Skip to main content
SpringerLink
Log in

Infected Wound Bed Management: The Diabetic Foot

  • Chapter
  • First Online:
Pearls and Pitfalls in Skin Ulcer Management

Abstract

The expression “Diabetic Foot” (DF) refers to any infection, ulceration, or destruction of foot tissues occurring in a person with diabetes mellitus, usually associated to peripheral neuropathy and/or peripheral artery disease (PAD). DF lesions can be classified according to their main cause into neuropathic, ischemic, neuro-ischemic, and infected. Neuropathic ulcers occur in high pressure points and are best treated with offloading. Ischemic lesions occur mostly at the extremities and require restoration of adequate blood flow to aim for healing. Neuro-ischemic lesions combine features of neuropathic and ischemic feet. Any diabetic foot lesion can complicate with infection that may range from mild and uncomplicated to limb- or life-threatening conditions. The mainstay of life-threatening diabetic foot infections and of limb-threatening conditions associated with deep purulent collections or rapid clinical worsening is immediate surgical debridement. Several clinico-pathologic entities may be responsible of a diabetic foot infection. The most commonly encountered in clinical practice are suppurative deep infections (e.g., abscesses and phlegmons), wet gangrene, necrotizing fasciitis, cellulitis, erysipelas, and diabetic foot osteomyelitis (DFO). Diagnosing DFO is often difficult and is based on a combination of clinical, radiological, and laboratory findings when culture and histology are not available. DFO treatment could be mainly surgical or mainly medical according to the extension of the infective process and patient’s surgical risk profile. A biopsy for culture and sensitivity testing is always advisable in order to drive appropriate antibiotic treatment and avoid selection of multi-drug-resistant germs.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 189.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Hardcover Book
USD 249.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. van Netten JJ, Bus SA, Apelqvist J, Lipsky BA, Hinchliffe RJ, Game F, Rayman G, Lazzarini PA, Forsythe RO, Peters EJG, Senneville É, Vas P, Monteiro-Soares M, Schaper NC, International Working Group on the Diabetic Foot. Definitions and criteria for diabetic foot disease. Diabetes Metab Res Rev. 2020;36(Suppl 1):e3268. https://doi.org/10.1002/dmrr.3268. Epub 2020 Jan 14.

    Article  PubMed  Google Scholar 

  2. Armstrong DG, Boulton AJ, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med. 2017;376:2367–75.

    Article  PubMed  Google Scholar 

  3. International Diabetes Federation. Diabetes atlas. 7th ed. Brussels: International Diabetes Federation; 2015. http://www.diabetesatlas.org.

    Google Scholar 

  4. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293:217–28.

    Article  CAS  PubMed  Google Scholar 

  5. Lavery LA, Armstrong DG, Wunderlich RP, Tredwell J, Boulton AJ. Diabetic foot syndrome: evaluating the prevalence and incidence of foot pathology in Mexican Americans and non-Hispanic whites from a diabetes disease management cohort. Diabetes Care. 2003;26:1435–8.

    Article  PubMed  Google Scholar 

  6. Iversen MM, Tell GS, Riise T, et al. History of foot ulcer increases mortality among individuals with diabetes: ten-year follow-up of the Nord-Trøndelag health study, Norway. Diabetes Care. 2009;32:2193–9.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Faglia E, Clerici G, Caminiti M, Quarantiello A, Gino M, Morabito A. The role of early surgical debridement and revascularization in patients with diabetes and deep foot space abscess: retrospective review of 106 patients with diabetes. J Foot Ankle Surg. 2006;45:220–6.

    Article  PubMed  Google Scholar 

  8. Nickinson ATO, Bridgwood B, Houghton JSM, Nduwayo S, Pepper C, Payne T, Bown MJ, Davies RSM, Sayers RD. A systematic review investigating the identification, causes, and outcomes of delays in the management of chronic limb-threatening ischemia and diabetic foot ulceration. J Vasc Surg. 2020;71(2):669–681.e2.

