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Diabetic Foot Infection – VASP


  • Plain radiograph for all pts; MRI w/contrast if abscess/osteo suspected

  • BCx (prior to antibiotics) if systemic signs of infection, or severe infection

    • Do not culture swabs of lesions, as these generally only grow colonizing organisms.
  • Consult podiatry if osteomyelitis present for bone specimen culture and pathology (either from debridement specimen or bone biopsy) prior to starting antibiotics.

  • Consult surgery if concern for abscess, gas in tissue, joint involvement

  • Assess peripheral vasculature, consider arterial flow studies/vascular surgery consult


  • Assess Severity:

    • Mild: Local infxn, skin/subQ tissue only, erythema >0.5 cm but ≤2cm from ulcer

    • Moderate: Local infxn w/erythema > 2 cm from ulcer or deeper structures included without SIRS

    • Severe: Local infxn with systemic inflammation as evidenced by >2 SIRS criteria

      • Consider anti-pseudomonal coverage if at risk for Pseudomonas infection (e.g. wet; failure of prior antibiotic therapy; chronic wound).

      • Consider anaerobic coverage with metronidazole if foul-smelling and/or necrotic.

Non-purulent, no MRSA risk factors

Purulent, MRSA risk factors


Cephalexin 500 QID OR

Amoxicillin-clavulanate 875/125 BID

TMP-SMX DS 1-2 tabs BID OR

Doxycycline 100 BID


Amoxicillin-clavulanate 875/125 BID OR

Ampicillin-sulbactam 3g q6h OR

Piperacillin-tazobactam 3.375g q8h ext infusion OR

Levofloxacin 500 daily

TMP-SMX DS 1-2 tabs BID + cephalexin 500 QID OR Amoxicillin-clavulanate 875/125 BID

Vancomycin 15-20mg/kg q8-12h + ampicillin-sulbactam 3g q6h (anaerobic, but NO Pseudomonas cvg) OR cefepime 2g q8h (Pseudomonas cvg) + metronidazole 500 q8h (anaerobic cvg)

Severe Vancomycin 15-20 mg/kg q8-12h + cefepime 2g q8h + metronidazole 500 q8h

Additional Information

  • If pt HDS, hold abx until deep tissue/operative cultures obtained.

  • Most diabetic foot infections are polymicrobial in nature.

  • Culture results may guide therapy, but all pathogens identified may not require treatment.

Last update: 2022-06-21 22:14:16