Covid-19 and diabetic foot disease - IWGDF Guidelines

• Updated on: 2020-04-24
• Read original article here

Covid-19 and diabetic foot disease
Covid-19 and diabetic foot disease
These are unprecedented times, where a global pandemic disrupts all aspects of local clinical practice. Yet, providing care for people with diabetic foot disease remains crucial: as clinicians caring for these patients, we can play our role in the Corona-crisis, by doing everything we can to keep our patients with diabetic foot disease free from hospital. Every hospital bed not needed by a person with diabetic foot disease (DFD), gives room for a patient suffering from Covid-19.
The increasing pressure from the Corona-crisis on healthcare systems around the world, means practicing evidence-based care in accordance with IWGDF and other guidelines is becoming increasingly challenging. Clinicians around the world are facing this challenge and asking:
What can we do to provide evidence-based care with increasingly limited physical resources?
On this page, IWGDF, D-Foot International and Diabetic Foot Australia are teaming up to try and answer these kind of questions. We will try to answer them as best we can, with the help of our global network of leading experts in diabetic foot disease from all fields and continents.
Please be aware: these answers are not medical advice, and we do not assume any liability or responsibility for damages or injury to any person or property arising from any use of any information, idea, or instruction contained below. Please also note: this website will not always be perfect, and we may not be able to answer your exact question, but in the face of a global crisis, we hope that collectively we can help each other make the best local evidence-based decisions with the global minds and resources we have available to us.
The questions and answers on this page are moderated, to ensure experts from our IWGDF working groups and elsewhere have had time to reflect and review. We welcome feedback and ideas, via  e-mail  or  social media , that helps bring us all closer to our global goal in this current Corona-crisis of keeping as many of our patients free from hospital as possible. Our diabetic foot community together acting locally can help achieve this globally.
Do you have a question for our experts? Stay tuned as this will be coming soon!
Priority Recommendations
What should be the priority recommendations for clinicians managing their patient with DFD to try and help them both stay free of hospital and COVID?
1 – Most patients with DFD do NOT need to be hospitalized.
Just to remind clinicians that most patients with DFD do NOT need to be hospitalized. Hospitalization should generally be reserved for those with severe infection (i.e., systemic manifestations, suggesting possible sepsis) who require urgent diagnostic tests and surgical assessment, as well as antibiotic and supportive treatment. Specifically, hospitalization is generally NOT required for: 1) initial assessment of any DFD, including most cases of infection and ischemia; 2) initial diagnostic testing (plain x-rays, blood tests, cultures); 3) antibiotic therapy for mild or moderate infections (oral administration of highly bioavailable agents is generally sufficient, including for bone infection). But, implementing non-hospital care requires either a multi-disciplinary foot clinic or a well-established network of individual clinicians working together with agreed-upon referral arrangements (via physical or telemedicine means).
2 – Triage as soon as you can.
We are triaging as soon as we can. We classify the severity of the lesion at our multi-disciplinary team as soon as possible. Patients with high risk severity for limb loss (severe infection or severe ischaemia) we discharge into hospital as soon as we can. Patients in postsurgical setting or with moderate risk severity for limb loss (infection or ischaemia), we treat in outpatients if we can and then plan homecare services. Patients with lesions of less severity (no infection), we organise a telemedicine follow-up with pictures &/or videocall with their caregivers or family. We also pay attention to our PPE measures.
3 – Consider alternative services 
For those with DFD and less severity of limb loss, consider alternatives to outpatient clinics such as telemedicine, setting up clinics in other locations away from the hospital (e.g. indoor gym, mobile health centers) or home visits. See a more extensive article about these alternatives by Rogers, Lavery, Joseph and Armstrong here. See also the telemedicine topic below.
Telehealth 
Should we be shifting most of our services to telehealth? And if yes, how?
Many DFD clinicians around the world are now shifting to telehealth. The most frequently used method by our clinicians are photos in combination with instant messaging, as these are accessible for many patients or their carers. But, be aware that diagnosing based on a photo is not very reliable, and even triaging for treatment urgency differs between clinicians (see the evidence here ). If possible, try to obtain additional information, such as with temperature monitoring, asking questions of patients via a videocall, or even assess the photo with multiple clinicians.
