Diagnosis Of Diabetic Foot Infections Research Articles

Vitabiotic: An alternative approach to diabetic foot.

Diabetic foot ulcers and infections are complications that can result in significant morbidity such as the need for amputations, especially in uncontrolled diabetes, thereby profoundly impacting quality of life. While traditional treatments like wound care and antibiotics are effective, there is growing interest in the role of micronutrients (such as vitamins C, D, E, zinc and magnesium) in improving outcomes. This study aims to evaluate how these micronutrients affect diabetic foot infections and the need for amputation, offering insights to enhance overall prognosis. Patients who were hospitalised with a diagnosis of diabetic foot infection in the Infectious Diseases Department of Ege University Faculty of Medicine Hospital between 1 April 2022, and 31 January 2023 were included in the study. The patients' socio-demographic information, characteristics of diabetic wounds, operation history, as well as their levels of micronutrients recorded on the case report form. A total of 202 patients were included in the study. The most common micronutrient deficiencies were vitamin D (69%), vitamin C (64%) and zinc (49%). The amputation rates were significantly higher in patients with deficiencies vitamin C, vitamin A and vitamin D (p < 0.005). Our research revealed a significant prevalence of vitamin deficiencies among the participants, and we observed a noteworthy correlation between amputation rates and these deficiencies. Although these findings show promise, it is essential to emphasise that micronutrient supplements should not replace traditional treatments but should rather be considered as a warning sign for preventing complications, particularly amputation or extremity loss.

Theruptor Novo, a novel wound dressing in the management of infected diabetic foot ulcer: two case reports

India is the world's center for diabetes, with an estimated 77 million adults over the age of 18 having type 2 diabetes and nearly 25 million are pre-diabetics. Approximately 15-20% of diabetic patients will suffer from diabetic foot ulcer at least once in their lifetime which can also lead to deformity and amputation if timely intervention is not done. The presence of at least two classic signs of inflammation or purulence is the basis of clinical diagnosis of diabetic foot infection and it usually presents with mono/polymicrobial etiology. The surgeon must know the course of the infection, principles of non-healing wound management, and biomechanics of the foot for an optimal outcome. We described 2 case reports who presented with non-healing infected wounds. Healing was achieved through multidisciplinary team approach, patient education about diabetes, off-loading regime and regular wound dressing using Theruptor Novo.

The Course of Diabetic Foot Infection in Elderly Patients: Data of Patients From Turkey.

With the aging population, it is expected that diabetes and related complications will increase rapidly. The aim of this study was to examine the signs and symptoms of diabetic foot infection in elderly individuals. Patients with diabetic foot infection were grouped as mild, moderate, and severe. Patients aged <65 years and those who did not meet the diagnosis of diabetic foot infection were excluded from the study. Only the first applications of patients who applied to the hospital multiple times with diabetic foot infection diagnosis were evaluated. 314 patients were included in the study. The mean age of the patients was 71.5 (±12). The number of patients aged 75 and over was 125 (39.8%). Of the patients, 25.7% had mild, 61.7% moderate, and 12.4% severe clinical forms. 131 (41.7%) of the patients had osteomyelitis. Amputation was performed in 112 of the patients. Antibiotic treatment was given to 102 patients only. While 89 patients died, a significant correlation was found between all groups between amputation rate and mortality frequency and clinical severity of diabetic foot infection (P < .001). In our study, it was observed that the clinical severity of diabetic foot infection was more severe and the overall mortality rate was higher in geriatric patients. In light of all these data, it can be concluded that an early and comprehensive roadmap should be followed in geriatric patients with diabetic foot infection who have an increased risk of morbidity and mortality.

This Month's Highlights.

