Diabetic Foot Infections Treatment & Management

Cellulitis is the easiest diabetic foot infection to cure, because it does not pose the same circulatory limitations that the more serious infections do, making it easier for medications to reach the infection site. In contrast, chronic osteomyelitis, which is the most difficult diabetic foot infection to cure, requires surgical debridement before antibiotic therapy can be effective. The patient may participate in activities as tolerated. However, weight bearing may be contraindicated.

Go to Diabetes Mellitus, Type 1; Diabetes Mellitus, Type 2; Diabetic Foot; and Diabetic Ulcers to see more complete information on these topics.

Infections in patients with diabetes are difficult to treat because they have impaired microvascular circulation, which limits the access of phagocytic cells to the infected area and results in a poor concentration of antibiotics in the infected tissues. For this reason, cellulitis is the most easily treatable and reversible form of foot infections in patients with diabetes. Deep-skin and soft-tissue infections are also usually curable, but they can be life threatening and result in substantial long-term morbidity.^{[1, 2, 3, 4, 5]}

In terms of the infecting microorganisms and the likelihood of successful treatment with antimicrobial therapy, acute osteomyelitis in people with diabetes is essentially the same as in those without diabetes.

As previously mentioned, in chronic osteomyelitis, a sequestrum and involucrum form; these represent islands of infected bone. Bone fragments that are isolated have no blood supply; administered antibiotics do not penetrate these devascularized, infected bone fragments and can enter the area of osteomyelitis via the remaining blood supply. Therefore, antibiotic therapy alone cannot cure patients with chronic osteomyelitis.

Adequate surgical debridement, in addition to antimicrobial therapy, is necessary to cure chronic osteomyelitis. Immobilization is important in acute or chronic osteomyelitis.

Dry gangrene is usually managed with expectant care, and gross infection is usually not present. Wet gangrene usually has an infectious component and requires surgical debridement and/or antimicrobial therapy to control the infection.

Surgical debridement in diabetic patients with chronic osteomyelitis is the most important therapeutic intervention, as this condition cannot be cured without it. This is because debridement removes the infected, bony fragments that antibiotics cannot reach so that affected areas can be treated with antimicrobial therapy; in some cases, amputation is required. Patients who have fetid foot require extensive surgical debridement and/or amputation. If amputation is performed, physical therapy and rehabilitation may be started on an inpatient basis and completed on an outpatient basis.

Appropriate consultation with a surgeon should be obtained for debridement and/or amputation in chronic osteomyelitis, as well as for debridement or decompression of compartment syndromes in patients with deep-skin and soft-tissue infections. In addition, a vascular surgical evaluation to bypass large-vessel occlusive disease should be considered in patients with diabetic foot infections and peripheral vascular disease. Note, however, that large-vessel bypass does not cure the microvascular component of diabetic foot infections.

An infectious disease specialist should be consulted in the treatment of all patients with diabetic foot infections to optimize the antimicrobial therapy.

Cellulitis

No further care is necessary.

Skin and soft-tissue infection

Additional debridement is generally indicated. If the foot is involved, the best care plan is aggressive therapy to avoid surgery beyond transmetatarsal amputation (ie, limit surgical extirpation to the forefoot).

Acute osteomyelitis

Monitor the patient's condition to ensure that the infection has resolved.

Chronic osteomyelitis

Ensure that debridement is complete and that no further remnants of infected bone remain.