    Article  PubMed  Google Scholar 

  9. Monteiro-Soares M, Russell D, Boyko EJ, Jeffcoate W, Mills JL, Morbach S, Game F. International working group on the diabetic foot (IWGDF). Guidelines on the classification of diabetic foot ulcers (IWGDF 2019). Diabetes Metab Res Rev. 2020;36(Suppl 1):e3273. https://doi.org/10.1002/dmrr.3273.

    Article  PubMed  Google Scholar 

  10. Mills JL Sr, Conte MS, Armstrong DG, Pomposelli FB, Schanzer A, Sidawy AN, Andros G. Society for Vascular Surgery Lower Extremity Guidelines Committee. The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg. 2014;59(1):220–34.e1–2. https://doi.org/10.1016/j.jvs.2013.08.003. Epub 2013 Oct 12.

    Article  PubMed  Google Scholar 

  11. Conte MS, Bradbury AW, Kolh P, et al. Global vascular guidelines on the management of chronic limb-threatening ischemia. Eur J Vasc Endovasc Surg. 2019;58(1S):S1–S109.e33. https://doi.org/10.1016/j.ejvs.2019.05.006. Epub 2019 Jun 8. Erratum in: Eur J Vasc Endovasc Surg. 2020 Mar;59(3):492–493. Erratum in: Eur J Vasc Endovasc Surg. 2020 Jul;60(1):158–159. PMID: 31182334; PMCID: PMC8369495.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Calhoun JH, Cantrell J, Cobos J, Lacy J, Valdez RR, Hokanson J, Mader JT. Treatment of diabetic foot infections: Wagner classification, therapy, and outcome. Foot Ankle. 1988;9:101–6.

    Article  CAS  PubMed  Google Scholar 

  13. Lavery LA, Armstrong DG, Harkless LB. Classification of diabetic foot wounds. J Foot Ankle Surg. 1996;35(6):528–31. https://doi.org/10.1016/s1067-2516(96)80125-6.

    Article  CAS  PubMed  Google Scholar 

  14. Ince P, Abbas ZG, Lutale JK, Basit A, Ali SM, Chohan F, et al. Use of the SINBAD classification system and score in comparing outcome of foot ulcer management on three continents. Diabetes Care. 2008;31(5):964–7.

    Article  PubMed  Google Scholar 

  15. Rogers LC, Andros G, Caporusso J, Harkless LB, Mills JL Sr, Armstrong DG. Toe and flow: essential components and structure of the amputation prevention team. J Vasc Surg. 2010;52(3 Suppl):23S–7S. https://doi.org/10.1016/j.jvs.2010.06.004.

    Article  PubMed  Google Scholar 

  16. Patel N, Tan TW, Weinkauf C, Rice AH, Rottman AM, Pappalardo J, Goshima K, Zhou W. Economic value of podiatry service in limb salvage alliance. J Vasc Surg. 2022;75(1):296–300. https://doi.org/10.1016/j.jvs.2021.07.126. Epub 2021 Jul 24. PMID: 34314830; PMCID: PMC8900989.

    Article  PubMed  Google Scholar 

  17. Ferraresi R, Casini A, Caminiti M, Losurdo F, Clerici G. Multidisciplinary approach to diabetic foot: a challenge of expertises. G Ital Cardiol (Rome). 2018;19(9):495–503. https://doi.org/10.1714/2951.29668.

    Article  PubMed  Google Scholar 

  18. Elraiyah T, Prutsky G, Domecq JP, Tsapas A, Nabhan M, Frykberg RG, Firwana B, Hasan R, Prokop LJ, Murad MH. A systematic review and meta-analysis of off-loading methods for diabetic foot ulcers. J Vasc Surg. 2016;63(2 Suppl):59S–68S.e1–2. https://doi.org/10.1016/j.jvs.2015.10.006.

    Article  PubMed  Google Scholar 

  19. Bus SA, Armstrong DG, van Deursen RW, Lewis JE, Caravaggi CF, Cavanagh PR, International Working Group on the Diabetic Foot. IWGDF guidance on footwear and offloading interventions to prevent and heal foot ulcers in patients with diabetes. Diabetes Metab Res Rev. 2016;32(Suppl 1):25–36. https://doi.org/10.1002/dmrr.2697.

