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The spectrum of foot infections in diabetes ranges from simple superficial cellulitis to chronic osteomyelitis.
In terms of the infecting microorganisms and the likelihood of successful treatment with antimicrobial therapy, acute osteomyelitis in people with diabetes is essentially the same as in those without diabetes. Patients with diabetes also can have a combined infection involving bone and soft tissue called fetid foot. Individuals with diabetes may also have peripheral vascular disease that involves the large vessels, in addition to microvascular and capillary disease that results in peripheral vascular disease with gangrene. Except for chronic osteomyelitis, infections in patients with diabetes are caused by the same microorganisms that can infect the extremities of those without diabetes. In chronic osteomyelitis, a sequestrum and involucrum form; these represent islands of infected bone.
Cellulitis may involve tender and erythematous nonraised skin lesions on the lower extremity that may or may not be accompanied by lymphangitis.
If bullae are present, Staphylococcus aureus is the most likely pathogen, but group A streptococci occasionally causes bullous lesions. Patients with deep skin and soft tissue infections may be acutely ill, with painful induration of the soft tissues in the extremity. These infections are particularly common in the thigh area, but they may be seen anywhere on the leg or foot. Extreme pain and tenderness indicate the possibility of a compartment syndrome, which may be diagnosed with the aid of a CT scan. Unless peripheral neuropathy is present, the patient has pain at the site of the involved bone.
The deep penetrating ulcers and sinuses are usually located between the toes or on the plantar surface of the foot. In patients with diabetes, chronic osteomyelitis usually does not occur on the medial malleoli, shins, or heels.
Importantly, deep penetrating foot ulcers or deep sinus tracts are diagnostic of chronic osteomyelitis. The microbiologic features of diabetic foot infections vary according to the tissue infected. In patients with diabetes, superficial skin infections such as cellulitis are caused by the same organisms as those in healthy hosts, namely group A streptococci and S aureus. Group B streptococcal cellulitis is uncommon in healthy hosts and not uncommon in patients with diabetes.
In patients with diabetes, deep soft tissue infections can be associated with gas-producing gram-negative bacilli. Acute osteomyelitis usually occurs as a result of foot trauma in an individual with diabetes. In chronic osteomyelitis, the pathogens are group A and group B streptococci, aerobic gram-negative bacilli, and Bacteroides fragilis, among others. Pseudomonas aeruginosa is generally not a pathogen in chronic osteomyelitis in patients with diabetes. P aeruginosa is frequently cultured from samples obtained from a draining sinus tract or deep penetrating ulcers in patients with diabetes. Because Pseudomonas organisms are water-borne, superficial ulcers may be contaminated by bacteria in wet socks or dressings.
Bone biopsy performed under aseptic conditions in the operating room reveals that chronic osteomyelitis in patients with diabetes is not due to P aeruginosa.
B fragilis is an important bone pathogen in chronic osteomyelitis in patients with diabetes. Other pathogens implicated in chronic osteomyelitis in patients with diabetes include Escherichia coli, Proteus mirabilis, and Klebsiella pneumoniae.
Fetid foot represents a combined deep skin and soft tissue infection caused by pathogens involved in chronic osteomyelitis. The CBC count and erythrocyte sedimentation rate (ESR) are slightly or moderately elevated in cellulitis. If bullae are present, Gram stain and culture results in aspirated exudate from a bullous lesion may provide clues to the etiology of the infection.
In a patient with diabetes considered to have a deep soft tissue infection, plain radiography, CT scan, or MRI may be performed to rule out a compartment syndrome and to demonstrate the presence of gas or a foreign body in the deep tissues. A finding of excessive gas signifies a mixed aerobic-anaerobic infection in contrast to gas gangrene (clostridial myonecrosis).
A bone scan is preferred to gallium or indium scans in the assessment of acute osteomyelitis.
Gallium or indium scans offer no additional information, and the findings are not more specific than those of bone scans in the diagnosis of osteomyelitis. Bone scans are usually unnecessary unless diagnostic confusion exists with another disorder. A bone tumor is best differentiated from chronic osteomyelitis with the aid of bone scanning or MRI prior to definitive bone biopsy. Patients with diabetic foot infections and peripheral vascular disease may benefit from vascular surgical evaluation to bypass large-vessel occlusive disease. Aspiration of a sample from the leading edge of the erythematous border in a patient with cellulitis is usually not necessary, but a sample may be aspirated if the likely organism must be identified on initial presentation.
