13920850-ref for diabetic foot

8/10/2019 13920850-Ref for Diabetic Foot

1/14

S104 CID 2004:39 (Suppl 2) Lipsky

S U P P L E M E N T A R T I C L E

Medical Treatment of Diabetic Foot Infections

Benjamin A. Lipsky

Department of Medicine, University of Washington School of Medicine, and General Internal Medicine Clinic, VA Puget Sound Health Care

System, Seattle, Washington

Diabetic foot infections frequently cause morbidity, hospitalization, and amputations. Gram-positive cocci,

especially staphylococci and also streptococci, are the predominant pathogens. Chronic or previously treated

wounds often yield several microbes on culture, including gram-negative bacilli and anaerobes. Optimal culture

specimens are wound tissue taken after debridement. Infection of a wound is defined clinically by the presence

of purulent discharge or inflammation; systemic signs and symptoms are often lacking. Only infected wounds

require antibiotic therapy, and the agents, route, and duration are predicated on the severity of infection.

Mild to moderate infections can usually be treated in the outpatient setting with oral agents; severe infectionsrequire hospitalization and parenteral therapy. Empirical therapy must cover gram-positive cocci and should

be broad spectrum for severe infections. Definitive therapy depends on culture results and the clinical response.

Bone infection is particularly difficult to treat and often requires surgery. Several adjuvant agents may be

beneficial in some cases.

Foot infections in diabetic patients usually begin in a

skin ulceration [1]. Although most infections remain

superficial, 25% will spread contiguously from the

skin to deeper subcutaneous tissues and/or bone. Up

to half of those who have a foot infection will have

another within a few years. About 10%30% of diabetic

patients with a foot ulcer will eventually progress to anamputation, which may be minor (i.e., foot sparing)

or major. Conversely, an infected foot ulcer precedes

60% of amputations [24], making infection perhaps

the most important proximate cause of this tragic

outcome.

PATHOPHYSIOLOGY

Among the factors predisposing diabetic patients to

foot infections are poorly understood immunologic dis-

turbances, such as impaired polymorphonuclear leu-

kocyte migration, phagocytosis, intracellular killing,

and chemotaxis [5]. The prevalence of these defects

appears to be correlated, at least in part, with the ad-

Reprints or correspondence: Dr. Benjamin A. Lipsky, VA Puget Sound Health

Care System, S-111-GIMC, 1660 South Columbian Way, Seattle, WA 98108-1597

([email protected]).

Clinical Infectious Diseases 2004;39:S10414

2004 by the Infectious Diseases Society of America. All rights reserved.

1058-4838/2004/3903S2-0007$15.00

equacy of glycemic control [6]. Ketosis, in particular,

impairs leukocyte function [7]. Some evidence suggests

that in diabetic patients, cellular immune responses,

monocyte function, and complement function are re-

duced as well. Their higher rates of carriage ofStaph-

ylococcus aureusin the anterior nares and skin [8], and

several types of skin and nail disorders, may increasethe risk of skin and soft-tissue infections in diabetic

patients. Accelerated atherosclerosis, especially of the

arteries between the knee and ankle, increases the like-

lihood of ischemia at the infection site. The anatomy

of the foot, with its various compartments, tendon

sheaths, and neurovascular bundles, may lead to prox-

imal spread of infection and favors ischemic necrosis

of the confined tissues [7, 9].

MICROBIOLOGICAL CONSIDERATIONS

Selecting appropriate antimicrobial therapy for diabeticfoot infections requires knowledge of the likely etiologic

agents. Various skin disorders and environmental ex-

posures, as well as recent antibiotic therapy, can alter

the colonizing flora of skin wounds [10, 11]. Although

acute infections in previously untreated patients are

usually caused by aerobic gram-positive cocci (often as

monomicrobial infections), chronic wounds develop

complex flora.


2/14

Diabetic Foot Treatment CID 2004:39 (Suppl 2) S105

Determining the microbial etiology of an infected wound

will usually assist in subsequent management. The etiologic

agent(s) can be identified by culture only if specimens are col-

lected and processed properly. Antibiotic-susceptibility results

generally help tailor (and in many cases constrain) antibiotic

regimens. Deep tissue specimens, obtained aseptically at sur-

gery, contain the true pathogens more often than do samples

obtained from superficial lesions. A curettage, or tissue scrapingwith a scalpel, from the base of a debrided ulcer provides more

accurate results than does a wound swab [1013]. Therapy

directed against organisms isolated from culture of a swab sam-

ple is likely to be unnecessarily broad and may occasionally

miss key pathogens. If multiple organisms are isolated, the

clinician must decide which require specifically targeted ther-

apy. Less virulent bacteria, such as enterococci, coagulase-neg-

ative staphylococci, or corynebacteria, may represent pathogens

but can sometimes be ignored. Organisms isolated from reliable

specimens that are the sole or predominant pathogens both on

the Gram-stained smear and in the culture are likely to be true

pathogens.S. aureus is the most important pathogen in diabetic foot

infections; even when it is not the only isolate, it is usually a

component of a mixed infection [8]. Serious infections in hos-

pitalized patients are often caused by 35 bacterial species, in-

cluding both aerobes and anaerobes [11, 13]. Gram-negative

bacilli, mainly of the family Enterobacteriaceae, are found in

many patients with chronic or previously treated infections.

Pseudomonasspecies are often isolated from wounds that have

been soaked or treated with wet dressings or hydrotherapy.

Enterococci are commonly obtained by culture from patients

who have previously received a cephalosporin. Obligate anaer-

obic species are most frequent in wounds with ischemic necrosis

or that involve deep tissues. Anaerobes are rarely the sole path-

ogen; most often they constitute a mixed infection with aerobes

[14]. Antibiotic-resistant organisms, especially methicillin-re-

sistantS. aureus,are frequently isolated from patients who have

previously received antibiotic therapy; they are often (but not

always) acquired during previous hospitalizations or at long-

term care facilities [15]. Definitive antibiotic therapy should

take into consideration the results of Gram-staining a smear

from a wound [16] and the culture and susceptibility tests.

Because some patients with diabetic foot infections are not

cured by antibiotics that cover the isolated bacteria, more sen-

sitive methods, such as rDNA sequencing, may detect missed

organisms [17].

DIAGNOSIS AND CLINICAL PRESENTATION

Diagnosing infection. Because all skin wounds contain mi-

croorganisms, infection must be diagnosed clinically, that is,

by the presence of systemic signs (e.g., fever, chills, and leu-

kocytosis), purulent secretions (pus), or 2 local classical signs

or symptoms of inflammation (warmth, redness, pain or ten-

derness, and induration). In chronic wounds, additional signs

suggesting infection may include delayed healing, abnormal

coloration, friability, or foul odor. Infection should be suspected

at the first appearance of a foot problem and at evidence of a

systemic infection or of a metabolic disorder. Peripheral neu-

ropathy or ischemia can either mask or mimic inflammation.