Our aim was to evaluate the role of SPECT/CT for the diagnosis of diabetic foot infection by labeled leukocytes. <b>Methods:</b> Seventeen patients with 19 clinically suspected sites of infection were included. After leukocyte labeling and administration, planar scans were acquired at 30 min, 4 h, and 24 h for 18 consecutive patients. SPECT/CT was obtained at 6 h. The final diagnosis was established by clinical follow-up (24 mo) in all cases and by bone biopsy for 14 sites. <b>Results:</b> Leukocyte scanning was positive in 16 of 19 lesions and negative in 3. SPECT/CT changed the interpretation of the planar and SPECT images for 10 of 19 suspected sites (52.6%): it excluded osteomyelitis in 6 cases, revealed bone infection in 1 case, and revealed both bone and soft-tissue infection in 3 cases. The hybrid device did not significantly contribute to the evaluation of patients with negative scan results. <b>Conclusion:</b> SPECT/CT can be useful for a more accurate diagnosis of diabetic foot infection by labeled leukocyte imaging.

MALDI-TOF MS Based Bacterial Antibiotics Resistance Finger Print for Diabetic Pedopathy.

Diabetes mellitus has become a major global health issue. Currently, the use of antibiotics remains the best foundational strategy in the control of diabetic foot infections. However, the lack of accurate identification of pathogens and the empirical use of antibiotics at early stages of infection represents a non-targeted treatment approach with a poor curative effect that may increase the of bacterial drug resistance. Therefore, the timely identification of drug resistant bacteria is the key to increasing the efficacy of treatments for diabetic foot infections. The traditional identification method is based on bacterial morphology, cell physiology, and biochemistry. Despite the simplicity and low costs associated with this method, it is time-consuming and has limited clinical value, which delays early diagnosis and treatment. In the recent years, MALDI-TOF MS has emerged as a promising new technology in the field of clinical microbial identification. In this study, we developed a strategy for the identification of drug resistance in the diagnosis of diabetic foot infections using a combination of macro-proteomics and MALDI MS analysis. The macro-proteomics result was utilized to determine the differential proteins in the resistance group and the corresponding peptide fragments were used as the finger print in a MALDI MS analysis. This strategy was successfully used in the research of drug resistance in patients with diabetic foot infections and achieved several biomarkers that could be used as a finger print for 4 different drugs, including ceftazidime, piperacillin, levofloxacin, and tetracycline. This method can quickly confirm the drug resistance of clinical diabetic foot infections, which can help aid in the early treatment of patients.

110. MRSA nasal swab as a stewardship tool to guide IV Vancomycin in diabetic foot infections

BackgroundThe Infectious Disease Society of America (IDSA) guidelines suggest empiric Methicillin-Resistant Staphylococcus Aureus (MRSA) coverage for Diabetic Foot Infection (DFI) with a history of MRSA infection, if local prevalence is high, or if the infection is severe. However, data suggests that there is overutilization of vancomycin in this population and this medication is associated with toxicity. MRSA nasal screen has a high negative predictive value (NPV) for ruling out MRSA in pneumonia and other sites. We performed a medication utilization evaluation (MUE) for Vancomycin IV in DFI patients who had an MRSA nares screen to determine our own NPV of this test and feasibility to use it as an antibiotic stewardship program (ASP) tool to guide vancomycin use in this population.MethodsWe retrospectively reviewed 224 patients from January 2015 to January 2020 who had a diagnosis of DFI and an MRSA nasal screen. 139 patients had cultures done. For the NPV, we excluded patients who had any MRSA positive culture or screen up to a year from admission (Figure 1).Figure 1. Flowchart from our medication utilization evaluation showing patient’s distribution by MRSA-screen result ResultsWe found 148 (66%) patients with DFI who had received IV vancomycin empirically during the admission and 196 of them were MRSA-nares negative (Figure 2). The average days of therapy (DOT) in the MRSA-nares negative patients was 5.2 days vs 4.8 in the MRSA-nares positive patients. Out of the 139 patients with a negative MRSA nasal swab, 124 had no MRSA in cultures, yielding an NPV of 89%. If we considered only the deep cultures, the NPV increased to 90%.Figure 2. Number of patients who received IV vancomycin grouped by MRSA-screen result ConclusionWe identified overutilization of IV vancomycin in patients with a diagnosis of DFI in our institution. Also, our NPV of the MRSA-nasal screening to rule out MRSA infection in DFI was high at 89% similar to previous studies. Based on these findings, we plan to implement a local ASP protocol (Figure 3) using MRSA nasal swab screen to decrease the empiric use of vancomycin. The results of these efforts will be analyzed and published in future iterations with the hopes to share this knowledge to reduce the use of IV vancomycin in this population in other centers.Figure 3. Protocol draft to be used as an ASP tool to guide IV vancomycin de-escalation based on MRSA-nasal screen for DFI patients Disclosures All Authors: No reported disclosures

Diagnosis of infection in the foot in diabetes: a systematic review.

