Document 6478744

Guideline for Management of Adult Diabetic Foot Infections
9
9
9
9
9
9
Doses are for guidance only and apply to adults of average size with normal renal and hepatic function.
Take appropriate samples, before antimicrobial therapy is commenced, if patient condition allows.
• Debride wound before specimen is obtained.
• Tissue biopsy or curettage, or aspiration from base of ulcer gives more sensitive and specific results than wound swabs.
• For small deep ulcers consider per nasal swab. See Diabetic Foot Ulcer Policy (investigations section)
Check recent culture results e.g. wound cultures & MRSA screens before prescribing empirically.
Antimicrobial therapy aims to cure the infection, but not to heal the wound. Continue until infection has resolved but not
necessarily until the wound has healed.
Antibiotic treatment must be reviewed in light of significant cultures and targeted appropriately.
Consider X-ray of both feet and lateral if osteomyelitis suspected (N.B. may be normal initially, consider repeat after 2 weeks)
PEDIS
grade
PEDIS
grade 1
PEDIS
grade 2
Definition
No signs of infection
Mild infection:
no systemic illness
and
≥ 2 symptoms/signs
of inflammation (i.e.
tenderness, pain,
erythema, warmth)
and
cellulitis ≤ 2cm
around the wound,
confined to
subcutaneous tissue
only
Likely microorganisms
Not infected
Most likely
monomicrobial with
Staphylococcus
aureus or βhaemolytic
streptococci
Previous
antimicrobial
treatment: May be
polymicrobial with
Gram negative
organisms in
addition to above
Empirical antimicrobial therapy
Duration
General comments
Review at 48 hours
with microbiology
results and target
antibiotic therapy
appropriately.
High risk of MRSA
if:
• Known MRSA
positive
• Inpatient >7 days
• Inpatient within
last 3 months in
any hospital
• From nursing/
residential home
Antimicrobials not indicated
IV treatment is not usually required
Treatment naïve:
Flucloxacillin 500mg–1g PO every 6 hours
Penicillin allergy:
Co-trimoxazole (Septrin®) 960mg PO every 12 hours
Expected duration
7 to 14 days.
Failed recent antimicrobial therapy (for example a
recent course of Flucloxacillin at a reasonable dose
e.g. 1g QDS): Co-amoxiclav 625mg PO every 8 hours
High risk MRSA positive:
Doxycycline 200mg PO once daily (drink plenty of
water SE :photosensitivity)
Management of Diabetic Foot Ulcer: Empirical Antimicrobial Therapy for Diabetic Skin and Soft Tissue Infection in Adults (Version 3 17.09.12)
Approved by the Antimicrobial Stewardship Group: September 18th 2012
Review date: September 2014
GPs Please refer all
patients to Diabetes
Liaison Podiatrist but
start antibiotics
pending appointment
Page 1 of 3
PEDIS
grade 3
PEDIS
grade 4
Moderate infection:
no systemic illness
and
lymphangitis
OR
deep tissue infection
involving SC tissue,
fascia, tendon, or
bone
OR
abscess
OR
cellulitis >2cm
around the wound
NB. Ischemia plus
moderate infection
should be treated
as severe infection
Severe infection:
any diabetic foot
infection with
systemic illness
(toxicity, fever,
rigors, vomiting,
shock,
confusion, metabolic
instability)
OR Ischemia plus
moderate infection
Most likely
monomicrobial with
Staphylococcus
aureus and/or βhaemolytic
streptococci
Previous
antimicrobial
treatment: May be
polymicrobial with
Gram negative
organisms in
addition to above
Empirically cover
polymicrobial Gram
positive and Gram
negative infection
including
anaerobes
1st choice: Co-amoxiclav 625mg PO every 8 hours or
Co-amoxiclav 1.2 grams IV every 8 hours
Penicillin allergy: Clindamycin 450–600mg PO/IV
every 6 hours
If lymphangitis add Clindamycin 450-600mg IV every
6 hours (if not already on it)
Failed recent antibiotic therapy:
Discuss with microbiology
Review at 48 hours
with microbiology
results and target
antibiotic therapy
appropriately.
Consider admission
or urgent referral to
diabetic foot clinic.
