Balakrishnan KR, Selva Raj DR, Ghosh S, Robertson GA. Diabetic foot attack: Managing severe sepsis in the diabetic patient. World J Crit Care Med 2025; 14(1): 98419 [DOI: 10.5492/wjccm.v14.i1.98419]
Corresponding Author of This Article
Kisshan Raj Balakrishnan, Department of Trauma and Orthopaedics, Wrexham Maelor Hospital, Croesnewydd Road, Wrexham LL13 7TD, United Kingdom. kisshan.raj1108@gmail.com
Research Domain of This Article
Critical Care Medicine
Article-Type of This Article
Editorial
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Kisshan Raj Balakrishnan, Dharshanan Raj Selva Raj, Sabyasachi Ghosh, Gregory AJ Robertson, Department of Trauma and Orthopaedics, Wrexham Maelor Hospital, Wrexham LL13 7TD, United Kingdom
Gregory AJ Robertson, Department of Trauma and Orthopaedics, The Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry SY10 7AG, United Kingdom
Author contributions: Balakrishnan KR conceived the methodology; Balakrishnan KR and Robertson GA performed the literature search and analysis, and wrote the manuscript; Selva Raj DR and Ghosh S advised on the study; and all authors reviewed and edited the manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Kisshan Raj Balakrishnan, Department of Trauma and Orthopaedics, Wrexham Maelor Hospital, Croesnewydd Road, Wrexham LL13 7TD, United Kingdom. kisshan.raj1108@gmail.com
Received: June 25, 2024 Revised: October 23, 2024 Accepted: November 15, 2024 Published online: March 9, 2025 Processing time: 168 Days and 13.6 Hours
Abstract
Diabetic foot attack (DFA) is the most severe presentation of diabetic foot disease, with the patient commonly displaying severe sepsis, which can be limb or life threatening. DFA can be classified into two main categories: Typical and atypical. A typical DFA is secondary to a severe infection in the foot, often initiated by minor breaches in skin integrity that allow pathogens to enter and proliferate. This form often progresses rapidly due to the underlying diabetic pathophysiology of neuropathy, microvascular disease, and hyperglycemia, which facilitate infection spread and tissue necrosis. This form of DFA can present as one of a number of severe infective pathologies including pyomyositis, necrotizing fasciitis, and myonecrosis, all of which can lead to systemic sepsis and multi-organ failure. An atypical DFA, however, is not primarily infection-driven. It can occur secondary to either ischemia or Charcot arthropathy. Management of the typical DFA involves prompt diagnosis, aggressive infection control, and a multidisciplinary approach. Treatment can be guided by the current International Working Group on the Diabetic Foot/Infectious Diseases Society of America guidelines on diabetic foot infections, and the combined British Orthopaedic Foot and Ankle Society-Vascular Society guidelines. This article highlights the importance of early recognition, comprehensive management strategies, and the need for further research to establish standardized protocols and improve clinical outcomes for patients with DFA.
Core Tip: Diabetic foot attack (DFA) represents the most severe presentation of diabetic foot disease, with typical and atypical forms that require distinct management strategies. A typical DFA results from a severe infection of the foot, propagated by the associated diabetic pathophysiology, leading to rapid spread of infection, tissue necrosis and potential systemic sepsis. An atypical DFA arises from either ischemia or Charcot arthropathy. Effective management of DFA necessitates early diagnosis, aggressive treatment of infections, and a multidisciplinary approach involving critical care, surgical intervention, and diabetes management teams. Current treatment practices are informed by guidelines for diabetic foot infections, but there is a critical need for dedicated research to develop standardized protocols for DFA management. This review highlights the urgent need for comprehensive care and research to optimize outcomes for patients experiencing DFA.
