INTRODUCTION

» Diabetes- related foot infections (DFIs) are associated with

substantial morbidities, requiring frequent healthcare provider visits,
daily wound care, antimicrobial therapy, surgical procedures, and high
healthcare costs.

» Outcome of Infected DFU:-In one large prospective study, at the end

of 1 year, the ulcer had healed in only 46% (and it later recurred in
10% of these), while 15% had died and 17% required a lower
extremity amputation.
» Diabetic Foot Ulcer(DFU):Break in the protective skin
envelope involving at least the epidermis and part of the
dermis.

» This complication most often occurs in those with peripheral

neuropathy and peripheral artery disease (PAD).

» Wound infection is a pathological state caused by the

invasion and multiplication of microorganisms in host tissues
that induce an inflammatory response, usually followed by
tissue damage.
» In patients with diabetes related foot complications , S/S of
inflammation is masked by the presence of peripheral
neuropathy, peripheral artery disease (PAD), or immune
dysfunction.

» Combination of infection with PAD is associated with a

markedly increased risk of poor healing and amputation,
clinicians should evaluate the state of wound perfusion and
the potential need for a revascularization procedure as
soon as possible in all patients with a DFI.
 Predisposing to
foot infection
 FACTORS THAT PREDISPOSE TO FOOT INFECTION

» Having a wound that is deep

» long-standing
» Recurrent
» Traumatic etiology
» Neutrophil dysfunction /CKD
DIAGNOSIS
RECOMMENDATIONS
 RECOMMENDATION - 1

» For clinical diagnosis, based on the presence of

local or systemic signs and symptoms of
inflammation and then, classify according to
IWGDF/IDSA classification scheme.
Rationale:
» DFI defined based on the presence of evidence of
inflammation of any part of the foot, not just of an ulcer, or
findings of SIRS.
» Because of Important diagnostic, therapeutic, and prognostic
implications of osteomyelitis, we separate it out by bone
infection with “(O)” after the grade number (3 or 4)
The Classification System for defining the presence and
severity of an infection of the foot in a person with diabetes
 RECOMMENDATION - 2

» Indications of Hospitalization:
Table 2: Characteristics suggesting a more serious diabetes-related
foot infection and potential indications for hospitalisation
Table 2: Characteristics suggesting a more serious diabetes-related
foot infection and potential indications for hospitalisation
 RECOMMENDATION - 3
» Biochemical Tests: CRP, ESR or Procalcitonin.
 Indication: If the clinical examination is diagnostically equivocal or
uninterpretable.
Rationale:
» A highly elevated ESR (≥ 70 mm/h) has a sensitivity, specificity, and AUC
for the diagnosis of DFO of 81%, 80%, and 0.84, respectively.
» CRP levels tend to rise more quickly with infection and fall more
quickly with the resolution of infection.
» Grade 2 (infected) DFU: Most accurate is CRP.
 RECOMMENDATION - 4
» Not to use foot temperature or quantitative microbial
analysis for the diagnosis of DFI.

Rationale:.
In published studies that assessed the validity of clinical signs for the
diagnosis of DFI using microbial analysis(Cutoff: >=105CFU/gm of tissue)
as a referent test, the criteria used to define infection varied among the
authors, and even between studies conducted by the same team.
 Clinical question

 Which test(s) can best identify the

causative pathogen, and result in
tailored use of antibiotics?
 RECOMMENDATION - 5
» Tissue specimen (by curettage or biopsy) from the wound
Indications of Empirical therapy without culture:
» Acute, non-severe DFI
» No recent antibiotic exposure
» No other risk factors for unusual or antibiotic-resistant
pathogens (e.g., based on specific exposures or previous
culture results).
 RECOMMENDATION - 6

 Which investigation is better for identification of pathogens from

soft tissue or bone samples?
Conventional Culture >>> molecular microbiology techniques

Rationale:
» Molecular microbiology techniques are currently unable to distinguish
dead from living bacterial cells, leading to unjustified use of broad-
spectrum antibiotics.
 RECOMMENDATION - 7

Initial Diagnostic tests for osteomyelitis of the foot

Combination of

 Probe-to-bone test
 Plain X-rays
 ESR, CRP, or procalcitonin.
Rationale:
(a) Probe-to-bone test:
A systematic review found that for detecting DFO the sensitivity
was 0.87 and specificity 0.83.
 Table 3: Features characteristic of diabetes-related osteomyelitis of
the foot on plain X-rays

Sequestrum, involucrum, and cloacae) are seen less frequently in diabetes-related foot osteomyelitis
 (c) Serum Biomarkers

» In a systematic published in 2019, it was found that ESR

≥70mm/hr had a sensitivity, specificity, and AUC of 0.81,
0.8 and 0.84 respectively.
» PCT had the highest diagnostic test accuracy with a sensitivity,
specificity, and AUC of 0.85, 0.67 and 0.844 at a cut-off value
of 0.33ng/mL.
 (c) Serum Biomarkers

» ESR > 60 mm/Hr plus CRP ≥ 80 mg/L had a high positive

predictive value, but a modest negative predictive value, for
the diagnosis of DFO.

» They also found that the combination of elevated ESR (>43

mm/h) with a positive PTB test showed a high correlation
with having positive bone culture and/or histology results.
 RECOMMENDATION - 8

 Indication of MRI in DFO.

 If clinical, plain X-rays and laboratory

findings are inconclusive.
 RECOMMENDATION - 9

» What if MRI not available or inconclusive?