Expected duration
10 days to 3
weeks.
High risk MRSA positive:
Add Vancomycin IV (dose in accordance with Trust
Vancomycin guideline). Send MRSA screen
Once patient improving switch to oral (obtain advice
from Diabetes Team or Microbiology)
1st choice: Clindamycin 600mg IV every 6 hours plus
Piperacillin-tazobactam (Tazocin) 4.5 grams IV every 8
hours
Penicillin allergy:
Clindamycin 600mg IV every 6 hours plus
Ciprofloxacin 400mg IV every 12 hours
High risk MRSA positive:
Add Vancomycin IV (dose in accordance with Trust
Vancomycin guideline). Send MRSA screen
Review at 48 hours
with microbiology
results and target
antibiotic therapy
appropriately.
Admit, inform
Diabetes Team of
admission as soon
as possible.
Expected duration
10 days to 3
weeks.
Once patient improving switch to oral (obtain advice
from Diabetes Team or Microbiology)
Management of Diabetic Foot Ulcer: Empirical Antimicrobial Therapy for Diabetic Skin and Soft Tissue Infection in Adults (Version 3 17.09.12)
Approved by the Antimicrobial Stewardship Group: September 18th 2012
Review date: September 2014
Page 2 of 3
Severe sepsis: any diabetic
foot infection with severe sepsis
Severe Sepsis: ≥2 SIRS criteria
AND evidence of infection AND
organ dysfunction
Empirically cover
polymicrobial Gram
positive and Gram
negative infection
including
anaerobes
1st choice: Clindamycin 600mg IV every 6 hours plus
Piperacillin-tazobactam (Tazocin) 4.5 grams IV every 8
hours
Discuss with
Microbiology
within 48 hours
Admit, inform
Diabetes Team of
admission as soon
as possible.
Mild penicillin allergy:
Meropenem 1gram IV every 8 hours
Severe penicillin allergy: Discuss with Microbiology
Suspected osteomyelitis
• Likely if bone visible or
probes to bone
• X-ray changes may be
absent initially, consider
repeat after 2 weeks
• If OM suspected contact
diabetic team
• Bone biopsy for histology
and culture, to establish
diagnosis, define the
pathogens and target
antimicrobials
Predominant
aetiological agent is
Staphylococcus
aureus, but range
of potential
pathogens
extensive
If high risk MRSA: Add vancomycin IV (dose in
accordance with Trust vancomycin guideline). Send
MRSA screen.
Suspected osteomyelitis:
Clindamycin 450–600mg PO every 6 hours plus
Ciprofloxacin 750mg PO every 12 hours
Oral treatment not suitable:
Clindamycin 450–600mg IV every 6 hours plus
Ciprofloxacin 400mg IV every 12 hours
4 to 6 weeks
Consider admission
minimum for
or urgent referral to
acute OM.
diabetic foot clinic.
Total duration
depends on
organisms isolated
and response to
treatment. Target
antimicrobials to
pathogens isolated.
Discuss with
Microbiology
Urgent review of new or acute foot problems can be arranged in the Diabetes centre on weekdays. The diabetic team and microbiologists are pleased to give
advice on any part of this protocol. Dr Mollie Donohoe and Dr Roderick Warren can be paged for advice. Microbiology clinical advice is available on bleep
176 during normal working hours, or via switchboard at other times.
After care: Patients not admitted but with signs of infection must be reviewed within 7 days, and earlier if concerns.
• Ensure patient has FU appointment in diabetic foot clinic (T: 01392402204, Secretary Shirley Brooks or Liz Martin).
• Prevent ulcer recurrence by education. Integrated patient foot care leaflets available from Shirley Brooks in Diabetic Foot clinic.
• Suggest Google Devon Diabetes Exeter for more detailed advice on our dedicated Web page.
• Ensure patient has appropriate footwear before leaving hospital.
Management of Diabetic Foot Ulcer: Empirical Antimicrobial Therapy for Diabetic Skin and Soft Tissue Infection in Adults (Version 3 17.09.12)
Approved by the Antimicrobial Stewardship Group: September 18th 2012
Review date: September 2014
Page 3 of 3