    Article  PubMed  Google Scholar 

  20. Losurdo F, Ferraresi R, Ucci A, Zanetti A, Clerici G, Zambon A. Association of infrapopliteal medial arterial calcification with lower-limb amputations in high-risk patients: a systematic review and meta-analysis. Vasc Med. 2021;26(2):164–73. https://doi.org/10.1177/1358863X20979738.

    Article  PubMed  Google Scholar 

  21. American Diabetes Association Professional Practice Committee, Draznin B, Aroda VR, Bakris G, Benson G, Brown FM, Freeman R, Green J, Huang E, Isaacs D, Kahan S, Leon J, Lyons SK, Peters AL, Prahalad P, JEB R, Young-Hyman D. 12. Retinopathy, neuropathy, and foot care: standards of medical care in diabetes-2022. Diabetes Care. 2022;45(Suppl 1):S185–94. https://doi.org/10.2337/dc22-S012.

    Article  Google Scholar 

  22. National Evidence-Based Guideline on Prevention, Identification and Management of Foot Complications in Diabetes (Part of the Guidelines on Management of Type 2 Diabetes). 2011. Melbourne Australia.

    Google Scholar 

  23. Simons JP, Schanzer A, Flahive JM, Osborne NH, Mills JL Sr, Bradbury AW, Conte MS. Survival prediction in patients with chronic limb-threatening ischemia who undergo infrainguinal revascularization. Eur J Vasc Endovasc Surg. 2019;58(1S):S120–S134.e3. https://doi.org/10.1016/j.ejvs.2019.04.009. Epub 2019 May 28.

    Article  PubMed  Google Scholar 

  24. https://qxmd.com/calculate/calculator_693/vqi-infrainguinal-revascularization-open-or-pvi-for-clti-30-day-and-2-year-survival.

  25. Prompers L, Huijberts M, Apelqvist J, Jude E, Piaggesi A, Bakker K, Edmonds M, Holstein P, Jirkovska A, Mauricio D, Ragnarson Tennvall G, Reike H, Spraul M, Uccioli L, Urbancic V, Van Acker K, van Baal J, van Merode F, Schaper N. High prevalence of ischaemia, infection and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia. 2007;50(1):18–25. https://doi.org/10.1007/s00125-006-0491-1. Epub 2006 Nov 9.

    Article  CAS  PubMed  Google Scholar 

  26. Lipsky BA, Senneville É, Abbas ZG, Aragón-Sánchez J, Diggle M, Embil JM, Kono S, Lavery LA, Malone M, van Asten SA, Urbančič-Rovan V, Peters EJG, International Working Group on the Diabetic Foot (IWGDF). Guidelines on the diagnosis and treatment of foot infection in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev. 2020;36(Suppl 1):e3280. https://doi.org/10.1002/dmrr.3280.

    Article  PubMed  Google Scholar 

  27. Senneville É, Lipsky BA, Abbas ZG, Aragón-Sánchez J, Diggle M, Embil JM, Kono S, Lavery LA, Malone M, van Asten SA, Urbančič-Rovan V, Peters EJG. Diagnosis of infection in the foot in diabetes: a systematic review. Diabetes Metab Res Rev. 2020;36(Suppl 1):e3281. https://doi.org/10.1002/dmrr.3281.

    Article  PubMed  Google Scholar 

  28. National Institute for Health and Clinical Excellence (NICE). Diabetic Foot Problems. Inpatient management of diabetic foot problems. London: National Institute for Health and Clinical Excellence (NICE); 2011.

    Google Scholar 

  29. Uçkay I, Aragón-Sánchez J, Lew D, Lipsky BA. Diabetic foot infections: what have we learned in the last 30 years? Int J Infect Dis. 2015;40:81–91. https://doi.org/10.1016/j.ijid.2015.09.02.

