Key Approaches to Managing Diabetic Foot Infection

In her session at the Spring Symposium on Advanced Wound Care in National Harbor, Maryland, Mary Bessesen, MD, Professor, Medicine-Infectious Disease, University of Colorado School of Medicine, focuses on the basic principles for diagnosing diabetic foot infections and reviews the key approaches to practicing evidence and consensus-based care for this patient population.

Additional Resource:

• Bessesen M. Practicing an Evidence and Consensus Based Approach to Diabetic Foot Infection. Presented at: The Symposium on Advanced Wound Care 2023; April 26 – April 30, 2023; Spring Harbor, MD. Accessed May 11, 2023. https://www.sawcspring.com/agenda22

Mary Bessesen, MD is a professor, Medicine-Infectious Disease, at the University of Colorado School of Medicine (Aurora, Colorado).

TRANSCRIPTION:

Mary Bessesen, MD: I'm Mary Bessesen. I'm an infectious disease specialist. I'm a professor of medicine at the University of Colorado and the Section Chief of Infectious Diseases at the Rocky Mountain Regional VA Medical Center.

Consultant360: Can you provide an overview of the learning objectives from your lecture on evidence and consensus-based approach to diabetic foot infection?

Dr Bessesen: So there are many great topics at this conference and so my role I think is mostly to give a bit of an overview. I'm going to focus on diagnosis and make the point that there's no red light-green light diagnostic test for diabetic foot osteomyelitis, that it's really a clinical diagnosis based on our clinical exam history, imaging and laboratory studies.

Secondly, I'll go over antimicrobial therapy. Somewhat again, there are other sessions about that, so I'm going to focus on some basic principles, the role of culture and when we are in need of empiric therapy while awaiting cultures, or unfortunately in the absence of cultures sometimes, how we make the best selections there.

C360: How does a clinician effectively utilize an evidence and or consensus-based approach to diabetic foot infection?

Dr Bessesen: Yes, good question. It's a clinical diagnosis, and that's the key. In order to make use of guidelines, you have to already know what you're treating. The guidelines tell you how to treat osteomyelitis, but is it there or not is the first question. And there are a couple of guidelines out there about infection in the diabetic foot and they don't always agree. So I'm going to go over some of the differences between them and how we come to a consensus on those as clinicians.

C360: How does that approach change depending on the severity of the infection that the care team is treating, for example, osteomyelitis versus a soft tissue infection?

Dr Bessesen: Yes, so when we're treating a soft tissue infection, it's a relatively short duration of therapy. We often don't have cultures to guide us, and it's usually an earlier infection, less severe, less risk of amputation and we're able to choose antibiotics empirically based on the pathogens typically found in that situation in most cases. Whereas when we're treating osteomyelitis, we're looking at several weeks of therapy, the risk of toxicity is substantial and the risk of failure is high if we don't choose the best antibiotics. So there it's really important that we make a bacteriologic diagnosis if we possibly can.

C360: Do you utilize a multidisciplinary approach to treating diabetic foot ulcers? And if so, who is typically part of that team?

Dr Bessesen: Yeah, multidisciplinary team is really critical to success in treating diabetic foot infection. So the lead on that team could be a podiatrist, could be the primary care doctor, could be an infectious disease doctor, and all of those people are involved at our facility.

In addition, we typically involve a vascular service if there's any consideration for poor perfusion. And that's certainly a critical piece and something that I'll go over today is how important it is to assess perfusion. Wound care is essential of course. And in fact, they're sometimes the lead on the case as well. And as a multidisciplinary group, while there always has to be a quarterback, if you will, keeping an eye on everything, every member of the team is really essential.

C360: What is the overall take-home messages from your session?

Dr Bessesen: Well, I think on diagnosis, I think to approach the histopathologic diagnosis with caution and keep in mind that our clinical suspicion and all of the clinical features of the case are so important and will support us better in making the right decision for patients than using histopathology as that red light-green light diagnostic test.

And secondly, that antibiotic selection varies with the stage and severity of the infection, that we don't always have to pull out the broadest spectrum, most intense antibiotics for every infection in a diabetic foot that early on it's mostly staph and strep. Later on or in complicated cases we may have highly resistant organisms and that's when we need to get out the broader spectrum, more intense antibiotics.