/necrosis, deep abscess, 1 Inform/refer to
osteomyelitis, pre-gangrene, gangrene orthopaedic
surgeons as
Contact on-call surgical SpR appropriate
Inform vascular surgeons

Regular change of soiled dressing and wound assessment

Change to oral antibiotics after clinical improvement (temp, WBC, CRP)
Diabetologist and podiatrist to assess weekly for diabetes control and wound debridment

Infection mild/resolved (see appendix 2 for discharge antibiotics)

Discharge on oral antibiotics for follow-up in next Friday Diabetic Foot

Clinic
Fax discharge letter/referral form (urgent) to: Ext- 5159

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Appendix 2

Diabetic Foot Infections

Mild Moderate Severe

Superficial A Cellulitis (erythema >3cm
infection around ulcer), lymphangitis A and/or B
(erythema + Toxicity
<3cm around B Deep abscess, tendon/bone
ulcer) involvement, or gangrene Fever,
pulse,
Outpatient A B WBC, CRP
Management Tachypnoea

IV Flucloxacillin 1-2g qds Co-amoxiclav 1.2g tds IV Tazocin 4.5g tds

Penicillin allergic:
IV Clarithromycin 500mg Penicillin anaphylaxis: Penicillin allergic:
bd IV Clindamycin 300mg qds IV Vancomycin (monitor
+ Oral Ciprofloxacin 500mg bd levels/renal function)
+ IV Metronidazole 500mg tds
+ Oral Ciprofloxacin 500mg bd

MRSA
Recent admissions Inform Infection Control
Patients from nursing home MRSA topical therapy
MRSA tagged on PAS Discuss with microbiologist
Microbiological confirmation about adding IV Vancomycin
Swab other relevant areas

Review microbiology report. Switching to

oral antibiotics 24-48 hours after cellulitis
and clinical signs of toxicity have resolved
MRSA Osteomyelitis
Discharge on oral antibiotics (1-2 weeks course) Rifampicin 600mg bd
Monotherapy: Flucloxacillin 500mg qds or clarithromycin + Doxycycline 200mg stat,
500mg bd then 100mg od x 4wks

If abnormal liver function

Osteomyelitis (non-surgical therapy), discharge on Sodium Fusidate 500mg tds
Oral Clindamycin 450mg qds + Trimethoprim 200mg bd
Or
Flucloxacillin 500mg qds + sodium fusidate 500mg tds
Clinical guidelines for the in-patient management of diabetic foot infections
If no improvement
Central Index: after 4-6 weeks August
(X-ray),2007
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*Monitor liver and renal7 function
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ciprofloxacin 750mg bd to cover for Pseudomonas
on all antibiotics