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Optimal Treatment of Infected Diabetic Foot Ulcers

  • Therapy In Practice
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Abstract

Foot ulceration can lead to devastating consequences in diabetic patients. They are not only associated with increased morbidity but also mortality. Foot infections result as a consequence of foot ulceration, which can occasionally lead to deep tissue infections and osteomyelitis; both of which can result in loss of limb. To prevent amputations prompt diagnosis and treatment is required. Understanding the pathology of the diabetic foot will help in the planning of appropriate investigations and treatment. Clinical diagnosis of infection is based on the presence of discharge from the ulcer, cellulitis, warmth and signs of toxicity; though the latter is uncommon. Deep tissue samples from the ulcer and/or blood cultures should be taken before, but without delaying the start of antibacterial treatment in limb and life-threatening infections. In milder infections wound sampling may direct appropriate antibacterial treatment. Staphylococcus aureus, followed by streptococci are the most common organisms causing infection and antibacterial treatment should be targeted against these organisms in mild infection possibly with monotherapy. But in serious infections combination therapy is required because these are usually caused by multiple organisms including anaerobes. Drug-resistant organisms are becoming more prevalent and methicillin-resistant infections can be treated effectively with a number of oral antibacterials either as monotherapy or in combination.

Surgical treatment with debridement, for example, callus removal or drainage of pus form an important part of diabetic foot ulcer management especially in the presence of infection. Occasionally limited surgery including dead infected bone removal may be necessary for resolution of infection. Amputation is sometimes required as a last resort for limb or life preservation.

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  1. The use of trade names is for product identification purposes only and does not imply endorsement.

References

  1. Amos AF, McCarty DJ, Zimmet P. The rising global burden of diabetes and its complications: estimates and projections to the year 2010. Diabet Med 1997; 14Suppl. 5: S7–S85

    Article  Google Scholar 

  2. Kumar S, Ashe HA, Parnell LN, et al. The prevalence of foot ulceration and its correlates in type 2 diabetic patients: a population based study. Diabet Med 1994; 11: 480–4

    Article  PubMed  CAS  Google Scholar 

  3. Morgan CL, Currie CJ, Stott NC, et al. The prevalence of multiple diabetes-related complications. Diabet Med 2000; 17: 146–51

    Article  PubMed  CAS  Google Scholar 

  4. Williams DRR. The size of the problem: epidemiological and economic aspects of foot problems in diabetes. In: Boulton AJM, Connor H, Cavanagh PR, editors. The foot in diabetes. 2nd ed. Chichester: John Wiley & Sons Ltd, 1994: 16–24

    Google Scholar 

  5. Boyko EJ, Ahroni JH, Smith DG, et al. Increased mortality associated with diabetic foot ulcer. Diabet Med 1996; 13: 967–72

    Article  PubMed  CAS  Google Scholar 

  6. Krentz AJ, Acheson P, Basu A, et al. Morbidity and mortality associated with diabetic foot disease: a 12 month prospective survey of hospital admissions in a single UK centre. Foot 1997; 7: 144–7

    Article  Google Scholar 

  7. Faglia E, Favales F, Morabito A. New ulceration, new major amputation, and survival rates in diabetic subjects hospitalised for foot ulceration from 1990–1993. Diabetes Care 2001; 24: 78–83

    Article  PubMed  CAS  Google Scholar 

  8. Currie CJ, Morgan CL, Peters JR. The epidemiologic and cost of inpatient care for peripheral vascular disease, infection, neuropathy and ulceration in diabetes. Diabetes Care 1998; 21: 42–8

    Article  PubMed  CAS  Google Scholar 

  9. Pecoraro RE, Reiber GE, Burgess EM. Pathways to diabetic limb amputation: basis for prevention. Diabetes Care 1990; 13: 513–21

    Article  PubMed  CAS  Google Scholar 

  10. New JP, McDowell D, Burns E, et al. Problem of amputations in patients with newly diagnosed diabetes mellitus. Diabet Med 1998; 15: 760–4

    Article  PubMed  CAS  Google Scholar 

  11. Goldner MG. The fate of the second leg in the diabetic amputee. Diabetes 1960; 9: 100–3

    PubMed  CAS  Google Scholar 

  12. Edmonds ME. Experience in a multidisciplinary diabetic foot clinic. In: Boulton AJM, Connor H, Ward JD, editors. The foot in diabetes. 1st ed. Chichester: Wiley, 1987: 121–33

