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Diabetic foot infection

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Diabetic foot infection is any infection of the foot in a diabetic person.[1] Symptoms may include pus from a wound, redness, swelling, pain, or warmth. Complications can include infection of the bone, tissue death, amputation, or sepsis.[1] They are common and occur equally frequently in males and females. Older people are more commonly affected.

They most often form following a diabetic foot ulcer, though not all foot ulcers become infected. Most are polymicrobial (contain multiple infective organisms), and bacteria that are commonly involved include staphylococcus, streptococci, pseudomonas, and gram-negative bacteria.[1][2] The underlying mechanism often involves poor blood flow and peripheral neuropathy. Diagnosis is based on symptoms and may be supported by deep tissue culture.[1]

Treatment involves proper wound care and antibiotics. The duration of antibiotics depends on the severity of infection, ranging anywhere from 1-12 weeks. Prevention includes wearing appropriate shoes, regular foot examinations, and control of risk factors.

Mechanism

The pathophysiology of diabetic foot infection includes neuropathy, peripheral artery disease, and trauma contribute individually and in combination to the pathophysiology of diabetic food infections.[3]

Neuropathy

Diabetes causes a symmetric polyneuropathy that may affect motor and sensory neurons.[3] Intrinsic atrophy of foot and ankle muscles leads to anatomic changes of the foot arch, most commonly depressing the metatarsal heads and creating high pressure zones.[3] In combination with decreased sensation in the lower extremities, the repetitive trauma with walking can lead to ulceration.[3] Poor foot care, including lack of moisturizing and frequent self-examination of the feet can exacerbate this.[3]

Peripheral artery disease

Metabolic changes in diabetes, including hyperglycemia, lead to increased likelihood of hyperlipidemia and developing atherosclerosis. In diabetes, this atherosclerosis is preferentially distributed to the posterior and anterior tibial arteries, decreasing perfusion to the lower extremities.[3] This may lead to loss of skin integrity, ischemic ulcers, and gangrene.

Infection may vary in the depth of tissue to which the it extends. Foot infections range from the most superficial, cellulitis, to deeper soft tissue necrotizing fasciitis, which may necessitate limb amputations or become life-threatening.[4][5][6] Infections may also extend to bone, termed osteomyelitis. Infections are commonly polymicrobial and involve antibiotic-resistant strains of organisms e.g. MRSA.[6]

Diagnosis

Initial diagnosis of diabetic foot infections is made primarily via thorough history and physical to include visual inspection of the feet, evaluation of any wounds, distal pulses, and neurologic function.

History and Physical

History should be taken for known recent foot trauma, and the lower extremities should be inspected for signs of recent trauma, including redness, induration, edema, visible ulceration with exudate or pus, or bony deformity.[7][8] Ulcers do occur in the absence of pathological infection. Diagnosis of an infected wound is classically made with ≥2 signs of inflammation or purulence.[9] Peripheral pulses should also be evaluated (posterior tibial and dorsal pedis), and if not palpable, should be further evaluated using ultrasound.[7] In patients with non-palpable pulses, evaluation of PAD with an ankle-brachial index should also be performed.[7] Ulceration or deeper wounds should be probed to identify the depth of penetration and determine involvement of bone, which would indicate osteomyelitis.[10] Neurologic testing includes testing peripheral sensation to vibratory stimuli, temperature, pain, along with deep tendon reflexes.[7]

Imaging

Imaging may also be used for further evaluation. Plain x-ray, the most common initial imaging study, may show fractures, osteomyelitis, gas collection from gas-producing infective organisms, calcification of blood vessels, or foreign bodies.[10][11] Magnetic resonance imaging is useful to determine the depth of soft tissue infection and evaluate for presence of osteomyelitis, especially in patients which do not respond to initial antibiotic therapy.[10][11] Finally, patency of the lower extremity vasculature may be evaluated by magnetic resonance angiography or ultrasonography[10][11]

Management

Acute management of diabetic foot infections generally includess antibiotic therapy, pressure offloading, re-vascularization, if appropriate, and debridement of infected tissues (or amputation if necessary). Hospitalization is more likely needed when lower extremity pulses are absent or when infection penetrates to the level of the fascia or more deeply.[12][13] Infections with skin gangrene may reflect deep space infection, abscess, and tissue necrosis. When debridement is necessary, wounds are left open so that serial debridements may be performed over the course of the wound’s healing.[12]

Antibiotic choice should be guided by deep tissue culture, severity of the infection, presence or absence of osteomyelitis, prior antibiotic treatment, and previous or current MRSA infection.[14] Wounds without confirmed infection should not be treated with antibiotics.[15] Length of treatment depends primarily on severity of infection; skin and superficial soft tissue infections may require treatment for 1-2 weeks while deeper infections (including osteomyelitis) may require 6-12 weeks, including those who undergo surgery.[16][17][14]

Prevention

Prevention of diabetic foot infections include regular foot examinations by a healthcare professional as well as maintenance of cardiovascular co-morbidities and risk factors.[18] This maintenance includes proper footwear, regulating blood glucose and hypertension, and limiting cardiovascular risk factors, such as smoking.[18] All patients with diabetes should be examined at least yearly if no additional risk factors, but more frequently if present. In those with a prior ulcer or amputation, examinations are needed every 1-2 months[18].

