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Diabetic Foot Infections Without Osteomyelitis

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Treatment Selecting and Modifying an Antibiotic Regimen ÎClinically uninfected wounds should NOT be treated with antibiotics (SR-L). Î ÎÎPrescribe antibiotics for all infected wounds, but note that this is often insufficient unless combined with appropriate wound care (SR-L). ÎÎClinicians should select an empirical antibiotic regimen based on the severity of the infection and the likely etiologic agent(s) (SR-L). •  For mild to moderate infections in patients who have not recently received antibiotic treatment, target only aerobic Gram-positive cocci (GPC) (WR-L). ▶▶ Initial empiric therapy should be based on the severity of the infection and on any available microbiological data, such as recent culture results and the local prevalence of pathogens, especially antibiotic-resistant strains. •  For most severe infections, start broad-spectrum empiric antibiotics, pending culture results and antibiotic susceptibility data (SR-L). •  Empiric therapy directed at Pseudomonas aeruginosa is usually unnecessary except for patients with risk factors for true infection with this organism (SR-L). •  Consider providing empiric therapy directed against methicillin-resistant Staphylococcus aureus (MRSA) (WR-L): ▶▶ in a patient with a prior history of MRSA infection ▶▶ when the local prevalence of MRSA colonization or infection is high ▶▶ if the infection is clinically severe ÎÎBase definitive therapy on both the results of an appropriately obtained culture and sensitivity testing of a wound specimen and the patient's clinical response to the empiric regimen (SR-L). ÎÎBase the route of therapy largely on infection severity — parenteral therapy for all severe, and some moderate, DFIs, at least initially (WR-L), with a switch to oral agents when the patient is systemically well and culture results are available. •  Clinicians can probably use highly bioavailable oral antibiotics alone in most mild, and   in many moderate, infections and topical therapy for selected mild superficial infections (SR-M). ÎÎContinue antibiotic therapy until, but not beyond, resolution of findings of infection, but not through complete healing of the wound (WR-L). •  An initial antibiotic course for a soft tissue infection is about 1-2 weeks for mild infections and 2-3 weeks for moderate to severe infections (WR-L). Abbreviations ABI, ankle-brachial index; C&S, culture and sensitivity; CPK, creatine phosphokinase; DFI, diabetic foot infection; DFO, diabetic foot osteomyelitis; ESBL, extended-spectrum β-lactamase; FDA, US Food and Drug Administration; GPC, Gram-positive cocci; GRADE, Grading of Recommendations Assessment, Development and Evaluation; IDSA, Infectious Diseases Society of America; IV, intravenous; IWGDF, International Working Group on the Diabetic Foot; MIC, minimum inhibitory concentration; MRI, magnetic resonance imaging; MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-sensitive S. aureus; PEDIS, perfusion, extent, depth, infection, sensation (IWGDF research scoring); PO, oral; prn, as needed; PTB, probe to bone; qid, four times a day; RCT, randomized controlled trial; SIRS, systemic inflammatory response syndrome; tid, three times a day

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