Guidelines for the Management of Diabetic Foot and Leg Ulcers · Guidelines for the Management of Diabetic Foot and Leg Ulcers Ratified by: Drugs & Therapeutics Committee Date of

Guidelines for the Management of Diabetic Foot and Leg Ulcers Ratified by: Drugs & Therapeutics Committee

Date of ratification: October 2013 Review Date: October 2016

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Guidelines for the Management of Diabetic Foot and Leg Ulcers

ID Number 2013 129

Author’s name Chantal Kong

Author’s job title Consultant Physician

Division Acute Medical Care

Department Diabetes & Endocrinology

Version number 2

Ratifying Committee Drugs & Therapeutics Committee

Ratified date October 2013

Review date October 2016

Upload date November 2013

Name of manager responsible for review Prema Singh

Job title of manager responsible for review Microbiologist Consultant

Email address for this manager [email protected]

Referenced (Yes/No) Yes

Key words (to aid searching) Diabetic, Foot, Leg Ulcers, Guidelines

User Group Clinical staff

The Trust is committed to promoting an environment that values diversity. All staff are responsible for ensuring that all patients and their carers are treated equally and fairly and not discriminated against on the grounds of race, sex, disability, religion, age, sexual orientation or any other unjustifiable reason in the application of this policy, and recognising the need to work in partnership with and seek guidance from other agencies and services to ensure that special needs are met.

mailto:[email protected]



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1. Change History 3

2. Introduction 3

3. Management of acute diabetic foot ulcers 3

4. Discharge and out-patient follow-up arrangements 3

5. Monitoring and Compliance 5

6. Management of the Acute Charcot Foot 6

Appendices

1 Antibiotic guidelines for the treatment of diabetic foot ulcers 7

2 Referral pathway for the acute diabetic foot to secondary care 8

3 Clinical Management Protocol for the Acute Diabetic Foot 9

4 Referral pathway for management of Acute Diabetic Charcot Foot 10

5 Diabetic Foot Inpatient Assessment Proforma 11



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1. Change History

Version Date Authors Reason Ratification Required

1 July 2013 Dr Chantal Kong New guideline Yes

2 October 2013 Dr Chantal Kong Revision Yes

2. Introduction

Diabetic foot ulcers are a major cause of morbidity and mortality and lead to the most common cause of non-traumatic lower extremity amputation in patients. As many as one in four diabetics will develop a foot problem at some point in their lives. Patients undergoing amputation exhibit a mortality rate of 50 – 75% within five years. Timely detection, early treatment and education of both patients and healthcare professionals in recognising clinical foot emergency is therefore essential in order to prevent foot complications /amputations and ultimately preserve life. This involves a partnership between professionals working together on a multi-disciplinary level across the health community in order to achieve maximum effectiveness. In the event that a clinical foot emergency is detected (identification of a foot ulcer/open wound/tissue breakdown or potential Charcot’s arthropathy), NICE guidelines recommend that the patient should receive a rapid assessment (within 24 hours where possible) and be referred to the Multidisciplinary Foot Care Team consisting of the Diabetes medical team, diabetes specialist nurses, podiatrists, vascular team, specialist orthopaedic team, tissue viability nurses and orthotists. Patients with active infected diabetes foot ulcers associated with moderate to severe cellulitis, faiIing to respond to oral antibiotics or with critical/near critical ischaemic limb should be admitted as an emergency for parenteral antibiotics and further urgent vascular assessment. In principle, these patients are best cared for by the Diabetes Medical team with prompt review by the vascular/specialist orthopaedic team (if osteomyelitis) unless if they have an acutely ischaemic toe(s)/ limb in which case they should be referred directly to the vascular team as well as with input by the Diabetes team. The attached flowcharts set out the recommended care pathway for these high risk patients.

