Journal List > J Korean Diabetes > v.12(2) > 1054820

Song: Antimicrobial Therapy in Diabetic Foot Infections

Abstract

Treatment of diabetic foot infection remains a challenging issue to be solved. Bacterial species complicating diabetic foot ulcer differ from those of non-diabetic patients. Empirical antibiotic regimens are selected based on the severity and type of infection (acute infection versus chronic infection), which should always include coverage for aerobic Gram-positive cocci, especially Staphylococcus aureus. Narrow-spectrum antibiotic agents are considered for mild-to-moderate, recent infections, while broad-spectrum agents are usually required for severe, chronic infections, targeting both Gram-positive cocci and Gram-negative bacilli.

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Table 1.
Distribution of causative micro-organisms of culture-positive diabetic foot infections
Micro-organisms, n (%)a Seo et al. [9] (n = 51) Park et al. [8] (n = 113) Choi et al. [7] (n = 121)
Gram-positive bacteria 39 (76.4) 72 (63.7) 90 (74.4)
 MSSA 38 (15.6) 35 (31.0) 30 (24.8)
 MRSA 15 (29.4) 10 (8.8)3 26 (21.5)
 Other Staphylococcus spp. - 11 (9.7)3 14 (11.6)
Streptococcus spp. 12 (23.5) - 10 (8.3)3
Enterococcus spp. 33 (5.9)3 36 (5.3)3 10 (8.3)3
 Other Gram-positive bacteria 31 (2.0)3 10 (8.8)3 -
Gram-negative bacteria 17 (33.3) 41 (36.3) 77 (63.6)
 Enterobacteriaceae 337 (13.7)3 20 (17.6) 47 (38.8)
Pseudomonas spp. 34 (7.8)3 10 (8.8)3 18 (14.9)
Acinetobacter baumannii 32 (3.9)3 - -
 Other Gram-negaitive bacteria 33 (5.9)3 11 (9.7)3 12 (9.9)3

MSSA, methicillin-susceptible Staphylococcus aureus; MRSA, methicillin-resistant Staphylococcus aureus.

a Summation is over 100% because of polymicrobial infections.

Table 2.
Route and duration of antibiotic treatment based on the severity and bone/joint involvement of diabetic foot infections
Bone/Joint involvement IDSA classification PEDIS gradea Clinical manifestations of infection Antibiotic route Duration of therapy
Non-involved cases Uninfected 1 Wound lacking purulence or any manifestations of inflammation - -
Mild 2 Presence of 2 manifestations of inflammation (purulence, or erythema, pain, tenderness, warmth, or induration)
  - cellulitis/erythema .2 cm around the ulcer
 - limited to the skin or superficial subcutaneous tissues
  - no other local complications or systemic illness.
Topical or oral 1-2 wk (up to 4 wk)
Moderate 3 Cellulitis > 2 cm, lymphangitic streaking or beneath the superficial fascia (deep-tissue abscess, gangrene, involvement of muscle or tendon, etc) Initial parenteral, switich to oral 2-4 wk
Severe Systemic toxicity or metabolic instability (fever, chills, tachycardia, hypotension, confusion, vomiting, leukocytosis, acidosis, severe hyperglycemia, or azotemia) 4 Initial parenteral, switich to oral 2-4 wk
Involved cases Moderate/Severe 3/4 Post-amputation (no residual infected bone) Parenteral or oral 2-5 day
Residual infected soft tissue Parenteral or oral 2-4 wk
Residual infected viable bone Initial parenteral, switich to oral 4-6 wk
No surgery Initial parenteral, switich to oral > 3 mo

IDSA, Infectious Diseases Society of America.

a PEDIS, perfusion, extent/size, depth/tissue loss, infection, and sensation (International Consensus on the Diabetic Foot).

Table 3.
Empirical antibiotic regimens for diabetic foot infections
Type Clinical setting Probable pathogens Antibiotic agents
Acute, mild to moderate nfections Antibiotic-naïve (low-risk MRSA) MSSA, β-Haemolytic streptococci Nafcillin, first-generation cephalosporins
Healthcare-associated MRSA Glycopeptides (vancomycin, teicoplanin), linezolid
High local community rates of MRSA MRSA Glycopeptides, linezolid, fluoroquinolone, trimethoprim-sulfamethoxazole, doxycycline, clindamycin
Chronic, severe infections Chronic, previous antibiotic treatment S. aureus, β-haemolytic streptococi and Enterobacteriaceae ± anaerobes β-Lactam + β-lactamase inhibitor, second- or third-generation cephalosporin, carbapenem, fluoroquinolone : add glycopeptides if MRSA infection is considered
Necrotic, gangrenous ischaemic limb, foul odour S. aureus, β-haemolytic streptococi and Enterobacteriaceae + obligate anaerobes Clindamycin + fluoroquinolone, metronidazole + fluoroquinolone, β-lactam + β-lactamase inhibitor, carbapenem : add glycopeptides if MRSA infection is considered
Hydrotherapy, green-blue-coloured drainage Pseudomonas aeruginosa Anti-pseudomonal fluoroquinolone, penicillin or cephalosporin : add glycopeptides if MRSA infection is considered

MSSA, methicillin-susceptible Staphylococcus aureus; MRSA, methicillin-resistant Staphylococcus aureus.

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