Diabetic Foot Infections Clinical Presentation
- Author: Michael Stuart Bronze, MD; Chief Editor: Romesh Khardori, MD, PhD, FACP more...
As previously mentioned, local trauma and/or pressure (often in association with lack of sensation because of neuropathy), in addition to microvascular disease, may lead to a diabetic foot infection. However, patients may not necessarily have a history of trauma or have suffered a previous infection.
Cellulitis may involve tender, erythematous, nonraised skin lesions on the lower extremity that may or may not be accompanied by lymphangitis. Lymphangitis suggests a group A streptococcal etiology. If bullae are present, S aureus is the most likely pathogen, but group A streptococci occasionally cause bullous lesions. No ulcer or wound exudate is present in patients with cellulitis.
Deep-skin and soft-tissue infections
Patients with deep-skin and soft-tissue infections may be acutely ill, with painful induration of the soft tissues in the extremity. These infections are particularly common in the thigh area, but they may be seen anywhere on the leg or foot. Wound discharge is usually not present.
In mixed infections that may involve anaerobes, crepitation may be noted over the afflicted area. Extreme pain and tenderness indicate the possibility of a compartment syndrome. Similarly, extreme pain may be an indication of infection with clostridial species (ie, gas gangrene). The tissues are not tense, and bullae may be present. If a discharge is present, it is often foul.
Unless peripheral neuropathy is present, the patient has pain at the site of the involved bone. Usually, fever and regional adenopathy are absent.
In chronic osteomyelitis, the patient's temperature is usually less than 102°F. Discharge is commonly foul. No lymphangitis is observed, and pain may or may not be present, depending on the degree of peripheral neuropathy.
The deep, penetrating ulcers and deep sinus tracts (which are diagnostic of chronic osteomyelitis) are usually located between the toes or on the plantar surface of the foot. In patients with diabetes, chronic osteomyelitis usually does not occur on the medial malleoli, shins, or heels. (See the image below.)
Malabu UH, Al-Rubeaan KA, Al-Derewish M. Diabetic foot osteomyelitis: usefulness of erythrocyte sedimentation rate in its diagnosis. West Afr J Med. 2007 Apr-Jun. 26(2):113-6. [Medline].
Lipsky BA, Armstrong DG, Citron DM, Tice AD, Morgenstern DE, Abramson MA. Ertapenem versus piperacillin/tazobactam for diabetic foot infections (SIDESTEP): prospective, randomised, controlled, double-blinded, multicentre trial. Lancet. 2005 Nov 12. 366(9498):1695-703. [Medline].
Lipsky BA, Giordano P, Choudhri S, Song J. Treating diabetic foot infections with sequential intravenous to oral moxifloxacin compared with piperacillin-tazobactam/amoxicillin-clavulanate. J Antimicrob Chemother. 2007 Aug. 60(2):370-6. [Medline]. [Full Text].
Lipsky BA, Stoutenburgh U. Daptomycin for treating infected diabetic foot ulcers: evidence from a randomized, controlled trial comparing daptomycin with vancomycin or semi-synthetic penicillins for complicated skin and skin-structure infections. J Antimicrob Chemother. 2005 Feb. 55(2):240-5. [Medline]. [Full Text].
Stein GE, Schooley S, Peloquin CA, Missavage A, Havlichek DH. Linezolid tissue penetration and serum activity against strains of methicillin-resistant Staphylococcus aureus with reduced vancomycin susceptibility in diabetic patients with foot infections. J Antimicrob Chemother. 2007 Oct. 60(4):819-23. [Medline]. [Full Text].
Wang S, Cunha BA, Hamid NS, Amato BM, Feuerman M, Malone B. Metronidazole single versus multiple daily dosing in serious intraabdominal/pelvic and diabetic foot infections. J Chemother. 2007 Aug. 19(4):410-6. [Medline].
Morbach S, Furchert H, Gröblinghoff U, Hoffmeier H, Kersten K, Klauke GT, et al. Long-Term Prognosis of Diabetic Foot Patients and Their Limbs: Amputation and death over the course of a decade. Diabetes Care. 2012 Jul 18. [Medline].
[Guideline] Hingorani A, LaMuraglia GM, Henke P, Meissner MH, Loretz L, Zinszer KM, et al. The management of diabetic foot: A clinical practice guideline by the Society for Vascular Surgery in collaboration with the American Podiatric Medical Association and the Society for Vascular Medicine. J Vasc Surg. 2016 Feb. 63 (2 Suppl):3S-21S. [Medline].
Tucker ME. New guidelines stress need for diabetic foot ulcer offloading. Medscape Medical News. Available at http://www.medscape.com/viewarticle/837220. Accessed: December 26, 2014.
Snyder RJ, Frykberg RG, Rogers LC, Applewhite AJ, Bell D, Bohn G. The management of diabetic foot ulcers through optimal off-loading: building consensus guidelines and practical recommendations to improve outcomes. J Am Podiatr Med Assoc. 2014 Nov. 104(6):555-67. [Medline].
Rogers LC, Frykberg RG, Armstrong DG, et al. The Charcot foot in diabetes. Diabetes Care. 2011 Sep. 34(9):2123-9. [Medline].
Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012 Jun. 54(12):e132-73. [Medline].
Tucker M. Short-Course Antibiotics Good in Diabetic Foot Osteomyelitis. Medscape Medical News. Available at http://www.medscape.com/viewarticle/835503. Accessed: November 27, 2014.
Tone A, Nguyen S, Devemy F, Topolinski H, Valette M, Cazaubiel M, et al. Six- Versus Twelve-Week Antibiotic Therapy for Nonsurgically Treated Diabetic Foot Osteomyelitis: A Multicenter Open-Label Controlled Randomized Study. Diabetes Care. 2014 Nov 20. [Medline].
US Food and Drug Administration. FDA Drug Safety Communication: Serious CNS reactions possible when linezolid (Zyvox®) is given to patients taking certain psychiatric medications. Available at http://www.fda.gov/Drugs/DrugSafety/ucm265305.htm. Accessed: July 27, 2011.
Lázaro-Martínez J, Aragón-Sánchez J, García-Morales E. Antibiotics versus conservative surgery for treating diabetic foot osteomyelitis. A randomized comparative trial. Diabetes Care. 2013 Oct 15. [Medline].
Nainggolan L. Antibiotics First Choice for Diabetic Foot Osteomyelitis. Available at http://www.medscape.com/viewarticle/813142. Accessed: October 28, 2013.