Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Read full text guideline  

 Dr Lipsky, could you provide some clarification on empiric antiobiotic choice?

In table 8, under moderate or severe DFIs, we have the following probable pathogens groups:

1) MSSA; Streptococcus spp; Enterobacteriaceae; obligate anaerobes

So far, everything clear; these are the pts with no risk for MRSA or Pseudomonas; treat them with “usual” antibiotics

2) MRSA – treat with linezolid, daptomycin, or vancomycin

Obvious

3) Pseudomonas - piperacillin-tazobactam

OK

4) MRSA, Enterobacteriacae, Pseudomonas, and obligate anaerobes; suggested antibiotics: vancomycin, ceftazidime, cefepime, piperacillin-tazobactam, aztreonam, or a carbapenem.

Now I have trouble – what clinical scenario is it? Did you mean patients with risk factors for both MRSA and Pseudomonas, and hence the need for very broad-spectrum antibiotics? If so, then we should probably use vancomycin (linezolid, daptomycin) AND one of the remaining (or, maybe more specifically, vancomycin plus piperacillin-tazobactam, because the latter is preferred for Pseudomonas). Why this list is longer, if required spectrum is broader?

Thank you.