Infected Wound Bed Management: The Diabetic Foot

The expression "Diabetic Foot" (DF) refers to any infection, ulceration, or destruction of foot tissues occurring in a person with diabetes mellitus, usually associated to peripheral neuropathy and/or peripheral artery disease (PAD). DF lesions can be classified according to their main cause into neuropathic, ischemic, neuro-ischemic, and infected. Neuropathic ulcers occur in high pressure points and are best treated with offloading. Ischemic lesions occur mostly at the extremities and require restoration of adequate blood flow to aim for healing. Neuro-ischemic lesions combine features of neuropathic and ischemic feet. Any diabetic foot lesion can complicate with infection that may range from mild and uncomplicated to limb- or life-threatening conditions. The mainstay of life-threatening diabetic foot infections and of limb-threatening conditions associated with deep purulent collections or rapid clinical worsening is immediate surgical debridement. Several clinico-pathologic entities may be responsible of a diabetic foot infection. The most commonly encountered in clinical practice are suppurative deep infections (e.g., abscesses and phlegmons), wet gangrene, necrotizing fasciitis, cellulitis, erysipelas, and diabetic foot osteomyelitis (DFO). Diagnosing DFO is often difficult and is based on a combination of clinical, radiological, and laboratory findings when culture and histology are not available. DFO treatment could be mainly surgical or mainly medical according to the extension of the infective process and patient's surgical risk profile. A biopsy for culture and sensitivity testing is always advisable in order to drive appropriate antibiotic treatment and avoid selection of multi-drug-resistant germs.