Choice of wound care in diabetic foot ulcer: A practical approach

Table 1 Antibiotic recommendation based on the severity of the infection

Site	Severity or extent	Route of administration	Duration of therapy
Soft tissue only	Mild	Topical or oral	1-2 wk may extend up to 4 wk if slow to resolve (outpatient)
	Moderate	Oral (or initial parenteral)	1-3 wk (Outpatient/inpatient)
	Severe	Initial parenteral, switch to oral when possible	2-4 wk (Inpatient, then outpatient)
Bone or joint	No residual infected tissue (e.g., post-amputation)	Parenteral or oral	2-5 d
	Residual infected soft tissue (but not bone)	Parenteral or oral	1-3 wk
	Residual infected (but viable) bone	Initial parenteral, then consider switching to oral	4-6 wk
	No surgery, or residual dead bone post-operatively	Initial parenteral, then consider switching to oral	≥ 3 mo

Table 2 Choice of wound care materials for necrotic and sloughy wounds

Wound classification	Choice of wound care material	Advantages	Disadvantages
Necrotic wound	Wet to dry	Good debriding capacity and inexpensive	Frequent dressing change Painful if not soaked with saline prior to dressing change
	Topical antibacterial such as metronidazole	Very good antibacterial coverage Maintains a moist wound healing environment by promoting autolysis and controls odor	Chance of maceration Contraindicated in infected necrotic wounds
	Hydrogel	Hydrates the wound by promoting autolysis	Chance of maceration Contraindicated in infected necrotic wounds and is expensive
	Hydrocolloid	Maintains a moist wound healing environment, which helps in autolytic debridement	Expensive Contraindicated in infected necrotic wounds
Sloughy wound	Wet to dry	Good debriding capacity Absorptive, adhesive and cheapest	Frequent dressing change Painful if not soaked with saline prior to dressing change
	Topical enzymes such as collagenase, papain, fibrinolysis	Promotes autolytic debridement by desloughing Can be used in combination with metronidazole or hydrogel	Contraindicated in granulating or epithelizing wounds
	Topical antibiotics such as metronidazole	Very good antibacterial coverage Maintains moist wound healing environment by promoting autolysis and controls odor	Chance of maceration
	Polyurethane Foam	Very effective in desloughing Maintains a moist wound healing environment by promoting granulation	Sometimes painful if not soaked with saline prior to dressing change
	Hydrogel	Hydrates the wound by promoting autolysis	Chance of maceration and is expensive
	Hydrocolloid	Maintains a moist wound environment, which helps in autolytic debridement	Chance of maceration and is expensive

Table 3 Choice of wound care materials for healing/sinus or cavity wounds

Wound classification	Choice of wound care materials	Advantages	Disadvantages
Granulating wounds	Non adherent dressing	Reduces trauma to the healing tissue Maintains a moist wound healing environment	Chance of shearing to new epithelium
	Wet to dry dressing	Promotes healing	Chance of bleeding if not soaked with saline before dressing change
	Polyurethane foam	Maintains a moist wound healing environment Promotes healing process	Chance of bleeding if not soaked before dressing change
	Topical antibacterial such as metronidazole, mupirocin, Tulle, Silver containing ointments, Acetic acid 0.5%-5% and povidone iodine	Maintains a moist wound healing environment, promotes epithelization and controls odor Effective against Gram positive cocci including MRSA. Silver sulfadiazine has broad antibacterial coverage, accelerates epithelization, and is very effective in burns. Acetic acid is very effective against Pseudomonas. Povidone iodine is very effective for gangrene as it hastens demarcation	Silver containing ointments cannot be used in Sulfa allergy patients Povidone iodine is cytotoxic to fibroblasts and delays the healing process
	Platelet derived growth factor	Faster healing and very effective	Expensive
	Hydrogel	Promotes healing	Chance of maceration and is expensive
	Hydrocolloid	Promotes healing Reduces the interval of dressing change	Chance of maceration and is expensive
Epithelizing wounds	Non adherent	Reduces trauma to the healing tissue Maintains a moist wound healing environment	Chances of shearing
	Wet to dry dressing	Promotes faster healing	Soaking of dressing is required prior to dressing change
	Topical antibacterial	As mentioned in granulating wounds	As mentioned in granulating wounds
	Epidermal growth factor	Effective and faster healing	Expensive
	Hydrogel	Effective	Chance of maceration and is expensive
	Hydrocolloid	Effective	Chance of maceration and is expensive
Cavity/Sinus wounds	Alginate	Highly absorbent and non-adherent Maintains a moist wound healing environment	Needs adequate padding and is expensive
	Hydrogel	Effective in promoting granulation tissue	Needs adequate padding and is expensive