Occasionally, inflammatory signs may be caused by other non-infectious disorders; on the other hand, some uninflamed ulcers

may be associated with underlying osteomyelitis [18]. Signs of

systemic toxicity are surprisingly uncommon in diabetic foot

infections [19], even those that are limb threatening. Proper

evaluation of a diabetic foot infection requires a methodical

approach [20]. Whenever infection is considered, this diagnosis

should be pursued aggressively; these infections can worsen

quickly, sometimes in a few hours.

Clinical presentation. Almost two-thirds of patients with

a diabetic foot infection have evidence of peripheral vascular

disease, and 80% have lost protective sensation [1]. Infections

most often involve the forefoot, especially the toes and meta-

tarsal heads, particularly on the plantar surface. About half of

the patients in reported series have received antibiotic therapy

for the foot lesion by the time they present, and up to one-

third have had a foot lesion for 11 month. Many patients do

not report pain, and more than half, including those with se-

rious infections, do not have a fever, elevated WBC count, or

elevated erythrocyte-sedimentation rate [1921].

Assessing severity. Several classification systems have been

proposed for diabetic foot lesions, none of which is universally

accepted. Keys to classifying a foot wound are assessing the

depth of the lesion (by visually inspecting the tissues involvedand by estimating the depth in millimeters) and checking for

ischemia (absent pulses or diminished blood pressure in the

foot) and for infection [22]. Whereas mild infections are rel-

atively easily treated, moderately severe infections may be limb

threatening, and severe infections may be life threatening. As-

sessing the severity of infection is essential to selecting an an-

tibiotic regimen, influences the route of drug administration,

and helps determine the need for hospitalization. Severity of

infection also helps assess the potential necessity and timing of

surgery and the likelihood of amputation [22]. The wound

should be carefully explored to seek foreign or necrotic material,

and it should be probed with a sterile metal instrument. Deepspace infections often have deceptively few superficial signs.

The clinician should suspect spread of infection when there is

inflammation distant from the skin wound, or when suppu-

rative lesions persist despite apparently appropriate therapy

[23]. A knowledgeable surgeon should evaluate any patient with

systemic toxicity for an occult deep space infection [9]. Clinical

features that help define the severity of infection are shown in

table 1.


3/14


Table 1. Clinical characteristics that help define the severity of an infection.

Feature Mild infection Severe infection

Presentation Slowly progressive Acute or rapidly progressive

Ulceration Involves only skin Penetrates to subcutaneous tissues

Tissues involved Epidermis, dermis Fascia, muscle, joint, bone

Cellulitis Minimal (!2 cm around ulcer rim) Extensive, or distant from ulceration

Local signs Limited inflammation Severe inflammation, crepitus, bullae, necrosis or gangrene

Systemic signs None or minimal Fever, chills, hypotension, confusion, volume depletion,

leukocytosis

Metabolic control Mildly abnormal (hyperglycemia) Severe hyperglycemia, acidosis, azotemia, electrolyte

abnormalities

Foot vasculature Minimally impaired (normal/reduced pulses) Absent pulses, reduced ankle or toe blood pressure

Complicating features None or minimal (callus, ulcer) Eschar, foreign body, puncture wound, abscess, marked edema,

implanted metalwork or other prostheses

One of the first, and the most financially dominant, decisions

when faced with a diabetic foot infection is to determine

whether a patient should be hospitalized [10]. Patients with a

serious infection should be admitted for possible surgical in-

terventions, fluid resuscitation, and control of metabolic de-

rangements. Hospitalization should also be considered if the

patient is unable or unwilling to perform proper wound care,

cannot or will not be able to off-load the affected area, is

unlikely to comply with antibiotic therapy, requires parenteral

antibiotic therapy, or needs close monitoring of response to

treatment. In the absence of these factors, most patients can

be treated cautiously on an outpatient basis, with frequent (i.e.,

every few days, initially) [10] reevaluation. Wound care (de-

bridement, dressing changes, and pressure off-loading) and gly-

cemic control should be optimized; antibiotics will not over-

come inattention to these fundamentals.

BONE INFECTION

Diabetic patients can have destructive bone changes caused by

peripheral neuropathy (i.e., neuroarthropathy, osteoarthropa-

thy, or Charcot disease) [24] that may be difficult to distinguish

from those caused by bone infection [25]. The latter generally

results from contiguous spread of a deep soft-tissue infection

through the bone cortex (osteitis) to the marrow (osteomye-

litis). About 50%60% of serious foot infections are compli-

cated by osteomyelitis. The proportion of apparently mild to

moderate infections that have bone involvement is probably in

the range of 10%20%. There are no validated or well-accepted

guidelines for diagnosing or treating diabetic foot osteomyelitis.

Among the important considerations are the anatomic site of

infection (i.e., forefoot, midfoot, or hindfoot), the vascular sup-

ply to the area, the extent of soft-tissue and bone destruction,

the degree of systemic illness, and the patients preferences.

Foot ulcers that are long standing (14 weeks), large (12 cm),

and deep (13 mm) or are associated with a substantially ele-

vated erythrocyte-sedimentation rate (170 mm/h) should be

evaluated for possible osteomyelitis [18, 25]. Clinical evaluation

should include gently probing to bone [26]; in one study of

patients with limb-threatening infections, the positive predic-

tive value of this test was almost 90%. Plain radiographs should

be obtained for most patients with a diabetic foot infection.

Radiographic changes in infected bone generally take at least

2 weeks to be evident; when the presence of bone infection is

in doubt but the patient is stable, repeating a plain radiograph

in a couple of weeks may be more cost effective than under-

taking more sophisticated imaging procedures.

If clinical and radiographic findings are not diagnostically

adequate, various types of scans may be useful [25, 27]. Bone

(e.g., Tc-99) scans are sensitive (85%) but too nonspecific

(45%). Leukocyte (e.g., In-111 or 99mTc-HMPAO) scans are

similarly sensitive but more specific (75%) and may also be

useful for demonstrating that the infection has been arrested.Radiolabeled antigranulocyte fragments (e.g., sulesomab) also

may increase the accuracy of scanning [28]. Among the di-

agnostic techniques for osteomyelitis that show promise are

high-resolution ultrasound [29] and positron-emission to-

mography. However, MRI is usually the diagnostic procedure

of choice, with a sensitivity of190% and a specificity of180%

[30, 31]. The diagnostic test characteristics of all these proce-

dures exhibit great variability across studies. Their interpreta-

tion is highly influenced by the pretest probability of disease

[27], and they are most helpful when the pretest probability is

intermediate.

