Antimicrobial Therapy in Diabetic Foot Infections

Joon Young Song

doi:10.4093/jkd.2011.12.2.83

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Song: Antimicrobial Therapy in Diabetic Foot Infections

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J Korean Diabetes 2011;12(2):83-87.

Published online: 22 January 2011

DOI: https://doi.org/10.4093/jkd.2011.12.2.83

Antimicrobial Therapy in Diabetic Foot Infections

Joon Young Song

Division of Infectious Disease, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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.

Keywords: Diabetes, Foot infection, Antimicrobial agent, Empirical therapy

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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 grade^a	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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