Diabetic foot infection
 
Gas gangrene due to diabetes
SymptomsPus from a wound, redness, swelling, pain, warmth[19]
ComplicationsInfection of the bone, tissue death, sepsis, amputation[20]
CausesDiabetic foot ulcer[20]
Diagnostic methodBased on symptoms[19]
Differential diagnosisPhlegmasia cerulea dolens, ischemic limb[20]
PreventionAppropriate shoes[20]
TreatmentWound care, antibiotics, hyperbaric oxygen therapy[20]
FrequencyCommon[20]

References

  1. ^ a b c d Murphy-Lavoie, Heather M.; Ramsey, Adam; Nguyen, Minhthao; Singh, Shikha (2021), "Diabetic Foot Infections", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 28722943, retrieved 2021-10-10
  2. ^ Lipsky, Benjamin (15 June 2012). "2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections". Clinical Infectious Diseases. 54: e132–e173.
  3. ^ a b c d e f Bandyk, Dennis F. (2018-06-01). "The diabetic foot: Pathophysiology, evaluation, and treatment". Seminars in Vascular Surgery. Fighting Diabetic Foot Ulcers. 31 (2): 43–48. doi:10.1053/j.semvascsurg.2019.02.001. ISSN 0895-7967.
  4. ^ Murphy-Lavoie, Heather M.; Ramsey, Adam; Nguyen, Minhthao; Singh, Shikha (2021), "Diabetic Foot Infections", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 28722943, retrieved 2021-10-10
  5. ^ Lipsky, Benjamin (15 June 2012). "2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections". Clinical Infectious Diseases. 54: e132–e173.
  6. ^ a b Gemechu, Fassil W.; Seemant, Fnu; Curley, Catherine A. (2013-08-01). "Diabetic Foot Infections". American Family Physician. 88 (3): 177–184. ISSN 0002-838X.
  7. ^ a b c d Boulton, Andrew J. M.; Armstrong, David G.; Albert, Stephen F.; Frykberg, Robert G.; Hellman, Richard; Kirkman, M. Sue; Lavery, Lawrence A.; LeMaster, Joseph W.; Mills, Joseph L.; Mueller, Michael J.; Sheehan, Peter (2008-08-01). "Comprehensive Foot Examination and Risk Assessment: A report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists". Diabetes Care. 31 (8): 1679–1685. doi:10.2337/dc08-9021. ISSN 0149-5992. PMID 18663232.
  8. ^ Gemechu, Fassil W.; Seemant, Fnu; Curley, Catherine A. (2013-08-01). "Diabetic Foot Infections". American Family Physician. 88 (3): 177–184. ISSN 0002-838X.
  9. ^ Lipsky, Benjamin (15 June 2012). "2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections". Clinical Infectious Diseases. 54: e132–e173.
  10. ^ a b c d Barwell, Nicholas D.; Devers, Marion C.; Kennon, Brian; Hopkinson, Helen E.; McDougall, Claire; Young, Matthew J.; Robertson, Hannah M. A.; Stang, Duncan; Dancer, Stephanie J.; Seaton, Andrew; Leese, Graham P. (2017). "Diabetic foot infection: Antibiotic therapy and good practice recommendations". International Journal of Clinical Practice. 71 (10): e13006. doi:10.1111/ijcp.13006. ISSN 1742-1241.
  11. ^ a b c Bandyk, Dennis F. (2018-06-01). "The diabetic foot: Pathophysiology, evaluation, and treatment". Seminars in Vascular Surgery. Fighting Diabetic Foot Ulcers. 31 (2): 43–48. doi:10.1053/j.semvascsurg.2019.02.001. ISSN 0895-7967.
  12. ^ a b Bandyk, Dennis F. (2018-06-01). "The diabetic foot: Pathophysiology, evaluation, and treatment". Seminars in Vascular Surgery. Fighting Diabetic Foot Ulcers. 31 (2): 43–48. doi:10.1053/j.semvascsurg.2019.02.001. ISSN 0895-7967.
  13. ^ Lipsky, Benjamin (15 June 2012). "2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections". Clinical Infectious Diseases. 54: e132–e173.
  14. ^ a b Gemechu, Fassil W.; Seemant, Fnu; Curley, Catherine A. (2013-08-01). "Diabetic Foot Infections". American Family Physician. 88 (3): 177–184. ISSN 0002-838X.
  15. ^ "Diabetic foot infections: a comprehensive overview". European Review. 2019-04-09. Retrieved 2021-10-10.
  16. ^ Barwell, Nicholas D.; Devers, Marion C.; Kennon, Brian; Hopkinson, Helen E.; McDougall, Claire; Young, Matthew J.; Robertson, Hannah M. A.; Stang, Duncan; Dancer, Stephanie J.; Seaton, Andrew; Leese, Graham P. (2017). "Diabetic foot infection: Antibiotic therapy and good practice recommendations". International Journal of Clinical Practice. 71 (10): e13006. doi:10.1111/ijcp.13006. ISSN 1742-1241.
  17. ^ Murphy-Lavoie, Heather M.; Ramsey, Adam; Nguyen, Minhthao; Singh, Shikha (2021), "Diabetic Foot Infections", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID 28722943, retrieved 2021-10-10
  18. ^ a b c Gemechu, Fassil W.; Seemant, Fnu; Curley, Catherine A. (2013-08-01). "Diabetic Foot Infections". American Family Physician. 88 (3): 177–184. ISSN 0002-838X.
  19. ^ a b Lipsky, Benjamin A.; Berendt, Anthony R.; Deery, H. Gunner; Embil, John M.; Joseph, Warren S.; Karchmer, Adolf W.; LeFrock, Jack L.; Lew, Daniel P.; Mader, Jon T.; Norden, Carl; Tan, James S. (1 October 2004). "Diagnosis and Treatment of Diabetic Foot Infections". Clinical Infectious Diseases. 39 (7): 885–910. doi:10.1086/424846.
  20. ^ a b c d e f Murphy-Lavoie, HM; Ramsey, A; Nguyen, M; Singh, S (January 2020). "Diabetic Foot Infections". PMID 28722943. {{cite journal}}: Cite journal requires |journal= (help)
 

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