Definitive diagnosis of osteomyelitis and identification of theetiologic agent(s) generally require obtaining a specimen of

bone. This should be processed for both culture and histology.

Specimens may be obtained by open (e.g., at the time of de-

bridement [32] or surgery) or percutaneous (usually image

guided) biopsy. To avoid contamination, specimens must be

obtained without traversal of an open wound. Patients who are

receiving antibiotic therapy may have a negative culture result,

but histopathologic findings (leukocytes and necrosis) can help


4/14


Table 2. Factors that may influence anti-biotic treatment of diabetic foot infections(specific agents, route of administration, andduration of therapy).

Factor

Clinical severity of the infection

Etiologic agent(s) (known or presumed)

Recent antibiotic therapy

Bone infection

Vascular status at infected site

Allergies to antibiotics

Renal or hepatic insufficiency

Gastrointestinal absorption impairment

Drug toxicity (interactions) potential

Local antibiotic susceptibility data

Formulary and cost considerations

Patient preferences

Published efficacy data

diagnose infection. These procedures are easy to perform and

are safe in experienced hands [33], although somewhat expen-

sive. Bone biopsy is appropriate if the diagnosis of osteomyelitis

remains in doubt after other diagnostic tests are performed, or

if the etiologic agent(s) cannot be predicted because of previous

antibiotic therapy or confusing culture results. Microbiological

studies of diabetic foot osteomyelitis have revealed that the

majority of cases are polymicrobial; S. aureusis the most com-mon etiologic agent (isolated in 40% of infections), but Staph-

ylococcus epidermidis ( 25%), streptococci (30%), and En-

terobacteriaceae (40%) are also common isolates [25].

TREATMENT

Almost all infected foot lesions (other than primary cellulitis)

require some surgical intervention, which is covered elsewhere

in this supplement issue of Clinical Infectious Diseases. Basic

factors that should be considered in choosing an antibiotic

regimen are outlined in table 2.

Antibiotic Therapy

Indications for therapy. Available data suggest that 40%

60% of diabetic patients who are treated for a foot ulcer receive

antibiotic therapy [34]. The role of antibiotics for clinically

uninfected wounds is a controversial issue. The concept that

reducing the bioburden of chronic skin wounds with anti-

microbial therapy may improve healing is plausible, and some

experimental animal data and studies with burn wounds and

skin grafts support this theory [35]. Although some practi-

tioners believe that any foot ulcer requires administration of

antibiotics, either for therapy or for prophylaxis, available stud-

ies do not generally support this view [36]. In most of thepublished clinical trials, antibiotic therapy did not improve the

outcome of uninfected lesions [37, 38]. One abstract [39] re-

ported a randomized trial in which 64 diabetic patients who

received antibiotic therapy for clinically uninfected foot ulcers

had a significantly increased likelihood of healing and had a

reduced incidence of clinical infection, hospitalization, and am-

putation. This provocative work will need to be published and

replicated before this strategy is considered. Antibiotic therapy

is associated with frequent adverse effects, substantial financial

costs, and the development of resistance and, thus, should cur-

rently be used only to treat established infection.

Route of therapy. The key to successful antibiotic therapy

is achieving a therapeutic drug concentration at the site of

infection. This typically requires first achieving adequate serum

levels. Intravenous antibiotics are indicated for patients who

are systemically ill, have a severe infection, are unable to tolerate

oral agents, or are known or suspected to have pathogens that

are not susceptible to available oral agents. After the patients

condition is stabilized and the infection is clearly responding,

most patients can have their treatment switched to oral therapy.

Patients who require prolonged intravenous therapy, such asfor osteomyelitis or infections resistant to oral agents, can often

be treated on an outpatient basis when a program to provide

this service is available.

Oral antibiotic therapy is less expensive, more convenient,

and probably associated with fewer complications than is par-

enteral therapy. Delivery of the first dose of antibiotic to the

infected site is slower with oral therapy, but this is an issue

only for critically ill patients. The main concern is the bioa-

vailability of orally administered agents. Gastrointestinal ab-

sorption of oral antibiotics is variable, but some agents, such

as clindamycin and the fluoroquinolones, have been shown to

be well absorbed with oral dosing [40]. Fluoroquinolones, inparticular, achieve high tissue concentrations at the site of di-

abetic foot infections (including in inflamed tissues [41]) when

administered orally, even for patients with gastroparesis [42].

Several newly licensed agents cover an expanded spectrum of

organisms; drugs with greater activity against antibiotic-resis-

tant gram-positive cocci, such as linezolid, daptomycin, and

newer fluoroquinolones, are especially appealing.

When peripheral vascular disease is present, therapeutic an-

tibiotic concentrations are often not achieved in the infected

tissues, even when serum levels are adequate. Recently, a study

of patients with leg ischemia (many of whom were diabetic)

who received intravenous ceftazidime before limb surgery

showed that delivery of the antibiotic to the skin was better

than to the muscles or bone, but the key hindrance to pene-

tration was the presence of ischemia, not diabetes [43]. Prob-

lems with arterial insufficiency have led to experimentation

with novel methods of antibiotic delivery. Retrograde venous

perfusion consists of injecting antibiotic solutions under pres-

sure into a foot vein while a sphygmomanometer is inflated

on the thigh. High local antibiotic concentrations have been


5/14


observed in anecdotal and uncontrolled reports [44]. Some

clinicans have also tried lower-extremity intra-arterial (e.g.,

femoral) antibiotic injections [45]. Still others have advocated

primary closure of carefully debrided wounds, with closed-

catheter instillation of antibiotics [46]. New vascular catheters

are being developed that may allow threading through leg veins

to the site of a foot infection; this might allow high local con-

centrations of antibiotics with minimal systemic exposure.Several other novel routes of therapy have been explored. Su-

perficial wounds allow consideration of direct applications of

antimicrobial agents. For infections that have undergone surgical

tissue resection, antibiotic-loaded beads (usually containing an

aminoglycoside) or cement have been used to supply high local

antibiotic concentrations and, in some instances, to fill the dead

space [47, 48]. Another approach is to implant an antibiotic-

impregnated bovine-collagen sponge into an infected lesion [49].