 Consider using PET CT , leukocyte scintigraphy or SPECT
Rationale:
» Specificity and PPV of MRI is lowered because of reactive bone
marrow oedema from non-infectious pathologies, such as
trauma, previous foot surgery or Charcot neuroarthropathy.
» Studies have showed that F-fluorodeoxyglucose (FDG)–PET and
99mTc- exametazime Hexa Methyl Propylene Amine Oxime
(HMPAO) labeled WBC scintigraphy offer the highest specificity
(0.92 for both) for diagnosing DFO.
» Advantages of PET-CT over other Nuclear Imaging
 precise anatomic localization,
 higher sensitivity for chronic infection,
 faster results, and low radiation exposure.
 RECOMMENDATION - 10

 Culture of bone is better than soft tissue culture for

diagnosing Diabetes related Foot osteomyelitis.
 Precautions:
» Bone specimen should be collected in an aseptic manner (i.e.,
percutaneously via intact and uninfected skin, or intraoperatively).
» To avoid a false-negative culture, bone biopsy should be delayed in a
patient who is receiving antibiotics until they have been off therapy for at
least 2 weeks.
» Bone biopsy may not be needed if an aseptically collected specimen
from a deep soft tissue infection grows only a single virulent pathogen,
especially S. aureus.
TREATMENT
For Soft tissue infection:

Recommendation 11: Not to treat clinically uninfected

foot ulcers.
Recommendation 12: Use any of the systemic antibiotic
regimens that have shown to be effective in published RCTs for
1-2 weeks and extend up to 3-4 weeks If the wound is extensive
with slower resolution or PAD.
Re-evaluate the patient if the infection has not resolved after 4
weeks .
Recommendation 13: Selection of Antibiotics:
 Likely or proven causative pathogen(s) and susceptibilities.
 Clinical severity of the infection
 Risk of adverse events
 Likelihood of drug interactions
 Availability and costs

Recommendation 14: Target aerobic gram-positive pathogens

only for mild infection, who have not recently received antibiotic therapy.
» Recommendation 15:
Indications of Empirical treatment of P. aeruginosa: if it has
been isolated from cultures of the affected site within the previous
few weeks in a person with moderate or severe infection who
resides in tropical/subtropical climates.
Table 4: Proposals for the empirical antibiotic therapy according to clinical
presentation and microbiological data (from Lipsky et al.)
» MRSA risk factors:
 prolonged hospitalization
 intensive care admission
 recent hospitalization
 recent antibiotic use
 invasive procedures, HIV infection, admission to nursing homes,
open wounds, haemodialysis, discharge with long-term CVP.
» Compared to 2019 guidelines, in which they advised a duration of
1-2 weeks for any soft-tissue DFIs, they have recommended 10-days
antibiotic therapy following a surgical debridement for moderate
or severe soft tissue DFIs.
» Studies have shown tigecycline to be significantly worse than
ertapenem, and ertapenem to have a slightly lower clinical
cure rate than piperacillin-tazobactam.
» The use of carbapenems was identified as an independent
predictor of need for a major amputation, and use of
vancomycin was an independent predictor of reinfection
or death in one study.
 Diabetes-related osteomyelitis of the foot
(DFO)

Recommendation 16:
 After minor amputation and positive bone margin
culture- 3 weeks of antibiotic therapy
 Without bone resection or amputation- 6 weeks
Table 5: Duration of antibiotic therapy according to the clinical
situation
 RECOMMENDATION - 17

» Remission of DFO: Minimum follow-up

duration of 6 months after the end of the
antibiotic therapy.
RECOMMENDATION - 18

 Indications of Urgent Surgical

Consultation
 Severe infection
 Extensive gangrene
 Necrotizing infection
 Deep abscess
 Compartment syndrome
 Severe lower limb ischemia
 RECOMMENDATION - 19

 Consider performing early (within 24-48

hours) surgery combined with antibiotics for
moderate and severe diabetes-related
foot infections.
 Rationale:

» Retrospective studies comparing early surgery (variously defined,

but usually within 72 hours of presentation) versus delayed
surgery (3-6 days after admission) have reported lower rates of
major lower extremity amputation and higher rates of wound
healing.
» The combination of infection plus PAD potents a poor clinical
outcome if both are not treated adequately. Therefore, in case of
infection, the patient should be assessed for the presence
and severity of PAD.
 RECOMMENDATION - 20

 Indications of a drainage and/or

revascularization procedure :
 PAD + Foot ulcer or gangrene + Infection
 RECOMMENDATION - 21

 Consider performing surgical resection of

infected bone combined with systemic
antibiotics in a person with diabetes-related
osteomyelitis of the foot.
 RECOMMENDATION - 22
 Indications of antibiotic treatment without
surgery

 forefoot osteomyelitis without an immediate need for

incision and drainage to control infection

 without peripheral artery disease, and

 without exposed bone.

 RECOMMENDATION - 23
Not using the following treatments to address
diabetes-related foot infections:
(a) adjunctive granulocyte colony-stimulating factor
treatment or
(b) topical antiseptics, silver preparations, honey,
bacteriophage therapy, or negative pressure wound
therapy.
 Rationale:

Silver compounds do not offer benefits in ulcer

healing (as described in the IWGDF wound healing
guidelines) and there is no evidence to support their
effectiveness in the treatment of the infectious
aspects of a DFU.
 RECOMMENDATION - 24

 Not using topical (sponge, cream, and cement)

antibiotics in combination with systemic antibiotics for
treating either soft-tissue infections or osteomyelitis of the
foot in patients with diabetes.
 RECOMMENDATION - 25

Not using hyperbaric oxygen therapy or topical

oxygen therapy as an adjunctive treatment for the sole
indication of treating a diabetes-related foot infection.
Thanks