Diabetic Foot Infections:

2012 IDSA Guidelines

Lisa Cornelius MD, MPH

December 2013
 Objectives
• Explain the changing epidemiology of obesity and
diabetes in the US and in Texas
• List the factors that aid in classification of a diabetic foot
infection (DFI)
• Explain the most recent recommendations for culturing
and antibiotic treatment of DFI

Financial Disclosures
• No conflicts

2
 Background
Diabetic foot infection = any inframalleolar infection in a
person with diabetes mellitus
Paronychia Cellulitis Myositis
Abscesses Septic arthritis Tendonitis
Osteomyelitis

• Common and costly

• Account for the largest number of diabetes-related
hospital bed-days
• Most common proximate, non-traumatic cause of
amputations
Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes
Among U.S. Adults
1994

Obesity (BMI≥30 kg/m2) Diabetes

Missing Data <14.0% Missing data <4.5%

14.0%–17.9% 18.0%–21.9% 4.5%–5.9% 6.0%–7.4%
22.0%–25.9% ≥26.0% 7.5%–8.9% ≥9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System

available at http://www.cdc.gov/diabetes/statistics
Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes
Among U.S. Adults
1995

Obesity (BMI≥30 kg/m2) Diabetes

Missing Data <14.0% Missing data <4.5%

14.0%–17.9% 18.0%–21.9% 4.5%–5.9% 6.0%–7.4%
22.0%–25.9% ≥26.0% 7.5%–8.9% ≥9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System

available at http://www.cdc.gov/diabetes/statistics
Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes
Among U.S. Adults
1996

Obesity (BMI≥30 kg/m2) Diabetes

Missing Data <14.0% Missing data <4.5%

14.0%–17.9% 18.0%–21.9% 4.5%–5.9% 6.0%–7.4%
22.0%–25.9% ≥26.0% 7.5%–8.9% ≥9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System

available at http://www.cdc.gov/diabetes/statistics
Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes
Among U.S. Adults
1997

Obesity (BMI≥30 kg/m2) Diabetes

Missing Data <14.0% Missing data <4.5%

14.0%–17.9% 18.0%–21.9% 4.5%–5.9% 6.0%–7.4%
22.0%–25.9% ≥26.0% 7.5%–8.9% ≥9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System

available at http://www.cdc.gov/diabetes/statistics
Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes
Among U.S. Adults
1998

Obesity (BMI≥30 kg/m2) Diabetes

Missing Data <14.0% Missing data <4.5%

14.0%–17.9% 18.0%–21.9% 4.5%–5.9% 6.0%–7.4%
22.0%–25.9% ≥26.0% 7.5%–8.9% ≥9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System

available at http://www.cdc.gov/diabetes/statistics
Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes
Among U.S. Adults
1999

Obesity (BMI≥30 kg/m2) Diabetes

Missing Data <14.0% Missing data <4.5%

14.0%–17.9% 18.0%–21.9% 4.5%–5.9% 6.0%–7.4%
22.0%–25.9% ≥26.0% 7.5%–8.9% ≥9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System

available at http://www.cdc.gov/diabetes/statistics
Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes
Among U.S. Adults
2000

Obesity (BMI≥30 kg/m2) Diabetes

Missing Data <14.0% Missing data <4.5%

14.0%–17.9% 18.0%–21.9% 4.5%–5.9% 6.0%–7.4%
22.0%–25.9% ≥26.0% 7.5%–8.9% ≥9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System

available at http://www.cdc.gov/diabetes/statistics
Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes
Among U.S. Adults
2001

Obesity (BMI≥30 kg/m2) Diabetes

Missing Data <14.0% Missing data <4.5%

14.0%–17.9% 18.0%–21.9% 4.5%–5.9% 6.0%–7.4%
22.0%–25.9% ≥26.0% 7.5%–8.9% ≥9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System

available at http://www.cdc.gov/diabetes/statistics
Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes
Among U.S. Adults
2002

Obesity (BMI≥30 kg/m2) Diabetes

Missing Data <14.0% Missing data <4.5%

14.0%–17.9% 18.0%–21.9% 4.5%–5.9% 6.0%–7.4%
22.0%–25.9% ≥26.0% 7.5%–8.9% ≥9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System

available at http://www.cdc.gov/diabetes/statistics
Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes
Among U.S. Adults
2003

Obesity (BMI≥30 kg/m2) Diabetes

Missing Data <14.0% Missing data <4.5%

14.0%–17.9% 18.0%–21.9% 4.5%–5.9% 6.0%–7.4%
22.0%–25.9% ≥26.0% 7.5%–8.9% ≥9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System

available at http://www.cdc.gov/diabetes/statistics
Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes
Among U.S. Adults
2004

Obesity (BMI≥30 kg/m2) Diabetes

Missing Data <14.0% Missing data <4.5%

14.0%–17.9% 18.0%–21.9% 4.5%–5.9% 6.0%–7.4%
22.0%–25.9% ≥26.0% 7.5%–8.9% ≥9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System

available at http://www.cdc.gov/diabetes/statistics
Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes
Among U.S. Adults
2005

