Tools Wisconsin Diabetes Mellitus Essential Care Guidelines • 2012 58 DIABETIC FOOT INFECTION • Trauma (injury), puncture wound, foreign body • Ulceration or gangrene • Swelling, drainage, odor • Systemic signs: fever, chills, malaise • Diabetes duration/control Significant History/Findings NON- LIMB-THREATENING INFECTION • ≤ 2 cm cellulitis • Superficial ulcer • Does NOT probe to bone • Limited edema, inflammation • No bone/joint involvement • No systemic toxicity • No significant ischemia LIMB-THREATENING INFECTION • > 2 cm cellulitis • Edema, pain, lymphangitis • Drainage, odor • Probe wound for extensions • Systemic signs: hypotension, cardiac arrhythmia (systemic toxicity) • Ischemic changes DIAGNOSTICS • Oral temperature • Deep wound culture from base of ulcer/wound tissue specimen if possible • Diagnostic imaging – Radiographs – MRI, WBC or bone scan • Vascular evaluation • Serologic testing – CBC with differential – Blood culture – ESR, CRP – Blood glucose – Renal metabolic profile TREATMENT • Surgical debridement of callus & ALL necrotic tissue • Wound care - See Pathway #3 • Empiric antibiotic coverage followed by culture directed antibiotics • Close monitoring of progress • Hospital admission if infection progresses or wound/foot deteriorates Outpatient Management TREATMENT • Surgical debridement off ALL necrotic tissue • Exploration & drainage of abscess • Surgical resection of osteomyelitis • Open wound management • Empiric antibiotics modified by culture directed antibiotics • Advanced wound management Negative pressure (NPWT) see Pathway #3 • Repeated wound debridement PRN • Revascularization, as needed • Foot-sparing reconstructive procedures • Definitive amputation, if necessary Hospital Admission CONSULTATIONS as Necessary • Endocrinology • Vascular surgery • Podiatric surgery • Infectious disease • Nephrology • Cardiology • General surgery OUTPATIENT CARE • Antibiotics • Home wound care • Off-loading • Office podiatric care Non-Infected Ulcer Proceed to Pathway #3 Open Wound/Ulcer or Healed Foot Proceed to Pathway #3 Infection Resolves Infection Resolves © 2006 by the American College of Foot and Ankle Surgeons. All rights reserved. The full guideline, including details regarding this pathway, is available at: acfas.org/cpg. Pathway # 3 can be found at: http://www.acfas.org/uploadedFiles/Healthcare_Community/Education_and_Publications/Clinical_Practice_ Guidelines/pway3--ulceration.pdf.

DIABETIC FOOT INFECTIONDIABETIC FOOT INFECTION • Trauma (injury), puncture wound, foreign body • Ulceration or gangrene • Swelling, drainage, odor • Systemic signs: fever,

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ToolsWisconsin Diabetes Mellitus Essential Care Guidelines • 2012

DIABETIC FOOT INFECTION

• Trauma (injury), puncture wound, foreign body• Ulceration or gangrene• Swelling, drainage, odor• Systemic signs: fever, chills, malaise• Diabetes duration/control

Significant History/Findings

NON- LIMB-THREATENING INFECTION• ≤ 2 cm cellulitis• Superfi cial ulcer• Does NOT probe to bone• Limited edema, infl ammation• No bone/joint involvement• No systemic toxicity• No signifi cant ischemia

LIMB-THREATENING INFECTION• > 2 cm cellulitis• Edema, pain, lymphangitis• Drainage, odor• Probe wound for extensions• Systemic signs: hypotension,

cardiac arrhythmia (systemic toxicity)

• Ischemic changes

DIAGNOSTICS• Oral temperature• Deep wound culture from base of ulcer/wound tissue specimen if possible• Diagnostic imaging – Radiographs – MRI, WBC or bone scan• Vascular evaluation• Serologic testing – CBC with diff erential – Blood culture – ESR, CRP – Blood glucose – Renal metabolic profi le

TREATMENT• Surgical debridement of callus & ALL

necrotic tissue• Wound care - See Pathway #3• Empiric antibiotic coverage followed by

culture directed antibiotics• Close monitoring of progress• Hospital admission if infection

progresses or wound/foot deteriorates

Outpatient Management

TREATMENT• Surgical debridement off ALL necrotic

tissue• Exploration & drainage of abscess• Surgical resection of osteomyelitis• Open wound management• Empiric antibiotics modifi ed by culture

directed antibiotics• Advanced wound management Negative pressure (NPWT) see Pathway #3• Repeated wound debridement PRN• Revascularization, as needed• Foot-sparing reconstructive procedures• Defi nitive amputation, if necessary

Hospital Admission

CONSULTATIONSas Necessary

• Endocrinology• Vascular surgery• Podiatric surgery• Infectious disease• Nephrology• Cardiology• General surgery

OUTPATIENT CARE

• Antibiotics• Home wound care• Off -loading• Offi ce podiatric care

Non-Infected UlcerProceed to Pathway #3

Open Wound/Ulceror Healed Foot

Proceed to Pathway #3

InfectionResolves

© 2006 by the American College of Foot and Ankle Surgeons. All rights reserved. The full guideline, including details regarding this pathway, is available at: acfas.org/cpg.Pathway # 3 can be found at: http://www.acfas.org/uploadedFiles/Healthcare_Community/Education_and_Publications/Clinical_Practice_Guidelines/pway3--ulceration.pdf.

http://www.acfas.org/uploadedFiles/Healthcare_Community/Education_and_Publications/Clinical_Practice_Guidelines/pway3--ulceration.pdf