The prevalence of foot ulcers is 4%-10% and the lifetime incidence is as high
Causative factors include neuropathy, excessive plantar pressure, and repetitive
trauma. Vascular insufficiency, poor healing, and polymicrobial infection are major
contributors to ulcer formation.
Screening to identify patients at risk for ulcers includes detection of loss of
protective sensation by monofilament and peripheralvascular disease.
- Poorly managed foot ulcers may result in limb loss from amputation. Patient
education should emphasize prevention: daily foot examination, application of
moisturizing lotion, use of proper footwear, and caution with self-pedicure.
- The exposed feet should be inspected and palpated at every patient encounter;
significant findings, such as calluses, hammertoes or other deformities, and soft
tissue lesions, should be evaluated.
- Diabetic foot infections should be treated aggressively. Proper management
includes a multidisciplinary approach that includes orthopedic surgeons,
specialized nursing care, and close monitoring. Revascularization should be
considered as an integral part of the management of food ulcers. The presence of
deep infection with abscess, cellulitis, gangrene, or osteomyelitis is an indication
for hospitalization and prompt surgical drainage. Acute treatment of foot infections
is dependent on severity, as outlined below.
pressure are essential components of treatment and should be initiated at first
presentation. In localized cellulitis and new ulcers, Staphylococcus aureus and
streptococci are the most frequent pathogens. Therapy with oral dicloxacillin,
first-generation cephalosporin, amoxicillin/clavulanate, or clindamycin is
- Moderate to severe cellulitis. This type of involvement requires intravenous*
therapy and admission to the hospital. Consultation for debridement and aerobic
and anaerobic cultures are necessary when necrotic tissue is present.
Intravenous oxacillin/nafcillin, a first-generation IV cephalosporin,
ampicillin/sulbactam, clindamycin, and vancomycin are options for therapy.
Antibiotic coverage should subsequently be tailored according to the clinical
response of the patient, culture results, and sensitivity testing.
- Moderate to severe cellulitis with ischemia or significant local necrosis. It
is important to determine the presence of bone involvement and peripheral
vascular disease since failure to diagnose osteomyelitis and ischemia often
results in failure of wound healing.
- Bone involvement is present if bone is seen at the base of the ulcer or is
not very sensitive for diagnosis and leukocyte scanning or magnetic
resonance imaging offers better specificity.
- Presence of peripheral vascular disease is suspected by absence of pedal
- Intravenous antibiotics, bedrest, surgical debridement, culture obtained from
- Ampicillin/sulbactam and ticarcillin/clavulanate are first-line agents;
cefepime, cefotaxime, or ceftriaxone plus metronidazole are good alternatives
for initial therapy.
- In the presence of osteomyelitis, 20-12 weeks of intravenous antibiotic
require surgical amputation.