Telehealth can not only be used for ulcer assessment, but also to provide self-care advice to your patients and their carers/nurses, to check their offloading and their dressings, and to discuss other questions. The reimbursement for telehealth differs per country. For the USA,  this excellent article  by Rogers and colleagues provides helpful guidance.
Also, see  this video  by David Armstrong for some inspiration.
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Patient Self-care
What should I discuss with my patients?
First, discuss hygiene and protection in relation to the corona-virus, to ensure your patient is aware and capable of protecting themselves. Second, discuss glycemic control, which may be harder during a lockdown. Try to arrange support in glycemic control if needed. Third, discuss the need to wear their prescribed offloading device or footwear at home as much as possible. This is very important at this time of limited physical resource or treatment options and try and check your patient is doing this by telemedicine. Fourth, discuss their daily exercise in times of lockdown. Try to motivate your patient to create an exercise routine compatible with their conditions, and with limited day-to-day variations.
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Infection
What questions can you ask your patient to help you diagnose infection when you do not see your patient in person?
These are the questions to typically ask:
How long have you had the ulcer? The longer the duration, the more likely it will be infected.
What do you think caused the ulcer? Traumatic wounds with a non-sterile object increase the risk for infection.
Do you have pain or tenderness in the ulcer or surrounding tissues? Presence, especially in a patient with known peripheral neuropathy, increases the risk of infection.
Has there been any drainage from the ulcer? If so, please describe it? If it is white/yellow/ greenish, non-translucent and thick, it is likely pus, which strongly suggests infection.
Has the wound had an unpleasant odour? if so, for how long? Presence increases the risk of infection, especially with obligate anaerobes.
Have you felt feverish or had chills/rigors? Presence increases risk of severe infection.
Have your blood glucose levels (if the patient checks) been more elevated than usual? This is common with an acute infection.
Have you used any topical or systemic medications (antimicrobial, antipyretic, home remedies) specifically to treat the ulcer? These may obscure or cause infection.
A person with a mild foot infection has had antibiotics for 2 weeks. How do you determine if you should continue if your patient cannot come in to see you?
Since we diagnose infection based on the presence of ≥2 classical signs/symptoms of inflammation (± so-called “secondary” findings suggestive of infection), the resolution of these findings (with no new ones) should reasonably suggest antibiotic treatment can be discontinued. Thus, I would ask about the current presence or absence of: pain/tenderness; local warmth or redness; induration/swelling; purulent secretions (opaque, thick, white/yellow/green discharge); or, fever. The patient should be able to provide observations of each of these findings. The clinician could also ask about the wound having foul odour, undermining of the rim of an ulcer, or non-purulent secretions. If video support is available (even via a mobile phone’s camera), the clinician can assess the patient’s reported findings; this is especially useful if the patient has taken photos/videos over time, to allow the clinician to assess the likelihood of improvement.
If surgery and hospitalization are not possible for a patient with osteomyelitis and a moderate foot infection, what’s required?
Almost all cases of osteomyelitis of the diabetic foot occur by direct extension from an overlying soft tissue infection, rather than by hematogenous spread. This type of contiguous osteomyelitis rarely causes an acute septic presentation (although the overlying soft tissue infection may do so). Thus, many (perhaps most) cases of diabetic foot osteomyelitis can be treated in the outpatient setting. What is required are: 1) making an initial accurate diagnosis (probing the wound for depth and palpable bone; obtaining plain x-rays; checking serum inflammatory markers, especially ESR); 2) obtaining material for culture (preferably bone, which a clinician can often do with a percutaneous biopsy in the outpatient setting); 3) prescribing an initial empiric antibiotic regimen, then modifying as needed based on the culture and sensitivity results. If bone debridement or resection is required, this can sometimes be done by a qualified surgeon in the outpatient setting.
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Offloading
How do you deal with offloading, when reducing contact with patients or visits from patients to your center?
We are facing this problem all day here in Italy, and since outpatient clinics are still going on, we decided to go with a cast (or non-removable walker) in cases of ulcers with high risk of worsening, like hindfoot ulcers or deep forefoot ulcers (obviously only when without any sign of infection). For other plantar ulcers, we mainly now use removable cast (or removable walker) with offloading insole and appropriate dressing, and we ask patients and nurses to email us every week a picture of the dressing and ulcer, organising where it is possible an outpatient appointment at clinic every two weeks.
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