Diabetic Foot Infection Guideline

Symptoms

No evidence of systemic infection and either

• Two or more features of inflammation: erythema, warmth, pain, pus , swelling/induration

or

• Any cellulitis <2cm around the wound confined to skin or subcutaneous tissue

Treatment duration

Treatment with the following agents is recommended for 7 days, after which treatment should be reviewed and continued or discontinued as appropriate.

Antibiotic-naïve

Oral Flucloxacillin 1g every 6 hours

or

Oral Doxycycline 100mg every 12 hours

Not antibiotic-naïve

Oral Doxycycline 100mg every 12 hours

or

Oral co-trimoxazole 960 mg every 12 hours

MRSA

Oral Doxycycline 100mg every 12 hours

or

Oral co-trimoxazole 960 mg every 12 hours

Symptoms

As for mild infection with either

• Lymphatic streaking, deep tissue infection involving subcutaneous tissue, tendon, fascia, bone or abscess

or

• Cellulitis >2cm

Treatment duration

Treatment with the following agents is recommended for 7 days, after which treatment should be reviewed and continued or discontinued as appropriate.

IV antibiotics may be switched to oral preparation after an appropriate interval.

Antibiotic-naïve

Oral Flucloxacillin 1g every 6 hours or IV 2g every 6 hours

Add oral metronidazole 400mg every 8 hours if anaerobes suspected

or

Oral Doxycycline 100mg every 12 hours

Add oral metronidazole 400mg every 8 hours if anaerobes suspected

or

Oral Co-amoxiclav 625mg every 8 hours

Not antibiotic-naïve

If suitable for oral therapy

Oral Doxycycline 100mg every 12 hours

+/- oral metronidazole 400mg every 8 hours if anaerobes suspected

or

Oral Co-trimoxazole 960mg every 12 hours

+/- oral metronidazole 400mg every 8 hours if anaerobes suspected

or

Oral Co-amoxiclav 625mg every 8 hours

IV therapy

IV Teicoplanin⁴

or

IV Ertapenem³ 1g every 24 hours

MRSA

IV Teicoplanin⁴ and discuss with diabetes / microbiology

Oral switch

Consider oral Doxycycline 100mg every 12 hours or oral Co-trimoxazole 960mg every 12 hours according to sensitivities

If unwell discuss with Microbiology.

Symptoms

• Any infection accompanied by systemic toxicity (fever, chills, shock, vomiting, confusion, metabolic instability). The presence of critical ischaemia of the involved limb may make the infection severe

• If any concern regarding necrotising fasciitis refer urgently to Orthopaedics and discuss with Consultant Microbiologist

Treatment duration

 Treatment with the following agents is recommended for 10-14 days, after which treatment should be reviewed and continued or discontinued as appropriate

IV antibiotics may be switched to oral preparation after an appropriate interval

If any concern regarding necrotising fasciitis refer urgently to Orthopaedics and discuss with Consultant Microbiologist.

Antibiotic-naïve

Most patients will require to be admitted as systemically unwell

If admitted:

IV Flucloxacillin 2g 6 hourly

+ gentamicin^{1 2} 

Add metronidazole 400 mg oral or 500 mg IV every 8 hours if anaerobes suspected

If allergic to penicillin:

Teicoplanin⁴ + gentamicin^{1 2}

Add metronidazole 400 mg oral or 500 mg IV every 8 hours if anaerobes suspected

If not admitting:

Teicoplanin⁴

IVOS to oral doxycycline 100mg every 12 hours or according to culture results

Not antibiotic-naïve

Consider reasons for previous treatment failure

IV Ertapenem³ 1g every 24 hours

IVOS depending on culture results or to one of doxycycline 100 mg 12 hourly, co-trimoxazole 960 mg 12 hourly, or co-amoxiclav 625 mg 8 hourly

MRSA

IV Teicoplanin⁴

Oral switch

Consider oral Doxycycline 100mg every 12 hours or oral Co-trimoxazole 960mg every 12 hours according to sensitivities

If unwell discuss with Microbiology.

Treatment duration

Treat for at least 6 weeks. Longer courses may be required. Usually at least 2 weeks of IV therapy in acute setting but oral therapy may be suitable in non-acute setting.

If infected bone fully excised, then a shorter course of 2 – 5 days post-excision may be appropriate

Antibiotic-naïve

Osteomyelitis suitable for oral therapy

Oral Doxycycline 100mg every 12 hours

+/- oral metronidazole 400mg every 8 hours if anaerobes suspected

or

Oral Co-trimoxazole 960mg every 12 hours

+/- oral metronidazole 400mg every 8 hours if anaerobes suspected

or

Oral Co-amoxiclav 625mg every 8 hours

Acute Osteomyelitis

Will require at least 2 weeks IV therapy

Admit if systemically unwell or concerns regarding deep-seated infection

If not admitting:

Teicoplanin⁴

IVOS to oral doxycycline 100mg every 12 hours

If admitted:

IV Flucloxacillin 2g 6 hourly

If allergic to penicillin: Teicoplanin⁴

+Add gentamicin^{1 2}, unless poor renal function – in which case discuss with Consultant Microbiologist

Not antibiotic-naïve

Osteomyelitis suitable for oral therapy

Oral Doxycycline 100mg every 12 hours

+/- oral metronidazole 400mg every 8 hours if anaerobic cover required

or

Oral Co-trimoxazole 960mg every 12 hours

+/- oral metronidazole 400mg every 8 hours if anaerobic cover required

or

Oral Co-amoxiclav 625mg every 8 hours

Acute Osteomyelitis

Admit if potentially unwell

Consider reasons for previous treatment failure (e.g. resistance, adherence)

IV Ertapenem³ 1g every 24 hours

MRSA

Acute

IV Teicoplanin⁴

+ consider adding oral co-trimoxazole 960mg every 12 hours OR oral doxycycline 100mg every 12 hours

Non-Acute

Usually combination therapy depending on sensitivities and Infection Specialist advice.