Pharmacotherapy of lower limb diabetic ulcers

OBJECTIVE: To discuss the pathophysiology, microbiology, and pharmacotherap y of lower extremity (LE) diabetic ulcers. DATA SOURCES: A MEDLINE search from 1966 to April 1999 was conducted. The s earch was limited to humans and English-language journals. Key search words included "diabetic ulcer," "fluoroquinolones," "beta-lactam," "hyperbaric oxygen," "diabetes mellitus," "diabetic foot," and "growth factor." STUDY SELECTION: Randomized and nonrandomized studies were selected for rev iew. Results of randomized, placebo-controlled studies were emphasized more than nonrandomized results. DATA SYNTHESIS: LE ulcers are a common cause of hospitalization, and cause significant morbidity and mortality. Staphylococcus aureus is is the most c ommon pathogen in non-limb-threatening infections; Gram-negative bacteria a nd anaerobes are most prevalent in limb-threatening and life-threatening in fections. Oral antibiotic therapy may be used in non-limb-threatening infec tions, if adequate response is achieved in 24-48 hours; otherwise, intraven ous antibiotics should be started. Intravenous antibiotics should be the in itial therapy for limb-threatening or life- threatening ulcers. Antimicrobi al therapy of at least 10-14 days has been effective in treating LE ulcers in the absence of osteomyelitis, Growth factors offer another treatment alt ernative, although only becaplermin is currently approved for diabetic ulce rs. CONCLUSION: Antibiotic therapy has been effective for the treatment of LE d iabetic ulcers. However, further studies are required to identify optimal a ntibiotics and dosage regimens. Growth factors may have a role but addition al research is needed to determine when best to initiate this therapy.