Diabetic foot infection

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Diabetic foot infection
DMgas gangrene.jpg
Gas gangrene due to diabetes
Symptoms Pus from a wound, redness, swelling, pain, warmth [1]
Complications Infection of the bone, tissue death, sepsis, amputation [2]
Causes Diabetic foot ulcer [2]
Diagnostic method Based on symptoms [1]
Differential diagnosis Phlegmasia cerulea dolens, ischemic limb [2]
PreventionAppropriate shoes [2]
Treatment Wound care, antibiotics, hyperbaric oxygen therapy [2]
FrequencyCommon [2]

Diabetic foot infection is any infection of the foot in a diabetic person. [3] The most frequent cause of hospitalization for diabetic patients is due to foot infections. [4] Symptoms may include pus from a wound, redness, swelling, pain, warmth, tachycardia, or tachypnea. [5] Complications can include infection of the bone, tissue death, amputation, or sepsis. [3] They are common and occur equally frequently in males and females. Older people are more commonly affected.

Contents

They most often form following a diabetic foot ulcer, though not all foot ulcers become infected. Diabetic foot ulcers can be caused by vascular disease or neuropathy and its prevalence occurs in approximately 25% of diabetics throughout their lifetime. [5] Some risk factors for developing diabetic foot infections include history of repeated foot ulcers, foot ulcers lasting for longer than 30 days, poor control over blood glucose levels, peripheral neuropathy, renal impairment, peripheral artery disease, injury or trauma to foot, walking barefoot frequently, and history of amputation in lower limbs. [5] [6] [7] Most diabetic foot infections are polymicrobial (contain multiple infective organisms), and bacteria that are commonly involved include staphylococcus, including methicillin resistant staphylococcus aureus (MRSA), streptococci, pseudomonas, and gram-negative bacteria. [3] [6] Previously, MRSA infections were usually acquired from hospital settings, however, recently MRSA infections acquired from the community are becoming more prevalent and are linked to poor treatment outcomes for diabetic patients. [7] Some risk factors for developing MRSA infections include use of antibiotics that cover a broad spectrum of pathogens for a long duration of time, prolonged hospital stay, or certain surgical procedures. [7] The underlying mechanism of diabetic foot infections often involves poor blood flow and peripheral neuropathy. Diagnosis is based on symptoms and may be supported by deep tissue culture. [3]

Treatment involves proper wound care and antibiotics. Pseudomonas aeruginosa empiric therapy is not warranted unless the patient had a previous infection with a culture identifying the organism, or if the patient has risk factors for it such as frequent use of wet dressings or living in hot climates. [6] [5] MRSA empiric therapy is also not warranted unless the patient has a critical infection such as sepsis, if the rate of MRSA infections are particularly high in a local area, or if the patient had a previous MRSA infection. [6] The duration of antibiotics depends on the severity of infection, ranging anywhere from 1–12 weeks. Treatment of mild-moderate infections should last 1–2 weeks and typically requires oral antibiotics that cover staphylococci and streptococci. [5] Severe infections typically require IV antibiotics that cover more pathogens, such as gram positive organisms, gram negative organisms, and obligate anaerobes to allow for better treatment outcomes. [5] Total antibiotic treatment of severe infections should be approximately 2–3 weeks or more, depending on how extensive the infection is. [6] Prevention includes wearing appropriate shoes, regular foot examinations, and control of risk factors.

Mechanism

Neuropathy, peripheral artery disease, and trauma contribute individually and in combination to the pathophysiology of diabetic foot infections. [8]

Neuropathy

Diabetes causes a symmetric polyneuropathy that may affect motor and sensory neurons. [9] Intrinsic atrophy of foot and ankle muscles leads to anatomic changes of the foot arch, most commonly depressing the metatarsal heads and creating high pressure zones. [9] Neuropathy is present in approximately 60% of patients who develop foot ulcers and are also diabetic. [5] Neuropathy can lead to a loss of sensation for diabetics in their feet, therefore when there is any trauma/injury or foot ulcer present in these patients it can take awhile for patients to notice; this can lead to an infection developing and worsening while the patient is unaware due to the loss of sensation and lack of pain. [5] In combination with decreased sensation in the lower extremities, repetitive trauma from walking can lead to ulceration. [9] Poor foot care, including lack of moisturizing and frequent self-examination of the feet can exacerbate this. [9]

Peripheral artery disease

Metabolic changes in diabetes, including hyperglycemia, lead to increased likelihood of -hyperlipidemia and developing atherosclerosis. In diabetes, this atherosclerosis is preferentially distributed to the posterior and anterior tibial arteries, decreasing perfusion to the lower extremities. [8] This may lead to loss of skin integrity, ischemic ulcers, and gangrene.

