Managing complications of the diabetic footBMJ 2009; 339 doi: https://doi.org/10.1136/bmj.b4905 (Published 02 December 2009) Cite this as: BMJ 2009;339:b4905
All rapid responses
Diabetic foot complications ending with major amputations are
devastating to patients and a huge drain on the health budget. Cheer et al
produced a very useful clinical review on its management(1).
One of their references is the Infectious Diseases Society of America
guideline on the management of diabetic foot infections(2). This
comprehensive guideline mentioned two very important issues in the
management of non-healing diabetic foot ulcers (DFU’s) that cannot be
overlooked. Firstly the diagnosis of osteomyelitis of underlying bone
should be made early and the best non-invasive method is MRI scanning.
This imaging modality is under-utilised in the UK. Secondly they refer
several times to hyperbaric oxygen therapy (HBOT) as a modality to be
considered in refractory cases. They made the quality of the evidence
supporting HBOT as Grade I, i.e. one or more properly randomised
controlled trials supporting it. They further state that the strength of
the recommendation should be grade B, i.e. moderate evidence to support a
recommendation for use and should generally be offered to appropriate
Kranke et al(3), in their 2004 Cochrane review, briefly mentions
several of the well known mechanisms of action of HBOT, however two other
possible mechanisms that add to this fascinating subject are stem cell
release(4) and vascular endothelial growth factor (VEGF) release triggered
by HBOT(5). In this Cochrane review they conclude that the evidence is
insufficient to recommend routine use of HBOT for diabetic foot ulcers.
This is completely understandable because all recent technology
assessments emphasise that HBOT has its place in the multidisciplinary
team, but not routinely, only for DFU’s not healing with standard therapy.
The Canadian Agency for Drugs and Technologies in Health(6) concluded that
HBOT reduces major lower extremity amputations from 32% to 11% in those
receiving HBOT and it decreases the proportion of unhealed wounds. They
found it cost effective and quoted several good quality studies. NHS
Quality Improvement Scotland in 2008 produced a clinical and cost
effectiveness study of HBOT and concluded that it is recommended for non-
healing DFU’s if transcutaneous oxygen pressures, measured under
hyperbaric conditions, are higher than 100 mmHg(7).
In conclusion it is clear that with careful assessment, good
selection and proper care, HBOT could play an important role in DFU’s
failing to heal with conventional therapy alone.
1. Cheer K, Shearman C, Jude E. Managing complications of the
diabetic foot. BMJ. 2009;339:1304-07.
2. Lipsky B, Berendt A, Deery H, Embil J, Joseph W, Karchmer A, et
al. Diagnosis and Treatment of Diabetic Foot Infections. Clinical
Infectious Diseases 2004;39:885-910.
3. Kranke P, Bennett M, Debus S, Roeckl-Wiedmann I, Schnabel A.
Hyperbaric oxygen therapy for chronic wounds. Cochrane Database of
Systematic Reviews. 2004(1).
4. Thom S, Bhopale V, Velazquez O, Goldstein L, Thom L, Donald G.
Stem cell mobilization by hyperbaric oxygen. Am J Physiol Heart Circ
5. Sheikh A, Gibson J, Rollins M, Hopf H, Hussain Z, Hunt T. Effect
of Hyperoxia on Vascular Endothelial Growth Factor Levels in a Wound
Model. Arch Surg. 2000;135:1293-7.
6. Hailey D, Jacobs P, Perry D, Chuck A, Morrison A, Boudreau R.
Adjunctive hyperbaric oxygen therapy for diabetic foot ulcer: An Economic
Analysis. [Technology report no 75]. Ottawa: Canadian Agency for Drugs
and Technologies in Health; 2007 [updated March 200731/01/2010]; Available
7. Ritchie K, Baxter S, Craig J, Macpherson K, Mandava L MH, Wilson
S. The clinical and cost effectiveness of hyperbaric oxygen therapy. HTA
programme: Systematic Review 2 - July 20082008 [updated July; cited 2010
31 January]; Available from:
Dr P Bothma is Lead Consultant for the East of England Hyperbaric unit at James Paget University Hospital in Great Yarmouth
Competing interests: No competing interests
Cheer and colleagues correctly highlight that infection in the
diabetic foot is a medical emergency1. A major risk factor is that 22 –
66 % of all foot ulcers are complicated by foot infection and
The National Institute for Health and Clinical Excellence (NICE) and
Infectious Diseases Society of America (IDSA) guidelines recommend that a
multidisciplinary specialist foot care team should include or have ready
access to the medical microbiologist or an infectious diseases specialist
for provision of expert input in assessment and management of patients
with diabetic foot infections.2,3 Yet Cheer et al omitted to mention the
need for this expert input which can not only optimise antimicrobial
effectiveness but also minimise the generation of antibiotic resistant
organisms and avoidable occurrence of Clostridium difficile diarrhoea.
In Salford the medical microbiologist is a core member of the
specialist foot care team involved in clinical assessment of the patient,
interpretation of microbiological results, provision of advice with regard
to choice of antibiotics, dosage, route of administration and duration of
therapy. Furthermore unnecessary hospital admission is facilitated by
ready access to administration of parenteral antibiotics to patients in
the community through Outpatient and Home Parenteral Antimicrobial therapy
(OHPAT). This is managed by the same medical microbiologists along with
intravenous therapy nurses.
We suggest that microbiological expertise should not just be
available to advise on this medical emergency, it should be an integral
part of the multidisciplinary team.
Chinari P K Subudhi Consultant Microbiologist
Paul R Chadwick Consultant Microbiologist
Bob Young Consultant Diabetologist
Salford Royal Hospital NHS Foundation Trust, Stott Lane, Salford M6
1 Cheer K, Shearman C, Jude EB. Managing complications of the
diabetic foot. BMJ 2009; 339: 1304-07.
2 National Institute for Health and Clinical Excellence. Type2
diabetes: prevention and management of foot problems. 2004.
3 Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW,
et al. Diagnosis and treatment of diabetic foot infections. Clin Infect
Dis 2004; 39:885-910.
Competing interests: No competing interests