    Google Scholar 

  13. Thomson FJ, Veves A, Ashe H, et al. A team approach to diabetic foot care: the Manchester experience. Foot 1991; 2: 75–82

    Article  Google Scholar 

  14. Oyibo SO, Jude EB, Voyatzoglou D, et al. Clinical characteristics of patients with diabetic foot problems: changing patterns of foot ulcer presentation. Pract Diab Int 2002; 19: 10–2

    Article  Google Scholar 

  15. Spanheimer RG. Inhibition of collagen production by diabetic rat serum: response to insulin-like growth factor-I added in vitro. Endocrinology 1991; 129: 3018–26

    Article  PubMed  CAS  Google Scholar 

  16. Spanheimer RG. Correlation between decreased collagen production in diabetic animals and in cells exposed to diabetic serum: response to insulin. Matrix 1992; 12: 101–7

    Article  PubMed  CAS  Google Scholar 

  17. Ferguson MWJ, Herrick SE, Spencer M-J, et al. The histology of diabetic foot ulcers. Diabet Med 1996; 13: S30–3

    PubMed  Google Scholar 

  18. Delmaire M, Maugendre D, Moreno M, et al. Impaired leucocyte functions in diabetic patients. Diabet Med 1997; 14: 29–34

    Article  Google Scholar 

  19. Thomas JF, Sadaty A, Jones WG. Diabetes impairs the late inflammatory response to wound healing. J Surg Res 1991; 50: 308–13

    Article  Google Scholar 

  20. Sapico FL, Bessman AN. Diabetic foot infections. In: Frykberg RG, editor. The high risk foot in diabetes mellitus. New York: Churchill Livinstone, 1991: 197–211

    Google Scholar 

  21. Rayfield EJ, Ault MJ, Keusch GR, et al. Infection and diabetes: the case for glucose control. Am J Med 1982; 72: 439–50

    Article  PubMed  CAS  Google Scholar 

  22. Baxter JK, Babineau TJ, Apovian CM, et al. Perioperative glucose control predicts increased nosocomial infection in diabetics [abstract]. Crit Care Med 1990; 18: 5707

    Article  Google Scholar 

  23. Pearl SH, Kanat IO. Diabetes and healing: a review of the literature. J Foot Surg 1988; 27: 268–70

    PubMed  CAS  Google Scholar 

  24. Jude EB, Boulton AJM. End stage complications of diabetic neuropathy. Diabetes Rev 1999; 7: 395–410

    Google Scholar 

  25. Jude EB, Boulton AJM. Peripheral neuropathy. Clin Podiatr Med Surg 1999; 16: 81–96

    PubMed  CAS  Google Scholar 

  26. Young MJ, Boulton AJM, Macleod AF, et al. A multicentre study of the prevalence of diabetic peripheral neuropathy in the UK hospital clinic population. Diabetologia 1993; 36: 150–4

    Article  PubMed  CAS  Google Scholar 

  27. Feldman EL, Brown MB, Stevens MJ, et al. A practical two-step quantitative clinical and electrophysiological assessment for the diagnosis and staging of diabetic neuropathy. Diabetes Care 1994; 17: 1281–889

    Article  PubMed  CAS  Google Scholar 

  28. Steiner G. Diabetes and atherosclerosis; epidemiology and intervention trials. In: Woodford FP, Davignon J, Sniderman A, editors. Atherosclerosis X. Amsterdam: Elsevier, 1995: 749–52

    Google Scholar 

  29. Kannel WB, McGee DL. Diabetes and glucose tolerance as risk factor for cardiovascular disease: the Framingham Study. Diabetes Care 1979; 2: 120–6

    Article  PubMed  CAS  Google Scholar 

  30. Krolewski AS, Warran JHM, Christlieb AR. Onset, source, complications and prognosis of diabetes mellitus. In: Marble A, Geall LP, Bradley RF, et al., editors. Joslin’s diabetes mellitus. 12th ed. Philadelphia (PA): Lea and Febiger, 1985: 251–77

    Google Scholar 

  31. Pyörälä K, Laakso M. Macrovascular disease in diabetes mellitus. In: Mann JI, Pyörälä K, Teuscher E, editors. Diabetes in epidemiological perspective. Edinburgh: Churchill Livingstone, 1983: 183–247

    Google Scholar 

  32. Weitz JL, Byrne J, Clagett GP, et al. Diagnosis and treatment of chronic arterial insufficiency of the lower extremities: a critical review. Circulation 1996; 94: 3026–49

