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What are the pathogenic factors in diabetic foot ulcers?
Infection, neuropathy, and ischemia.
What are the typical signs of infection in diabetics?
Inflammation, purulence, sinus tracts, crepitation, cellulitis, hyperglycemia are usually seen in associated with foot infections. Do not rely on fever, chills, or leukocytosis since their absence has been reported in over two thirds of patients with limb threatening infections.
What is a common sign of limb- or life-threatening infection?

What organisms are involved in mild diabetic foot infections? 
Aerobic gram- positive cocci such as Staphyloccocus aureus or streptococcus.
What organisms are involved in severe limb threatening infections?
Polymicrobial infections usually involve:
aerobic gram-positive cocci (staph. or strep),
gram negative bacilli (E. Coli, klebsiella, or proteus),
and anaerobes (bacteroides and Peptostreptococcus).
In the diabetic foot, what diagnosis must be considered if redness, swelling, and warmth exist?
Charcot disease must be ruled out unless obvious signs of infection.
What is the preferred weightbearing status of an infected or noninfected neuropathic ulcer?
Ideally avoidance of any weightbearing is preferred, however, realistically minimized pressure can be achieved with total contact casting or felted foam dressings in order to provide decreased pressure to the affected area and allow healing to occur.
In the diabetic foot, what are the common signs of infection typically seen?
Due to the diabetes, signs of local infection are often subtle and may not manifest until severe infection. Hyperglycemia and flu-like symptoms may be the only warning signs
What is the ultimate goal in the management of the diabetic foot?
Prevention of ulceration or recurrent ulceration, which increases the patient's susceptibility to infection.
What are the steps to preventing infection in the diabetic foot?
Regular foot inspection with an emphasis on proper foot hygiene. 

Daily shoe inspection including the changing of shoes after several hours to prevent repetitive pressure to a focal area.

Adequate control of the blood sugars, cessation of smoking, exercise, and periodic physican examination will assist in the avoidance of infection.
What are the typical organisms seen in severe diabetic foot ulcers?
In severe cases, polymicrobial infection with aerobic gram positive cocci, aerobic gram negative bacilli, and anaerobic isolates of gram negative and or gram positive bacteria.
Name common organisms seen in diabetic foot infections.

  • Staphylococcus aureus

  • Staphylococcus epidermidis

  • Streptococcus

  • Enterococcus

  • Escherichia coli

  • Proteus species

  • Bacteroides species

  • Peptococcus

  • Peptostreptococcus

  • Clostridium

How does one select an antibiotic for a diabetic foot infection?
One must first determine whether the infection is non limb threatening, limb threatening, or life threatening. This will allow for empirical coverage via expected pathogens.
Then the patient's history, in terms of drug allergies, renal and liver functions must be determined prior to the onset of any antibiotic.
When possible, wound cultures should be sent to microbiology to assist in the appropriate selection of antibiotics.
When treating a diabetic foot infection with oral antibiotics, what must one consider?
Diabetic gastropathy which may alter the absoprtion of any oral medication. Thus the antibiotic serum levels may be less than adequate for eradication.
What is the initial treatment of a limb or life-threatening diabetic foot infection?
Early incision and drainage with debridement of all necrotic soft tissue and bone.
What is the initial treatment of a non-limb or life-threatening diabtic foot infection?
Pending a thorough examination of the diabetic foot, one's clinical judgment will determine whether the wound is non-limb-threatening versus limb/life-threatening. Provided the wound is deemed non-limb-threatening, an antiobiotic course of therapy can begin.
What is the most important risk factor for ulceration in the diabetic foot? and how can one slow the progression?
Neuropathy is the major factor in which glycemic control can slow its progression.
What is the management of osteomyelitis in the diabetic foot?
Upon diagnosis the infected bone must be debrided or limited amputation. A two-three week course of antibiotics will follow to eliminate any remaining soft tissue infection.
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