How should I manage a recurrent abscess in a patient with underlying conditions such as diabetes?

When managing a recurrent abscess in a patient with diabetes, it is crucial to approach it as a suspected diabetic foot infection, requiring prompt investigation and treatment ¹.

• Investigation: If a wound is present, send a soft tissue or bone sample from the base of the debrided wound for microbiological examination ¹. If this is not possible, a deep swab may provide useful information for antibiotic choice ¹. Consider an X-ray of the affected foot to determine the extent of the problem ¹. If osteomyelitis is suspected, even with normal inflammatory markers or X-rays, consider an MRI to confirm the diagnosis ¹.
• Antibiotic Treatment: Start antibiotic treatment as soon as possible, ideally after taking microbiological samples ¹. The choice of antibiotic should consider the severity of the infection (mild, moderate, or severe), previous microbiological results, and prior antibiotic use ¹. For moderate or severe infections, first-choice antibiotics include Flucloxacillin, Gentamicin, Metronidazole, Co-amoxiclav, Co-trimoxazole (in penicillin allergy), or Ceftriaxone with Metronidazole ¹. If MRSA infection is suspected or confirmed, consider Vancomycin, Teicoplanin, or Linezolid (specialist use only) ¹. Review the antibiotic choice when microbiological results are available and change to a narrow-spectrum antibiotic if appropriate ¹. The course length is based on clinical assessment, typically a minimum of 7 days and up to 6 weeks for osteomyelitis ¹. Intravenous antibiotics should be reviewed by 48 hours, with a switch to oral antibiotics considered if possible ¹.
• Reassessment and Red Flags: Reassess the patient if symptoms worsen rapidly or significantly, do not start to improve within 1 to 2 days, or if the person becomes systemically unwell or has severe pain out of proportion to the infection ¹. Be aware of other possible diagnoses such as pressure sores, gout, non-infected ulcers, or more serious conditions like limb ischaemia, osteomyelitis, necrotising fasciitis, or sepsis ¹.
• Specialist Referral: For complex or severe cases, or if acute Charcot arthropathy is suspected (indicated by redness, warmth, swelling, or deformity, especially with peripheral neuropathy), refer the person within 1 working day to the multidisciplinary foot care service ¹.