Wet necrosis

The microbiological principles of managing wet necrosis are similar to those for the management of infection of the foot with extensive soft tissue infection or the foot with blue discolouration as described in Chapter 5. When the patient initially presents, deep wound swabs and tissue specimens are sent off for microbiology. Deep tissue taken at operative debridement must also go for culture.

Intravenous antibiotic therapy Both neuropathic and neuroischaemic patients need parenteral therapy. They are admitted to hospital and given intravenous antibiotic therapy as follows: amoxicillin 500 mg tds, flucloxacillin 500 mg qds, metronidazole

500 mg tds and ceftazidime 1 g tds. For patients who are allergic to penicillin we substitute erythromycin 500 mg qds, vancomycin 1 g bd or clindamycin 600 mg qds for amoxicillin and flucloxacillin. We use this regime because these infections are often polymicrobial. Other regimes are in use including:

• Ciprofloxacin with clindamycin

• Piperacillin/tazobactam

• Ampicillin/sulbactam

• Ticarcillin/clavulanate

Intravenous antibiotics can be replaced with oral therapy after operative debridement and when infection is controlled. On discharge from hospital, oral antibiotics are continued and reviewed regularly in the diabetic foot clinic. When the wound is granulating well and swabs are negative then the antibiotics are stopped.

It is often difficult to have all wet necrosis removed surgically. The foot may be ischaemic, and the patient may not be fit for an operation. In these circumstances we believe that it is best to leave the necrosis and convert wet necrosis to dry necrosis using antibiotics and allow it to separate. The presence of necrosis will increase the risk of infection: however, these patients are under very close surveillance and early signs of wet necrosis are carefully sought for.

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