Aside from blood culturing, radiography, and nuclear imaging studies, bone biopsy is not necessary in acute osteomyelitis because the pathogens are predictable. Bone biopsy performed under aseptic conditions in the operating room is the preferred way to identify the causative pathogen in chronic osteomyelitis. A general or vascular surgeon should be consulted for the debridement or decompression of compartment syndromes in patients with deep skin and soft tissue infections. An infectious disease specialist should be consulted in the treatment of all patients with diabetic foot infections to optimize the antimicrobial therapy.
In patients with diabetes, cellulitis is generally caused by group A and group B streptococci and, occasionally, S aureus. In patients with diabetes, deep skin and severe soft tissue infections are usually due to mixed aerobic and anaerobic organisms. Acute osteomyelitis, which usually is due to S aureus, may be treated with cefazolin, clindamycin, and an antistaphylococcal penicillin (eg, nafcillin). In chronic osteomyelitis, coverage must be directed against S aureus, group A and group B streptococci, aerobic gram-negative bacilli (excluding P aeruginosa), and B fragilis. First-generation semisynthetic cephalosporin that arrests bacterial cell-wall synthesis, inhibiting bacterial growth. Lincosamide for the treatment of serious skin and soft tissue staphylococcal infections.Also effective against aerobic and anaerobic streptococci, except enterococci. Initial therapy for suspected penicillin G–resistant streptococcal or staphylococcal infections. Bactericidal activity results from inhibition of cell wall synthesis and is mediated through ertapenem binding to penicillin binding proteins.
Treats infections caused by susceptible gram-negative and gram-positive organisms, in addition to infections caused by susceptible Chlamydia, Rickettsia, and Mycoplasma. The Center for Wound Care and Hyperbaric Medicine at Wellington Regional Medical Center is pleased to offer specialized services devoted to foot health for diabetic patients. The specialists at The Diabetic Foot are dedicated to staying on top of the leading advances in wound care treatment.
Note:The information on this Web site is provided as general health guidelines and may not be applicable to your particular health condition. The information, content and artwork provided by this Web site is intended for non-commercial use by the reader. Wellington Regional Medical Center offers a wide range of high quality medical services to residents of Wellington, Florida and surrounding communities. Whether you are getting ready for a procedure at Wellington Regional Medical Center or planning to visit a patient, get the information you'll need to make your trip more pleasant. Stay up to date with the latest news and events at Wellington Regional Medical Center, including health fairs, classes and seminars.
In recent times, diabetes, also known as diabetes mellitus has become one of the largest harmful chronic diseases across the world. There are mainly six types of diabetic foot complications like skin changes, neuropathy, calluses, foot ulcers, poor circulation and amputation. Poorly fitting shoes can cause calluses on the top of the toes, and excessive running can cause calluses on the sole of the feet. Prominent bony toes, deformities of the skin and thin skin increase the chances of calluses. Poor blood circulation occurs when different parts of the body don’t receive adequate blood flow. The symptoms of poor blood circulation are numb feet, cold feet, pale blue colour of the skin of legs, hair loss on the feet, vulnerable toe nails, cracked skin on foot and slow healing of wounds. Diabetic foot ulcer is one of the most well-known complications of diabetes mellitus and also one of the most problematic diabetic foot problems. Diabetic feet problems require immense attention as sore heals increase the chances of infection.

Every day, before going to bed give your feet a complete attentive going over to locate the signs of blisters, sores, cuts, scrapes or any small injuries that can lead to a significant problem. One in five people with diabetes will develop serious foot problems that require professional medical treatment.
Vitamin E is the most important antioxidant that neutralizes free radicals and also help prevent cellular damage from occurring. The foot muscles, like other muscles need daily exercise to remain active for a longer period. A clean foot is a healthy foot and diabetic patients can try the above-mentioned foot care procedures to prevent diabetic foot diseases and lead a healthy life. Read the full post and i would like to say that I really really the post and I love it and would like say enthusiastically, like that I also suggest my patients and friends to do the same and will also suggest them to read your blog its really nice! Thanks for your valuable information, it is useful for the people who are at diabetic risk.