Infection may vary in the depth of tissue to which it extends. Foot infections range from the most superficial, cellulitis, to deeper soft tissue necrotizing fasciitis, which may necessitate limb amputations or become life-threatening. [10] [11] [12] Infections may also extend to bone, termed osteomyelitis. Infections are commonly polymicrobial and involve antibiotic-resistant strains of organisms e.g. MRSA (Methicillin-resistant Staphylococcus aureus). [12]

Diagnosis

Initial diagnosis of diabetic foot infections is made primarily via thorough history and physical to include visual inspection of the feet, evaluation of any wounds, distal pulses, and neurologic function.

History and physical

History should be taken for known recent foot trauma, and the lower extremities should be inspected for signs of recent trauma, including redness, induration, edema, visible ulceration with exudate or pus, or bony deformity. [13] [12] Ulcers do occur in the absence of pathological infection. Diagnosis of an infected wound is classically made with ≥2 signs of inflammation or purulence. [14] Peripheral pulses should also be evaluated (posterior tibial and dorsal pedis), and if not palpable, should be further evaluated using ultrasound. [13] In patients with non-palpable pulses, evaluation of PAD with an ankle-brachial index should also be performed. [13] Ulceration or deeper wounds should be probed to identify the depth of penetration and determine involvement of bone, which would indicate osteomyelitis. [15] Neurologic testing includes testing peripheral sensation to vibratory stimuli, temperature, pain, along with deep tendon reflexes. [13]

Imaging

Imaging may also be used for further evaluation. Plain x-ray, the most common initial imaging study, may show fractures, osteomyelitis, gas collection from gas-producing infective organisms, calcification of blood vessels, or foreign bodies. [15] [8] Magnetic resonance imaging (MRI) is useful to determine the depth of soft tissue infection and evaluate for presence of osteomyelitis, especially in patients which do not respond to initial antibiotic therapy. [15] [8] Finally, patency of the lower extremity vasculature may be evaluated by magnetic resonance angiography or ultrasonography [15] [8] If a patient is experiencing a diabetic foot infection for the first time, a plain radiograph should be conducted to look for any bone abnormalities. [16] MRI is more sensitive and specific than a radiograph, and is typically done if osteomyelitis is suspected and the diagnosis is unclear from the radiograph, or if an abscess is suspected in soft tissue.

[16]

Management

Acute management of diabetic foot infections generally includes antibiotic therapy, pressure offloading, re-vascularization, if appropriate, and debridement of infected tissues (or amputation if necessary). Hospitalization is more likely needed when lower extremity pulses are absent or when infection penetrates to the level of the fascia or more deeply. [8] [17] Infections with skin gangrene may reflect deep space infection, abscess, and tissue necrosis. When debridement is necessary, wounds are left open so that serial debridements may be performed over the course of the wound’s healing. [8]

Antibiotic choice should be guided by deep tissue culture, severity of the infection, presence or absence of osteomyelitis, prior antibiotic treatment, and previous or current MRSA infection. [18] Wounds without confirmed infection should not be treated with antibiotics, nor should be sent for culture. [19] [20] Cultures are not necessarily warranted if a patient has a mild infection and they have not been on any antibiotics recently. [20] Before starting empiric therapy, cultures should be obtained and once results come back from the lab, an appropriate antibiotic with a narrower spectrum should be chosen. [20] Length of treatment depends primarily on severity of infection; skin and superficial soft tissue infections may require treatment for 1–2 weeks while deeper infections (including osteomyelitis) may require 6–12 weeks, including those who undergo surgery. [21] [3] [18]

Prevention

One crucial aspect for prevention of diabetic foot infections is educating patients of what to monitor for and when to follow up with a healthcare professional. [4] Patients should be regularly checking their feet daily, if they are not able to view the bottom of their feet they can use a mirror to aid them. [4] Prevention of diabetic foot infections include regular foot examinations by a healthcare professional as well as maintenance of cardiovascular co-morbidities and risk factors. [12] This maintenance includes proper footwear, regulating blood glucose and hypertension, and limiting cardiovascular risk factors, such as smoking. [12] Patients should avoid exposing their feet to hot water or harsh chemicals, as well should avoid walking barefoot to prevent development of diabetic foot infections. [4] Patients should also be educated about the importance of regularly trimming their toenails and ensuring they are kept short to avoid an infection from developing. [4]