Securing an early accurate diagnosis of diabetic foot infections and assessment of their severity are of paramount importance since these infections can cause great morbidity and potentially mortality and present formidable challenges in surgical and antimicrobial treatment. In June 2018, we searched the literature using PuEbMed and EMBASE for published studies on the diagnosis of diabetic foot infection. On the basis of predetermined criteria, we reviewed prospective controlled, as well as noncontrolled, studies in any language, seeking translations for those not in English. We then developed evidence statements on the basis of the included papers. From the 4242 records screened, we selected 35 papers that met our inclusion criteria. The quality of all but one of the evidence statements was low because of the weak methodology of nearly all of the studies. The available data suggest that diagnosing diabetic foot infections on the basis of clinical signs and symptoms and classified according to the International Working Group of the Diabetic Foot scheme correlates with the patient's likelihood of ulcer healing, of lower extremity amputation, and risk of death. Elevated levels of selected serum inflammatory markers are supportive, but not diagnostic, of soft tissue or bone infection. In patients with suspected diabetic foot osteomyelitis, both a positive probe-to-bone test and an elevated erythrocyte sedimentation rate are strongly associated with its presence. Culturing tissue samples of soft tissues or bone, when care is taken to avoid contamination, provides more accurate microbiological information than culturing superficial (swab) samples. Plain X-ray remains the first-line imaging examination when there is suspicion of diabetic foot osteomyelitis, but advanced imaging methods help in cases when either the diagnosis or the localization of infection is uncertain. The results of this first reported systematic review on the diagnosis of diabetic foot infections provide some guidance for clinicians, but there is a need for more prospective controlled studies of high quality.

The role of soluble urokinase plasminogen activator receptor (suPAR) in the diagnostics of diabetic foot infection

Background: To investigate the role of soluble urokinase plasminogen activator receptor (suPAR) in the diagnosis of diabetic foot infection and to determine whether it is superior to other infection markers like leukocyte, neutrophil, erythrocyte sedimentation rate, c-reactive protein and procalcitonin.Methods: The present prospective study consisted of four groups: Group 1, healthy volunteers (n = 38); Group 2, patients without diabetic foot ulcers (n = 40); Group 3, diabetic patients with uninfected foot ulcers (n = 33); and Group 4, patients who had diabetic foot infection (n = 48). In each group, the leukocyte, neutrophil, erythrocyte sedimentation rate, c-reactive protein and procalcitonin and suPAR levels were examined. The results were then statistically compared. In addition, the patients in Group 4 were further divided according to the presence of mild, moderate, and severe infection. Also osteomyelitis were evaluated in Group 4 and statistically compared.Results: All infection markers were significantly higher in group 4 patients than those in the other three groups (p < .05). Similarly, all infection markers in the severe diabetic foot infection group were statistically higher than mild diabetic foot infection group (p < .05); however, only suPAR and erythrocyte sedimentation rate were significantly high in cases with osteomyelitis (p < .05). In the receiver operating characteristic analysis, the optimal cut-off value for suPAR was determined to be 2.8 ng/ml, and the sensitivity and specificity above this value were 95.8% and 82.8%, respectively.Conclusions: The current study demonstrated that suPAR might be used as a supportive diagnostic method for the diagnosis of diabetic foot infections.