Collagen is well tolerated, biodegradable, and an excellent drug

carrier. Limited anecdotal data have shown efficacy of antibiotic-

impregnated collagen (combined, at least initially, with oral an-

tibiotics) in treating diabetic foot infections (including osteo-

myelitis) [49]. For mildly infected foot ulcers, an additional

option is topical antimicrobial therapy. This has several theo-

retical advantages, including high local drug levels, avoidance of

systemic antibiotic adverse effects, the possibility of using novel

agents not available for systemic use, and the focusing of the

attention of both the patient and the physician to the foot and

to the need for good wound care. Antiseptics are generally too

harsh on the host tissues, but topical antibiotics may have a role.

Silver sulfadiazine, neomycin, polymixin B, gentamicin, metron-

idazole, and mupirocin have each been used for soft-tissue in-

fections in other sites, but there are no published data on theirefficacy in treating diabetic foot infections. An investigational

peptide antibiotic, pexiganin acetate 1% cream (MSI-78), has

been shown, in 2 large multicenter phase III randomized trials,

to be safe and nearly as effective (85%90% clinical response

rate) as oral ofloxacin for mildly infected diabetic foot ulcers

[50]. These results are encouraging and suggest that other topical

antimicrobial agents should be explored. None of these therapies

has been adequately evaluated, and they cannot currently be

routinely recommended.

Choice of antibiotic agents. Most patients will begin an-

tibiotic therapy with an empirical regimen. This should aim to

cover the most common pathogens, with some modificationaccording to severity of infection. Relatively narrow-spectrum

agents may be used for minor infections, because there is likely

to be time to alter treatment if there is no clinical response.

Regimens for severe infection should be broader spectrum and

most often administered intravenously, because the stakes are

higher. Empirical regimens must also take into consideration

such factors as patient allergies, renal dysfunction, recent an-

tibiotic therapy, and known local antibiotic susceptibility pat-

terns. Obtaining a Gram-stained smear of a wound specimen

may help direct empirical antibiotic therapy. Culture results

show organisms consistent with the Gram staining in 95% of

cases [16]. The overall sensitivity of the smear in identifying

organisms that grow on culture is 70%, but the sensitivity is

about twice as good for gram-positive cocci as for gram-

negative bacilli. This is unfortunate, because empirical antibi-

otic therapy for gram-positive organisms is usually required,and the important question is whether to broaden the spectrum

to cover gram-negative species.

An antibiotic regimen should almost always include an agent

active against staphylococci and streptococci. Previously treated

or severe cases may need extended coverage that also includes

commonly isolated gram-negative bacilli and Enterococcusspe-

cies. Necrotic, gangrenous, or foul-smelling wounds usually

require anti-anaerobic therapy. When culture and susceptibility

results are available, more specific therapy should be chosen.

Narrower-spectrum agents are preferred, but it is important to

assess how the infection has been responding to the empirical

regimen. If the lesion is healing and the patient is tolerating

therapy, there may be no reason to change, even if some or all

of the isolated organisms are resistant to the agents prescribed.

On the other hand, if the infection is not responding, treatment

should cover all the isolated organisms. If the infection is wors-

ening despite susceptibility of the isolated bacteria to the chosen

regimen, the need for surgical intervention or the possibility

that fastidious organisms were missed on culture should be

reconsidered.

Although theoretical and pharmacokinetic considerations are

important, the proof of an antibiotics efficacy is the clinical

trial. Agents that have demonstrated clinical effectiveness,aloneor in combination, in prospective studies including entirely or

mostly patients with diabetic foot infections, include the fol-

lowing [51]: cephalosporins (cephalexin orally; cefoxitin and

ceftizoxime parenterally) [10, 5256]; penicillin/b-lactamasein-

hibitor congeners (amoxicillin/clavulanate orally; ampicillin/

sulbactam, piperacillin/tazobactam, and ticarcillin/clavulanate

parenterally) [5761]; fluoroquinolones (ciprofloxacin, oflox-

acin, levofloxacin, and trovafloxacin orally and parenterally)

[57, 6165]; and the miscellaneous agents clindamycin (orally

and parenterally) [10, 63, 65], imipenem/cilastatin (parenter-

ally) [58, 66], amdinocillin (parenterally) [55], linezolid (orally

and parenterally) [67], and pexiganan acetate (topically) [50].A few randomized controlled studies have compared differ-

ent oral and parenteral regimens; all had power only to dem-

onstrate equivalence, and they did. Overall, the clinical and

microbiological response rates have been similar in trials with

the various antibiotics, and no agent or combination has

emerged as most effective [68]. Currently, several trials testing

different dosing regimens of established agents (e.g., pipera-

cillin/tazobactam) or newly approved agents (e.g., ertapenem


6/14


Table 3. Suggested antibiotic regimens for treatment of diabetic foot infections.

Severity of infection (administration) Recommendeda

Alternativeb

Mi ld/moderate ( oral for entir e cour se) C ephalexin (500 mg. q.i .d.) Levofloxacin (750 mg q.d.) clindamycin (300 mg t.i.d.)c

Amoxicillin/clavulanate (875/125 mg b.i.d.) Trimethoprim-sulfamethoxazole (2 double-strength b.i.d.)

Clindamycin (300 mg t.i.d.)

Moderate/severe (iv until stable, then

switch to oral equivalent)

Ampicillin/sulbactamd,e

(3.0 g q. i.d.) Pip er ac il lin/ta zob act am (3.3 g q. i.d.)d

Clindamycin (450 mg q.i.d.) + ciprofloxacin

(750 mg b.i.d.)

Clindamycin (600 t.i.d.) + ceftazidime (2 g t.i.d.)b

Life-threatening (prolonged iv) Imipenem/cilastin (500 mg q.i.d.)d,e

Vancomycin (15 mg/kg b.i.d.) + aztreonam (2.0 g t.i.d.) +

metronidazole (7.5 mg/kg q.i.d.)

Clindamycin (900 mg t.i.d.) + tobramycind

(5.1

mg/kg./d) + ampicillin (50 mg/kg. q.i.d.)

NOTE. Regimen should be given at usual recommended doses for serious infections; modify for conditions such as azotemia.a

On the basis of theoretical considerations and available clinical trials.b

Prescribed in special circumstances, for example, patient allergies, recent treatment with recommended agent, and cost considerations.c, with or without.

dA similar agent of the same class or generation may be substituted.

eA high local prevalence of methicillin resistance among staphylococci may require use of vancomycin, linezolid, or other appropriate agents active against

these organisms.

and daptomycin) are under way. New antibiotics are intro-

duced, and some older ones are made obsolete by the emer-

gence of resistance or newly appreciated toxicities. Understand-

ing the principles of antibiotic therapy is therefore more

important than knowing the specific agents that are currently

in vogue [51, 68]. Whereas the US Food and Drug Adminis-

tration has approved all the above agents (and others) for treat-

ing complicated skin and soft-tissue infections, the only drugsspecifically approved for diabetic foot infections are trovaflox-

acin (which is now rarely used) and linezolid.

