Guideline for Management of Adult Diabetic Foot Infections 9 9 9 9 9 9 Doses are for guidance only and apply to adults of average size with normal renal and hepatic function. Take appropriate samples, before antimicrobial therapy is commenced, if patient condition allows. • Debride wound before specimen is obtained. • Tissue biopsy or curettage, or aspiration from base of ulcer gives more sensitive and specific results than wound swabs. • For small deep ulcers consider per nasal swab. See Diabetic Foot Ulcer Policy (investigations section) Check recent culture results e.g. wound cultures & MRSA screens before prescribing empirically. Antimicrobial therapy aims to cure the infection, but not to heal the wound. Continue until infection has resolved but not necessarily until the wound has healed. Antibiotic treatment must be reviewed in light of significant cultures and targeted appropriately. Consider X-ray of both feet and lateral if osteomyelitis suspected (N.B. may be normal initially, consider repeat after 2 weeks) PEDIS grade PEDIS grade 1 PEDIS grade 2 Definition No signs of infection Mild infection: no systemic illness and ≥ 2 symptoms/signs of inflammation (i.e. tenderness, pain, erythema, warmth) and cellulitis ≤ 2cm around the wound, confined to subcutaneous tissue only Likely microorganisms Not infected Most likely monomicrobial with Staphylococcus aureus or βhaemolytic streptococci Previous antimicrobial treatment: May be polymicrobial with Gram negative organisms in addition to above Empirical antimicrobial therapy Duration General comments Review at 48 hours with microbiology results and target antibiotic therapy appropriately. High risk of MRSA if: • Known MRSA positive • Inpatient >7 days • Inpatient within last 3 months in any hospital • From nursing/ residential home Antimicrobials not indicated IV treatment is not usually required Treatment naïve: Flucloxacillin 500mg–1g PO every 6 hours Penicillin allergy: Co-trimoxazole (Septrin®) 960mg PO every 12 hours Expected duration 7 to 14 days. Failed recent antimicrobial therapy (for example a recent course of Flucloxacillin at a reasonable dose e.g. 1g QDS): Co-amoxiclav 625mg PO every 8 hours High risk MRSA positive: Doxycycline 200mg PO once daily (drink plenty of water SE :photosensitivity) Management of Diabetic Foot Ulcer: Empirical Antimicrobial Therapy for Diabetic Skin and Soft Tissue Infection in Adults (Version 3 17.09.12) Approved by the Antimicrobial Stewardship Group: September 18th 2012 Review date: September 2014 GPs Please refer all patients to Diabetes Liaison Podiatrist but start antibiotics pending appointment Page 1 of 3 PEDIS grade 3 PEDIS grade 4 Moderate infection: no systemic illness and lymphangitis OR deep tissue infection involving SC tissue, fascia, tendon, or bone OR abscess OR cellulitis >2cm around the wound NB. Ischemia plus moderate infection should be treated as severe infection Severe infection: any diabetic foot infection with systemic illness (toxicity, fever, rigors, vomiting, shock, confusion, metabolic instability) OR Ischemia plus moderate infection Most likely monomicrobial with Staphylococcus aureus and/or βhaemolytic streptococci Previous antimicrobial treatment: May be polymicrobial with Gram negative organisms in addition to above Empirically cover polymicrobial Gram positive and Gram negative infection including anaerobes 1st choice: Co-amoxiclav 625mg PO every 8 hours or Co-amoxiclav 1.2 grams IV every 8 hours Penicillin allergy: Clindamycin 450–600mg PO/IV every 6 hours If lymphangitis add Clindamycin 450-600mg IV every 6 hours (if not already on it) Failed recent antibiotic therapy: Discuss with microbiology Review at 48 hours with microbiology results and target antibiotic therapy appropriately. Consider admission or urgent referral to diabetic foot clinic. Expected duration 10 days to 3 weeks. High risk MRSA positive: Add Vancomycin IV (dose in accordance with Trust Vancomycin guideline). Send MRSA screen Once patient improving switch to oral (obtain advice from Diabetes Team or Microbiology) 1st choice: Clindamycin 600mg IV every 6 hours plus Piperacillin-tazobactam (Tazocin) 4.5 grams IV every 8 hours Penicillin allergy: Clindamycin 600mg IV every 6 hours plus Ciprofloxacin 400mg IV every 12 hours High risk MRSA positive: Add Vancomycin IV (dose in accordance with Trust Vancomycin guideline). Send MRSA screen Review at 48 hours with microbiology results and target antibiotic therapy appropriately. Admit, inform Diabetes Team of admission as soon as possible. Expected duration 10 days to 3 weeks. Once patient improving switch to oral (obtain advice from Diabetes Team or Microbiology) Management of Diabetic Foot Ulcer: Empirical Antimicrobial Therapy for Diabetic Skin and Soft Tissue Infection in Adults (Version 3 17.09.12) Approved by the Antimicrobial Stewardship Group: September 18th 2012 Review date: September 2014 Page 2 of 3 Severe sepsis: any diabetic foot infection with severe sepsis Severe Sepsis: ≥2 SIRS criteria AND evidence of infection AND organ dysfunction Empirically cover polymicrobial Gram positive and Gram negative infection including anaerobes 1st choice: Clindamycin 600mg IV every 6 hours plus Piperacillin-tazobactam (Tazocin) 4.5 grams IV every 8 hours Discuss with Microbiology within 48 hours Admit, inform Diabetes Team of admission as soon as possible. Mild penicillin allergy: Meropenem 1gram IV every 8 hours Severe penicillin allergy: Discuss with Microbiology Suspected osteomyelitis • Likely if bone visible or probes to bone • X-ray changes may be absent initially, consider repeat after 2 weeks • If OM suspected contact diabetic team • Bone biopsy for histology and culture, to establish diagnosis, define the pathogens and target antimicrobials Predominant aetiological agent is Staphylococcus aureus, but range of potential pathogens extensive If high risk MRSA: Add vancomycin IV (dose in accordance with Trust vancomycin guideline). Send MRSA screen. Suspected osteomyelitis: Clindamycin 450–600mg PO every 6 hours plus Ciprofloxacin 750mg PO every 12 hours Oral treatment not suitable: Clindamycin 450–600mg IV every 6 hours plus Ciprofloxacin 400mg IV every 12 hours 4 to 6 weeks Consider admission minimum for or urgent referral to acute OM. diabetic foot clinic. Total duration depends on organisms isolated and response to treatment. Target antimicrobials to pathogens isolated. Discuss with Microbiology Urgent review of new or acute foot problems can be arranged in the Diabetes centre on weekdays. The diabetic team and microbiologists are pleased to give advice on any part of this protocol. Dr Mollie Donohoe and Dr Roderick Warren can be paged for advice. Microbiology clinical advice is available on bleep 176 during normal working hours, or via switchboard at other times. After care: Patients not admitted but with signs of infection must be reviewed within 7 days, and earlier if concerns. • Ensure patient has FU appointment in diabetic foot clinic (T: 01392402204, Secretary Shirley Brooks or Liz Martin). • Prevent ulcer recurrence by education. Integrated patient foot care leaflets available from Shirley Brooks in Diabetic Foot clinic. • Suggest Google Devon Diabetes Exeter for more detailed advice on our dedicated Web page. • Ensure patient has appropriate footwear before leaving hospital. Management of Diabetic Foot Ulcer: Empirical Antimicrobial Therapy for Diabetic Skin and Soft Tissue Infection in Adults (Version 3 17.09.12) Approved by the Antimicrobial Stewardship Group: September 18th 2012 Review date: September 2014 Page 3 of 3