302. Role of Inflammatory Markers in Diagnosing Diabetic Foot Infection: A Meta-Analysis

BackgroundDiabetic foot ulcers (DFUs) cause significant morbidity and put great economic burden on patient and healthcare facilities. Infection is the main driving force behind admissions related to DFU. Culture of soft tissue or bone is invaluable in diagnosing infection but is time consuming. Inflammatory markers including erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and procalcitonin (PCT) are rapid, simple, and inexpensive laboratory tests that can aid in early diagnosis of diabetic foot infection (DFI) and monitor response to treatment. We did a meta-analysis to compare diagnostic performance of inflammatory markers for detecting DFI.MethodsWe searched PubMed, Embase, and Cochrane databases from their inception to December 2017. This meta-analysis was performed according to PRISMA guidelines. We included studies based on following inclusion criteria: (1) at least one of the biomarkers (ESR, CRP, PCT) was evaluated; (2) both sensitivity and specificity were measured as outcomes; and (3) sufficient data were available to construct 2 × 2 contingency table. We used bivariate random effect regression model to pool the sensitivity and specificity of the targeted biomarkers.ResultsA comprehensive literature search identified a total of 73 studies. Twelve studies met our inclusion criteria. Number of studies reporting data on each individual biomarker was as follows: 11 for ESR, seven for CRP, and five for PCT. Pooled sensitivity and specificity for ESR were calculated to be 0.84 (95% CI 0.76–0.89) and 0.82 (95% CI 0.73–0.89) with area under receiver operating characteristic curve (AUROC) of 0.90 (95% CI 0.87–0.92). Pooled sensitivity and specificity for CRP were found to be 0.64 (95% CI 0.46–0.80) and 0.87 (95% CI 0.75–0.93) with AUROC of 0.85 (95% CI0.82–0.88). Pooled sensitivity and specificity for PCT were 0.74 (95% CI 0.62–0.83) with AUROC of 0.84 (95% CI 0.81–0.87).ConclusionESR could be beneficial in ruling out infection in persons who have low suspicion of disease. For those who have high suspicion of disease, PCT could be helpful in ruling in infection. Clinicians should avoid ordering both ESR and CRP because role of CRP is limited. All inflammatory markers need standardization of threshold levels for detecting infection. Disclosures All authors: No reported disclosures.

Peripheral arterial disease increases the risk of multidrug-resistant bacteria and amputation in diabetic foot infections

The aim of this study was to investigate the microbiological profile and resistance rates of diabetic foot infections (DFIs) and to determine the effect of peripheral arterial disease (PAD) on the microbiology, clinical condition, and treatment outcomes. Characteristics, laboratory and imaging data, and the treatment modalities of patients admitted to our hospital with a diagnosis of DFI (PEDIS classification 3–4) during 2005–2016 were analyzed according to the presence of PAD. Of 112 patients who were included in this study, 86 (76.8%) had PAD. Patients with PAD were older and had higher amputation rates (P < 0.05). A microbiological profile of patients revealed a predominance of gram-positive bacteria (57.1%). Staphylococcus aureus and Streptococcus spp. were the most frequently encountered bacteria. Incidence of Pseudomonas spp. infection was higher in the PAD group (P < 0.05). Of all patients, 24.1% had multidrug-resistant (MDR) microorganisms in their wound cultures. Presence of MDR bacteria in patients with PAD was 4.9-fold higher than that in patients without PAD (P < 0.05). This retrospective study indicates that PAD has a significant role, especially in elderly patients with DFIs. Patients should be promptly evaluated and treated for PAD to prevent infections with resistant microorganisms and limb loss.

