Foot infection

For the gentleman in the case vignette we would review him in the multidisciplinary foot clinic and clarify his vascular and neurological status. The ulcer should be debrided and tissue sent for culture and the foot X-rayed. The foot is ischaemic, so the lack of classical signs does not preclude infection. The yellow slough and arrested healing are suggestive of infection, so we would start treatment with coamoxiclav, pending the results of the cultures. The ulcer would be offloaded and the patient reviewed after 3-4 days when the culture results are available. At this stage the antibiotics can be focused if appropriate and continued for 2 weeks, when the need for ongoing antibiotics can be reviewed. If there is evidence of critical limb ischaemia, urgent vascular review and angiography should be organized. Even in the absence of such critical, severe ischaemia, the lack of foot pulses necessitates consideration of vascular imaging, particularly if the ulcer fails to respond to debridement, off loading and antibiotics. A review of metabolic control and vascular protective measures, e.g. aspirin, smoking status, lipid lowering and blood pressure management, would also be prudent, although evidence of acute benefit is lacking. At present, there are insufficient data to recommend particular dressings but research in the field is ongoing. Management of diabetic foot ulceration requires a multifaceted multidisciplinary approach and the use of antibiotics is an important element, but must be based on robust microbiological evidence. © 2006 Diabetes.