Cost of therapy is also an important factor in selecting a

regimen. A large prospective study of deep foot infections in

Sweden found that antibiotics accounted for only 4% of the

total costs of treatment; costs of topical wound treatments were

considerably higher [69]. Variables that explained 95% of the

total treatment costs were the time intervals between diagnosis,

the final required procedure, and wound healing and the num-

ber of surgical procedures performed [69]. One American study

demonstrated that therapy with ampicillin/sulbactam was sig-

nificantly less expensive than therapy with imipenem/cilastatin,for limb-threatening diabetic foot infections, primarily because

of the lower drug and hospitalization costs and the less severe

side effects associated with the former treatment [70]. More

comparative trials and economic analyses are needed.Published

suggestions on specific antibiotic regimens for diabetic foot

infections vary but are more alike than different. My empirical

antibiotic recommendations, by type of infection, are given in

table 3.

Duration of therapy. The optimal duration of antibiotic

therapy for diabetic foot infections has not been studied. For

mild to moderate infections, a 12-week course has been found

to be effective [10], whereas for more serious infections, treat-

ment has usually been given for 2 weeks, sometimes longer.

Adequate debridement, resection, or amputation of infected

tissue can shorten the necessary duration of therapy. For those

few patients with diabetic foot infection who develop bacter-

emia, therapy for at least 2 weeks seems prudent. Antibiotic

therapy can generally be discontinued when all signs and symp-

toms of infection have resolved, even if the wound has not

completely healed. Healing any skin ulcer is a separate, albeit

important, issue in treating diabetic foot infections. In someinstances of extensive infection, large areas of gangrene or ne-

crotic tissue, or poor vascular supply, more prolonged therapy

may be needed. Some patients who cannot, or will not, undergo

surgical resection or who have surgical hardware at the site of

infection may require prolonged or intermittent suppressive

antibiotic therapy.

Treatment of Osteomyelitis

Antibiotic choices should optimally be based on results of bone

culture, when possible, especially because of the need for long-

duration therapy [25]. Soft-tissue or sinus-tract cultures do notaccurately predict bone pathogens. If empirical therapy is nec-

essary, it should always coverS. aureus; broader coverage should

be considered if the history or results of soft-tissue culture

suggest the necessity. Antibiotics may not penetrate well to

infected bone, and the number and function of leukocytes in

this environment are suboptimal. Thus, treatment of osteo-

myelitis should usually be parenteral (at least initially) and

prolonged (at least 6 weeks). Cure of chronic osteomyelitis has

generally been thought to require removing the infected bone

by debridement or resection. Several recent retrospective series

have shown, as discussed elsewhere in this supplement issue of

Clinical Infectious Diseases, that diabetic foot osteomyelitis can

be arrested with antibiotic therapy alone in about two-thirds


7/14


8/14


Figure 2. Approach to selecting antibiotic therapy for a foot infection in a patient with diabetes. GNR, gram-negative rods; GPC, gram-positive

cocci; MRSA, methicillin-resistant Staphylococcus aureus.

however, significantly lower at 9 weeks among the G-CSFtreated

patients. A Korean study found that neutrophil superoxide pro-

duction in 12 diabetic patients with foot infections was signifi-

cantly lower than in 12 healthy nondiabetic controls [75]. G-

CSF (lenograstim) dramatically enhanced in vitro neutrophil

function in the diabetic patients, compared with the controls.

Larger trials are needed to define whether, and for whom, these

promising compounds can be recommended.

Hyperbaric oxygen. This treatment is designed to increase

oxygen delivery to ischemic tissue, which may help fight in-

fection and improve wound healing in the high-risk foot. For

years, anecdotal and uncontrolled reports have suggested ben-

efit in diabetic foot infections. Recently, prospective studies,

including a double-blind randomized trial, have shown im-

proved wound healing and a reduced rate of amputation with

hyperbaric oxygen therapy [76, 77]. Of 8 published studies of

hyperbaric oxygen therapy for diabetic foot disorders, 5 in-

cluded a control group. Inadequate evaluation of comorbid

conditions, small sample size, and poor documentation of

wound size and severity hamper interpretation of these reports

[77, 78]. Potential candidates for hyperbaric oxygen include

those with deeply infected lesions who have not responded to

standard therapy and for whom amputation is a realistic pos-

sibility [79]. If hyperbaric oxygen is used, it should usually be

continually assessed for whether it is of value. Typically, the

treatment can be expected to be beneficial if the transcutaneous

oxygen pressure near the ulcer is !40 mm Hg before therapy

and rises to 1200 mm Hg after therapy [79]. Hyperbaric oxygen

is an expensive and limited resource that should remain re-

served for severe cases, even if it is further confirmed as

effective.

Revascularization. Improving blood flow may also be cru-

cial to controlling infection in an ischemic foot. Although initial

debridement must be done even in the face of poor arterial


9/14


circulation, revascularization is generally postponed until sepsis

is controlled [80]. However, waiting for more than a few days

in hopes of sterilizing the wound is inappropriate and may

result in further tissue loss [81, 82]. An aggressive approach to

revascularization in an ischemic infected foot can result in 3-

year limb-salvage rates of up to 98% [83].

Larval (maggot) therapy. Biosurgery with fly larvae

(maggots) has been used for many years, but it is enjoying arecent revival [32, 84]. Uncontrolled trials with sterilized larvae

suggest they are useful for treating infection (of soft tissue and

bone), debriding wounds, and controlling wound odor. Larvae

are relatively inexpensive and are available from commercial

laboratories. This treatment is currently used with apparent

benefit at several centers, but it requires proper staff training

and acceptance by the patient. Controlled trials are needed to

define which types of infections may benefit from this therapy.

Edema control. Edema caused by increased hydrostatic

pressure frequently complicates diabetic foot infections. By im-

pairing antegrade nutrient (and perhaps leukocyte) delivery, as

well as restricting removal of metabolites and cell debris, edemacan hinder wound healing. A recent randomized trial found

that aggressively controlling edema with a pneumatic pedal

compression device increased wound healing in diabetic pa-

tients with a foot infection. Simpler interventions, such as leg

elevation and compression stockings, are likely to be beneficial

as well [85].

An algorithmic overview of the approach to treating a dia-

betic patient with a foot lesion is shown in figure 1. The ap-

proach to selecting an antibiotic regimen for a diabetic foot

infection is outlined in figure 2.