3. Management

There are 8 factors which need to be managed:

Underlying loss of bone density suggesting osteomyelitis any foreign body gas in the deep tissues indicating severe infection Charcot’s joint



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2) Metabolic control Wound healing and neutrophil function is impaired by hyperglycaemia, therefore

tight glycaemic control (aim for CBG 4 - <10 mmol/l) is paramount along with optimal blood pressure control (NICE). Ensure no other systemic, metabolic or nutritional disturbance to retard healing.

Baseline blood tests required: FBC, CRP, U&Es, LFTs, recent HbA1c (within last 2 months), blood cultures if patient pyrexial or systemically unwell.

3) Vascular assessment

All patients with acutely ischaemic or neuroischaemic foot ulcers should be referred promptly to the vascular team for further assessment and early appropriate vascular investigations and intervention.

4) Wound management

All wounds should be debrided with removal of dead tissue and foreign bodies and cleaned up. Ulcers need to be dressed with sterile non-adherent dressings unless specified otherwise by the tissue viability nurses and podiatrists. Some cases may require surgical debridement.

5) Pain control

Ischaemic and neuroischaemic ulcers can be quite painful especially if infected. Please refer to West Hertfordshire Pain control guidelines. Initiate with simple analgesics. Many patients will require stronger narcotic analgesics. Consider the use of Entonox for acute pain relief, such as local non-surgical wound debridement. Refer to the pain control team for further specialist advice if unsure. Neuropathic pain may respond to Amitriptyline +/- Pregabalin +/- Duloxetine or other atypical agents and often needs specialist hospital referral.

6) Pressure relief

Bed rest facilitates wound healing. Avoidance of pressure can also be attained by e.g. crutches, wheelchairs, orthotic assessment (need to offload neuropathic ulcers by casting once open wound has healed).

7) Educational

Patients should be given full explanation of their foot problems with reinforcement of foot health care education with the intended management plan.

8) Antibiotics and Antimicrobial guidelines

All clinically infected wounds should have swabs taken and sent for microbiology, culture and sensitivity without delay. Deep swabs or deep tissue or bone sequestra should be sent after debridement. Blood cultures should also be taken if there is evidence of systemic infection clinically. There should be close consultation with the microbiology department and patients with positive results should be treated with appropriate antibiotics until there is evidence of clinical and microbiological cure.

Always take an allergy history before prescribing any drug and check on contraindications, cautions, drug interactions and adverse effects (refer to the British National Formulary www.bnf.org)

The following are guidelines for empirical treatment prior to positive culture results which should allow specific antibiotic treatment according to sensitivities. However, be aware that infections are usually more extensive than the initial appearance. Careful clinical assessment of the patient’s clinical status including severity of the infected diabetic ulcer/wound is vital to help decide on the most appropriate antibiotics along with any swab results. Advise consult with Microbiology if unsure.

Patients presenting with mildly infected foot ulcers (please see definition on next page) do not need hospital admission unless there is evidence of acute ischaemia and can be



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managed in the community. However, these patients should be promptly referred to the appropriate Diabetes Multidisciplinary Specialist Foot clinic following discharge from the acute trust.

Patients with moderate to severe infected diabetic foot ulcers especially with signs of near to critical limb ischaemia need acute hospital admission for further appropriate treatment and management including intravenous antibiotics initially.

All patients admitted with an active diabetic foot ulcer need to be followed up and should be promptly referred to the diabetes multidisciplinary foot clinic after hospital discharge.

Please fax copy of discharge summary with covering referral letter to the following:

Watford residents Maria Whitlock (Secretary) Dr Pusalkar (Consultant)

Tel Ext Fax

01923 217696 7696 01923 217952

Hemel & St Albans residents

Judith Conlon Drs Chantal Kong/ Thomas Galliford (Consultants)

Tel Ext Fax

01442 287083 2083 01442 287381

St Albans residents AS WELL AS TO:

Nancy Kemp (Temp secretary) Dr Chantal Kong (Consultant) Community Podiatry Service

Tel Ext Fax Tel Fax

01727 897858 4858 01727 897518 01582 711544 01582 760329

Patients may also be followed up in the vascular or orthopaedic clinics as requested by the appropriate surgical clinical teams.