    Article  PubMed  CAS  Google Scholar 

  33. Wagner FW. Algorithms of diabetic foot care. In: Levin ME, O’Neal LW, editors. The diabetic foot. 2nd ed. St. Louis (MO): Mosby Yearbook, 1983: 201–302

    Google Scholar 

  34. Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic wounds. J Foot Ankle Surg 1996; 35: 528–31

    Article  PubMed  CAS  Google Scholar 

  35. Oyibo SO, Jude EB, Tarawneh I, et al. Comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas Systems. Diabetes Care 2001; 24: 84–8

    Article  PubMed  CAS  Google Scholar 

  36. Lipsky BA, Pecoraro RF, Wheat LJ. The diabetic foot: soft tissue and bone infection. Infect Dis Clin North Am 1990; 4: 409–32

    PubMed  CAS  Google Scholar 

  37. Newman LG, Waller J, Palestro CJ, et al. Unsuspected osteomyelitis in diabetic foot ulcers: diagnosing and monitoring by leucocyte scanning with indium In111 oxyquinolone. JAMA 1991; 266: 1246–51

    Article  PubMed  CAS  Google Scholar 

  38. Oyibo SO, Jude EB, Tarawneh I, et al. The effects of ulcer size and site, patient’s age, gender and type and duration of diabetes on the outcome of diabetic foot ulcers. Diabetic Med 2001; 18: 133–8

    Article  PubMed  CAS  Google Scholar 

  39. Grayson ML, Gibbons GW, Balogh K, et al. Probing to bone in infected pedal ulcers: a clinical sign of underlying osteomyelitis in diabetic patients. J Am Podiatry Assoc 1995; 273: 721–3

    Article  CAS  Google Scholar 

  40. Karchmer AW, Gibbons GW. Foot infections in diabetes: evaluation and management. Curr Clin Top Infect Dis 1994; 14: 1–22

    PubMed  CAS  Google Scholar 

  41. Grayson ML, Gibbons GW, Habershaw GM, et al. Use of ampicillin/sulbactam versus imipenem/cilastin in the treatment of limb threatening foot infections in diabetic patients. Clin Infect Dis 1994; 18: 683–93

    Article  PubMed  CAS  Google Scholar 

  42. Leichter SB, Allweiss P, Harley J, et al. Clinical characteristics of diabetic patients with serious pedal infections. Metabolism 1988; 37: 22–4

    Article  PubMed  CAS  Google Scholar 

  43. Armstrong DG, Lavery LA, et al. Leucocytosis is a poor indicator of acute osteomyelitis of the foot in diabetic mellitus. J Foot Ankle Surg 1996; 35: 280–3

    Article  PubMed  CAS  Google Scholar 

  44. Jude EB, Selby PL, Mawer EB, et al. Inflammatory and bone turnover markers in Charcot arthropathy and osteomyelitis of the feet in diabetic patients [abstract]. Diabetologia 2002; 25 Suppl.: 1056

    Google Scholar 

  45. Browne AC, Vearncombe M, et al. High bacterial load in asymptomatic diabetic patients with neurotrophic ulcers retards wound healing after application of Dermagraft. Ostomy Wound Manage 2001; 47: 44–9

    PubMed  CAS  Google Scholar 

  46. Sapico FL, Canawati HN, Witte JL, et al. Quantitative aerobic and anaerobic bacteriology of infected diabetic foot. J Clin Microbiol 1980; 12: 413–20

    PubMed  CAS  Google Scholar 

  47. Pellizzer G, Strazzabosco M, Presi S, et al. Deep tissue biopsy vs superficial swab culture monitoring in the microbiological assessment of limb-threatening diabetic foot infection. Diabet Med 2001; 18: 822–7

    Article  PubMed  CAS  Google Scholar 

  48. Sapico FL. Foot infections in diabetic patients and infections associated with pressure sores. In: Baddour L, Gorbach SL, editors. Therapy in infectious diseases. Philadelphia (PA): Saunders, 2003: 343–6

    Google Scholar 

  49. Caputo GM, Cavanagh PR, Ulbrecht JS, et al. Assessment and management of foot disease in patients with diabetes. N Engl J Med 1994; 331: 854–60

    Article  PubMed  CAS  Google Scholar 

  50. Tentolouris N, Jude EB, Smirnof I, et al. Methicillin-resistant Staphylococcus aureus: an increasing problem in a diabetic foot clinic. Diabet Med 1999; 16: 767–71

