ANTIBIOTIC MANAGEMENT GUIDELINES FOR DIABETIC FOOT INFECTIONS AND ULCERS

General Management Diabetic foot ulcers and infections should be referred to the Diabetes Specialist Podiatrists for full clinical assessment. (Tel: 0161 746 2320). Patients with suspected osteomyelitis or Charcot neuroarthropathy (patients presenting with a hot, red, swollen foot) should be referred urgently to the Diabetic Foot Ulcer Service (Tel 0161 746 2320). Ulcers that fail to heal or, infections to resolve, within 6 weeks will be referred through to the Trafford Diabetic Foot Ulcer Service (clinics on Thursday pm) by the diabetes specialist podiatrists. For patients reporting penicillin allergy, a risk assessment should be undertaken as per Trust Guidelines to establish the nature of the allergy and exclude intolerances. Empiric antibiotic management of patients Antibiotic therapy is necessary for o all infected wounds; o all Grade 2 & Grade 3 ulcers; o superficial ischaemic ulcers that are deteriorating, as ischaemia can mask signs of infection. Antibiotic therapy is insufficient without appropriate wound care. Referral to the Diabetes Specialist Podiatrists (Tel: 0161 746 2320) is required for proper wound cleansing, debridement of any callus and necrotic tissue and, especially, off-loading of pressure to be implemented. Take into consideration any recent antibiotic therapy and, if concerns about resistant organisms exist (e.g. MRSA), discuss with Microbiology (0161 746 2469). Treatment can be modified based on the clinical response, as determined by the diabetes specialist podiatrists clinical assessment. Microbiology results (cultures and sensitivities) can then be used to modify antibiotic usage, dependent on clinical response. Continue antibiotic therapy until there is evidence that the infection has resolved, but not necessarily until a wound has healed (based upon assessment by the Diabetes Specialist Podiatrists). Appropriate microbiological sampling Curettage or tissue scraping from base of derided ulcer Aspirate of purulent secretions Piece of surgically obtained tissue Sampling frequency Samples should be taken at initial presentation of foot ulcer Repeat samples are NOT required unless worsening infection (e.g. at 48hours) Samples should not be taken routinely

In the absence of the above a deep swab may be taken this practice is NOT recommended due to the risk of contamination with commensal organisms. Superficial swabs are NOT useful, except in the surveillance of antibiotic resistant flora. Imaging studies may help diagnose or better define deep, soft-tissue purulent collections and are usually needed to detect pathological findings in bone. Plain X-rays may be adequate in many cases, but if soft tissue infection is suspected, refer to the Diabetic Foot Ulcer Service, where MRI will be considered for detection of soft-tissue lesions. Clinical information required on microbiology forms Neuropathy / neuroischaemia Clinical evidence of ulcer infection / no clinical evidence of ulcer infection Superficial infection / ulcer penetrating dermis Deep infection of ulcer / penetrating fascia Limb threatening infection Evidence of sepsis Clinical Follow-Up Discuss with Diabetes Specialist Podiatrist (Tel: 0161 746 2320) if patient deteriorating Measure C-reactive protein at each out-patient visit Amend therapy based on clinical response as determined by Diabetes Specialist Podiatrist. Culture results can assist if antibiotics are indicated on clinical assessment If osteomyelitis is suspected refer to the Diabetic Foot Ulcer Service with clinics on Thursday pm If MRSA is suspected discuss with Microbiology

Clinical Criteria for Grade 0 to 1

Grade 0 Pre or post-ulcerative lesion completely epithelialised Grade 1 Superficial ulcer not involving tendon, capsule or bone Infection comprising erythema and warmth extending no more than 2cms beyond edges of ulcer and no lymphangitis, swelling or systemic effects. Specimens for culture Ulcer swabs 1st Line Therapy Flucloxacillin orally 1g four times a day Plus Amoxicillin orally 1g three times a day 2nd Line Therapy Co-amoxiclav orally 625mg three times a day (if no improvement at 14 days) Penicillin allergic Clarithromycin orally 500mg twice a day Usual Duration 7 to 14 days. Refer all patients to the Diabetes Specialist Podiatrists (Tel 0161 746 2320) for clinical assessment. Ulcers failing to heal within 6 weeks will then be referred to the Thursday Diabetic Foot Ulcer Clinic.