All patients with diabetes should be examined at least yearly if no additional risk factors, but more frequently if present. In those with a prior ulcer or amputation, examinations are needed every 1–2 months. [12]

Related Research Articles

Methicillin-resistant <i>Staphylococcus aureus</i> Bacterium responsible for difficult-to-treat infections in humans

Methicillin-resistant Staphylococcus aureus (MRSA) is a group of gram-positive bacteria that are genetically distinct from other strains of Staphylococcus aureus. MRSA is responsible for several difficult-to-treat infections in humans. It caused more than 100,000 deaths worldwide attributable to antimicrobial resistance in 2019.

<span class="mw-page-title-main">Gangrene</span> Type of tissue death by a lack of blood supply

Gangrene is a type of tissue death caused by a lack of blood supply. Symptoms may include a change in skin color to red or black, numbness, swelling, pain, skin breakdown, and coolness. The feet and hands are most commonly affected. If the gangrene is caused by an infectious agent, it may present with a fever or sepsis.

<span class="mw-page-title-main">Ulcer (dermatology)</span> Type of cutaneous condition

An ulcer is a sore on the skin or a mucous membrane, accompanied by the disintegration of tissue. Ulcers can result in complete loss of the epidermis and often portions of the dermis and even subcutaneous fat. Ulcers are most common on the skin of the lower extremities and in the gastrointestinal tract. An ulcer that appears on the skin is often visible as an inflamed tissue with an area of reddened skin. A skin ulcer is often visible in the event of exposure to heat or cold, irritation, or a problem with blood circulation.

Bloodstream infections (BSIs), septicemia which include bacteremias when the infections are bacterial and fungemias when the infections are fungal, are infections present in the blood. Blood is normally a sterile environment, so the detection of microbes in the blood is always abnormal. A bloodstream infection is different from sepsis, which is the host response to bacteria.

<span class="mw-page-title-main">Linezolid</span> Antibiotic medication

Linezolid is an antibiotic used for the treatment of infections caused by Gram-positive bacteria that are resistant to other antibiotics. Linezolid is active against most Gram-positive bacteria that cause disease, including streptococci, vancomycin-resistant enterococci (VRE), and methicillin-resistant Staphylococcus aureus (MRSA). The main uses are infections of the skin and pneumonia although it may be used for a variety of other infections including drug-resistant tuberculosis. It is used either by injection into a vein or by mouth.

Diabetic neuropathy is various types of nerve damage associated with diabetes mellitus. Symptoms depend on the site of nerve damage and can include motor changes such as weakness; sensory symptoms such as numbness, tingling, or pain; or autonomic changes such as urinary symptoms. These changes are thought to result from a microvascular injury involving small blood vessels that supply nerves. Relatively common conditions which may be associated with diabetic neuropathy include distal symmetric polyneuropathy; third, fourth, or sixth cranial nerve palsy; mononeuropathy; mononeuropathy multiplex; diabetic amyotrophy; and autonomic neuropathy.

<span class="mw-page-title-main">Septic arthritis</span> Medical condition

Acute septic arthritis, infectious arthritis, suppurative arthritis, pyogenic arthritis, osteomyelitis, or joint infection is the invasion of a joint by an infectious agent resulting in joint inflammation. Generally speaking, symptoms typically include redness, heat and pain in a single joint associated with a decreased ability to move the joint. Onset is usually rapid. Other symptoms may include fever, weakness and headache. Occasionally, more than one joint may be involved, especially in neonates, younger children and immunocompromised individuals. In neonates, infants during the first year of life, and toddlers, the signs and symptoms of septic arthritis can be deceptive and mimic other infectious and non-infectious disorders.

<span class="mw-page-title-main">Osteomyelitis</span> Infection of the bones

Osteomyelitis (OM) is an infection of bone. Symptoms may include pain in a specific bone with overlying redness, fever, and weakness. The long bones of the arms and legs are most commonly involved in children e.g. the femur and humerus, while the feet, spine, and hips are most commonly involved in adults.