OUTCOME OF TREATMENT

A good clinical response for mild to moderate infections can

be expected in 80%90% of appropriately treated patients [10,

50] and, for deeper or more extensive infections, in 50%60%

[64, 86]. When infection involves deep soft-tissue structures or

bone, more thorough debridement is usually needed. Bone re-

sections or partial amputations are required in about two-thirds

of this patient group. Most of these amputations can be foot

sparing, and long-term control of infection is achieved in 180%

of cases. Infection recurs in 20%30% of patients, many of

whom have underlying osteomyelitis. Factors that predict heal-

ing include the absence of exposed bone, a palpable poplitealpulse, toe pressure of145 mm Hg or an ankle pressure of180

mm Hg, and a peripheral WBC count of !12,000/mm3 [19].

The presence of edema or atherosclerotic cardiovascular disease

increases the likelihood of amputation. Amputation may be

more often required for patients with combined soft-tissue and

bone infection than for patients with either type of infection

alone [86]. Patients who have had one infection are at sub-

stantial risk of having another within a few years; thus, edu-

cating them about prevention techniques and about prompt

consultation when foot problems occur is critical.

Acknowledgments

Financial support. The author has received research support from

Pfizer (formerly Pharmacia) and Merck.

Conflict of interest. The author is a member of the speakers bureaus

and advisory boards for Pfizer (formerly Pharmacia) and Merck.

References

1. Lipsky BA. Infectious problems of the foot in diabetic patients. In:

Bowker JH, Pfeifer MA, eds. The diabetic foot. 6th ed. St. Louis: Mosby,

2001: 46780.

2. International Working Group on the Diabetic Foot. International con-

sensus on the diabetic foot. Amsterdam, 1999: 196.

3. Pecoraro RE, Ahroni JH, Boyko EJ, Stencil VL. Chronology and de-

terminants of tissue repair in diabetic lower-extremity ulcers. Diabetes

1991; 40:130513.

4. Reiber GE, Pecoraro RE, Koepsell TD. Risk factors for amputation in

patients with diabetes mellitus: a case control study. Ann Intern Med

1992; 117:97105.

5. Wilson RM. Neutrophil function in diabetes. Diabet Med 1986; 3:

50912.

6. McMahon MM, Bistrian BR. Host defenses and susceptibility to in-

fection in patients with diabetes mellitus. Infect Dis Clin North Am

1995; 9:110.

7. Sentochnik DE, Eliopoulos GM. Infection and diabetes. In: Kahn CR,

Weir GC, eds. Joslins diabetes mellitus. 13th ed. Philadelphia: Lea &

Febiger, 1994:86788.

8. Breen JD, Karchmer AW. Staphylococcus aureus infections in diabetic

patients. Infect Dis Clin North Am 1995; 9:1124.

9. Bridges RM, Deitch EA. Diabetic foot infections. Pathophysiology and

treatment. Surg Clin North Am 1994; 74:53755.

10. Lipsky BA, Pecoraro RE, Larson SA, Ahroni JH. Outpatient manage-

ment of uncomplicated lower-extremity infections in diabetic patients.

Arch Intern Med 1990; 150:7907.11. Lipsky BA, Pecoraro RE, Wheat JL. The diabetic foot: soft tissue and

bone infection. Infect Dis Clin North Am 1990; 4:40932.

12. Wheat LJ, Allen SD, Henry M, et al. Diabetic foot infections: bacte-

riologic analysis. Arch Intern Med 1986; 146:193540.

13. Sapico FL, Witte JL, Canawati HN, Montgomerie JZ, Bessman AW.

The infected foot of the diabetic patient: quantitative microbiologyand

analysis of clinical features. Rev Infect Dis 1984; 6(Suppl 1):1716.

14. Gerding DN. Foot infections in diabetic patients: the role of anaerobes.

Clin Infect Dis 1995; 20(Suppl 2):S2838.

15. Tentolouris N, Jude EB, Smirnof I, Knowles EA, Boulton AJM. Meth-

icillin-resistant Staphylococcus aureus: an increasing problem in a di-

abetic foot clinic. Diabet Med 1999; 16:76771.

16. Lipsky BA, Hiatt HI, Holroyd KJ. Results and prognostic value of Gram

stain of tissue curettage specimens of infected diabetic foot ulcers [ab-

stract 145]. In: Proceedings of the 37th annual meeting of the InfectiousDiseases Society of America (Philadelphia). Alexandria, VA: Infectious

Diseases Society of America, 1999.

17. Redkar R, Kalns J, Butler W, et al. Identification of bacteria from a

non-healing diabetic foot wound by 16 S rDNA sequencing. Mol Cell

Probes 2000; 14:1639.

18. Newman LG, Waller J, Palestro CJ, et al. Unsuspected osteomyelitis in

diabetic foot ulcers: diagnosis and monitoring by leukocyte scanning

with indium 111 oxyquinoline. JAMA 1991; 266:124651.

19. Eneroth M, Apelqvist J, Stenstrom A. Clinical characteristics and out-

come in 223 diabetic patients with deep foot infections. Foot Ankle

Int 1997; 18:71622.


10/14


20. Edelson GW, Armstrong DG, Lavery LA, Caicco G. The acutely infected

diabetic foot is not adequately evaluated in an inpatient setting. Arch

Intern Med 1996; 156:23738.

21. Armstrong DG, Perales TA, Murff RT, Edelson GW, Welchon JG. Value

of white blood cell count with differential in the acute diabetic foot

infection. J Am Podiatr Med Assoc 1996; 86:2247.

22. Armstrong DG, Lavery LA, Harkless LB. Validation of adiabetic wound

classification system: the contribution of depth, infection, and ischemia

to risk of amputation. Diabetes Care 1998; 21:8559.

23. Ger R. Newer concepts in the surgical management of lesions of the

foot in the patient with diabetes. Surg Gynecol Obstet 1984; 158:2135.

24. Frykberg RG, Mendeszoon ER. Charcot arthropathy: pathogenesis and

management. Wounds 2000; 12(Suppl B):35B42B.

25. Lipsky BA. Osteomyelitis of the foot in diabetic patients. Clin Infect

Dis 1997; 25:131826.

26. Grayson ML, Gibbons GW, Balogh K, Levin E, Karchmer AW. Probing

to bone in infected pedal ulcers: a clinical sign of underlying osteo-

myelitis in diabetic patients. JAMA 1995; 273:7213.

27. Wrobel JS, Connolly JE. Making the diagnosis of osteomyelitis: the

role of prevalence. J Am Podiatr Med Assoc 1998; 88:33743.

28. Harwood SJ, Valdivia S, Hung GL, Quenzer RW. Use of sulesomab, a

radiolabeled antibody fragment, to detect osteomyelitis in diabetic pa-

tients with foot ulcers by leukoscintigraphy. Clin Infect Dis 1999;28:

12005.