Thanks for the valuable piece of information and it can definitely create an awareness among the people about how one should take care of these problems. Diabetes is also the cause of foot problems and foot infections.  Improper nail cutting and poorly fitting footwear can be dangerous. At FootMedics we assess and treat feet for diabetes related problems and we assess diabetic foot ulceration risk. These are wounds that occur in your legs and are the major reason that chronic wounds, which is a wound that will not heal in a set of stages in an orderly manner and an amount of time that is predictable the way most normal wounds do, happen in seventy to ninety percent of venous stasis ulcers. Venous stasis ulcer is usually found in the lower leg on the inner part that is just above your ankle but can occur anywhere on the leg below the knee and can affect one or both legs. Normally a venous stasis ulcer will present itself as an open sore, which will usually be in an area on the leg that is already a red to brown discoloration which may have been there for a long time. Before the formation of the venous stasis ulcer the skin may have been itchy and flaky, which is known as stasis dermatitis. The skin around the venous stasis ulcer may appear swollen, shiny, and tight with a tinge of reddish-brown and the skin may appear thin.
The pain associated with a venous stasis ulcer will vary and can be a burning or aching sensation along with a fullness or heaviness in the leg. The cause of venous stasis ulcer is a poor function of your venous system which simply means that your legs are not pumping blood back to your heart properly. Having a history of trauma to your lower leg which some physicians consider the number one source of these type of ulcers. Having an inflammatory disease like lupus, sclerodema, or vasculitis or other rheumatological disease. If a person cannot stand compression over the venous stasis ulcer because of the pain physicians have used in recent years a medication called Pentoxifylline (Trental).
They will usually remove the dead tissue in order to better treat the venous stasis ulcer because the dead tissue can harbor bacteria and when the dead tissue is removed it will help to clear up the infection. These individuals are predisposed to foot infections because of a compromised vascular supply secondary to diabetes. Infections in patients with diabetes are difficult to treat because these patients have impaired microvascular circulation, which limits the access of phagocytic cells to the infected area and results in a poor concentration of antibiotics in the infected tissues. Chronic osteomyelitis in patients with diabetes mellitus is the most difficult infection to cure. Dry gangrene is usually managed with expectant care, and gross infection is usually not present.
Gas gangrene is conspicuous because of its low incidence in patients with diabetes, but deep skin and soft tissue infections, which are due to gas-producing organisms, frequently occur in patients with diabetes. In the extremities, microvascular disease due to "sugar-coated capillaries" limits the blood supply to the superficial and deep structures. Most diabetic foot infections occur in the setting of good dorsalis pedis pulses; this finding indicates that the primary problem in diabetic foot infections is microvascular compromise.
In mixed infections that may involve anaerobes, crepitation may be noted over the afflicted area. Similarly, extreme pain may be an indication of infection with clostridial species (ie, gas gangrene).
However, in unusual epidemiologic circumstances, organisms such as Pasteurella multocida (eg, from dog or cat bites or scratches) may be noted and should always be considered.
Clinically, these infections appear as necrotizing fasciitis, compartment syndrome, or myositis.
The distribution of organisms is the same as in an individual without diabetes who has acute osteomyelitis. However, these organisms are superficial colonizers and are generally not the cause of the bone infection. To the author's knowledge, no well-documented cases of biopsy-proven P aeruginosa infection have been reported in patients with chronic osteomyelitis. Soft tissue swelling and periosteal elevation are the earliest signs of acute osteomyelitis on a plain radiograph. However, large-vessel bypass does not cure the microvascular component of diabetic foot infections. Because surgical debridement is critical in treating chronic osteomyelitis, bone biopsy specimens are usually not obtained during the surgical debridement procedure.
Cellulitis may be treated with single antibiotics that have the appropriate spectrum or with combination therapy that covers the appropriate organisms.
Although gram-negative organisms are the unusual causes of cellulitis, even in diabetes, if they are suspected, a fluoroquinolone (eg, levofloxacin) may be used in conjunction with clindamycin. These infections may be treated with monotherapy involving meropenem or piperacillin and tazobactam. Monotherapy for chronic osteomyelitis may include ampicillin and sulbactam, piperacillin and tazobactam, or meropenem.
Inhibits biosynthesis of cell wall mucopeptide and is effective during the active multiplication stage. Primarily active against skin flora, including S aureus.Typically used alone for skin and skin-structure coverage. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, arresting RNA-dependent protein synthesis.
Fluoroquinolones should be used empirically in patients likely to develop exacerbation due to resistant organisms to other antibiotics. Initially, use parenteral therapy in severe infections; change to PO therapy as condition warrants.