A clinical study of peripheral vascular disease due to atherosclerosis in diabetic foot infections

Background: Foot infection is a common problem affecting diabetics. Ischemia is a major factor contributing to progress and morbidity of the disease. The prevalence of peripheral vascular disease is higher in diabetics, with faster progression. The prevalence differs among populations. This study aimed to clinical prevalence of peripheral vascular disease due to atherosclerosis in patients with diabetic foot infections presenting to this tertiary care centre.Methods: This clinical study was conducted in ASRAM hospital, Eluru, Andhra Pradesh, India. All patients admitted with a diagnosis of diabetic foot infection to the department of general surgery during a period between October 2015 to October 2017, who fulfilled the inclusion and exclusion criteria, were enrolled for the study. After recording the pertinent information (as per performa), patients were subjected to a lower limb arterial Doppler and ABPI findings were tabulated.Results: Peripheral vascular disease was found in 35% of patients studied. Majority had distal below the knee vessels stenosis or occlusion. There was significant correlation with age, history of tobacco use and various risk factors. The clinical presentations and outcomes were worse in individuals found to have peripheral vascular compromise on arterial Doppler study.Conclusions: The care of diabetic patients should start with preventive measures which include proper foot care, glycaemic control and education about diabetic foot are key factors for better out come and quality of life.

Polymerase chain reaction–denaturing gradient gel electrophoresis (PCR–DGGE): A promising tool to diagnose bacterial infections in diabetic foot ulcers

AimThe diagnosis of diabetic foot infections is difficult due to limitations of conventional culture-based techniques. The objective of this study was to evaluate the contribution of denaturing gradient gel electrophoresis (DGGE) in the microbiological diagnosis of diabetic foot ulcers in comparison to conventional techniques, and also to evaluate the need to perform a biopsy sample for this diagnosis. MethodsTwenty diabetic patients (types 1 and 2) with foot ulcers (grades 1–4) were included. After debridement of their wounds, samples were taken in duplicate by surface swabbing and deep-tissue biopsy. The samples were analyzed by conventional culture and by a new molecular biology tool, DGGE technology. ResultsPolymerase chain reaction (PCR)–DGGE led to the identification of more bacteria than did conventional cultures (mean: 2.35 vs 0.80, respectively). In 11 cases, the technology detected pathogenic species not isolated by classical cultures. PCR–DGGE also identified significantly more pathogenic species at deep levels compared with species detected at superficial levels (87% vs 58%, respectively; P=0.03). In 9/20 cases, pathogenic bacteria were detected only in deep samples, revealing the need to perform tissue biopsy sampling. ConclusionDGGE, achievable in 48h, could be a useful technique for the bacteriological diagnosis of diabetic foot infections. It may help to identify pathogenic bacteria in deeply infected ulcers, thereby contributing to a more appropriate use of antibiotics.

Utility of 99mTc-labelled antimicrobial peptide ubiquicidin (29-41) in the diagnosis of diabetic foot infection

Detection of osteomyelitis beneath a diabetic foot ulcer is imperative for proper management; however, accurate and noninvasive diagnosis of osteomyelitis remains a challenge. Ubiquicidin 29-41 (UBI 29-41) is a synthetic antimicrobial peptide fragment reported to be highly infection-specific. (99m)Tc-UBI 29-41 has recently been reported to be a promising radiotracer for infection imaging. The aim of this prospective study was to evaluate the utility of (99m)Tc-UBI 29-41 scintigraphy in diabetic patients with suspected osteomyelitis of the foot. Included in the study were 65 patients with type 2 diabetes mellitus and foot ulcer and with clinical suspicion of osteomyelitis . Each patient had a three-phase bone scan and a (99m)Tc-UBI scan at 30 and 60 min after injection. The scan was considered to be consistent with osteomyelitis when the (99m)Tc-UBI 29-41 uptake was concordant with the (99m)Tc-MDP uptake. It was considered negative for osteomyelitis if there was no uptake of (99m)Tc-UBI 29-41 or if (99m)Tc-UBI 29-41 accumulated in an area not concordant with the abnormal uptake of (99m)Tc-MDP on the bone scan. In the latter case a diagnosis of soft-tissue infection was made. Bone infection was confirmed by bone biopsy/culture and by clinical and radiological follow-up. Final analysis was done in 55 patients. Osteomyelitis was confirmed in 37 patients, and 18 patients were free of bone infection. (99m)Tc-UBI 29-41 was positive in all 37 patients and with the bone scan as the reference for the bone identified all osteomyelitic foci (68 in total). (99m)Tc-UBI 29-41 was negative for osteomyelitis in all 18 patients, and 17 of these patients were diagnosed with soft-tissue infection ((99m)Tc-UBI 29-41 accumulation without concordant abnormal uptake on bone scintigraphy). The sensitivity, specificity and accuracy of (99m)Tc-UBI 29-41 scan in combination with three-phase bone scan for the diagnosis of osteomyelitis in diabetic foot was 100%. Accuracy for soft-tissue infection was also 100%. Maximum accumulation of the (99m)Tc-UBI 29-41 with maximum target to background activity was observed in the infectious foci at 30 min after injection. Tc-UBI 29-41 may be a useful agent for the accurate diagnosis of bone infection in diabetic foot because of the high accuracy demonstrated in this pilot study. It was able to differentiate between bone and soft-tissue involvement effectively in combination with a bone scan.

