Tayside Diabetes MCN Handbook
Pathway for Acute Diabetes Foot Disease

Defined as a foot that is / has

  • Newly developed ulcer
  • Red
  • Swollen
  • Tender
  • Infection - cellulitis or pus
  • Acute pain in the absence of trauma or after trauma


Criteria for Admission

  • Critical ischaemia/rest pain
  • Spreading cellulitis
  • Systemic infection associated with foot ulcer


A foot problem should be excluded in all patients with diabetes presenting with fever or unexplained ill health


Immediate Care: 0- 4 hours of Admission

  • Examine both feet – remove socks/bandages, check pulses, sensation and look for ulcers
  • Check CPR for feet and arrange foot protection if neuropathic (see below)
  • Assess for infection. If present, give antibiotics promptly *
  • Assess blood supply - consider investigations
  • Unexplained swelling & inflammation of the foot?  Consider Acute Charcot Neuroarthropathy
  • Obtain input and advice from the Specialist Diabetes team as soon as possible
  • Review  glycaemic control and alter usual diabetes regimen if necessary
  • Request initial investigations


Second Phase Care: 4 - 24 hours of Admission

  • Review results of investigations and response to treatment
  • Consider the need for Vascular Surgery input
  • If the patient is fit for discharge and no Diabetes Team member is available (e.g. OOH/at the weekend), ensure that follow-up is arranged by emailing the patient’s Name, Address, CHI, Contact Number & Admission Details to: tay.diabendoreferrals@nhs.scot 


Initial Investigations

  • Lab glucose
  • WCC
  • CRP
  • Consider blood cultures
  • Wound culture
  • Plain foot X-ray if osteomyelitis is suspected
  • Consider MRI


*Initial Antibiotic Choices


Cellulitis/ No Ulcer

As per Tayside Antibiotic Protocol

Ulcer – Antibiotic Naïve

Flucloxacillin 1g QDS (only if signs of infection)

Ulcer – previous Antibiotic Therapy



Next Steps: If not improving

  • Correct antibiotic choice. Consider discussing with   Microbiology team
  • Consider Vascular Surgery input


Contact Vascular Surgery for:

  • Critical ischaemia/rest pain
  • Spreading cellulitis despite adequate antibiotic therapy
  • If debridement is required


Contact Diabetes Specialist Team for advice on diabetes treatment optimisation to improve healing


Antibiotic therapy


Promote Check Protect Refer (CPR) and provide pressure relief:

Heelsafe over mattress pad PECOS 226221

Footsafe prevention boot PECOS 226160

Solesafe bed end pad PECOS 226238

Other product as per NHS Tayside Pressure Ulcer Prevention and Care for Adults in Hospital policy


Ensure that the person with diabetes is aware of the importance of complying with wearing / using pressure relief products to improve outcomes.

Refer to Diabetes Podiatry Team for ulcer care on discharge from hospital