Inhibits bacterial protein translation by binding to 30S ribosomal subunit and blocks entry of amino-acyl tRNA molecules in ribosome A site.
Stable against hydrolysis by various beta-lactamases, including penicillinases, cephalosporinases, and extended spectrum beta-lactamases.
Binds to bacterial membranes and causes rapid membrane potential depolarization, thereby inhibiting protein, DNA, and RNA synthesis, and ultimately causing cell death.Indicated to treat complicated skin and skin structure infections caused by S aureus (including methicillin-resistant strains), S pyogenes, S agalactiae, S dysgalactiae, and E faecalis (vancomycin-susceptible strains only). Every year, chronic wounds caused by diabetes, poor circulation or other conditions keep three to five million Americans just like you from doing the things they love to do. Your individual health status and any required medical treatments can only be properly addressed by a professional healthcare provider of your choice. The main causes of diabetes are the modern day sedentary lifestyle, genetic susceptibility, overdependence on harmful processed and packed foods, obesity and lack of physical activity. The main causes of neuropathy are repetitive injury, metabolic problems, physical trauma, and infection. The other causes of poor circulation are smoking, high blood pressure and high cholesterol. Peripheral artery disease, smoking, diabetic neuropathy, poor glycemic control and ischemia of small blood vessels increase the chance of foot ulcers. Amputation is a surgical procedure in which parts of the limb like foot, toe are removed due to injury, infection, surgery and disease. Even health conscious people most of the time skip proper washing of the feet in the shower regularly. Diabetes usually damages the nerves of the feet and reduce the ability to feel discomfort or pain. Also, they play significant roles within the body including immune and nervous system functions. She has done her masters in English and has done her graduation from Banaras Hindu University.
It can lead to lack of feeling in the feet and poor circulation to the feet which can have devastating consequences.
These types of ulcers are also known as ulcus crusis, stasis ulcers, leg ulcers, or varicose ulcers.
This is eczema of your skin because of blood that is perfusing through and settling into layers of your skin. This is known as fibrous tissue which is basically scar tissue that did not promote healing. The medication can help to improve the circulation down to your feet and can help improve the wound environment so that it will heal faster.

If the wound is not infected, removing the dead tissue will help reduce the chances of it becoming infected. For this reason, cellulitis is the most easily treatable and reversible form of foot infections in patients with diabetes. Adequate surgical debridement, in addition to antimicrobial therapy, is necessary to cure chronic osteomyelitis. In general, people with diabetes have infections that are more severe and take longer to cure than equivalent infections in other people. Pressure due to ill-fitting shoes or trauma further compromises the local blood supply at the microvascular level, predisposing the patient to infection.
Impaired microvascular circulation hinders white cell migration into the area of infection and limits the ability of antibiotics to reach the site of infection in an effective concentration. Administered antibiotics do not penetrate the devascularized infected bone fragments; they can enter the area of osteomyelitis only via the remaining blood supply.
In chronic osteomyelitis, antimicrobial therapy without adequate debridement does not eliminate the infection.
Has slightly increased activity against gram-negative species and slightly decreased activity against staphylococci and streptococci compared with imipenem.
Because of thrombophlebitis, particularly in elderly patients, use parenteral administration only for a short term (1-2 d); change to PO route as clinically indicated. Indicated for complicated skin and skin structure infections caused by E coli, E faecalis (vancomycin-susceptible isolates only), S aureus (methicillin-susceptible and -resistant isolates), S agalactiae, S anginosus grp (includes S anginosus, S intermedius, S constellatus), S pyogenes, and B fragilis.
The Center for Wound Care and Hyperbaric Medicine at Wellington can help you get your life back. Remember: There is no adequate substitution for a personal consultation with your physician. The feet of diabetic patients are at risk because diabetes can cause harm to the blood supply and nerves.
Calluses must not be ignored because once intensified; they can cause diabetic foot ulcers.
Many times, plaques form in the blood vessels during this situation and the blood vessels can’t supply sufficient amount of blood to the surrounding cells. Exercise is good for treating poor circulation and stimulates the flow of blood in the feet and legs. But don’t take things up in your hands and try bathroom surgeries, as this can complicate things further.
Diabetes can cause blood circulation problems that increase the chance of heart attack and stroke.
A daily walk helps keep the ligaments and tendons flexible, and also helps strengthen leg muscles. Many times a plaque form in the blood vessels during this situation and the blood vessels can not supply a sufficient amount of blood to the surrounding cells. Each B vitamin has specific roles to play, but they all work together to maintain a healthy life.
