Diabetic foot resident survival guide
|Diabetic foot Resident Survival Guide Microchapters|
Diabetic foot is a complication of long-standing and poorly controlled diabetes mellitus. Poor glycemic control, peripheral neuropathy, improper footwear, ischemia and possible foot deformities including charcot arthropathy are the main known causes of diabetic foot. A detailed history of the patient's diabetes status, foot care, deformities, foot hygiene, symptoms of ischemia, and history of smoking is necessary to classify the wound or ulcer and treat the underlying cause. Physical examination includes an assessment of the ulcer and tests to detect the severity of peripheral neuropathy (such as Semmes-Weinstein monofilament test) and ischemia (such as Ankle-Brachial Index (ABI)). Routine laboratory investigations are recommended, such as HbA1c. If an infection is suspected, a wound culture is necessary to guide antibiotic therapy. Mechanical offloading such as cast walkers, total contact casting or therapeutic shoes, and podiatric care are essential. Surgical interventions, such as revascularization surgery) may be considered for patient's with ischemia. Antibiotic therapy is based on culture, risk of MRSA infection, risk of pseudomonas infection, presence or absence of complications, such as osteomyelitis and history of recent antibiotic use. Hyperbaric oxygen therapy is considered for a diabetic foot that persists despite treatment for more than 30 days.
Life Threatening Causes
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated. Diabetic foot superseded with the following may result in sepsis and death.
- Poor glycemic control
- Peripheral neuropathy
- Peripheral arterial disease
- Peripheral ischemia
- Improper footwear
- Foot deformities including charcot arthropathy
Assessment of diabetic foot includes evaluation of peripheral arterial disease, peripheral neuropathy, and foot deformities. Shown below is an algorithm summarizing the diagnosis of diabetic foot and diabetic foot ulcers according to the recommendations of the American Diabetes Association and International Diabetes Federation- Clinical Practice Recommendations on the Diabetic Foot 2017. 
Characterize the symptoms:
❑ Type of sensation
❑ Nocturnal variation
❑ Aggravating factors
❑ Relieving factors
Obtain a detailed history:
❑ Onset of diabetes
❑ Duration of diabetes
❑ Compliance with medication
❑ History of glycemic control
❑ History of other diabetic complications
❑ Foot deformities/injuries/ulcers
❑ History of lower limb amputation
❑ Type of footwear
❑ Foot hygiene
❑ History of claudication
❑ Smoking history
Examine the patient:
❑ Location of ulcer
❑ Integrity and charcteristic (dry/cracked) of skin
❑ Pedal (dorsalis pedis) pulses
❑ Vibration sensation
❑ Ulcer site- warmth, tenderness, edema
❑ Semmes-Weinstein monofilament test
❑ Probe-to-bone test if suspected osteomyelitis
❑ Measure ABI (Ankle-Brachial Index) with a Arterial doppler
Assessment of diabetic foot includes evaluation of peripheral arterial disease, peripheral neuropathy, and foot deformities. Shown below is an algorithm summarizing the diagnosis of diabetic foot and diabetic foot ulcers according to the recommendations of the American Diabetes Association and International Diabetes Federation- Clinical Practice Recommendations on the Diabetic Foot 2017.    
Prophylactic measures and Diabetic foot care in all patients
❑ Glycemic control
❑ Apporpriate footwear and podiatric care
• ❑ Mechanical offloading
• Cast Walkers
• Total contact casting
• Therapeutic shoes
❑ Vascular care to prevent and treat peripheral arterial disease
❑ Local wound care
❑ Debridement - Mechanical or chemical
|Peripheral arterial disease or signs of ischemia||Medication/Surgical or endovascular revascularization|
|Presence of infection||• Mechanical or chemical wound debridement |
• Culture • Biopsy
|• Assess severity of infection according to the table below|
• Treat with antiobiotics according to the table below
|If infection does not resolve within 30 days- |
• Consider hyperbaric oxygen therapy
|• Observe foot |
• Establish regular care
• Reassess in 2-3 months
- DFI is classified based on its severity according to the Infectious Diseases Society of America (IDSA) guideline or the PEDIS grade developed by the International Working Group on the Diabetic Foot (IWGDF). (see Table below)
- Selection of an empiric antimicrobial regimen should be determined by the severity of DFI and the likely etiologic agents.
- 5. What is the appropriate route, setting, and duration of antibiotic therapy?
- The table below describes the recommended route, setting, and duration of antibiotic therapy based on the extent and severity of DFI.
▸ Click on the following categories to expand treatment regimens.
- Check for signs of ischemia.
- Check for signs of infection.
- Always get a wound culture to determine the type of organism and choice of an antibiotic.
- Prophylactic podiatric care.
- Mechanical offloading in all patients. 
- Don't treat the ulcer without treating the underlying infection, ischemia, and appropriate glycemic control.
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- American Diabetes Association (2020). "11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes-2020". Diabetes Care. 43 (Suppl 1): S135–S151. doi:10.2337/dc20-S011. PMID 31862754.
- Rathur HM, Boulton AJ (2007). "The diabetic foot". Clin Dermatol. 25 (1): 109–20. doi:10.1016/j.clindermatol.2006.09.015. PMID 17276208.
- Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG; et al. (2012). "2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections". Clin Infect Dis. 54 (12): e132–73. doi:10.1093/cid/cis346. PMID 22619242.
- Wukich DK, Armstrong DG, Attinger CE, Boulton AJ, Burns PR, Frykberg RG; et al. (2013). "Inpatient management of diabetic foot disorders: a clinical guide". Diabetes Care. 36 (9): 2862–71. doi:10.2337/dc12-2712. PMC 3747877. PMID 23970716.