Guidelines on Management of the Patient with Diabetic Foot Infection

Objective: This guideline provides recommendations for the management of diabetic foot infections (DFI) and is meant to standardize in-hospital and post-discharge care with the aim of reducing post-infection disability, particularly from high amputation rates prevalent in Jamaica. It is targeted at General Surgeons leading multidisciplinary treatment teams in the local, Jamaican context, but may be relevant in other middle-income countries with similar healthcare and socio-economic demographics. Methods: The format of the guideline borrows generic elements from others identified in the literature. Synthesis involved crafting a discussion paper outlining all components of management of DFI, detailed systematic examination of the literature, particularly research emanating from Jamaica and the Caribbean, and preparation of referenced draft recommendations. Several iterations later, the final guideline was approved by the full committee. Recommendations: Recommended public health interventions to prevent DFI precede the guideline. The guideline recommends hospitalization for established DFI and management by multidisciplinary teams led by General Surgeons. Hyperglycaemia is managed preferably with basal-bolus insulin. The affected limb should be clinically assessed for severe or critical limb ischaemia (CLI) and ankle-brachial index (ABI) measured, non-invasive angiography (duplex or computed tomography) performed if ABI <= 0.5 and the result discussed with a vascular surgeon. If CLI is diagnosed and revascularization is not feasible, amputation no lower than below knee level should be contemplated. Wounds should be assessed for extent of infection (including osteomyelitis) and debrided, tissue sent for culture, and empirical bactericidal broad spectrum intravenous antibiotic therapy initiated. Methicillin-resistant Staphylococcus aureus coverage should be considered for severe or rapidly spreading DFI, pending culture reports. Wounds should be inspected, debrided and dressed daily. After-discharge care includes provision of diabetic foot care education, outpatient wound care, discontinuation of antibiotics when appropriate, early off-loading for slowly healing plantar wounds originating from or evolving into neuropathic ulcers, and referral for orthoses and prostheses.