Diabetic foot infection Management Setting of care IDSA Q Does the patient have a severe infection? Q Does the patient have a moderate infection with complicating features (such as severe peripheral arterial disease or lack of home support)? Q Is the patient unable to comply with the required outpatient treatment regimen for psychological or social reasons? Q Is the patient failing to improve with outpatient therapy? Yes to any Hospitalize patients with severe infection, patients with moderate infection and complicating features (such as severe peripheral arterial disease or lack of home support), and patients unable to comply with outpatient treatment for psychological or social reasons. B Consider hospitalizing patients not meeting the above criteria but not improving with outpatient therapy. B No to all Empiric antibiotic therapy, diabetic foot infection Do not initiate antibiotic therapy in patients with clinically uninfected wounds. D Initiate antibiotic therapy (combined with appropriate wound care) in all patients with infected wounds. B Decide on the choice of an empiric antibiotic regimen based on the severity of the infection and the likely etiologic agents. B Consider targeting aerobic Gram-positive cocci in patients with mild-to-moderate infections with no recent history of antibiotic therapy. C Administer broad-spectrum empiric antibiotics in most patients with severe infections, pending culture results and antibiotic susceptibility data. B Avoid targeting P. aeruginosa empirically, except for patients with risk factors for true infection with this organism. D Consider administering empiric therapy directed against MRSA in patients with a prior history of MRSA infection, when the local prevalence of MRSA colonization or infection is high, or if the infection is clinically severe. C Surgical interventions IDSA Q Does the patient have gas in the deep tissues or other signs of necrotizing fasciitis? Q Does the patient have a soft tissue abscess? Yes to any Perform urgent surgical intervention for foot infections accompanied by gas in the deeper tissues, an abscess, or necrotizing fasciitis, and less urgent surgery for wounds with substantial nonviable tissue or extensive bone or joint involvement. B No to all Wound debridement IDSA Q Does the wound have necrotic tissue or surrounding callus? Yes Perform debridement of wounds with necrotic tissue or surrounding callus. B No Tailor definitive therapy according to the results of an appropriately obtained culture and sensitivity testing of a wound specimen, as well as the patient's clinical response to the empiric regimen. B Consider choosing the route of therapy largely based on infection severity, with parenteral therapy preferred for all severe and some moderate infections, at least initially. C Switch to oral agents when the patient is systemically well and culture results are available. Consider administering highly bioavailable oral antibiotics alone in most mild and in many moderate infections. Consider offering topical therapy for selected mild superficial infections. B Definitive antibiotic therapy Tailor definitive therapy according to the results of an appropriately obtained culture and sensitivity testing of a wound specimen, as well as the patient's clinical response to the empiric regimen. B Consider choosing the route of therapy largely based on infection severity, with parenteral therapy preferred for all severe and some moderate infections, at least initially. C Switch to oral agents when the patient is systemically well and culture results are available. Consider administering highly bioavailable oral antibiotics alone in most mild and in many moderate infections. Consider offering topical therapy for selected mild superficial infections. B Duration of treatment, diabetic foot infection Consider completing 1-2 weeks of antibiotic therapy for mild infections and 2-3 weeks of antibiotic therapy for moderate-to-severe infections. C Consider continuing antibiotic therapy until, but not beyond, resolution of findings of infection, but not through complete healing of the wound. C General principles Q Does the patient have diabetic foot osteomyelitis? Yes Consider offering either primarily surgical or primarily medical strategies for the treatment of diabetic foot osteomyelitis in properly selected patients. C Duration of treatment, diabetic foot osteomyelitis Consider continuing antibiotic therapy for 2-5 days in patients with diabetic foot osteomyelitis undergone a radical resection leaving no remaining infected tissue. C Consider continuing treatment for 4 weeks in the presence of persistent infected or necrotic bone. C Adjunctive therapies (diabetic foot osteomyelitis) Avoid offering the following adjunctive therapies for the treatment of diabetic foot osteomyelitis: hyperbaric oxygen therapy growth factors, including G-CSF maggots (larvae) negative pressure therapy (such as vacuum-assisted closure). D No Wound care Provide appropriate wound care in patients with diabetic foot ulcers. B Perform debridement of wounds to remove debris, eschar, and surrounding callus. B Prefer sharp/surgical methods. (strong, low) Consider offering mechanical, autolytic, or larval debridement techniques for some wounds. B Redistribute pressure off the wound to the entire weight-bearing surface of the foot ("off- loading") in case of plantar wounds and relieve pressure caused by dressings, footwear, or ambulation to any surface of the wound. A Use dressings allowing for moist wound healing and control of excess exudation, with the choice of dressing based on the size, depth, and nature of the ulcer. B Adjunctive therapies Diabetic foot infection Q Does the patient have a wound that is slow to heal? Yes Consider offering the following adjunctive therapies for selected slow-healing diabetic foot wounds: bioengineered skin equivalents C growth factors, G-CSFs C hyperbaric oxygen therapy B negative pressure wound therapy. C No Discharge criteria Q Is the patient clinically stable? Q Has adequate glycemic control been achieved? Q Has the patient undergone any urgently needed surgery? Q Is the patient able to manage (on his/her own or with help) at the designated discharge location? Q Does the patient have a well-defined post-discharge plan that includes an appropriate antibiotic regimen, an off-loading scheme (if needed), specific wound care instructions, and appropriate outpatient follow-up? Yes to all Discharge patients with DFI meeting the following criteria: patient is clinically stable, and acceptable glycemic control has been attained patient has undergone any urgently needed surgery patient is able to manage on his/her own or with help at the designated discharge location patient has a well-defined plan that includes an appropriate antibiotic regimen to which he/she will adhere, an off-loading scheme if needed, specific wound care instructions, and appropriate outpatient follow-up. B No to any Continue management and follow-up as clinically appropriate.