DIABETIC FOOT DISEASE


See also Pressure Ulcers for discussion of non-diabetic pressure ulcers

I. Foot ulcers, infections, and other foot problems are a major cause of morbidity (including amputations) and mortality in DM and are probably due to the dual effects of neuropathy (decreasing pt's awareness of early foot problems, e.g. minor trauma) and ischemia (leading to poor healing and infection).

II. Risk factors for foot ulcers in pts with DM:

III. Prevention of foot ulcers in high-risk patients, per ADA 1998:

IV. In DM foot ulcers, it is important to determine whether there is infection present, particularly Osteomyelitis.  Such infections are commonly polymicrobial and usually require broad-spectrum abx, at least initially.  Predictors of & diagnostic modalities for osteomyelitis in DM foot infections (Clin. Inf. Dis. 25:1318, 1997--rvw;AFP):

V. Management of DM foot ulcers:

  1. Use: apply 1/16-inch thick continuous layer of gel daily to ulcer base and cover wound w/saline-moistenet dressing. After 12h, rince off the gel and re-cover the wound.
  2. Higher healing rates c/w placebo in 2 randomized trials w/total 500 pts treated x 20wks (Med. Lett. 40:73, 1998)
  3. No adverse effects identified

VI. Management of infected DM foot ulcers:

  • Empiric antibiotics (ofloxacin & Unasyn equally good in one study: Clin. Inf. Dis 24:643, 1997-JW) IV then PO
  • Wound cultures & adjustment of abx based on culture & sensitivity results
  • Consider osteomyelitis (see above) and if present tx with bone debridement and abx
  • G-CSF: 40 diabetics w/foot infection randomized to filgastrim (G-CSF) vs. placebo; filgastrim ass'd with earlier eradication of pathogens from the ulcer, quicker resolution of cellulitis, decrased antibiotic requirement, and shorter hospital stay; also less requirement for surgery (Lancet 350:855, 1997--UW Pharm Letter)