It is crucial that all members of the multidisciplinary footcare team should communicate closely with each other on the best management care plan for each individual patient as well as on the agreed follow-up arrangements.

5. Monitoring and Compliance

In order to ensure effective continuing healing of infected diabetic foot ulcer wounds and improve patient compliance, it is important that patients are informed of their follow-up management and diabetes care plans including prescription of any antibiotics and/or other changes made to their other diabetes treatment, especially on discharge. A copy of the patient’s TTA should be sent to their GP as well as to the specialist foot team +/_ vascular/orthopaedic team as appropriate, including instructions to the GP regarding appropriate continuation of antibiotics if needed based on clinical review of the patient.

There should also be clear arrangements made for regular change of wound dressings, for eg, via the district nurses with appropriate clinical monitoring prior to being reviewed in the diabetes foot clinic.

Adherence to these guidelines will be monitored via regular audits carried out by the medical diabetes team.



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6. Management of Acute Charcot Joint

This is a serious condition which, if unrecognised and untreated, causes collapse and deformity with considerable long term morbidity and high risk for foot ulceration. Early diagnosis and treatment is essential. Charcot usually involves midfoot, but may involve any part of foot or ankle. It may be difficult to differentiate from osteomyelitis. Osteomyelitis is usually preceded by an ulcer and often affects the metatarsals and calcaneum, whereas Charcot Joint more often affects the midfoot or ankle. The differential diagnosis includes cellulitis, osteomyelitis or gout. History:

Suspect if acute onset unilateral erythema, oedema and warmth.

Pain may or may not be present.

History of mild trauma. Examination: Document the following:

Site and description of cellulitis/ulcer/deformity

Reflexes, light touch, vibration, position sense, pain and temperature, 10g monofilament

Pulses femoral, popliteal, DP and PT

Document lying and standing BP Investigations:

Us & Es, bone profile, CRP, urate, HbA1c, FBC, ESR, glucose

Foot x-ray (to include weight bearing view)

Isotope bone scan

MRI or white cell scan may be needed – Consultant decision only in consultation with radiologist.

Management:

Urgent referral to diabetes medical team.

Podiatry review same day if possible.

Urgent antibiotics if osteomyelitis is possible continue till excluded.

Optimise glycaemic control.

Radiology review. MRI scan may be required.

Review by orthopaedic foot surgeon with special interest.

Immobilisation non weight bearing cast for 1 month then total contact cast or aircast with very gradual mobilisation.

Regular measurements of CRP and Alk phosphatase at diagnosis and follow-up. Pharmacological: There is a limited evidence base for management of acute Charcot Joint and local protocols may vary.

Please seek urgent advice from Diabetes consultant. Pamidronate infusion under specialist supervision ONLY may be appropriate (up to 6 infusions at 2 to 4 weekly intervals may be necessary). This is an unlicensed indication. Follow-up:

Regular clinical assessment by foot health services, usually in consultation with diabetes physician.

Footwear assessment moulded inserts etc.

Regular podiatry 2 to 4 weeks when discharged

Orthopaedic follow-up may be indicated

Repeat isotope bone scan at 3 months and 6 months

The affected joint must be relieved of all pressure from weight bearing by an offloading orthotic appliance.

Guidelines for the Management of Diabetic Foot and Leg Ulcers

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Indication First line (Antibiotic naive) Alternative therapy, e.g. peniciliin allergy or non-

antibiotic naive

Duration/comment

Mild Infection:

Pus or 2 or more of: erythema, warmth, pain, tenderness, induration

Any cellulitis,2cm around the wound confined to skin or subcutaneous tissue, and

No evidence of systemic infection

Flucloxacillin 500 mgs qds PO Doxycycline 100mgs bd PO or Clindamycin 300 – 450 mg qds

7-14 days and review No hospital admission

required. Refer to the Diabetes MDT Specialist Foot

clinic.

