Diabetes mellitus
Principles of foot ulcer management

NB: Notify / refer all patients to Diabetes Resource Centre.

All ulcers need consideration of:

Wound control:- chiropody or debridement.
Mechanical control:- rest, insoles, shoes, casts, elevation, protection, other heel.
Vascular control:- see protocol
Metabolic control:- aim for blood glucose less than 10
Microbiological control:- see below

· Treat all open lesions with antibiotics until healed (watch for diarrhoea with Clindamycin).
· Regular deep swabs (including bone) NB do not stop antibiotics with "no growth"
· There is no substitute for direct clinical examination on regular basis to modify protocol

All ulcers contain mixed organisms

Simple ulcer - neuropathic or ischaemic	Amoxycillin 500mg x 3 (by mouth) Flucloxacillin 500mg x 4 (by mouth)	Will miss some anaerobes and coliforms
Ulcer with surrounding soft tissue infection / gangrene X-RAY	Newly presenting: Amoxycillin 500mg x 3 Flucloxacillin 500mg x 4 Metronidazole 400mg x 3 (all by mouth) Worsening of known ulcer: Clindamycin 300mg x 4 (450mg x 4 in obese) by mouth
Spreading infection and cellulitis X-RAY & ADMIT	Elevation IV Ampicillin / Flucloxacillin. Metronidazole P0 for at least 48 hours or Oral Clindamycin - dose as above	Cheap but time consuming vs Easy but expensive
Osteomyelitis (acute / chronic) guided by clinical signs / X-rays / CRP	Clindamycin dose as above / Ciprofloxacin 750mg x 2 (excellent bone concentration) + Metronidazole 400g x 3 by mouth Treat 4-6 weeks minimum. If no improxement add Flucloxacillin 500mg x 2	Esp. staph aureus - doesn't or cover gram negatives

MRSA on culture - discuss with Clinical Microbiologist

Change in antibiotic therapy may be indicated when culture results are available.

Allergy to Penicillin: For outpatients use Erythromycin 500mg x 4

Source: Northumbria NHS Health Care Trust diabetes protocol