ÎInvolve a vascular surgeon early on to consider revascularization whenever ischemia complicates a DFI, but especially in any patient with a critically ischemic limb (SR-M).
ÎAlthough most qualified surgeons can perform an urgently needed debridement or drainage, in DFI cases requiring more complex or reconstructive procedures the surgeon should have experience with these problems and adequate knowledge of the anatomy of the foot (SR-L).
Wound Care
ÎDiabetic patients with a foot wound should receive appropriate wound care, which usually consists of:
• Debridement, aimed at removing debris, eschar and surrounding callus (SR-M). Note: Sharp (or surgical) methods are generally best (SR-L), but mechanical, autolytic or larval debridement techniques may be appropriate for some wounds (WR-L).
• Redistribute pressure off the wound to the entire weight-bearing surface of the foot ("off-loading"). Note: While particularly important for plantar wounds, this is also necessary to relieve pressure caused by dressings, footwear or ambulation to any surface of the wound (SR-H).
ÎTopical antimicrobials are not necessary for most clinically uninfected wounds.
ÎNo adjunctive therapy has been proven to improve resolution of infection, but for selected diabetic foot wounds that are slow to heal, consider using bioengineered skin equivalents (WR-M), growth factors (WR-M,) granulocyte colony stimulating factors (WR-M), hyperbaric oxygen therapy (SR-M), or negative pressure wound therapy (WR-L).
Table 2. Microbiology of DFIs Aerobes
Staphylococcus aureus Coagulase-negative staphylococci Beta-hemolytic Streptococcus (usually group B)
Enterococcus spp. Anaerobes
Bacteroides spp. Finegoldia magna
Peptostreptococcus spp. Peptococcus spp.
Adapted from May AK, et al. Treatment of complicated skin and soft tissue infections. Surgical Infections. 2009;10(5):488.
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Enterobacteriaceae, including E. coli, Proteus, Klebsiella and Enterobacter spp. Pseudomonas aeruginosa
• Select dressings that allow for moist wound healing, and control excess exudation. Base the choice of dressing on the size, depth, and nature of the ulcer (eg, dry, exudative, purulent) (SR-L).