    Article  PubMed  Google Scholar 

  30. Edmonds M. Body of knowledge around the diabetic foot and limb salvage. J Cardiovasc Surg. 2012;53(5):605–16.

    CAS  Google Scholar 

  31. Smith-Strøm H, Iversen MM, Igland J, Østbye T, Graue M, Skeie S, Wu B, Rokne B. Severity and duration of diabetic foot ulcer (DFU) before seeking care as predictors of healing time: a retrospective cohort study. PLoS One. 2017;12(5):e0177176. https://doi.org/10.1371/journal.pone.0177176. PMID: 28498862; PMCID: PMC5428931.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Joret MO, Osman K, Dean A, Cao C, van der Werf B, Bhamidipaty V. Multidisciplinary clinics reduce treatment costs and improve patient outcomes in diabetic foot disease. J Vasc Surg. 2019;70(3):806–14. https://doi.org/10.1016/j.jvs.2018.11.032. Epub 2019 Mar 6.

    Article  PubMed  Google Scholar 

  33. Setacci C. Time is tissue. J Endovasc Ther. 2012;19(4):515–6. https://doi.org/10.1583/12-3933E.1.

    Article  PubMed  Google Scholar 

  34. Ledermann HP, Morrison WB, Schweitzer ME, Raikin SM. Tendon involvement in pedal infection: MR analysis of frequency, distribution, and spread of infection. AJR Am J Roentgenol. 2002;179(4):939–47.

    Article  PubMed  Google Scholar 

  35. Mismar A, Yousef M, Badran D, Younes N. Ascending infection of foot tendons in diabetic patients. Int J Low Extrem Wounds. 2013;12(4):271–5. https://doi.org/10.1177/1534734613493290. Epub 2013 Sep 16.

    Article  PubMed  Google Scholar 

  36. Khanna AK, Tiwary SK, Kumar P, Khanna R, Khanna A. A case series describing 118 patients with lower limb necrotizing fasciitis. Int J Low Extrem Wounds. 2009;8(2):112–6. https://doi.org/10.1177/1534734609334809.

    Article  CAS  PubMed  Google Scholar 

  37. Tarricone A, Mata K, Gee A, Axman W, Buricea C, Mandato MG, Trepal M, Krishnan P. A systematic review and meta-analysis of the effectiveness of LRINEC score for predicting upper and lower extremity necrotizing fasciitis. J Foot Ankle Surg. 2022;61(2):384–9. https://doi.org/10.1053/j.jfas.2021.09.015. Epub 2021 Sep 20.

    Article  PubMed  Google Scholar 

  38. Schmitt SK. Osteomyelitis. Infect Dis Clin N Am. 2017;31(2):325–38. https://doi.org/10.1016/j.idc.2017.01.010.

    Article  Google Scholar 

  39. Garwood CS, Kim PJ. Relevance of osteomyelitis to clinical practice. In: Boffelli TJ, editor. Osteomyelitis of the foot and ankle. 1st ed. Switzerland: Springer; 2015. p. 1–11.

    Google Scholar 

  40. Chihara S, Segreti J. Osteomyelitis. Dis Mon. 2010;56(1):5–31. https://doi.org/10.1016/j.disamonth.2009.07.001.

    Article  PubMed  Google Scholar 

  41. Hawkins BK, Barnard M, Barber KE, Stover KR, Cretella DA, Wingler MJB, Wagner JL. Diabetic foot infections: a microbiologic review. Foot (Edinb). 2022;51:101877. https://doi.org/10.1016/j.foot.2021.101877. Epub 2021 Oct 25.

    Article  PubMed  Google Scholar 

  42. Waldvogel FA, Medoff G, Swartz MN. Osteomyelitis: a review of clinical features, therapeutic considerations and unusual aspects. 3. Osteomyelitis associated with vascular insufficiency. N Engl J Med. 1970;282(6):316–22. https://doi.org/10.1056/NEJM197002052820606.

    Article  CAS  PubMed  Google Scholar 

  43. Cierny G 3rd, Mader JT, Penninck JJ. A clinical staging system for adult osteomyelitis. Clin Orthop Relat Res. 2003;414:7–24. https://doi.org/10.1097/01.blo.0000088564.81746.62.

    Article  Google Scholar 

  44. Buckholz JM. The surgical management of osteomyelitis: with special reference to a surgical classification. J Foot Surg. 1987;26(1 Suppl):S17–24.

    CAS  PubMed  Google Scholar 

  45. Keel SB. Pathologic diagnosis of osteomyelitis. In: Boffelli TJ, editor. Osteomyelitis of the foot and ankle. 1st ed. Switzerland: Springer; 2015. p. 49–53.

