Presentation And Diagnosis

When feet reach stage 4, they have developed infection. This is a highly significant staging post on the road to amputation. Although amputation may result from severe ischaemia or gross deformity of Charcot's osteoarthropathy, this is rare, and infection is usually the final common pathway to amputation.

More people undergo major amputation because of combined diabetes and infection than for all other causes. In this chapter we describe how infected diabetic feet are managed at King's College Hospital, London, both in the outpatient diabetic foot clinic and on the wards.

Diabetic foot patients with diffuse spreading cellulitis and extensive soft tissue infection are often in immediate danger of losing life and limb. We discuss the polymicrobial organisms associated with deep wound infections and detail the meticulous care these patients need. We have tried to illustrate these points with very detailed case studies. We hope that we have outlined a good case for multidisciplinary care, with daily input from medical and surgical teams for inpatients with severe infections.

Our aim has always been to devise a practical approach which can diagnose infections early, treat them rapidly and aggressively, and thus prevent amputations. We are guided in our decision making by a combination of the signs or symptoms of infection, the results of properly taken wound swabs and tissue cultures, and our knowledge of individual patients. Our guiding principle is that we do not forget that 85% of major amputations in people with diabetes begin with a 'clean' ulcer.

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