Antibiotic treatment for diabetic foot infection

Guidance on antibiotics for the treatment of infection in the diabetic foot

Diabetic foot infection empirical antibiotic NHS Borders guideline

General

Inform diabetes and diabetic podiatry teams of all hospital admissions with diabetic foot infection
If concern re. collection, discuss with orthopaedics
If concern re. necrosis, discuss with vascular team
Check previous microbiology results before prescribing empirical antibiotics
Doses stated assume adult patient with normal renal and hepatic function. If renal failure/dysfunction or hepatic failure/dysfunction, seek advice
Consider suitability for OPAT in moderate infections or osteomyelitis – discuss with infection specialist

Notes

1. Requires monitoring for complications

2. Monitor serum concentration

3. Maximum 3 days then review. Switch to ciprofloxacin empirically or alternative agent based on sensitivities.

4. Fluorquinolone warning:

EMEA warning Nov 2018 states that fluoroquinolones should generally be avoided in patients who have previously had serious side effects with a fluoroquinolone antibiotic; use with special caution in the elderly, patients with kidney disease and organ transplant patients (due to higher risk of tendon injury).
Avoid concomitant use with corticosteroids.
Patients should be advised to stop the fluoroquinolone and seek medical advice if they experience side effects involving muscles, tendons, joints or the nervous system.
www.ema.europa.eu MHRA warning Nov 2018 also advices careful benefit-risk assessment in patients at risk for aortic aneurysm and dissection; patients should be advised to seek immediate medical attention in case of severe abdominal, chest or back pain.
www.gov.uk. These cautions should be considered if a quinolone-based regimen is necessary.

5. Ertapenem is a beta-Lactam antibacterial. Avoid if history of immediate hypersensitivity reaction to beta-lactam antibacterials.

6. Caution: 20-25% of MSSA isolated from STI/bone samples are resistant to clindamycin.

Abbreviations

BD = twice a day, TDS = three times a day, QDS = four times a day

MRSA = methicillin resistant Staphylococcus aureus

MSSA= methicillin sensitive Staphylococcus aureus

Reference

Barwell ND, Devers MC, Kennon B, Hopkinson HE, McDougall C, Young MJ et al; Scottish Diabetes Foot Action Group. Diabetic foot infection: Antibiotic therapy and good practice recommendations. Int J Clin Pract 2017 Oct 71(10). DOI: 10.1111/ijcp.13006 Free full text

Mild infection

Symptoms	Pus or two or more of: erythema, warmth, pain, tenderness, induration Any cellulitis <2cm around the wound confined to skin or subcutaneous tissue, and No evidence of systemic infection
Treatment duration	Treatment with the agents shown below is recommended for 7 days, after which treatment should be reviewed and continued or discontinued as appropriate
Antibiotic naive	Primary - Oral Flucloxacillin¹ 1g QDS Alternative - Oral Doxycycline 100mg BD
Not antibiotic naive	Primary - Oral Doxycycline 100mg BD
MRSA	Oral Doxycycline 100mg BD

Moderate infection

Symptoms	Lymphatic streaking, deep tissue infection involving subcutaneous tissue, tendon, fascia, bone or abscess Cellulitis >2cm, and No evidence of systemic infection
Treatment duration	Treatment with the agents shown below is recommended for 7 days, after which treatment should be reviewed and continued or discontinued as appropriate IV antibiotics may be switched to oral preparation after an appropriate interval
Antibiotic naive	Primary oral flucloxicillin¹ 1g QDS or IV 2g QDS Add oral metronidazole 400mg TDS if anaerobes suspected Alternatives oral co-amoxiclav 625mg TDS, or oral clindamycin⁶ 450mg QDS or IV 600mg QDS Add oral metronidazole 400mg TDS if anaerobes suspected
Not antibiotic naive	Primary oral co-amoxiclav 625mg TDS or IV 1.2g TDS Alternatives oral clindamycin⁶ 450mg QDS + IV metronidazole 500mg TDS IV vancomycin^1,2+ IV metronidazole 500mg TDS
MRSA	Primary IV vancomycin^1,2and discuss with diabetes / microbiology Oral switch - Non-osteomyelitis doxycyline 100mg BD