    Article  PubMed  CAS  Google Scholar 

  51. Delbridge L, Ctereko G, Fowler C, et al. The aetiology of diabetic neuropathic ulceration of the foot. Br J Surg 1985; 72: 1–6

    Article  PubMed  CAS  Google Scholar 

  52. Wheat LJ, Allen SD, Henry M, et al. Diabetic foot infections: bacteriologic analysis. Arch Intern Med 1986; 146: 1935–40

    Article  PubMed  CAS  Google Scholar 

  53. Lipsky BA. Osteomyelitis of the foot in diabetic patients. Clin Infect Dis 1997; 25: 1318–26

    Article  PubMed  CAS  Google Scholar 

  54. Dang CN, Prasad YDM, Boulton AJM, et al. Methicillin-resis-tant Staphylococcus aureus in the diabetic foot clinc: a worsening problem. Diabet Med 2003; 20: 159–61

    Article  PubMed  CAS  Google Scholar 

  55. Eckman MH, Greenfield S, Mackey WC, et al. Foot infections in diabetic patients: decision and cost-effectiveness analyses. JAMA 1995; 273: 712–20

    Article  PubMed  CAS  Google Scholar 

  56. Bridges MRJ. Diabetic foot infections. Surg Clin North Am 1994; 74: 537–55

    PubMed  Google Scholar 

  57. Capitanio MA, Kirkpatrick JA. Early roentgen observation in acute osteomyelitis. Am J Roentgenol Radium Ther Nucl Med 1970 Mar; 108(3): 488–96

    PubMed  CAS  Google Scholar 

  58. Waldvogel FA, Medoff G, Schwartz MN. Osteomyelitis: a review of clinical features, therapeutic considerations and unusual aspects. N Engl J Med 1970; 282: 198–206

    Article  PubMed  CAS  Google Scholar 

  59. Wang A, Weinstein D, Greenfield L, et al. MRI and diabetic foot infections. Magn Reson Imaging 1990; 8: 805–9

    Article  PubMed  CAS  Google Scholar 

  60. Johnson JE, Kennedy EJ, Shereff MJ, et al. Prospective study of bone, indium-111-labeled white blood cell, and gallium-67 scanning on the evaluation of osteomyelitis in the diabetic foot. Foot Ankle Int 1996; 17: 10–6

    PubMed  CAS  Google Scholar 

  61. AlSheikh W, Afakianokis GN, Mnaymneh W, et al. Subacute and chronic bone infections: diagnosis using 111In, 67Ga and 99mTc-MDP bone scintigraphy and radiography. Radiology 1985; 155: 501–6

    CAS  Google Scholar 

  62. Hoffer P. Gallium: mechanisms. J Nucl Med 1980; 21: 282–5

    PubMed  CAS  Google Scholar 

  63. Palestro CJ. The current role of Gallium imaging in infection. Semin Nucl Med 1994; 24: 128–41

    Article  PubMed  CAS  Google Scholar 

  64. Sorsdahl OA, Goodhart GL, Williams HT, et al. Quantitative bone gallium scintigraphy in osteomyelitis. Skeletal Radiol 1993; 22: 239–42

    Article  PubMed  CAS  Google Scholar 

  65. Schauwecker DS, Park HM, Burt RW, et al. Combined bone scintigraphy and indium-111 leukocyte scans in neuropathic foot disease. J Nucl Med 1988; 29: 1651–5

    PubMed  CAS  Google Scholar 

  66. Enderle MD, Coerper S, Schweizer HP, et al. Correlation of imaging techniques to histopathology in patients with diabetic foot syndrome and clinical suspicion of chronic osteomyelitis. Diabetes Care 1999; 22: 294–9

    Article  PubMed  CAS  Google Scholar 

  67. Harwood SJ, Valdivia S, Hung G-L, et al. Use of Sulesomab, a radiolabled antibody fragment, to detect osteomyelitis in diabetic patients with foot ulcers by leukoscintigraphy. Clin Infect Dis 1999; 28: 1200–5

    Article  PubMed  CAS  Google Scholar 

  68. Diabetes care and related research in Europe: the Saint Vincent Declaration. Diabetic Med 1990; 7: 360

  69. Delamaire M, Maugendre D, Moreno M, et al. Impaired leukocyte functions in diabetic patients. Diabetic Med 1997: 14: 29–34

    Article  PubMed  CAS  Google Scholar 

  70. Mason J, O’Keeffe C, Hutchinson A, et al. A systematic review of foot ulcer in patients with type 2 diabetes mellitus. II: treatment. Diabet Med 1999; 16: 889–909