Moderate infection:

Lymphatic streaking, deep tissue infection involving subcutaneous tissue, tendon, fascia, bone or abscess, or

Cellulitis >2cm, and

No evidence of systemic infection

Flucloxacillin1g qds IV(for MSSA or beta-haemolytic streptococci)

Alternatives: Co-Amoxiclav 625 mgs tds IV

Add Metronidazole 400 mg tds PO if anaerobes suspected

If pseudomonas isolated: Add Ciprofloxacin 500 mg bd PO

(PLSE CONSULT WITH MICROBIOLOGY)

If MRSA:

IV Teicoplanin Oral switch:

Rifampicin 300mg bd (with either trimethoprim 200mgs bd, doxycycline

100mg bd, or fusidic acid 500 mg tds) or Linezolid 600 mg bd

(see full Abx guidelines)

Osteomyelitis

Clindamycin 300-450mgs qds for 4-6 weeks minimum prior to review

If MRSA infection of bone, add Rifampicin 600mg bd or

Sodium Fusidate 500mg tds

Clindamycin 300 – 450 mg qds PO

If pseudomonas isolated: Add Ciprofloxacin 500 mg

bd PO

(PLEASE DISCUSS WITH MICROBIOLOGY FIRST DUE

TO RISK OF C. DIFFICILE)

14-21 days course and review

IV antibiotics may be switched to oral after

an appropriate interval

Rifampicin: Monitor patient’s LFTS weekly

Linezolid – monitor FBC weekly

Sodium Fusidate – monitor LFT’s

Severe Infection:

Any infection accompanied by severe toxicity (fever, chills, shock, vomiting, confusion, metabolic instability).

The presence of critical ischaemia of the involved limb may make the infection severe

Piperacillin/tazobactam 4.5 mgs tds IV Add gentamicin 5 mg/kg once daily if

required (Note: Initial oral therapy inappropriate)

If MRSA:

IV Teicoplanin Oral switch:

Rifampicin 300mg bd (with either trimethoprim 200mgs bd, doxycycline

100mg bd, or fusidic acid 500 mg tds) or Linezolid 600 mg bd

Osteomyelitis

Clindamycin 300-450mg qds for 4-6 weeks minimum prior to review

If MRSA infection of bone, add Rifampicin 600mg bd or

Sodium Fusidate 500mg tds

If penicillin-allergic or concerned about renal function

IV ciprofloxacin 400mg bd and metronidazole 500mg tds

Add IV Teicoplanin if MRSA suspected

If non-antibiotic naïve/not

penicillin allergic: IV piperacillin/tazobactam

4.5g tds, Add IV Teicoplanin if MRSA

suspected

Oral switch

Ciprofloxacin 500-750mg bd and metronidazole 400mg tds

14-28 days initially, then review

IV antibiotics may be switched to oral at an

appropriate interval

Rifampicin: Monitor patient’s LFT’s weekly

Linezolid – monitor

FBC weekly

Sodium Fusidate – monitor LFT’s

Limb/life threatening infected gangrene

Admit for Intravenous antibiotics and urgent surgical review

Piperacillin/tazobactam 4.5 mg tds IV and Metronidazole 500mg tds IV

Convert to oral therapy once clinically appropriate

Admit for Intravenous antibiotics and urgent surgical review

IV Teicoplanin 400 mg OD plus IV Ciprofloxacin 400mg bd plus Metronidazole 500mg tds

IV

14-28 day course and review

References:

Managing the Diabetic Foot. Edmonds M.E. and Foster A.V.M. Blackwell Sciences 2002 Diabetic Foot ulcer classification system for research purposes. Diabetes Metab Res Rev 20(Suppl 1):S90-5, Schaper (2004) A review of the revised Infectious Disease Society of America diabetic foot infection guidelines. The Diabetic Foot Journal

Vol 16 No2 2013; p56-62



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aaaaaabcabscess?/Ne

Refer urgently to Surgical Registrar on-call within 4 hrs

and to Medical SpR on-call for review

Refer to Medical Registrar

on-call (AAU L1)