29. Enderle MD, Coerpre S, Schweizer HP, et al. Correlation of imaging

techniques to histopathology in patients with diabetic foot syndromeand clinical suspicion of chronic osteomyelitis. The role of high-

resolution ultrasound. Diabetes Care 1999; 22:2949.

30. Craig JG, Amin MB, Wu K, et al. Osteomyelitis of the diabetic foot:

MR imaging-pathological correlation. Radiology1997; 203:84955.

31. Rosenberg ZA, Beltran J, Bencardino JT. MR imaging of the ankle and

foot. Radio Graphics2000; 20(Special issue):S15379.

32. Jones V. Debridement of diabetic foot lesions. Diabetic Foot 1998; 1:

8894.

33. Sutton P, Harley J, Jacobson A, Lipsky BA. Diagnosing osteomyelitis

with percutaneous bone biopsy in patients with diabetes and foot in-

fection [abstract 30]. In: Proceedings of the 38th annual meeting of

the Infectious Diseases Society of America (New Orleans). Alexandria,

VA: Infectious Diseases Society of America, 2000.

34. Jaegeblad G, Apelqvist J, Nyberg P, Berger B. The diabetic foot: from

ulcer to multidisciplinary team approach; a process analysis [abstractP87]. In: Abstracts of the 3rd International Symposium of the Diabetic

Foot (Noordwijkerhout, The Netherlands), 1998:149.

35. Robson MC, Mannari RJ, Smith PD, Payne WG. Maintenance of

wound bacterial balance. Am J Surg 1999; 178:399402.

36. OMeara SM, Cullum NA, Majid M, Sheldon TA. Systemic review of

antimicrobial agents used for chronic wounds. Br J Surg2001; 88:421.

37. Chantelau E, Tanudjaja T, Altenhofer F, Ersanli Z, Lacigova S, Metzger

C. Antibiotic treatment for uncomplicated neuropathic forefoot ulcers

in diabetes: a controlled trial. Diabet Med 1996; 13:1569.

38. Hirschl M, Hirschl AM. Bacterial flora in mal perforant and antimi-

crobial treatment with ceftriaxone. Chemotherapy1992; 38:27580.

39. Foster AVM, Bates M, Doxford M, Edmonds ME. Should oral anti-

biotics be given to clean foot ulcers with no cellulitis? [abstract O13].

In: Abstracts of the 3rd International Symposium of the Diabetic Foot

(Noordwijkerhout, The Netherlands), 1998.

40. Kuck EM, Bouter KP, Hoekstra JBL, Conemans JMH, Diepersloot RJA.

Tissue concentrations after a single-dose, orally administered ofloxacin

in patients with diabetic foot infections. Foot Ankle Int1998; 19:3840.

41. Muller M, Brunner M, Hollenstein U, et al. Penetration of ciprofloxacin

into the interstitial space of inflamed foot lesions in noninsulin-

dependent diabetes mellitus patients. Antimicrob Agents Chemother

1999; 43:20568.

42. Marangos MN, Skoutelis AT, Nightengale CH, et al. Absorption of

ciprofloxacin in patients with diabetic gastroparesis. AntimicrobAgents

Chemother1995; 39:21613.

43. Raymakers JT, Houben AJ, van de Heyden JJ, Tordoir JH, Kitslaar PJ,

Schaper NC. The effect of diabetes and severe ischaemia on the pen-

etration of ceftazidime into tissues of the limb. Diabet Med 2001;18:

22934.

44. El-Sherif El-Sarkey M. Local intravenous therapy in chronic inflam-

matory and vascular disorders of the foot. Int Surg 1997; 82:17581.

45. Dorigo B, Cameli AM, Trapani M, Raspanti D, Torri M, Mosconi G.

Efficacy of femoral intra-arterial administration of teicoplanin in gram-

positive diabetic foot infections. Angiology1995; 46:111522.

46. Connolly JE, Wrobel JS, Anderson RF. Primary closure of infected

diabetic foot wounds: a report of closed instillation in 30 cases. J AmPodiatr Med Assoc2000; 90:17582.

47. Roeder B, Van Gils CC, Maling S. Antibiotic beads in the treatment

of diabetic pedal osteomyelitis. J Foot Ankle Surg 2000; 39:12430.

48. Yamashita Y, Uchida A, Yamakawa T, Shinto Y, Araki N, Kato K. Treat-

ment of chronic osteomyelitis using calcium hydroxyapatite ceramic

implants impregnated with antibiotics. Int Orthop 1998; 22:24751.

49. Kollenberg LO. A new topical antibiotic delivery system. World Wide

Wounds 1998; 1:119. Available at: http://www.worldwidewounds

.com/1998/july/Topical-Antibiotic-Delivery-System/topical-antibiotic

-delivery-system.html. Accessed on 8 July 2004.

50. Lipsky BA, McDonald D, Litka PA. Treatment of infected diabetic foot

ulcers: topical MSI-78 vs. oral ofloxacin [abstract]. Diabetologia

1997; 40(Suppl 1):482.

51. Lipsky BA. Evidence-based antibiotic therapy of diabetic foot infec-

tions. FEMS Immunol Med Microbiol 1999; 26:26776.

52. Fierer J, Daniel D, Davis C. The fetid foot: lower extremity infections

in patients with diabetes with diabetic mellitus. Rev Infect Dis1979;

1:2107.

53. Hughes CA, Johnson CC, Bamberger DM, et al. Treatment and long-

term follow-up of foot infections in patients with diabetes or ischemia:

a randomized, prospective, double-blind comparison of cefoxitin and

ceftizoxime. Clin Ther1987; 10(Suppl A):3649.

54. LeFrock JL, Blais F, Schell RF, et al. Cefoxitin in the treatmentof diabetic

patients with lower extremity infections. Infect Surg1983May:36174.

55. File TM, Tan JS. Amdinocillin plus cefoxitin versus cefoxitin alone in

therapy of mixed soft tissue infections (including diabetic foot infec-

tions). Am J Med 1983; 80(Suppl):1005.

56. Anania WC, Chinkes SL, Rosen RC, Turner PR, Helfand AE. A selective

clinical trial of ceftizoxime. J Am Podiatr Med Assoc 1987; 77:648652.

57. Lipsky BA, Baker PD, Landon GC, Fernau R. Antibiotic therapy for

diabetic foot infections: comparison of two parental-to-oral regimens.

Clin Infect Dis 1997; 24:6438.

