16. Diabetic foot ulcers

Assessment of depth of ulcer and bone involvement CRUCIAL for determining the duration of antibiotic treatment. Infections tend to be polymicrobial. MRSA status is important in the choice of antibiotics. Refer to microbiology for advice on MRSA infection.

Infection	IV treatment	Oral treatment	Total duration
Diabetic foot ulcers Grade 0-1 Texas wound classification	Amoxicillin 500mg tds plus flucloxacillin 500mg qds	Amoxicillin 500mg tds plus flucloxacillin 500mg-1g qds	1-2 weeks
Diabetic foot ulcers Grade 0-1 Texas wound  classification Penicillin allergy	Clarithromycin 500mg bd or clindamycin 450mg qds	Clarithromycin 500mg bd or clindamycin 450mg qds orally	1-2 weeks
Diabetic foot ulcers Grade 2-3 Texas wound classification	Flucloxacillin 2g qds plus amoxicillin 1g tds- qds plus gentamicin 5 mg/kg OD (See protocol for dose. Monitor levels) NOTE: add metronidazole 500mg if necrosis or anaerobic infection suspected	Flucloxacillin 1g qds plus amoxicillin 500mg tds plus ciprofloxacin 500-750mg bd NOTE: add metronidazole 400mg tds if necrosis or anaerobic infection suspected	Treat initially with IV therapy for at least 3-5days until clinical improvement. Grade 2 treat for 2-4 weeks Grade 3 treat for 6 weeks
Diabetic foot ulcers Grade 2-3 Texas wound classification Penicillin allergy	Clindamycin 600mg qds plus gentamicin 5mg/kg OD IV (See protocol for dose. Monitor levels) NOTE: add metronidazole 500mg if necrosis or anaerobic infection suspected	Clindamycin 300-450mg qds orally plus ciprofloxacin 500-750mg every 12 hours orally. NOTE: add metronidazole 400mg tds if necrosis or anaerobic infection suspected	Treat initially with IV therapy for at least 3-5days until clinical improvement.   Grade 2 treat for 2-4 weeks Grade 3 treat for 6 weeks

Texas wound classification

Grade 0	Grade 1	Grade 2	Grade 3
Pre or post ulcerative lesion completely epithelialised	Superficial ulcer not involving tendon,  capsule, or bone.  Infection comprising erythema and warmth extending no more  than 2cm beyond edges of ulcer and no lymphangitis, swelling or systemic  effects	Wound extending to tendon/capsule or  infection characterised  by extensive erythema  and warmth (> 2cm  beyond edge of ulcer) or lymphangitis, or infection induced necrosis or systemic effects or 'localised infection'  not responding to treatment.	Penetrating ulcer involving bone and/or joint +/- evidence of osteomyelitis (x-ray, MR or Bone scan)