When Diabetic Foot Ulcers Can Be Managed At Home

By Ronald A. Sage, DPM
Revascularization procedures are provided if necessary and feasible. Once the patient is medically stable, and the wound appears clean and viable, one may emphasize home care. University Of Texas Wound Classification System4 Grade I-A: non-infected, non-ischemic superficial ulceration Grade I-B: infected, non-ischemic superficial ulceration Grade I-C: ischemic, non-infected superficial ulceration Grade I-D: ischemic and infected superficial ulceration Grade II-A: non-infected, non-ischemic ulcer that penetrates to capsule or bone Grade II-B: infected, non-ischemic ulcer that penetrates to capsule or bone Grade II-C: ischemic, non-infected ulcer that penetrates to capsule or bone Grade II-D: ischemic and infected ulcer that penetrates to capsule or bone Grade III-A: non-infected, non-ischemic ulcer that penetrates to bone or a deep abscess Grade III-B: infected, non-ischemic ulcer that penetrates to bone or a deep abscess Grade III-C: ischemic, non-infected ulcer that penetrates to bone or a deep abscess Grade III-D: ischemic and infected ulcer that penetrates to bone or a deep abscess What You Should Know About Monitoring Infection, Cultures And Antibiotic Selection The principles of treating diabetic foot ulceration can be distilled down to infection control, evaluation of vascular perfusion, optimal metabolic management and pressure relief via offloading. If the infection is not limb-threatening, one may emphasize treatment at home. Using the aforementioned University of Texas evaluation system, the most suitable ulcerations for home care are grade I-A, I-B II-A or II-B. When it comes to grade I-C and II-C ulcers with localized infection, one should take reliable cultures from infected tissues and select an appropriate oral antibiotic therapy based on the culture results. Since grade III ulcerations probe to bone, they are considered, almost by definition, to have osteomyelitis and may require hospitalization to initiate therapy. If osteomyelitis is present, performing bone debridement or obtaining a biopsy is necessary in order to establish the infecting agent. Then one would need to administer long-term (possibly IV) antibiotics.6 The difficulty arises when Grade I and II ulcers are present for a prolonged period of time and deep infection is uncertain. If such an ulcer is present for three months or more, unsuspected osteomyelitis may be present. Obtaining a bone scan or MRI may be helpful to make the diagnosis. One can do this on an outpatient basis for patients without systemic febrile illness. However, be aware these imaging studies are not always conclusive. In highly suspicious cases, one should biopsy and culture the bone underlying the ulceration, and subsequently provide appropriate antibiotic treatment. One may utilize outpatient surgical facilities for this purpose if the patient is stable and you consider the infection to be non-limb-threatening. It is easy to initiate wound care and oral antibiotics in the home setting. If soft tissue infection is present, one should obtain accurate cultures to ensure proper antibiotic therapy. Be aware that an array of organisms can contaminate diabetic wounds. To obtain a reliable culture, one must clean the superficial aspects of the wound and swab the deeper, obviously infected tissues. Samples of deeper or debrided tissue will yield the best bacteriologic information.7 When treating non-limb-threatening infections, one may proceed with empiric broad-spectrum antibiotics (such as cephalosporins, quinolones, or penicillin clavulanate combinations) while awaiting culture results.6 Keep in mind that methicillin resistant Staph aureus (MRSA) is becoming a bigger problem and now there are community-acquired strains of MRSA. If this organism is an infecting agent, IV vancomycin or oral linezolid therapy is indicated. If surgical debridement and long-term IV access is necessary, one can initiate this in the hospital. Once the patient is stable, one can have the patient continue the antibiotic therapy at home. Converting Chronic Wounds Into Wounds That May Be Ready For Home Care One should monitor grade I or II A or B ulcerations for signs of infection and healing on a weekly basis at the least. This can be done by a visiting nurse upon orders from a podiatric physician.

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