Diabetic foot problems include:

• Diabetic foot ulcers
• Soft tissue infection
• Heel pressure sores (and other deep tissue destruction)
• Osteomyelitis
• Charcot arthropathy

Refer to the hospital immediately if any of the following:

• Gangrene (+/- ulceration)
• Ulceration with fever or any signs of sepsis
• Ulceration with limb ischaemia
• Concern of osteomyelitis or deep soft tissue infection

Assess the patient's feet for:

• Neuropathy with a 10g monofilament to test for sensory function
• PADPeripheral arterial disease with ABPIAnkle-brachial pressure index measurement

 

• Inspect for
  • Ulceration
  • Callus
  • Infection and/or inflammation
  • Deformity
  • Gangrene
  • Charcot arthropathy

Risk stratification:
 

Risk category	Criteria
Low risk	Nothing else except callus alone
Moderate risk	Any of the following: Neuropathy PADPeripheral arterial disease Deformity
High risk	Any of the following: Previous ulceration / amputation On RRTRenal replacement therapy PADPeripheral arterial disease + neuropathy Neuropathy + callus and/or deformity PADPeripheral arterial disease + callus and/or deformity

 

Low risk:

• Emphasise on foot careImportant advice includes: - Daily foot inspection - Keep feet clean and dry - Wear appropriate footwear - Avoid smoking importance
• Yearly foot assessment

Moderate or high risk:

• Emphasise on foot careImportant advice includes: - Daily foot inspection - Keep feet clean and dry - Wear appropriate footwear - Avoid smoking importance
• Refer to foot protection service
• Pressure redistribution device (to offload heel pressure)
• More frequent monitoring (every 3-6 months for moderate risk, every 1-2 months for high risk)

Assess and document the following of a foot ulcer:

• Ulcer information (location / size / depth)
• Any ischaemia / neuropathy / infection

NICE recommends offering 1 or more of the following standard care (NICE did not make specific recommendations on when to offer, thus the relevant information is base on clinical practice):
 

Care component	When to offer
Wound dressing	All patients with an ulcer
Offloading (pressure-redistributing devices)	Only for neuropathic, non-ischaemic, uninfected ulcers
Wound debridement (+/- negative wound pressure)	Only consider if there is extensive necrosis
Control of infection	Only offer antibiotics if there are signs of infection
Control of ischaemia	Only if there is ischaemia or PADPeripheral arterial disease

Consider dermal or skin substitutes as an adjunct to standard care, if healing has not progressed and on the advice of the multidisciplinary foot care service.

 

If soft tissue infection is suspected:

• Soft tissue sample for microbiology
• Alternative: deep swab

If osteomyelitis is suspected:

• Probe-to-bone testing
• X-ray
• MRI - confirmatory test
• Bone sample for microbiology

Give oral antibiotic if the person can take oral medications

• IV antibiotic is necessary in severe infection

Choice of antibiotics:
 

Scenario	Recommended antibiotics
Mild infection	1st line: flucloxacillin 2nd line: Erythromycin (suitable in pregnancy) Clarithromycin Doxycycline
Moderate / severe infection	1st line: Flucloxacillin +/- gentamicin and/or metronidazole, or Co-amoxicalv +/- gentamicin, or Ceftriaxone + metronidazole Penicillin allergy: Co-trimoxazole +/- gentamicin and/or metronidazole
Suspected / confirmed Pseudomonas aeruginosa	Antibiotic choices: Piperacillin with tazobactam (Tazocin), or Clindamycin + ciprofloxacin and/or gentamicin
Suspected / confirmed MRSA	Antibiotics to be added: Vancomycin, or Teicoplanin, or Linezolid (specialist use only)

 

Suspect acute Charcot arthropathy if:

• Redness / warmth / swelling / deformity (esp. if the skin is intact)
• More likely if there is peripheral neuropathy or renal failure
• Even if there is no pain or deformity

Investigation:

• 1st line: X-ray (weight-bearing)
• 2nd line: MRI

Offer a non-removable offloading device to all patients

Only consider surgical reconstruction for severe deformities or unstable foot

NICE guideline Diabetic foot problems: prevention and management