<span class="mw-page-title-main">Cellulitis</span> Bacterial infection of the inner layers of the skin called the dermis

Cellulitis is usually a bacterial infection involving the inner layers of the skin. It specifically affects the dermis and subcutaneous fat. Signs and symptoms include an area of redness which increases in size over a few days. The borders of the area of redness are generally not sharp and the skin may be swollen. While the redness often turns white when pressure is applied, this is not always the case. The area of infection is usually painful. Lymphatic vessels may occasionally be involved, and the person may have a fever and feel tired.

A complication in medicine, or medical complication, is an unfavorable result of a disease, health condition, or treatment. Complications may adversely affect the prognosis, or outcome, of a disease. Complications generally involve a worsening in the severity of the disease or the development of new signs, symptoms, or pathological changes that may become widespread throughout the body and affect other organ systems. Thus, complications may lead to the development of new diseases resulting from previously existing diseases. Complications may also arise as a result of various treatments.

<span class="mw-page-title-main">Neuropathic arthropathy</span> Medical condition

Neuropathic arthropathy, also known as Charcot joint after the first to describe it, Jean-Martin Charcot, refers to progressive degeneration of a weight-bearing joint, a process marked by bony destruction, bone resorption, and eventual deformity due to loss of sensation. Onset is usually insidious.

<span class="mw-page-title-main">Maggot therapy</span> Wound care by maggot therapy

Maggot therapy is a type of biotherapy involving the introduction of live, disinfected maggots into non-healing skin and soft-tissue wounds of a human or other animal for the purpose of cleaning out the necrotic (dead) tissue within a wound (debridement), and disinfection.

A chronic wound is a wound that does not heal in an orderly set of stages and in a predictable amount of time the way most wounds do; wounds that do not heal within three months are often considered chronic. Chronic wounds seem to be detained in one or more of the phases of wound healing. For example, chronic wounds often remain in the inflammatory stage for too long. To overcome that stage and jump-start the healing process, a number of factors need to be addressed such as bacterial burden, necrotic tissue, and moisture balance of the whole wound. In acute wounds, there is a precise balance between production and degradation of molecules such as collagen; in chronic wounds this balance is lost and degradation plays too large a role.

<span class="mw-page-title-main">Flucloxacillin</span> Penicillin

Flucloxacillin, also known as floxacillin, is an antibiotic used to treat skin infections, external ear infections, infections of leg ulcers, diabetic foot infections, and infection of bone. It may be used together with other medications to treat pneumonia, and endocarditis. It may also be used prior to surgery to prevent Staphylococcus infections. It is not effective against methicillin-resistant Staphylococcus aureus (MRSA). It is taken by mouth or given by injection into a vein or muscle.

<span class="mw-page-title-main">Arterial insufficiency ulcer</span> Medical condition

Arterial insufficiency ulcers are mostly located on the lateral surface of the ankle or the distal digits. They are commonly caused by peripheral artery disease (PAD).

Complications of diabetes are secondary diseases that are a result of elevated blood glucose levels that occur in diabetic patients. These complications can be divided into two types: acute and chronic. Acute complications are complications that develop rapidly and can be exemplified as diabetic ketoacidosis (DKA), hyperglycemic hyperosmolar state (HHS), lactic acidosis (LA), and hypoglycemia. Chronic complications develop over time and are generally classified in two categories: microvascular and macrovascular. Microvascular complications include neuropathy, nephropathy, and retinopathy; while cardiovascular disease, stroke, and peripheral vascular disease are included in the macrovascular complications.

<span class="mw-page-title-main">Diabetic foot</span> Medical condition

A diabetic foot disease is any condition that results directly from peripheral artery disease (PAD) or sensory neuropathy affecting the feet of people living with diabetes. Diabetic foot conditions can be acute or chronic complications of diabetes. Presence of several characteristic diabetic foot pathologies such as infection, diabetic foot ulcer and neuropathic osteoarthropathy is called diabetic foot syndrome. The resulting bone deformity is known as Charcot foot.

<span class="mw-page-title-main">Malum perforans</span> Medical condition

Malum perforans is a long-lasting, usually painless ulcer that penetrates deep into or through the skin, usually on the sole of the foot. It is often a complication in diabetes mellitus and other conditions affecting the nerves.

<span class="mw-page-title-main">Diabetic foot ulcer</span> Medical condition

Diabetic foot ulcer is a breakdown of the skin and sometimes deeper tissues of the foot that leads to sore formation. It may occur due to a variety of mechanisms. It is thought to occur due to abnormal pressure or mechanical stress chronically applied to the foot, usually with concomitant predisposing conditions such as peripheral sensory neuropathy, peripheral motor neuropathy, autonomic neuropathy or peripheral arterial disease. It is a major complication of diabetes mellitus, and it is a type of diabetic foot disease. Secondary complications to the ulcer, such as infection of the skin or subcutaneous tissue, bone infection, gangrene or sepsis are possible, often leading to amputation.

