It is important to help guide you through the rather involved process of a diabetic foot infection. Properly understanding this situation can mean the difference between keeping your leg or losing it. Over the next three posts, I will be discussing this rather significant diabetic problem.
Dr’s RESPONSE: A diabetic foot infection is a serious concern. Infections typically refer to bacteria, but keep in mind many other organisms can create an infection: fungus, viruses, parasites, insects, etc. Bacteria are by far the most prevalent. Some bacteria are harmful while others are beneficial. Keep in mind, bacteria are all around us, on the floor, on doorknobs, on keys, on dishes, on pens, etc. You get the idea.
The usual route of infection for a diabetic typically begins with a break in the skin. Let’s use an example. Harry is a diabetic preparing for his grandson’s wedding in just over a months time. He is trying on a pair of rental shoes that come with his tuxedo. He unknowingly creates a small cut on the top of his foot while trying on a pair of shoes that are too small for him. Because he is diabetic and has sensory neuropathy, he is unable to feel this cut and continues to go about his day, oblivious to the fact that he has a small opening on the top of his foot. Also, because he is diabetic, his immune system is not functioning optimally and is unable to mount the proper immune response that a healthy individual would be able to do.
For an infection to occur, either the friendly bacteria has multiplied to dangerous levels or the dangerous bacteria has gain a foothold against the body. Obviously with a diabetic, this can easily occur because the normal immune system response is muted in a diabetic. Otherwise healthy bacteria can also prove harmful because they are multiplying unchecked. Additionally, this condition can also lead to large numbers of several different types of bacteria, which also limits the body’s immune response. Bacteria can be seeded by openings in the skin, corns, calluses, punctures, small fissures, ingrown nails, burns, and a variety of other methods.
So going back to our example, the bacteria have now seeded themselves on the top of Harry’s foot from the used rental shoe. They have begun to rapidly multiply after a few days and Harry is still unaware that he has a problem. After about a week, Harry begins to complain of a low grade fever and notices that he has some smelly yellow fluid on his white socks. Harry is no dummy, he already is a patient of a local podiatrist, a physician who has special training in all aspects of foot, ankle, and leg conditions. He makes an appointment to see the doctor the following week.
So what does an actual diabetic infection look like? Well, first, there typically is a sore or ulcer present. Around this ulcer, there is usually red and inflammed tissue. Also, there may be no swelling, some swelling, or significant swelling. There may also be warmth to the touch. Additionally, pus or foul smelling fluid may be draining from the ulcer. The skin in the area of the ulcer may appear to be flaking or peeling away. Also, in serious situations, there may be red streaking up the limb. There may or may not be pain because of sensory neuropathy for the diabetic patient. Diabetics cannot rely on sensation to realize that they have a problem. They must rely on their vision to detect any abnormalities on their feet. Even their sense of smell may not be that good at an older age. People with serious infections may have nausea, vomiting, fever, and/or chills.
Harry should have inspected his feet daily. Had he followed his doctors’ instructions to check his feet everyday because he is diabetic, he may have caught the infection in time when it was at a manageable level. But because Harry didn’t realize his problem until he noticed the yellow drainage on his sock, too much time had elapsed. The bacteria had a lot of time to seed itself, multiply itself, and has overcome any weakened immune response directed against it. This is where daily foot inspections are so vitally important. Missed infections can worsen to the point of amputation or hospitalization.
So now Harry is at his podiatrist’s office that afternoon in the exam room. The physician is alarmed by what she sees because when she last saw Harry, he was problem free and anticipating his participation in his grandson’s wedding. The physician has a difficult time explaining to Harry that he needs to be admitted to the hospital for IV antibiotic administration as well as advanced imaging studies. Quite possibly, due to the severity of the infection, Harry may need to stay for a few days to have this infection surgically treated. Of course, the physician relates that if prolonged, Harry may miss his grandson’s wedding.
It is important to note that all diabetic foot infections must be evaluated by a physician, no matter how minor or trivial it may seem to the patient. Misdiagnosing yourself can lead to serious repercussions involving your foot. It could even prove fatal if left untreated. Home treatment without physician evaluation is not an option in diabetics for any level of infection.
The next morning, Harry is visited in the hospital by his podiatrist. Harry has been on IV antibiotics since his arrival in the emergency room, but he has seen no change in the condition of his right foot. In fact, Harry has now lost his appetite and complains of some episodes of nausea. The physician carefully explains the situation to Harry. He has a severe infection involving his right foot. This infection is severe enough and has progressed enough that he will need to go to the operating room to remove the infected tissue and attempt to washout the bacteria present. The xray has shown no changes but the MRI has suggested evidence of possible osteomyelitis, a bone infection, in his right foot.
That evening, Harry goes to the operating room where his podiatrist debrides the infected and dead tissue. She also washes out the wound to try and reduce the bacterial load present. She also cultures the wound to help influence the correct antibiotic choice. Lastly, she takes a small piece of bone to be sent to the pathologist to check to see if there is microscopic evidence of an infection.
After three days, the cultures return with an exact bacteria identified. This is important because now the best antibiotic can be chosen to fight that particular bacteria. Harry is still in the hospital, and although he feels better and his right foot has improved, he’s about to hear the dreaded word that all diabetics hear “amputation.” Harry’s physician tells him that he needs to have part of his foot amputated because the bone sample has come back positive for infection.
Harry has now come to a fork in the road. He can have the amputation and get back on his feet quickly, possibly in time for his grandson’s upcoming wedding. Or he can elect to continue IV antibiotics only for up to six weeks, which carries a less than 5% success rate to eliminate bacteria once seeded in bone. Reluctantly, Harry agrees to the amputation. He is discharged from the hospital three days later, having spent a total of ten days there. He is able to attend his grandson’s wedding, although he is not wearing his rental shoes and he is not dancing. But he is able to appreciate the fact that he could have lost his leg had he not been properly cared for. Harry is thankful for all of these things, and he now visually inspects his feet everyday. More importantly, Harry is now well educated concerning his disease and he has taken measures to combat any problems that may develop in his future.
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