Obesity (BMI≥30 kg/m2) Diabetes

Missing Data <14.0% Missing data <4.5%

14.0%–17.9% 18.0%–21.9% 4.5%–5.9% 6.0%–7.4%
22.0%–25.9% ≥26.0% 7.5%–8.9% ≥9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System

available at http://www.cdc.gov/diabetes/statistics
Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes
Among U.S. Adults
2006

Obesity (BMI≥30 kg/m2) Diabetes

Missing Data <14.0% Missing data <4.5%

14.0%–17.9% 18.0%–21.9% 4.5%–5.9% 6.0%–7.4%
22.0%–25.9% ≥26.0% 7.5%–8.9% ≥9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System

available at http://www.cdc.gov/diabetes/statistics
Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes
Among U.S. Adults
2007

Obesity (BMI≥30 kg/m2) Diabetes

Missing Data <14.0% Missing data <4.5%

14.0%–17.9% 18.0%–21.9% 4.5%–5.9% 6.0%–7.4%
22.0%–25.9% ≥26.0% 7.5%–8.9% ≥9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System

available at http://www.cdc.gov/diabetes/statistics
Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes
Among U.S. Adults
2008

Obesity (BMI≥30 kg/m2) Diabetes

Missing Data <14.0% Missing data <4.5%

14.0%–17.9% 18.0%–21.9% 4.5%–5.9% 6.0%–7.4%
22.0%–25.9% ≥26.0% 7.5%–8.9% ≥9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System

available at http://www.cdc.gov/diabetes/statistics
Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes
Among U.S. Adults
2009

Obesity (BMI≥30 kg/m2) Diabetes

Missing Data <14.0% Missing data <4.5%

14.0%–17.9% 18.0%–21.9% 4.5%–5.9% 6.0%–7.4%
22.0%–25.9% ≥26.0% 7.5%–8.9% ≥9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System

available at http://www.cdc.gov/diabetes/statistics
Age-Adjusted Prevalence of Obesity and Diagnosed Diabetes
Among U.S. Adults
2010

Obesity (BMI≥30 kg/m2) Diabetes

Missing Data <14.0% Missing data <4.5%

14.0%–17.9% 18.0%–21.9% 4.5%–5.9% 6.0%–7.4%
22.0%–25.9% ≥26.0% 7.5%–8.9% ≥9.0%

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System

available at http://www.cdc.gov/diabetes/statistics
 Rate of new cases of type 1 and type 2 diabetes among youth
aged <20 years, by race/ethnicity, 2002–2005

<10 years 10–19 years

Source: SEARCH for Diabetes in Youth Study

NHW=non-Hispanic whites; NHB=non-Hispanic blacks; H=Hispanics; API=Asians/Pacific Islanders; AI=American Indians
http://www.cdc.gov/diabetes/pubs/factsheet11.htm?loc=diabetes-statistics
 Texas Projected Diabetes Cases 2000 - 2040*

Hispanic (Prevalence = 12.3%) Black, non-Hispanic (Prevalence = 12.9%)

White, non-Hispanic (Prevalence = 8.5%) TOTAL (Prevalence = 10.3%)

3,000,000

2,500,000
Number of Diabetes Cases

2,000,000

1,500,000

1,000,000

500,000

0
2000 2010 2020 2030 2040

YEAR
* Uses 2007 diabetes prevalence by race/ethnicity from BRFSS and population data from the Texas State Data
Center - Office of the State Demographer, Institute for Demographic and Socioeconomic Research. Uses 0.5
migration scenario.

http://www.dshs.state.tx.us/diabetes/tdcdata.shtm
Hospital Discharges for Non-traumatic Lower
Extremity Amputation with Diabetes

http://www.cdc.gov/diabetes/statistics/lea/fig1.htm
Mendes J Diabetic Foot Complic 2012;4:26-45
 Infection should be diagnosed
clinically on the basis of the
presence of purulent secretions
or at least 2 of the cardinal manifestations
of inflammation:
redness
warmth
swelling or induration
pain or tenderness

Not all
Ulcers are
infected!

IDSA guidelines CID 2004;39:885-910

Factors that increase risk of DFI
• Positive probe-to-bone test
• Ulcer present for > 30 days
• History of recurrent foot ulcers
• Traumatic foot wound
• Presence of peripheral vascular disease in the affected
limb
• Previous lower extremity amputation
• Loss of protective sensation
• Presence of renal insufficiency
• History of walking barefoot
*
26
 Clinical classification of Perfusion
Extent/size
a diabetic foot infection Depth/tissue
loss
Infection
Sensation

Clinical manifestations of infection Infection PEDIS

severity grade

No symptoms or signs of infection Uninfected 1

Infection present, as defined by at least 2 of the following:

• local swelling or Induration
• erythema
• local tenderness or pain
• local warmth
• purulent discharge (thick, opaque to white or sanguineous
secretion)

IDSA guidelines CID 2012;54:132-73

 Clinical classification of
a diabetic foot infection
Clinical manifestations of infection Infection PEDIS
severity grade

Local infection involving only the skin and the subcutaneous Mild 2
tissue without involvement of deeper tissues and without systemic
signs

If erythema, must be >0.5cm to <2cm around ulcer.