Bloods (FBC, CRP, U&Es, glucose, HbAlc, blood cultures)

Plain Foot X-ray Deep wound swab If evidence of infection, start antibiotics

Refer urgently to Vascular Consultant on call for review within 24 hours

Admit under Vascular

team

Refer to Diabetes SpR (Bleep 1027) on the next

working day Admit Heronsgate Ward

(CAT1 Endo)

Bloods (FBC, CRP, U&Es, glucose, HbAlc, blood cultures)

Plain Foot X-ray Deep wound swab If evidence of infection, start antibiotics



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Clinical Management Protocol for the Acute Diabetic Foot

Examine patient’s feet and lower legs to detect risk factors:

Neuropathy (test foot sensation using 10g monofilament

or tuning fork for vibration)

Ischaemia (palpation of foot pulses)

Foot deformity

Inspection of footwear

DOCUMENT ON DIABETIC FOOT PROFORMA

Is the foot critically

ischaemic?

(Necrosis /gangrene)

Yes No

Refer urgently to Vascular

Surgical Team on call

Active foot ulceration

with moderate cellulitis

+ patient septic

Suspected acute Charcot’s

foot if hot foot +/- ulcer

Refer to:

Diabetes Medical Team

Vascular Team

TVN

Chiropodist

Baseline Assessment

Bloods (FBC, CRP, U&Es, glucose,

HbAlc, blood cultures)

Plain Foot X-ray

Deep wound swab

Start antibiotics (refer to WHHT

Diabetes Guidelines)

Offload the affected foot

Offload the affected foot

Refer to the Medical

Diabetes Team for further

assessment &

management

Once clinically stable and no

longer requiring in-patient

management, discharge to

the Diabetes MDT Foot clinic

+/- Vascular +/- Orthopaedic

clinics for follow-up



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Appendix 4

CHARCOT REFERRAL PATHWAY

Definition: This diagnosis is always difficult and often mimics cellulitis/ foot infection initially. Think

Charcot if there is no break in the skin, the erythema is not very clearly demarcated, there is a lot of

foot or ankle swelling, any new deformity, or the patient has systemic symptoms. It is also worth noting

that Charcot occurs in the neuropath if previously diagnosed. If there is ANY doubt REFER!

Yes No

Yes No

No

Yes

Diabetes and Hot foot/feet +/- swelling

and/or deformity, pain or not

Is an ulcer present?

Follow the Acute Diabetic Foot ulcer

Pathway

Is there sign of cellulitis/infection?

Is the patient systemically

unwell, and/or are there signs

of toxicity?

Advise patient to non weight-bear

Refer to the MDT Foot clinic within

24 hrs

Follow the Acute Diabetic Foot ulcer

Pathway Start on oral Flucloxacillin 500 mgs qds or Doxycycline 100 mgs bd if

penicillin-allergic. Refer to MDT Foot clinic within 24

hrs. Risk stratify



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: Document ulcer size, ulcer depth, deformity (e.g. Charcot), cellulitis, gangrene.

Right Foot Left Foot

Posterior Tibial Present Absent

Present Absent

Dorsalis Pedis Present Absent

Present Absent

Sensation Normal Impaired - see next step Level:______________________

Normal Impaired – see next step Level:________________________

DATE _ _ / _ _ / _ _ _ _ Growth: ______________________________________________________ DATE _ _ / _ _ / _ _ _ _ Growth: ______________________________________________________ DATE _ _ / _ _ / _ _ _ _ Growth: ______________________________________________________

Q: Has the patient been on antibiotics for a diabetic foot problem pre-admission? Y / N Q: If yes, please state type of antibiotic(s) and duration: ____________________________

(place patient label OR complete the following:

Name:…………………………………………………….. D.O.B:…………………………………………………….. Hospital no:………………………………………………..



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Documents

Guidelines for the Management of Diabetic Foot and Leg Ulcers · Guidelines for the Management of Diabetic Foot and Leg Ulcers Ratified by: Drugs & Therapeutics Committee Date of