58. Grayson ML, Gibbons GW, Habershaw GM, et al. Use of ampicillin/

sulbactam versus imipenem/cilastatin in the treatment of limb-threat-

ening foot infections in diabetic patients. Clin Infect Dis 1994;18:

68393.

59. Akova M, Ozcebe O, Gullu Unal S, et al. Efficacy of sulbactam-am-

picillin for the treatment of severe diabetic foot infections. J Chemother

1996; 8:2849.

60. Zeillemaker AM, Veldkamp KE, van Kraaij MG, Hoekstra JBL, van

Papendrecht AA, Dipersloot RJ. Piperacillin/tazobactam therapy for

diabetic foot infection. Foot Ankle Int 1998; 19:16972.

61. Graham DR, Talan DA, Nichols RL, et al. Once-daily, high-dose lev-

ofloxacin versus ticarcillin-clavulanate alone or followed by amoxicil-

lin-clavulanate for complicated skin and skin-structure infections: a

randomized, open-label trial. Clin Infect Dis 2002; 35:3819.

62. Peterson LR, Lissack LM, Canter K, Fasching CE, Clabots C, Gerding

DN. Therapy of lower extremity infections with ciprofloxacin in pa-

tients with diabetes mellitus, peripheral vascular disease, or both. Am

J Med 1989; 86:8018.

63. Sesin GP, Paszko A, OKeefe EO. Oral clindamycin and ciprofloxacin

therapy for diabetic foot infections. Pharmacotherapy1990; 10:1546.

64. Beam TR, Gutierrez I, Powell S, et al. Prospective study of the efficacy

and safety of oral and intravenous ciprofloxacin in the treatment of

diabetic foot infections. Rev Infect Dis 1989; 11(Suppl 5):S1163.

65. Diamantopoulos EJ, Haritos D, Yfandi G, et al. Management of severe


11/14


diabetic foot infections. Exp Clin Endocrinol Diabetes 1998;106:

34652.

66. Calandra GB, Raupp W, Brown KR. Imipenem/cilastatin treatment of

lower extremity skin and soft tissue infections in diabetics. Scand J

Infect Dis Suppl 1987; 52:159.

67. Lipsky BA, Itani K, Norden C, and the Linezolid Diabetic Foot Infec-

tions Study Group. Treating foot infections in diabetic patients: a ran-

domized, multicenter, open-label trial of linezolid versus ampicillin-

sulbactam/amoxicillin-clavulanate. Clin Infect Dis 2004; 38:1724.

68. Cunha BA. Antibiotic selection for diabetic foot infections: a review.

J Foot Ankle Surg 2000; 39:2537.

69. Tennvall GR, Apelqvist J, Eneroth M. Costs of deep foot infections.

An analysis of factors determining treatment costs. Pharmacoecon-

omics2000; 18:22538.

70. McKinnon PS, Paladino JA, Grayson ML, Gibbons GW, Karchmer AW.

Cost effectiveness of ampicillin/sulbactam versus imipenem/cilastatin

in the treatment of limb-threatening foot infections in diabetic patients.

Clin Infect Dis 1997; 24:5763.

71. Venkatesan P, Lawn S, Macfarlane RM, Fletcher EM, Finch RG, Jeff-

coate WJ. Conservative management of osteomyelitis in the feet of

diabetic patients. Diabet Med 1997; 14:48790.

72. Pittet D, Wyssa B, Herter-Clavel C, Kursteiner K, Vaucher J, Lew DP.

Outcome of diabetic foot infections treated conservatively: a retro-

spective cohort study with long-term follow-up. Arch Intern Med

1999; 159:8516.

73. Gough A, Clapperton M, Rolando N, Foster AVM, Philpott-HowardJ, Edmonds ME. Randomized placebo-controlled trial of granulocyte-

colony stimulating factor in diabetic foot infections. Lancet1997; 350:

8559.

74. De Lalla F, Pellizzer G, Strazzabosco M, et al. Randomized prospective

controlled trial of recombinant granulocyte-colony stimulating factor

as adjunctive therapy for limb-threatening diabetic foot infection. An-

timicrob Agents Chemother 2001; 45:10948.

75. Peck KR, Son DW, Song JH, Kim S, Oh MD, Choe KW. Enhanced

neutrophil functions by recombinant human granulocyte colony-stim-

ulating factor in diabetic patients with foot infections in vitro. J Korean

Med Sci 2001; 16:3944.

76. Stone JA, Cianci P. The adjunctive role of hyperbaric oxygen in the

treatment of lower extremity wounds in patients with diabetes. Diabetes

Spectrum1997; 10:11823.

77. Wunderlich RP, Peters EJG, Lavery L. Systemic hyperbaric oxygen ther-

apy: lower-extremity wound healing and the diabetic foot. Diabetes

Care2000; 23:15515.

78. Lee SS, Chen CY, Chan YS, Yen CY, Chao EK, Ueng SWN. Hyperbaric

oxygen in the treatment of diabetic foot infection. Chang Gung MedicalJournal1997; 20:1722.

79. Bakker DJ. Hyperbaric oxygen therapy and the diabetic foot. Diabetes

Metab Res Rev2000; 16(Suppl 1):S558.

80. Caputo GM, Cavanaugh PR, Ulbrecht JS, Gibbons GW, Karchmer AW.

Assessment and management of foot disease in patients with diabetes.

N Engl J Med 1994; 331:85460.

81. Estes JM, Pomposelli FB Jr. Lower extremity arterial reconstruction in

patients with diabetes mellitus. Diabet Med 1996; 13:S437.

82. Chang BB, Darling RC III, Paty PSK, Lloyd WE, Shah DM, Leather

RP. Expeditious management of ischemic invasive foot infections. Car-

diovasc Surg 1996; 4:7925.

83. Tannenbaum GA, Pomposelli FB Jr, Marcaccio EJ, et al. Safety of vein

bypass grafting to the dorsal pedal artery in diabetic patients with foot

infections. J Vasc Surg 1992; 15:98290.

84. Rayman A, Stansfield G, Woollard T, Mackie A, Rayman G. Use oflarvae in the treatment of the diabetic necrotic foot. Diabetic Foot

1998; 1:713.

85. Armstrong DG, Nguyen HC. Improvement in healing with aggressive

edema reduction after debridement of foot infection in persons with

diabetes. Arch Surg 2000; 135:14059.

86. Eneroth M, Larsson J, Apelqvist J. Deep foot infection in diabetes

mellitus: an entity with different characteristics, treatment, and prog-

nosis [abstract P01]. In: Abstracts of the 3rd International Symposium

of the Diabetic Foot (Noordwijkerhout, The Netherlands), 1998:21.


12/14


13/14


14/14

13920850-ref for diabetic foot

Documents