Diabetic Foot Infection Outpatient Management in Adults

A guideline is intended to assist healthcare professionals in the choice of disease-specific treatments.

Clinical judgement should be exercised on the applicability of any guideline, influenced by individual patient characteristics. Clinicians should be mindful of the potential for harmful polypharmacy and increased susceptibility to adverse drug reactions in patients with multiple morbidities or frailty.

If, after discussion with the patient or carer, there are good reasons for not following a guideline, it is good practice to record these and communicate them to others involved in the care of the patient.

Good practice points

Patients with severe infection (as per IDSA classification1) should be considered for inpatient management
PRIOR to commencing antibiotic therapy for osteomyelitis:
- ensure wound swabs have been taken*
- consider antibiotic oral bioavailability, bone penetration, current and prior microbiology, allergy/tolerability history, renal and hepatic function and drug-drug/drug-food interactions
Discuss treatment with an infection specialist (Microbiology OR Infectious Diseases**) prior to initiating therapy for osteomyelitis if:
- recommended empirical antibiotics are contra-indicated due to allergy, co-morbidities or drug interactions
- recurrent osteomyelitis
- current or previous positive microbiology
All patients receiving treatment for osteomyelitis should be highlighted to the diabetes team to ensure ongoing review of culture/sensitivity results, tolerability of therapy and laboratory/ECG monitoring when required.
*Wound swabs are not reliable for detecting the causative pathogen(s) in osteomyelitis and should not be used in isolation to guide therapy. Deep tissue/bone biopsy following local debridement is preferred to optimise appropriate therapy.

** Microbiology : North & Clyde 0141 201 8551 (18551), South 0141 354 9132 (89133), QEUH DFI MDT patients – contact Dr Beth White or Dr Neil Ritchie via email/switchboard, OPAT referrals via Trakcare or Tel. 83017 (0141 452 3017)

Use the following empirical guidance in the absence of positive microbiology

Empirical Antibiotic Choice and Duration

Localised non-severe Cellulitis

As per Scottish Diabetes Foot Action Group Guidance¹ Oral Flucloxacillin 1g QDS
Or if true penicillin/β lactam allergy: Oral Doxycycline 100mg BD

Duration:7 days

Non-acute Osteomyelitis

Doxycycline 100mg BD
OR
Clindamycin 600mg TDS
Duration: 6 weeks (highlight to diabetes team for review)

Additional Comments

ALWAYS review patient’s concomitant medication for drug interactions and counsel patient regarding potential side-effects. Use the British National formulary or Stockley’s Drug Interaction Checker available via Staffnet or contact Pharmacy.

Doxycycline absorption is reduced with multivalent cations e.g. Ca2+, Mg2+ iron preparations and some nutritional supplements. This risks treatment failure. Withhold cation preparations or ensure doses separated to minimise effect see BNF (oral iron MUST be withheld). Note associated risk of photosensitivity reactions and oesophageal ulceration – refer to BNF.

Clindamycin is associated with increased risk of C.difficile infection, particularly in patients aged>65. Avoid if previous C.diff or discuss with ID/microbiology. Patient should stop if diarrhoea occurs and discuss urgently with diabetic foot team. Monitor LFTs, FBC and renal function for courses longer than 10 days.

Oral flucloxacillin has no place in osteomyelitis treatment as suboptimal oral absorption (which is further reduced by administration with food)