Total contact casting (TCC) is a specially designed cast designed to take weight off of the foot (off-loading) in patients with diabetic foot ulcers (DFUs). Reducing pressure on the wound by taking weight off the foot has proven to be very effective in DFU treatment. DFUs are a major factor leading to lower leg amputations among the diabetic population in the US with 85% of amputations in diabetics being preceded by a DFU. Furthermore, the five-year post-amputation mortality rate among diabetics is estimated at 45% for those with neuropathic DFUs.

References

  1. 1 2 Lipsky, Benjamin A.; Berendt, Anthony R.; Deery, H. Gunner; Embil, John M.; Joseph, Warren S.; Karchmer, Adolf W.; LeFrock, Jack L.; Lew, Daniel P.; Mader, Jon T.; Norden, Carl; Tan, James S. (1 October 2004). "Diagnosis and Treatment of Diabetic Foot Infections". Clinical Infectious Diseases. 39 (7): 885–910. doi: 10.1086/424846 . PMID   15472838. S2CID   19826519.
  2. 1 2 3 4 5 6 Murphy-Lavoie, HM; Ramsey, A; Nguyen, M; Singh, S (January 2020). "Diabetic Foot Infections". PMID   28722943.{{cite journal}}: Cite journal requires |journal= (help)
  3. 1 2 3 4 5 Murphy-Lavoie, Heather M.; Ramsey, Adam; Nguyen, Minhthao; Singh, Shikha (2021), "Diabetic Foot Infections", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   28722943 , retrieved 2021-10-10
  4. 1 2 3 4 5 Gleckman, R. A.; Roth, R. M. (February 1985). "Diabetic foot infections--prevention and treatment". The Western Journal of Medicine. 142 (2): 263–265. ISSN   0093-0415. PMC   1306006 . PMID   4013261.
  5. 1 2 3 4 5 6 7 8 Noor, Saba; Khan, Rizwan Ullah; Ahmad, Jamal (April 2017). "Understanding Diabetic Foot Infection and its Management". Diabetes & Metabolic Syndrome: Clinical Research & Reviews. 11 (2): 149–156. doi:10.1016/j.dsx.2016.06.023. PMID   27377687.
  6. 1 2 3 4 5 Lipsky, Benjamin A.; Berendt, Anthony R.; Cornia, Paul B.; Pile, James C.; Peters, Edgar J. G.; Armstrong, David G.; Deery, H. Gunner; Embil, John M.; Joseph, Warren S.; Karchmer, Adolf W.; Pinzur, Michael S. (2012-06-15). "2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infectionsa". Clinical Infectious Diseases. 54 (12): e132–e173. doi: 10.1093/cid/cis346 . ISSN   1537-6591. PMID   22619242.
  7. 1 2 3 Lipsky, Benjamin A.; Berendt, Anthony R.; Deery, H Gunner; Embil, John M.; Joseph, Warren S.; Karchmer, Adolf W.; LeFrock, Jack L.; Lew, Daniel P.; Mader, Jon T.; Norden, Carl; Tan, James S. (June 2006). "Diagnosis and Treatment of Diabetic Foot Infections". Plastic and Reconstructive Surgery. 117 (SUPPLEMENT): 212S–238S. doi:10.1097/01.prs.0000222737.09322.77. ISSN   0032-1052. PMID   16799390. S2CID   8275000.
  8. 1 2 3 4 5 6 7 Bandyk, Dennis F. (2018-06-01). "The diabetic foot: Pathophysiology, evaluation, and treatment". Seminars in Vascular Surgery. Fighting Diabetic Foot Ulcers. 31 (2): 43–48. doi:10.1053/j.semvascsurg.2019.02.001. ISSN   0895-7967. PMID   30876640. S2CID   80626840.
  9. 1 2 3 4 Bandyk, Dennis F. (2018-06-01). "The diabetic foot: Pathophysiology, evaluation, and treatment". Seminars in Vascular Surgery. Fighting Diabetic Foot Ulcers. 31 (2): 43–48. doi:10.1053/j.semvascsurg.2019.02.001. ISSN   0895-7967. PMID   30876640. S2CID   80626840.
  10. ↑ Murphy-Lavoie, Heather M.; Ramsey, Adam; Nguyen, Minhthao; Singh, Shikha (2021), "Diabetic Foot Infections", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   28722943 , retrieved 2021-10-10