Clinical Criteria for Grade 2 Grade 2 Wound penetrating to tendon or capsule or infection comprising extensive erythema and warmth (> 2cms beyond edge of ulcer) or lymphangitis or infection induced tissue necrosis or systemic effects or localised infection not responding to treatment. Specimen for culture Blood if systemic effects, soft tissue biopsy in neuropathic ulcers, ulcer swabs from inflamed margin In-patient Therapy Option 1st Line therapy Co-amoxiclav intravenous 1.2g three times a day Plus Gentamicin intravenous 5mg/kg/day (as per gentamicin algorithm) Then oral agents as indicated on microbiology specimens and culture. Penicillin allergic Clindamycin intravenous 900mg three times a day Plus Ciprofloxacin orally 750mg twice a day (500mg twice a day if small/frail) NB: Warn patients about diarrhoea Then oral agents as indicated on microbiology specimens and culture.

Outpatient / (Oral) Therapy Option 1st Line therapy Co-amoxiclav orally 625 mg three times a day Plus Ciprofloxacin orally 750mg twice a day (500mg twice a day if small/frail) Penicillin allergic
A risk assessment must be undertaken as per Trust guidelines. If patient has a true allergy to penicillin and is at high risk of C difficile or had previous C difficile infection, then do not use Clindamycin, but contact microbiology for advice.

Clindamycin orally 450mg four times a day (300mg four times a day if small/frail) Plus Ciprofloxacin orally 750mg twice a day (500mg twice a day if small/frail) NB: Warn patients about diarrhoea

Refer all patients urgently to the Diabetes Specialist Podiatrists and Thursday Diabetic Foot Ulcer Clinic on Tel 0161 746 2320 for ongoing clinical and antibiotic management.

Clinical Criteria for Grade 3 Grade 3 Ulcer penetrating to bone or joint + / - X-ray evidence of osteomyelitis (MR or Bone Scan may later need to be considered)

Specimen for Culture Blood culture; bone biopsy (wherever possible), deep soft tissue biopsy; deep soft tissue swabs (of limited use) In-patient Therapy Option 1st Line therapy Tazocin intravenous 4.5g three times a day Then oral agents as indicated on microbiology specimens and culture Penicillin allergic Clindamycin intravenous 900mg three times a day Plus Ciprofloxacin orally 750mg twice a day (500mg twice a day if small/frail) NB: Warn patients about diarrhoea Then oral agent as indicated on microbiology specimens and culture

Outpatient / (Oral) Therapy Option 1st Line therapy Co-amoxiclav orally 625 mg three times a day Plus Ciprofloxacin orally 750mg twice a day (500mg twice a day if small/frail) Penicillin allergic
A risk assessment must be undertaken as per Trust guidelines. If patient has a true allergy to penicillin and is at high risk of C difficile or had previous C difficile infection, then do not use Clindamycin, but contact microbiology for advice.

Clindamycin orally 450mg four times a day (300mg four times a day if small/frail) Plus Ciprofloxacin orally 750mg twice a day (500mg twice a day if small/frail) NB: Warn patients about diarrhoea Refer all patients urgently to the Diabetes Specialist Podiatrists and Thursday Diabetic Foot Ulcer Clinic on Tel 0161 746 2320 for ongoing clinical and antibiotic management

Date of Enactment: Reviewed: Review Date: Approved by: Authors:

November 2004 October 2007 October 2008 Medicines Management Group and Clinical Standards Group Dr W P Stephens, Consultant Physician; Dr C L Adamson, Associate Specialist; Dr B Faris, Consultant Microbiologist; David Milligan, Deputy Director of Pharmacy