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Mild diabetic foot infection — MSRA MCQ

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ModerateAnkle and FootMild diabetic foot infectionMSRA

A 62-year-old man with type 2 diabetes and established peripheral sensory neuropathy attends general practice with a 2-day history of a blister beneath the right second metatarsal head after wearing new shoes. He is systemically well and has no penicillin allergy. His eGFR is 74 mL/min/1.73 m². Examination shows a 7 mm superficial plantar ulcer with a small amount of purulent discharge. There is local warmth and erythema extending 1 cm beyond the ulcer edge. The ulcer does not probe to bone. There is no fluctuance, lymphangitis, necrosis, malodour, crepitus or pain out of proportion. Pedal pulses are palpable and the foot is warm. He has no fever. What is the most appropriate management today?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: D — Start oral flucloxacillin 1 g four times daily for 7 days and refer within 1 working day to the local diabetic foot service for triage

Explanation lettering: E = shown as A · C = shown as B · D = shown as C · A = shown as D · B = shown as E

This is a mild diabetic foot infection: purulent discharge, warmth and erythema establish local infection, but erythema extends less than 2 cm from the ulcer and there are no features of moderate or severe infection, deep infection, osteomyelitis, limb ischaemia or systemic illness. NICE recommends prompt antibiotic treatment for suspected diabetic foot infection. For a mild infection in an adult who can take oral treatment and has no penicillin allergy, flucloxacillin is first choice; 500 mg to 1 g four times daily for 7 days is recommended. This dose is appropriate with normal renal function. The ulcer is also an active diabetic foot problem. Even though it is not limb-threatening, it requires referral within 1 working day to the local multidisciplinary foot care or foot protection service for triage. The patient should additionally be advised to seek urgent reassessment if symptoms worsen or do not begin to improve within 1–2 days. B uses a permissible flucloxacillin dose but incorrectly delays specialist foot-service triage. C provides unnecessarily broader therapy for a mild infection without risk factors indicating moderate or severe disease. D would be appropriate for severe infection, suspected deep infection, sepsis, gangrene or limb-threatening ischaemia. E fails to treat a clinically infected ulcer.

Reference: Diabetic foot problems: prevention and management (NG19) — Recommendations (Published 2015; antimicrobial recommendations updated 2019; surveillance reviewed 2025) — https://www.nice.org.uk/guidance/ng19/chapter/Recommendations Diabetic foot problems: prevention and management (NG19) — Table 1 antibiotics for mild diabetic foot infection (Published 2015; antimicrobial recommendations updated 2019) — https://www.nice.org.uk/guidance/ng19/chapter/Recommendations Diabetic foot infection: antimicrobial prescribing — visual summary (September 2024) — https://www.nice.org.uk/guidance/ng19/resources/visual-summary-pdf-6954030109