  11. ↑ Lipsky, Benjamin (15 June 2012). "2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections". Clinical Infectious Diseases. 54 (12): e132–e173. doi: 10.1093/cid/cis346 . PMID   22619242.
  12. 1 2 3 4 5 6 Gemechu, Fassil W.; Seemant, Fnu; Curley, Catherine A. (2013-08-01). "Diabetic Foot Infections". American Family Physician. 88 (3): 177–184. ISSN   0002-838X. PMID   23939696.
  13. 1 2 3 4 Boulton, Andrew J. M.; Armstrong, David G.; Albert, Stephen F.; Frykberg, Robert G.; Hellman, Richard; Kirkman, M. Sue; Lavery, Lawrence A.; LeMaster, Joseph W.; Mills, Joseph L.; Mueller, Michael J.; Sheehan, Peter (2008-08-01). "Comprehensive Foot Examination and Risk Assessment: A report of the Task Force of the Foot Care Interest Group of the American Diabetes Association, with endorsement by the American Association of Clinical Endocrinologists". Diabetes Care. 31 (8): 1679–1685. doi:10.2337/dc08-9021. ISSN   0149-5992. PMC   2494620 . PMID   18663232.
  14. ↑ Lipsky, Benjamin (15 June 2012). "2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections". Clinical Infectious Diseases. 54 (12): e132–e173. doi: 10.1093/cid/cis346 . PMID   22619242.
  15. 1 2 3 4 Barwell, Nicholas D.; Devers, Marion C.; Kennon, Brian; Hopkinson, Helen E.; McDougall, Claire; Young, Matthew J.; Robertson, Hannah M. A.; Stang, Duncan; Dancer, Stephanie J.; Seaton, Andrew; Leese, Graham P. (2017). "Diabetic foot infection: Antibiotic therapy and good practice recommendations". International Journal of Clinical Practice. 71 (10): e13006. doi: 10.1111/ijcp.13006 . ISSN   1742-1241. PMID   28892282. S2CID   40277094.
  16. 1 2 Lipsky, Benjamin A.; Berendt, Anthony R.; Cornia, Paul B.; Pile, James C.; Peters, Edgar J. G.; Armstrong, David G.; Deery, H. Gunner; Embil, John M.; Joseph, Warren S.; Karchmer, Adolf W.; Pinzur, Michael S. (2012-06-15). "2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infectionsa". Clinical Infectious Diseases. 54 (12): e132–e173. doi: 10.1093/cid/cis346 . ISSN   1537-6591. PMID   22619242.
  17. ↑ Lipsky, Benjamin (15 June 2012). "2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections". Clinical Infectious Diseases. 54 (12): e132–e173. doi: 10.1093/cid/cis346 . PMID   22619242.
  18. 1 2 Gemechu, Fassil W.; Seemant, Fnu; Curley, Catherine A. (2013-08-01). "Diabetic Foot Infections". American Family Physician. 88 (3): 177–184. ISSN   0002-838X. PMID   23939696.
  19. ↑ "Diabetic foot infections: a comprehensive overview". European Review. 2019-04-09. Retrieved 2021-10-10.
  20. 1 2 3 Lipsky, Benjamin A.; Berendt, Anthony R.; Cornia, Paul B.; Pile, James C.; Peters, Edgar J. G.; Armstrong, David G.; Deery, H. Gunner; Embil, John M.; Joseph, Warren S.; Karchmer, Adolf W.; Pinzur, Michael S. (2012-06-15). "2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infectionsa". Clinical Infectious Diseases. 54 (12): e132–e173. doi: 10.1093/cid/cis346 . ISSN   1537-6591. PMID   22619242.
  21. ↑ Barwell, Nicholas D.; Devers, Marion C.; Kennon, Brian; Hopkinson, Helen E.; McDougall, Claire; Young, Matthew J.; Robertson, Hannah M. A.; Stang, Duncan; Dancer, Stephanie J.; Seaton, Andrew; Leese, Graham P. (2017). "Diabetic foot infection: Antibiotic therapy and good practice recommendations". International Journal of Clinical Practice. 71 (10): e13006. doi: 10.1111/ijcp.13006 . ISSN   1742-1241. PMID   28892282. S2CID   40277094.
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