The Diabetes Complication That Kills

A foot or leg amputation is one of the most dreaded complications of diabetes. In the US, more than 65,000 such amputations occur each year.

But the tragedy does not stop there. According to recent research, about half of all people who have a foot amputation die within five years of the surgery-a worse mortality rate than most cancers. That's partly because diabetic patients who have amputations often have poorer glycemic control and more complications such as kidney disease. Amputation also can lead to increased pressure on the remaining limb and the possibility of new ulcers and infections.

Latest development: To combat the increasingly widespread problem of foot infections and amputations, new guidelines for the diagnosis and treatment of diabetic foot infections have been created by the Infectious Diseases Society of America (IDSA).

What you need to know…

How Foot Infections Start

Diabetes can lead to foot infections in two main ways-peripheral neuropathy (nerve damage that can cause loss of sensation in the feet. and ischemia inadequate blood flow).

To understand why these conditions can be so dangerous, think back to the last time you had a pebble inside your shoe. How long did it take before the irritation became unbearable? Individuals with peripheral neuropathy and ischemia usually don't feel any pain in their feet. Without pain, the pebble will stay in the shoe and eventually cause a sore on the sole of the foot.

Similarly, people with diabetes will not feel the rub of an ill-fitting shoe or the pressure of standing on one foot too long, so they are at risk of developing pressure sores or blisters.

These small wounds can lead to big trouble. About 25% of people with diabetes will develop a foot ulcer-ranging from mild to severe-at some point in their lives. Any ulcer, blister, cut or irritation has the potential to become infected. If the infection becomes too severe to treat effectively with antibiotics, amputation of a foot or leg may be the only way to prevent the infection from spreading throughout the body and save the person's life.

A Fast-Moving Danger

Sores on the foot can progress rapidly. While some foot sores remain unchanged for months, it is possible for an irritation to lead to an open wound (ulcer), infection and amputation in as little as a few days. That is why experts recommend that people with diabetes seek medical care promptly for any open sore on the feet or any new area of redness or irritation that could possibly lead to an open wound.

Important: Fully half of diabetic foot ulcers are infected and require immediate medical treatment and sometimes hospitalization.

Don't try to diagnose yourself-diagnosis requires a trained medical expert. An ulcer that appears very small on the surface could have actually spread underneath the skin, so you very well could be seeing just a small portion of the infection.

What Your Doctor Will Do

The first step is to identify the bacteria causing the infection. To do this, physicians collect specimens from deep inside the wound. Once the bacteria have been identified, the proper antibiotics can be prescribed.

Physicians also need to know the magnitude of the infection-for example, whether there is bone infection, abscesses or other internal problems. Therefore, all diabetes patients who have new foot infections should have X-rays. If more detailed imaging is needed, an MRI or a bone scan may be ordered.

The doctor will then classify the wound and infection as mild, moderate or severe and create a treatment plan.

How To Get The Best Treatment

Each person's wound is unique, so there are no cookie-cutter treatment plans. However, most treatment plans should include…

A diabetic foot-care team. For moderate or severe infections, a team of experts should coordinate treatment. This will be done for you-by the hospital or your primary care physician. The number of specialists on the team depends on the patient's specific needs but may include experts in podiatry and vascular surgery. In rural or smaller communities, this may be done via online communication with experts from larger hospitals (telemedicine).
Antibiotic treatment. Milder infections usually involve a single bacterium. Antibiotics will typically be needed for about one week. With more severe infections, multiple bacteria are likely involved, so you will require multiple antibiotics, and treatment will need to continue for a longer period—sometimes four weeks or more if bone is affected.

Foot Care Is Critical if You Have Diabetes

To protect yourself from foot injuries…

Never walk barefoot, even around the house.
Don't wear sandals—the straps can irritate the side of the foot.
Wear thick socks with soft leather shoes. Leather is a good choice because it "breathes," molds to the feet and does not retain moisture. Laced-up shoes with cushioned soles provide the most support.

In addition, pharmacies carry special "diabetic socks" that protect and cushion your feet without cutting off circulation at the ankle. These socks usually have no seams that could chafe. They also wick moisture away from feet, which reduces risk for infection and foot ulcers.

See a podiatrist. This physician can help you find appropriate footwear-even if you have foot deformities. Ask your primary care physician or endocrinologist for a recommendation, or consult the American Podiatric Medical Association, www.apma.org.

Also: Inspect your feet every day. If you see any sign of a sore, seek prompt medical care. You should also see a doctor if you experience an infected or ingrown toenail, callus formation, bunions or other deformity, fissured (cracked) skin on your feet or you notice any change in sensation.

If the infection is severe...or even moderate but complicated by, say, poor blood circulation, hospitalization may be required for a few days to a few weeks, depending on the course of the recovery.

Wound care. Many patients who have foot infections receive antibiotic therapy only, which is often insufficient. Proper wound care is also necessary. In addition to frequent wound cleansing and dressing changes, this may include surgical removal of dead tissue (debridement)... and the use of specially designed shoes or shoe inserts-provided by a podiatrist—to redistribute pressure off the wound (off-loading).
Surgery. Surgery doesn't always mean amputation. It is sometimes used not only to remove dead or damaged tissue or bone but also to improve blood flow to the foot.

If an infection fails to improve: The first question physicians know to ask is: "Is the patient complying with wound care instructions?"

Which Exercises Are Best for You?

If you have diabetes…

Exercise can lower blood sugar almost as well as medication. Recent guidelines for people with diabetes recommend 150 minutes of moderate to strenuous aerobic exercise weekly, in addition to three strength-training sessions that work all the major muscle groups-increasing muscle mass is believed to be a particularly effective way of controlling blood sugar.

All aerobic exercises are beneficial, but those that use both your upper- and lower-body muscles are best because they help deliver blood glucose to muscle cells throughout your body-try an elliptical machine, the Schwinn Airdyne (a stationary bike that adds arm movements) or NuStep (a recumbent stepper that incorporates arm movements). If you walk, use poles to involve your arms. Try to do some type of exercise every day-this helps ensure its blood sugar-lowering benefits.

If you use insulin on a regular schedule: Exercise at the same time each day, if possible, to help maintain even, predictable blood sugar levels. Insulin should typically be used 60 to 90 minutes after your workout-check with your doctor or diabetes educator.

To prevent excessive drops in blood sugar: Eat something before or just after exercise and adjust your insulin dose on the days you work out. Talk to your doctor for specific advice.

Too many patients lose a leg because they don't take their antibiotics as prescribed or care for the injury as prescribed.

Never forget: Following your doctors' specific orders could literally mean the difference between having one leg or two.