Treatment of lower extremity infections in diabetics

Despite recent medical advances in the treatment of diabetes mellitus, foot infection remains a major cause of morbidity and mortality in patients with this disorder. Three main factors are responsible for this: neuropathy, angiopathy and immunopathy. Neuropathy is probably the most important factor: minor irritations and trauma can lead to limb-threatening infections without the patient feeling the changes. Angiopathy plays only a minor role, while immunopathy has implications for antibiotic treatment, in that bactericidal agents are needed. A classification scheme that incorporates clinical and laboratory findings can direct the selection of empirical antibiotic therapy in patients with foot infections. These infections may be defined as mild, moderate and severe. In less severe cases, there are effective oral agents that can stop the progress of the infection and obviate the need for patient hospitalisation. Moderate to severe infections require hospitalisation with the use of parenteral agents. With some of the new broad spectrum drugs, single agent therapy is now possible, eliminating the need for expensive, potentially toxic combinations. Antibiotics, however, are only part of the cure. Aggressive surgical debridement followed by conscientious local wound care plays an equal role. The ultimate goal is foot salvage, and the clinical judgement of the practitioner is paramount in determining the treatment strategies needed to achieve this objective.