This type of ulcer affects approximately five hundred thousand to six hundred thousand people in the United States each year along with the lost of two million work days. When this happens it breaks down the skin and deposits melanin and hemosiderin, which is the blood seeping into your skin and staining your skin because the venous system is unable to pump it up to your heart adequately. Usually the standard treatment involves using compression of the leg that is affected to help minimize swelling because if you do not get rid of the constant swelling you are reducing dramatically having the wound close. Though most of the fungi are harmless and reside in our skin, if an individual’s immune system gets weak or the fungus undergoes a change, an infection can occur.
For additional information, see Medscape’s Diabetic Microvascular Complications Resource Center. Deep skin and soft tissue infections are also usually curable, but they can be life threatening and result in substantial long-term morbidity. Therefore, antibiotic therapy alone cannot cure patients with chronic osteomyelitis without surgical debridement to remove these isolated infected elements. Structurally similar to beta-lactam antibiotics, but not related to beta-lactam drugs in terms of hypersensitivity. Good monotherapy with extended coverage against Pseudomonas species, as well as excellent activity against pneumococci. At the Center, a talented team of specialists treat stubborn, chronic wounds, some that have resisted healing after months or even years of traditional treatment.
According to researchers, approximately 383 million people throughout the world were suffering from diabetes in 2013. This happens because the body is transforming the water into urine to surpass additional glucose from the body. In peripheral artery disease, people face the problems of poor blood circulation which can also cause serious foot problems. Many times a plaque form in the blood vessels during this situation and the blood vessels cannot supply sufficient amount of blood to the surrounding cells.
Don’t forget to clean between the toes as cleaning of toes also reduce the chances of infection. The patients suffering from foot ulcers should opt for customized shoes that reduce the risk of developing foot ulcers in the future.
Doctors consider the changes in skin colour and also examine between the toes as many infections can start from there. Diabetes usually damages the nerves of the feet that reduce the ability to feel discomfort or pain. Treatment costs for venous stasis ulcer is approximately three billion dollars each year in the United States. The types of compression that may be used include using ace bandages or other multilayer compression wraps or compression stockings. This may allow for incidental trauma that goes unrecognized (eg, blistering, penetrating foreign body). Surgical debridement is essential to remove the infected bony fragments that the antibiotics cannot reach so that affected areas can be treated with antimicrobial therapy. Carbapenems and monobactams do not cross-react in patients who are allergic to penicillin, even those who have an anaphylactic reaction to penicillin. The Center's healing rate is over 80 percent and most patients realize complete wound closure in just a few months. Diabetes increases the risks of stroke, heart attack, foot ulcers, eye damage and kidney failure. The skin becomes dry when the damaged nerves of legs and feet don’t receive a signal to sweat. In peripheral artery disease, people face the problems of inadequate blood circulation which can also cause serious foot problems. The feet remain confined in closed shoes for a long time and the moisture and sweat increases the chances of bacterial infection. Antioxidants protect skin by reducing the production of free radicals that can damage skin cells. Vitamin B12 also helps regulate our skin’s pigment production and location and also prevents hyperpigmentation. Various other medical conditions that can lead to neuropathy include kidney disease, liver disease, excessive alcohol intake, cancer and HIV. If we don’t wash the feet daily it can cause foot odor, other skin problems and fungal infections. But regular walking helps in imporving blood circulation and recovering sensation in the feet. These infections can be contagious and are found superficially on the top layers of the skin. Broken skin increases the chances of infection as germs can easily enter the skin through the cracked area.
Red scaly edges with shiny lashes can appear on these folds and then spread to other areas. As far as climate is concerned, hot and humid climates are considered as favourable for the growth of yeast and lead to this skin condition with excessing sweating and itching. It is formulated to work in the skin by permeating inside and targeting the fungal infection.
Itching and peeling of the skin, redness in the groin area with ring-shaped skin rashes are some of the common symptoms associated with jock itch.
Also, you need to take a good care of your diet and lifestyle practices to prevent further spread of this skin condition.Even if you have had treatment before for yeast or fungal infections you should never consider these kinds of infections as “minor”. Treatment  with anti-fungal products and OTC yeast infection cures may work for occasional outbreaks but seek the advice of a doctor for answers for yeast and fungal infections on the skin if you have a recurring problem.

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