    Article  PubMed  CAS  Google Scholar 

  71. Lipsky BA, Pecoraro RF, Larson SA. Outpatient management of uncomplicated lower-extremity infections in diabetic patients. Arch Intern Med 1990; 150: 790–7

    Article  PubMed  CAS  Google Scholar 

  72. Karchmer AW. Microbiology and treatment of diabetic foot infections. In: Veves A, Giurini JM, LoGerfo FW, editors. The diabetic foot. Totowa (NJ): Humana Press, 2002: 207–19

    Chapter  Google Scholar 

  73. Peterson LR, Lissack LM, Canter K, et al. Therapy of lower extremity infection with ciprofloxacin in patients with diabetes mellitus, peripheral vascular disease or both. Am J Med 1989; 86: 801–8

    Article  PubMed  CAS  Google Scholar 

  74. Gentry LO, Ramiez-Ronda CH, Rodriquez-Noriega E, et al. Oral ofloxacin vs parenteral cefotaxime in the treatment of difficult skin and skin structure infections. Arch Intern Med 1989; 149: 2579–83

    Article  PubMed  CAS  Google Scholar 

  75. Gentry LO, Rodriquez-Gomez G, Zeluff BJ, et al. A comparative evaluation of oral ofloxacin versus intravenous cefotaxime therapy for serious skin and skin structure infections. Am J Med 1988; 87Suppl. 6C: 57S–60S

    Google Scholar 

  76. Bryskier A. Anti-anaerobic activity of antibacterial agents. Expert Opin Investig Drugs. 2001 Feb; 10(2): 239–67

    Article  PubMed  CAS  Google Scholar 

  77. Gibbons GW, Eliopoulos GM. Infection of the diabetic foot. In: Kozak GP, Campbell DR, Frykberg RG, et al., editors. Management of diabetic foot problems. Philadelphia (PA): WB Saunders, 1995: 121

    Google Scholar 

  78. Lipsky BA, Berendt AR. Antibiotic therapy and diabetic foot infections. Podiatry Today 1998 Nov; 11: 24–36

    Google Scholar 

  79. Nathwani D, Barlow GD, Ajdukiewicz K, et al. Cost-minimisation analysis and audit of antibiotic management of bone and joint infections with ambulatory teicoplanin, in patient care or outpatient oral linezolid therapy. J Antimicrob Chemother 2003; 51: 391–6

    Article  PubMed  CAS  Google Scholar 

  80. Perry CM, Jarvis B. Linezolid: a review of its use in the management of serious gram-positive infections. Drugs 2001; 61: 525–51

    Article  PubMed  CAS  Google Scholar 

  81. Melzer M, Goldsmith D, Gransden W. Successful treatment of vertebral osteomyelitis with linezolid in a patient receiving hemodialysis and with persistent methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus bacteremias. Clin Infect Dis 2000; 31: 208–9

    Article  PubMed  CAS  Google Scholar 

  82. Raghavan M, Linden PK. Newer treatment options for skin and soft tissue infections. Drugs 2004: 64(15) 1621–42

    Article  PubMed  CAS  Google Scholar 

  83. Lipsky BA, Itani K, Norden C, et al. Treating foot infections in diabetic patients: a randomized, multicentre, open-label trial of linezolid versus ampicillin-sulbactam/amoxicillin-clavulanate. Clin Infect Dis 2004; 38: 17–24

    Article  PubMed  CAS  Google Scholar 

  84. Venkatesan P, Lawn S, Macfarlane RM, et al. Conservative management of osteomyelitis in the feet of diabetic patients. Diabet Med 1997; 14: 487–90

    Article  PubMed  CAS  Google Scholar 

  85. Petrova A. Gipsfulung von Knochenhohlen bei Osteomyelitis. Zentral Ges Chir 1928; 43: 885

    Google Scholar 

  86. Armstrong DG, Findlow A, Oyibo SO, et al. The use of absorbable antibiotic-impregnated calcium sulphate pellets in the management of diabetic foot ulcers. Diabet Med 2001; 18: 941–2

    Article  Google Scholar 

  87. Mackey D, Varlet A, Debeaumont D. Antibiotic loaded Plaster of Paris pellets: an in vitro study of a possible method of local antibiotic therapy in bone infection. Clin Orthop 1982; 167: 263–8

