Antibiotics And DFIs: What The Evidence Reveals

Author(s): 
Anne Spichler, MD, PhD, and David G. Armstrong, DPM, MD, PhD

Given the prevalence of foot infections in patients with diabetes, aggressive and judicious management with antibiotics is crucial. These authors discuss the recent Infectious Diseases Society of America guideline on diabetic foot infections, emphasize the importance of a team approach in managing inpatients with diabetic foot disorders and investigate the efficacy of promising new antibiotic agents.

   Individuals with diabetes have an approximately 25 percent chance of developing a foot ulcer in their lifetime and about half of these ulcers are clinically infected at presentation.1-3 Foot wounds are now the most frequent diabetes-related cause of hospitalization and often lead to amputation.1,4 Hospitalizations are usually required for moderate or severely infected diabetic foot ulcers. When these patients are hospitalized, aggressive management is critical to increase the success of limb salvage.

   Aggressive management includes the correct identification and classification of infected and ischemic wounds, surgical intervention as appropriate, and an accurate culture specimen collection in association with the appropriate use of antibiotic therapy. Emerging publications in recent years have also emphasized an inpatient diabetic foot service to help manage hospitalized high-risk patients with diabetic foot disorders.5,6

   In order to provide curative measures for these patients and optimize the transition from inpatient to outpatient care, the members of the inpatient management team should have a number of key skills including the following that specifically pertain to diabetic foot infections:

• assessing wound infection;
• collecting appropriate wound cultures; and
• selecting antibiotic therapy for infected wounds.6

   In their guide to inpatient management, Wukich and colleagues also recommend having a pathway to address emergent treatment of diabetic foot infections and the implementation of effective hospital discharge planning to prevent the recurrence of infection.6

   A team approach to management is optimal in patients with diabetic foot infections in order to ultimately increase the likelihood of limb salvage as well as ensure the administration of appropriate antibiotics to inpatients and those who are transitioning from inpatient to outpatient.6 As a part of this team management, one should consult an infectious diseases specialist when cultures yield multiple or antibiotic-resistant organisms, the patient has substantial renal impairment, or the infection does not respond to appropriate medical or surgical therapy in a timely manner. Some goals and the success of establishing an inpatient diabetic foot service are to provide definitive treatment for soft tissue and bone infections; arrange for appropriate medical and surgical consultations when appropriate; and educate emergency department personnel on the importance of prompt consultation for patients with diabetic foot infections. Furthermore, proper antibiotic management of lower extremity infections reduces complications and length of stay.6

   Discharge planning should begin when the signs and symptoms of infection are clearly responding to treatment (resolution of the local and systemic signs of infection and improvement in white blood cell count). Clinicians can transition most patients from parenteral to oral antibiotic therapy to complete a course of therapy as outpatients. In addition, the inpatient team should aim to seamlessly perform appropriate postoperative monitoring to reduce risks of re-ulceration and infection after hospital discharge to home, a rehabilitation unit or a skilled nursing facility.6

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