    Chapter  Google Scholar 

  46. Cecilia-Matilla A, Lázaro-Martínez JL, Aragón-Sánchez J, García-Morales E, García-Álvarez Y, Beneit-Montesinos JV. Histopathologic characteristics of bone infection complicating foot ulcers in diabetic patients. J Am Podiatr Med Assoc. 2013;103(1):24–31. https://doi.org/10.7547/1030024.

    Article  PubMed  Google Scholar 

  47. Newman LG, Waller J, Palestro CJ, Schwartz M, Klein MJ, Hermann G, Harrington E, Harrington M, Roman SH, Stagnaro-Green A. Unsuspected osteomyelitis in diabetic foot ulcers. Diagnosis and monitoring by leukocyte scanning with indium in 111 oxyquinoline. JAMA. 1991;266(9):1246–51. https://doi.org/10.1001/jama.266.9.1246.

    Article  CAS  PubMed  Google Scholar 

  48. Kosmopoulou OA, Dumont IJ. Feasibility of percutaneous bone biopsy as part of the management of diabetic foot osteomyelitis in a 100% neuropathic, grade 3 IDSA/IWGDF population on an outpatient basis. Int J Low Extrem Wounds. 2020;19(4):382–7. https://doi.org/10.1177/1534734620902609. Epub 2020 Jan 30.

    Article  PubMed  Google Scholar 

  49. Féron F, de Ponfilly GP, Potier L, Gauthier DC, Salle L, Laloi-Michelin M, Munier AL, Jacquier H, Vidal-Trécan T, Julla JB, Carlier A, Abouleka Y, Venteclef N, Grall N, Mercier F, Riveline JP, Senneville É, Gautier JF, Roussel R, Kevorkian JP. Reliability and safety of bedside blind bone biopsy performed by a Diabetologist for the diagnosis and treatment of diabetic foot osteomyelitis. Diabetes Care. 2021;44(11):2480–6. https://doi.org/10.2337/dc20-3170. Epub 2021 Sep 2.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Amputation Prevention Centre—Diabetic Foot Unit, Policlinico di Abano Terme and Clinica San Carlo Paderno Dugnano, Padua and Milan, Italy

    Giacomo Clerici & Andrea Casini

  2. ASST Ovest Milanese - Diabetic Foot Unit - “C. Cantù” Hospital, Abbiategrasso, MI, Italy

    Fabrizio Losurdo

  3. Manchester University NHS Foundation Trust (MFT), Manchester, UK

    Iulia Valeria Rusu

  4. Midwestern University, Glendale, AZ, USA

    Robert G. Frykberg

Authors
  1. Giacomo Clerici
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Fabrizio Losurdo
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Andrea Casini
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Iulia Valeria Rusu
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Robert G. Frykberg
    View author publications

    You can also search for this author in PubMed Google Scholar

Editor information

Editors and Affiliations

  1. Unit of Plastic and Reconstructive Surgery, Department of Precision and Regenerative Medicine and Jonic Area, University of Bari, Bari, Italy

    Michele Maruccia

  2. Plastic Surgery Unit, University of Trieste, Cattinara Hospital, Trieste, Italy

    Giovanni Papa

  3. Difficult Wound Healing Unit, Policlinico di Monza, Vercelli, Italy, Italy

    Elia Ricci

  4. Plastic and Reconstructive Surgery, University of Bari Aldo Moro, Bari, Italy

    Giuseppe Giudice

Rights and permissions

Reprints and permissions

Copyright information

© 2023 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Clerici, G., Losurdo, F., Casini, A., Rusu, I.V., Frykberg, R.G. (2023). Infected Wound Bed Management: The Diabetic Foot. In: Maruccia, M., Papa, G., Ricci, E., Giudice, G. (eds) Pearls and Pitfalls in Skin Ulcer Management. Springer, Cham. https://doi.org/10.1007/978-3-031-45453-0_35

Download citation

  • DOI: https://doi.org/10.1007/978-3-031-45453-0_35

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-031-45452-3

  • Online ISBN: 978-3-031-45453-0

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation