The mortality rate for diabetics due to poor treatments of infected foot wounds that can subsequently lead to lower extremity amputation is worse than for the majority of cancers, given that around 50% of diabetics with foot amputations die within five years. The IDSA diabetic foot infection guidelines published in the journal Clinical Infectious Diseases have now revealed that about half of these lower extremity amputations can in fact be prevented through proper care of foot infections.
Diabetics generally suffer from poor blood circulation, which means their sense of touch or pain sensitivity can be greatly compromised. For instance, a simple sore caused by a rubbing shoe or a cut can easily go unnoticed and become worse. One in four diabetics will have a foot ulcer, i.e. an open sore in their lifetime, which can easily become infected. If left untreated, these infections can spread and kill soft tissue and bone, which means that the dead and infected tissue needs to be surgically removed, and in severe cases, this means amputation of the toe, foot, or even part of the leg. Almost 80% of all non-traumatic amputations are performed in people with diabetes, and 85% of these amputations start with an open foot sore.
Leading author, Benjamin A. Lipsky, MD, chair of the review panel, guidelines and professor of medicine at Washington University and VA Puget Sound in Seattle declared:
"Lower extremity amputation takes a terrible toll on the diabetic patient. People who have had a foot amputated often can no longer walk, their occupational and social opportunities shrink, and they often become depressed and are at significant risk for a second amputation. Clearly, preventing amputations is vital, and in most cases, possible."
The guidelines highlight the importance for a rapid and appropriate treatment of infected wounds on the lower extremities. For instance, surgically removing (debridement) dead tissues, administering proper antibiotics and, wherever required, alleviating pressure on the wound and restoring blood flow to the area. Solely prescribing antibiotics for diabetics with foot infections, as is often the case, often proves insufficient if the wound is not also properly cared for, including surgical interventions.
Treating diabetic foot infections can pose a real challenge. The revised and updated IDSA 2004 diabetic foot infections guidelines therefore recommend involving a multidisciplinary team that can evaluate and address different aspects of the problem. According to research since the previous guidelines, many foot infections are treated inappropriately, i.e. by prescribing the wrong antibiotic, or failing to take into account underlying conditions like peripheral arterial disease.
The new guidelines feature 10 common questions health care providers may encounter when considering treatment options for a diabetic patient with a foot wound, to which the IDSA panel of experts has written a comprehensive answer based on extensive evidence. For instance, the first step is establishing whether the wound is infected. The guidelines state that a sign of infection includes at least two of the following symptoms: redness, tenderness, warmth, pain or swelling. Around 50% of ulcers are not infected and therefore do not require antibiotic therapy, unlike those in which an infection has been diagnosed, whilst individuals with a severe infection should be referred for immediate hospitalization.
Diabetics with infected foot ulcers should generally have their foot imaged to determine whether the infection has spread to the bone. Another important treatment aspect is to grow a culture of the bacteria that has caused the infection, as this will assist in choosing the best antibiotics. The guidelines recommend employing a multidisciplinary team due to the complexity of diabetic foot infections, which includes infectious diseases specialists, surgeons, podiatrists and orthopedists. Dr. Lipsky noted that doctors in rural areas could potentially use telemedicine in order to consult with the necessary experts.
The guidelines' co-author, Warren S. Joseph, DPM, a consultant for lower extremity infectious diseases at Philadelphia's Roxborough Memorial Hospital explained:
"There is quite a bit of over-prescribing or inappropriate prescribing of antibiotics for diabetic foot wounds, which doesn't help the patient and can lead to antibiotic resistance. The guidelines note that when antibiotics are necessary they should be discontinued when the infection is gone, even if the wound hasn't completely healed."
The voluntary guidelines have been developed to support doctors in their decision-making for each individual patient given that all patients' circumstances are different.
IDSA has developed over 50 treatment guidelines for various conditions and infections, which range from HIV/AIDS to Clostridium difficile. All IDSA guidelines will be available in smart phone format and as a pocket-sized quick-reference edition.
Written By Petra Rattue