Severe infection

Symptoms	Any infection accompanied by systemic toxicity (fever, chills, shock, vomiting, confusion, metabolic instability). The presence of critical ischaemia of the involved limb may make the infection severe
Treatment duration	Treatment with the following agents is recommended for 10-14 days, after which treatment should be reviewed and continued or discontinued as appropriate IV antibiotics may be switched to oral preparation after an appropriate interval
Antibiotic naive	Primary IV flucloxacillin¹ 2g QDS + IV gentamicin^1,2,3 + IV clindamycin⁴ 600mg–1200mg QDS NOTE: Oral therapy inappropriate If allergic to penicillin: IV vancomycin (aim for a trough vancomycin concentration of 15-20mg/L)^1,2 + IV gentamicin^1,2,3 + IV clindamycin⁶ 600mg – 1200mg QDS Oral switch Review Microbiology results. Consider broader spectrum than below based on microbiology results and patient’s progress. Flucloxacillin¹ 1g QDS+ Clindamycin⁶ 450mg QDS Or,if allergic to penicillin Linezolid¹ 600mg BD
Not antibiotic naive	Primary IV ertapenem⁵ 1g daily + IV vancomycin (aim for a trough vancomycin concentration of 15-20mg/L)^1,2 If allergic to penicillin: IV vancomycin(aim for a trough vancomycin concentration of 15-20mg/L)^1,2 + IV gentamicin^1,2,3 + IV metronidazole 500mg TDS Oral switch Flucloxacillin 1g QDS + Ciprofloxacin⁴ 500mg (750mg if Pseudomonas isolated) BD + Metronidazole 400mg TDS Or, Clindamycin⁶ 450mg QDS + Ciprofloxacin⁴ 500mg (750mg if Pseudomonas isolated) BD
MRSA	Primary IV vancomycin (aim for a trough vancomycin concentration of 15-20mg/L)^1,2 Oral switch - Non-osteomyelitis Doxycyline 100mg BD

Osteomyelitis

Treatment duration	Treat for at least 6 weeks. Longer courses may be required. Usually at least 2 weeks of IV therapy in acute setting but oral therapy may be suitable in non-acute setting.
Antibiotic naive	Severe or Acute (IDSA/IWGDF-PEDIS Grade4) IV Flucloxacillin 2g QDS¹ + Oral Clindamycin⁶ 450mg QDS +/- IV Gentamicin^1,2,3 Moderate or Non-Acute (IDSA/IWGDF-PEDIS Grade 2-3) Oral Flucloxacillin 1g QDS¹ + Oral Clindamicin⁶ 450mg QDS + Oral Ciprofloxacin⁴ 750mg BD Penicillin allergy remove flucloxacilin from combinations above
Not antibiotic naive	Severe or Acute IV ertapenem 1g daily + IV vancomycin (aim for a trough vancomycin concentration of 15- 20mg/L)^1,2 Penicillin allergy IV vancomycin (aim for a trough vancomycin concentration of 15- 20mg/L)^1,2 + oral Clindamycin 450mg QDS +/- IV Gentamicin^1,2,3 Moderate or Non-Acute Oral Flucloxacillin 1g QDS + Oral Clindamycin⁶ 450mg QDS +Oral Ciprofloxacin⁴ 750mg BD Penicillin allergy remove flucloxacillin from combination above
MRSA	Acute IV Vancomycin (aim for a trough vancomycin concentration of 15-20mg/L)^1,2 + oral Rifampicin 450mg BD Non-Acute Usually combination therapy depending on sensitivities and infection specialist advice.

Last reviewed: 01/11/2021

Next review date: 01/11/2023

Author(s): Herlihy O.

Version: V2

Author email(s): olive.herlihy@borders.scot.nhs.uk.

Co-Author(s): Williamson R, Duguid A.

Approved By: Antimicrobial Management Team

Reviewer name(s): Herlihy O.

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