Excludes other causes of an inflammatory response of the skin
(trauma, gout, fx, thrombosis, venous stasis)

Local infection with erythema >2 cm, or involving structures Moderate 3

deeper than skin and subcutaneous tissues
(abscess, osteomyelitis, septic arthritis, fasciitis) AND
No systemic inflammatory response signs

IDSA guidelines CID 2012;54:132-73

 Clinical classification of
a diabetic foot infection

Clinical manifestations of infection Infection PEDIS

severity grade
Local infection (as above) with the signs of SIRS, Severe 4
manifested by 2+ of the following:

• Temp >380C or <360C

• Heart rate >90 beats/min
• RR >20 breaths/min or PaCO2 <32 mm Hg
• WBC >12000 or <4000 cells/mcL or ≥10% bands

IDSA guidelines CID 2012;54:132-73

IDSA guidelines CID 2012;54:132-73
 Infected wounds
The most important initial task is to recognize patients
who require
• immediate hospitalization,
• parental and broad-spectrum empirical abx, and
• urgent consideration of diagnostic testing and
surgical consultation!
= severe infections: potentially life-threatening!

**distinction b/t moderate and severe has less to do with the foot
and more to do with the patient to whom it is attached
Consider hospitalization
if any of the following are
present:
Systemic toxicity: fever and
leukocytosis
Metabolic instability: acidosis
or hypoglycemia
Rapidly progressive or
deep-tissue infection
Substantial necrosis or
gangrene or critical ischemia
Requirement of urgent
diagnostic or therapeutic
interventions
Inability to care for self or
inadequate home support
 *
IDSA guidelines CID 2012;54:132-73
Curing an infection
often contributes to,
but is not defined by,
healing of an ulcer
IDSA guidelines CID 2012;54:132-73
Available published evidence DOES NOT support the use of
antibiotics
for the management of
clinically uninfected ulcerations,
either to enhance wound healing or
as prophylaxis against infection

** antibiotic use encourages antimicrobial resistance,

additional financial cost, risk for drug-related adverse
events
 Avoid Swabs!
• Superficial swab culture
o Notoriously inaccurate
• Identifies deep soft-tissue organisms in only 75% of cases
• Identifies bone bacteria in only 30% of cases

o Useful only in determining if the patient should be placed in

contact isolation – MRSA, VRE, etc.

Foot Ankle Clin N Am, 2006

Senneville CID 2006;42:57-62
• 2005 study from
Diabetic Medicine – 21
diabetic patients
• Comparison of needle
puncture vs. superficial
swabbing for
bacteriologic diagnosis
of osteomyelitis
IDSA guidelines CID 2012;54:132-73
Treat MRSA if

44
 *
IDSA guidelines CID 2004;39:885-910
If no prior abx,
just GPC coverage
is sufficient

IDSA guidelines CID 2012;54:132-73

47
48
49
 Definitive therapy
• Based on the results of appropriately obtained culture
and sensitivity testing + patient’s clinical response to the
empiric regimen
• Continue antibiotics until, but not beyond, resolution of
findings of infection, but NOT through complete
healing of wound
o About 1-2 weeks for mild infections
o About 2-3 weeks for moderate to severe infections

50
 Imaging?
• All patients presenting with a new DFI should have plain
XR of the affected foot to look for bone abnormalities
and soft tissue gas or radio-opaque foreign bodies
• MRI is the study of choice for those that need further
imaging for soft tissue abscess or if diagnosis of
osteomyelitis is uncertain
• If MRI unavailable, next best is combination of
radionuclide bone scan and a labeled white blood cell
scan

51
Wound Care Techniques?
• Debridement – better if sharp (or surgical) methods used
o Mechanical, autolytic, or larval debridement techniques may be appropriate for
some wounds
• Redistribution of pressure off the wound
• Selection of dressings that allow for moist wound healing
and control excess exudation
• Do not advocate using topical antimicrobials for treating
most clinically uninfected wounds
• No adjunctive therapy has been proven to improve
resolution of infection, but for selected wounds that are
slow to heal, consider bioengineered skin equivalents,
growth factors, granulocyte colony-stimulating factors,
HBO, or negative pressure wound therapy

52
 Follow-up
• Careful observation of the patient’s response to therapy
is essential:
o Daily for inpatients
o Q2-5 days for outpatients

• Primary indicators of improvement:

o Resolution of local and systemic symptoms
o Resolution of clinical signs of inflammation
IDSA guidelines CID 2012;54:132-73
 Summary
1. Select the definitive antibiotic regimen, if required
**specific antibacterial therapy- none has been
proven superior: Over 40 studies to date
**no evidence supports giving antibiotics for the entire time
that the wound remains open
2. Re-evaluate the wound
3. Review the offloading and wound care regimens
4. Surgical intervention is often needed
5. Evaluate for an ischemic foot
6. Multidisciplinary teams improve outcomes