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Diabetic Foot Infections Without Osteomyelitis

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Approach to the Infected Diabetic Foot Diabetic patient with a suspected foot infection without osteomyelitis •  Assess neurological and vascular status of foot •  Assess for purulence or signs of inflammation •  Assess any medical comorbidities •  Assess patient's psycho-social situation •  Consider obtaining plain radiographs   (or MRI) •  Obtain appropriate specimen(s) for culture if clinically infected •  Obtain other appropriate laboratory tests •  Determine if surgical consultation is needed Cleanse, debride and probe the wound Classify the wound (if infected) Mild/Moderate •  Assess the need for inpatient treatment •  Review any available microbiological data •  Select initial antibiotic regimen (consider oral, relatively narrow-spectrum) •  Select appropriate wound care (dressings, off-loading) •  If treated as outpatient, set up return visit, consultations •  Arrange for investigation or surgery if needed •  If not hospitalized, reassess in 2-4 days, or earlier if substantially worse Severe Hospitalize the patient •  Consider obtaining blood cultures •  Attend to fluid, electrolyte, metabolic needs •  Select empiric, broad-spectrum parenteral antibiotic regimen (consider multi-drug resistant organisms) •  Arrange for urgent surgery, if needed •  Reassess clinically at least once daily •  Check inflammatory markers as needed Improving Improving Consider de-escalating antibiotic regimen (narrower spectrum, less toxic/expensive) Not improving/ worsening •  Review culture & sensitivity results •  Assess patient's adherence to treatment regimen •  Reassess wound care, need to hospitalize •  Consider further imaging •  Reculture wound •  Reassess ~ weekly until infection resolves •  If fails to resolve or relapses, consider deep abscess, osteomyelitis or resistant pathogen Not improving/ worsening Switch to appropriate oral antibiotic regimen Follow-up as outpatient •  Define extent of tissue involved (MRI, surgical exploration) •  Review culture & sensitivity results; cover all isolates •  Reassess need for surgery, including revascularization or amputation Consider broadening antibiotic spectrum

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