Diagnosis and Treatment of Diabetic Foot Infections
Benjamin A. Lipsky,1,a Anthony R. Berendt,2,a H. Gunner Deery,3 John M. Embil,4 Warren S. Joseph,5 Adolf W. Karchmer,6 Jack L. LeFrock,7 Daniel P. Lew,8 Jon T. Mader,9,b Carl Norden,10 and James S. Tan11
Medical Service, Veterans Affairs Puget Sound Health Care System, and Division of General Internal Medicine, Department ofMedicine, University of Washington School of Medicine, Seattle, Washington; 2Bone Infection Unit, Nufﬁeld Orthopaedic Centre, Oxford, United Kingdom; 3 Northern Michigan Infectious Diseases, Petoskey, Michigan; 4Section of Infectious Diseases, Department of Medicine, University of Manitoba, Winnipeg, Manitoba; 5Section of Podiatry, Department of Primary Care, Veterans Affairs Medical Center,Coatesville, Pennsylvania; 6Division of Infectious Diseases, Department of Medicine, Harvard Medical School, and Beth Israel Deaconess Medical Center, Boston, Massachusetts; 7 Dimensional Dosing Systems, Sarasota, Florida; 8Department of Medicine, Service of Infectious Diseases, University of Geneva Hospitals, Geneva, Switzerland; 9Department of Internal Medicine, The Marine Biomedical Institute, andDepartment of Orthopaedics and Rehabilitation, University of Texas Medical Branch, Galveston, Texas; 10Department of Medicine, New Jersey School of Medicine and Dentistry, and Cooper Hospital, Camden, New Jersey; and 11Department of Internal Medicine, Summa Health System, and Northeastern Ohio Universities College of Medicine, Akron, Ohio
EXECUTIVE SUMMARY 1. Foot infections in patients withdiabetes cause substantial morbidity and frequent visits to health care professionals and may lead to amputation of a lower extremity. 2. Diabetic foot infections require attention to local (foot) and systemic (metabolic) issues and coordinated management, preferably by a multidisciplinary footcare team (A-II) (table 1). The team managing these infections should include, or have ready access to,an infectious diseases specialist or a medical microbiologist (B-II). 3. The major predisposing factor to these infections is foot ulceration, which is usually related to peripheral neuropathy. Peripheral vascular disease and various immunological disturbances play a secondary role. 4. Aerobic gram-positive cocci (especially Staphylococcus aureus) are the predominant pathogens in diabetic footinfections. Patients who have chronic
Received 2 July 2004; accepted 2 July 2004; electronically published 10 September 2004. These guidelines were developed and issued on behalf of the Infectious Diseases Society of America. a B.A.L. served as the chairman and A.R.B. served as the vice chairman of the Infectious Diseases Society of America Guidelines Committee on Diabetic Foot Infections. bDeceased. Reprints or correspondence: Dr. Benjamin A. Lipsky, Veterans Affairs Puget Sound Health Care System, S-111-GIMC, 1660 S. Columbian Way, Seattle, WA 981089804 (Benjamin.Lipsky@med.va.gov). Clinical Infectious Diseases 2004; 39:885–910 This article is in the public domain, and no copyright is claimed. 1058-4838/2004/3907-0001
wounds or who have recently received antibiotic therapy may alsobe infected with gram-negative rods, and those with foot ischemia or gangrene may have obligate anaerobic pathogens. 5. Wound infections must be diagnosed clinically on the basis of local (and occasionally systemic) signs and symptoms of inﬂammation. Laboratory (including microbiological) investigations are of limited use for diagnosing infection, except in cases of osteomyelitis (B-II). 6. Sendappropriately obtained specimens for culture prior to starting empirical antibiotic therapy in all cases of infection, except perhaps those that are mild and previously untreated (B-III). Tissue specimens obtained by biopsy, ulcer curettage, or aspiration are preferable to wound swab specimens (A-I). 7. Imaging studies may help diagnose or better deﬁne deep, soft-tissue purulent collections and...