- Blood cultures (10mls per bottle send before starting antibiotics)
- X-rays (check for osteomyelitis; if severe infection or patient not improving)
- Consider bone biopsy prior to antibiotics if osteomyelitis is identified.
- Consider assessing arterial supply and need for debridement.
Diabetic Foot Infection
Patients should be managed by a multidisciplinary diabetic foot care team.
- Seek specialist advice from diabetic foot clinic at RIE (Dr Matthew Young) or SJH (Dr Karen Adamson)
Assessment
Use the answers to the following 4 questions to decide on the antibiotic choices in the guidance below.
- Has the patient been identified as a carrier of MRSA or had an infection caused by MRSA? If so use the recommendations for MRSA.
- Has the patient received antibiotics in the last month? If "Yes", then use the non-antibiotic naive recommendations.
- Does the patient have a penicillin allergy label? If so review the nature of the allergy here. If the label of allergy is felt to be accurate then follow the recommendation for penicillin allergy.
- Use the table below to decide on the severity of infection.
Mild |
No systemic illness with either:
|
Moderate |
No systemic illness, two or more features of inflammation and one of either:
|
Severe |
|
If previous organisms related to the current infection that are resistant to the antibiotics recommended contact microbiology.
Recommended duration: 7 days
Antibiotic naive |
Flucloxacillin 1g every 6 hours orally |
Non-antibiotic naive OR Penicillin allergy OR Previous MRSA (check sensitivities) |
Doxycycline 100mg every 12 hours orally OR Co-trimoxazole 960mg every 12 hours orally |
Recommended duration: 7 days (IV & oral)
Antibiotic naive |
Flucloxacillin 1g every 6 hours orally or 2g every 6 hours IV (if deep tissue infection) AND Metronidazole 400mg every 8 hours orally |
Non-antibiotic naive OR Penicillin allergy OR Previous MRSA (check sensitivities) |
Oral therapy Co-trimoxazole 960mg every 12 hours orally AND Metronidazole 400mg every 8 hours orally IV therapy: Vancomycin IV (use NHS Lothian Calculator located AMT intranet page) choose trough 15-20mg/L AND Metronidazole 400mg every 8 hours orally (500mg every 8 hours IV if oral route unavailable) |
Recommended duration: 7 days (IV & oral) minimum
- Discuss all severe cases with microbiology and the diabetic foot team.
- Patients may need prolonged courses of antibiotics (particularly if there is osteomyelitis)
Antibiotic naive |
Flucloxacillin 2g every 6 hours IV AND Gentamicin IV (use NHS Lothian Calculator located AMT intranet page) AND Metronidazole 400mg every 8 hours orally (500mg every 8 hours IV if oral route unavailable) |
Non-antibiotic naive OR Penicillin allergy OR Previous MRSA (Check sensitivities) |
Vancomycin IV (use NHS Lothian Calculator located AMT intranet page) choose trough 15-20mg/L AND Gentamicin IV (use NHS Lothian Calculator located AMT intranet page) AND Metronidazole 400mg every 8 hours orally (500mg every 8 hours IV if oral route unavailable) |
Therapy if Pseudomonas aeruginosa suspected/confirmed
Antibiotic recommendation |
Piperacillin-tazobactam 4.5g every 6 hours IV |
Previous MRSA |
Vancomycin IV (use NHS Lothian Calculator located AMT intranet page); trough 15-20 AND Piperacillin-tazobactam 4.5g every 6 hours IV |
Penicillin allergy |
Vancomycin IV (use NHS Lothian Calculator located AMT intranet page); trough 15-20 AND Gentamicin IV (use NHS Lothian Calculator located AMT intranet page) AND Metronidazole 400mg every 8 hours orally (500mg every 8 hours IV if oral route unavailable) |
Discuss oral switch options with an infection specialist. Checklist - before you phone microbiology.
- Likely organism: often polymicrobial and/or Staphylococcus aureus often isolated