    PubMed  Google Scholar 

  88. Lamb HM, Wiseman LR. Pexiganan acetate. Drugs 1998; 56: 1047–52

    Article  PubMed  CAS  Google Scholar 

  89. Tan JS, File TM. Diagnosis and treatment of diabetic foot infections. Baillieres Best Pract Res Clin Rheumatol 1999 Mar; 13(1): 149–61

    Article  PubMed  CAS  Google Scholar 

  90. Bamberger DM, Daus GP, Gerding DN. Osteomyelitis in the feet of diabetic patients: long-term results, prognostic factors, and the role of antimicrobial and surgical therapy. Am J Med 1987; 83: 653–60

    Article  PubMed  CAS  Google Scholar 

  91. Apelqvist J, Larsson J, Agardh CD. Medical risk factors in diabetic patients with foot ulcers and severe peripheral vascular disease and their influence on outcome. J Diabetes Complications 1992; 6: 167–74

    Article  PubMed  CAS  Google Scholar 

  92. McIntyre KE. Control of infection in the diabetic foot: the role of microbiology, immunopathy, antibiotics and guillotine amputation. J Vasc Surg 1987; 5: 787–90

    PubMed  CAS  Google Scholar 

  93. Scher KS, Steele FJ. The septic foot in patients with diabetes. Surgery 1988; 104: 661–6

    PubMed  CAS  Google Scholar 

  94. Jude EB, Spittle M, Connor H, et al. The diabetic foot, 1998. Diabet Med 1999; 16: 104–6

    Article  Google Scholar 

  95. LoGerfo FW, Gibbons GW, Pomposelli FB, et al. Trends in the care of the diabetic foot: expanded role of arterial reconstruction. Arch Surg 1992; 127: 617–20

    Article  PubMed  CAS  Google Scholar 

  96. Gough A, Clapperton M, Rolando N, et al. Randomised placebo-controlled trial of granulocyte-colony stimulating factor in diabetic foot infection. Lancet 1997; 350: 855–9

    Article  PubMed  CAS  Google Scholar 

  97. Thomas S, Jones M, Shutler S, et al. Using larvae in modern wound management. J Wound Care 1996; 5: 60–9

    PubMed  CAS  Google Scholar 

  98. Thomas S. New drugs for diabetic foot ulcers: larval therapy. In: Boulton AJM, Connor H, Cavanagh PR, editors. The foot in diabetes. 3rd ed. Chichester: John Wiley & Son, 2000: 185–91

    Chapter  Google Scholar 

  99. Casu RE, Eisemann CH, Vuoclo T, et al. The major excretory/secretory protease from Lucilia cuprina larvae is also gut digestive protease. Int J Parasitol 1996; 26: 623–8

    Article  PubMed  CAS  Google Scholar 

  100. Rayman A, Stansfield G, Woollard T, et al. Use of larvae in the treatment of the diabetic necrotic foot. Diabetic Foot 1998; 1: 7–13

    Google Scholar 

  101. Nwomeh BC, Yager DR, Cohen IK. Physiology of the chronic wound. Clin Plast Surg 1998; 25: 341–56

    PubMed  CAS  Google Scholar 

  102. Bakker DJ. Hyperbaric oxygen therapy and the diabetic foot. Diabetes Metab Res Rev 2000; 16Suppl. 1: S55–8

    Article  PubMed  Google Scholar 

  103. Lansdown ABG, Sampson B, Laupattarakasem P, et al. Silver aids healing in the sterile skin wound: experimental studies in the laboratory rat. Br J Dermatol 1997; 137: 728–35

    Article  PubMed  CAS  Google Scholar 

  104. Russell AD, Hugo WB. Antimicrobial activity and action of silver. Prog Med Chem 1994; 31: 351–70

    Article  PubMed  CAS  Google Scholar 

  105. Hostynek JJ, Hinz RS, Lorence CR, et al. Metals and the skin. Crit Rev Toxicol 1993; 23(2): 171–235

    Article  PubMed  CAS  Google Scholar 

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Acknowledgements

Dr Jude has received funding from Pfizer and Bristol-Myers Squibb and Dr Philip Unsworth from Bayer PLC.

The authors have no conflicts of interest that are directly relevant to the content of this review.

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  1. Tameside General Hospital, Ashton-Under-Lyne, Lancashire, UK

    Edward B. Jude & Philip F. Unsworth

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Jude, E.B., Unsworth, P.F. Optimal Treatment of Infected Diabetic Foot Ulcers. Drugs Aging 21, 833–850 (2004). https://doi.org/10.2165/00002512-200421130-00002

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