Can procalcitonin predict bone infection in people with diabetes with infected foot ulcers? A pilot study

Aims The diagnosis of osteomyelitis is a key step of diabetic foot management. Previous studies showed that procalcitonin (PCT), a novel infection marker, is superior to conventional infection markers in the diagnosis of diabetic foot infection. This study aimed to investigate the serum levels of PCT and other conventional infection markers in diabetic persons with and without osteomyelitis. Methods Twenty-four patients (18 male, mean age: 61.9 ± 10.8 years) with infected foot ulcers were prospectively enrolled. Clinical characteristics of the wounds were noted. Blood samples were obtained for biochemical analysis. Magnetic resonance imaging of the foot was performed in all patients to diagnose osteomyelitis. Results Osteomyelitis was found in 13 of 24 (54%) patients. PCT levels were 66.7 ± 43.5 pg/ml in patients with osteomyelitis and 58.6 ± 35.5 pg/ml in patients without osteomyelitis. The difference did not reach statistical significance ( p = 0.627). Erythrocyte sedimentation rate, but not C-reactive protein and white blood cell count, was found significantly higher in patients with osteomyelitis. Conclusion In this group of patients, PCT failed to discriminate patients with bone infection. Erythrocyte sedimentation rate can be used as a marker of osteomyelitis in diabetic persons.

Diabetic Foot Infection: Usefulness of SPECT/CT for 99mTc-HMPAO-Labeled Leukocyte Imaging

Our aim was to evaluate the role of SPECT/CT for the diagnosis of diabetic foot infection by labeled leukocytes. Seventeen patients with 19 clinically suspected sites of infection were included. After leukocyte labeling and administration, planar scans were acquired at 30 min, 4 h, and 24 h for 18 consecutive patients. SPECT/CT was obtained at 6 h. The final diagnosis was established by clinical follow-up (24 mo) in all cases and by bone biopsy for 14 sites. Leukocyte scanning was positive in 16 of 19 lesions and negative in 3. SPECT/CT changed the interpretation of the planar and SPECT images for 10 of 19 suspected sites (52.6%): it excluded osteomyelitis in 6 cases, revealed bone infection in 1 case, and revealed both bone and soft-tissue infection in 3 cases. The hybrid device did not significantly contribute to the evaluation of patients with negative scan results. SPECT/CT can be useful for a more accurate diagnosis of diabetic foot infection by labeled leukocyte imaging.

Procalcitonin as a Diagnostic Aid in Diabetic Foot Infections

The diagnosis of diabetic foot infection (DFI) is usually a challenge to the clinician. Procalcitonin (PCT), a 116-amino acid propeptide of calcitonin, is a new marker of bacterial infections and sepsis. We evaluated the serum value of PCT as a marker of bacterial infection in diabetic patients with foot ulcers. Forty-nine diabetic patients with foot ulcers were consecutively enrolled into the study. DFI was diagnosed clinically by the presence of purulent secretions or at least two of the symptoms of inflammation including redness, warmth, swelling, and pain. According to these criteria, DFI was determined in 27 patients (DFI group) and not detected in 22 patients (NDFI group). The blood samples were taken for biochemical analysis on admission. PCT, white blood cell count (WBC) and erythrocyte sedimentation rate (ESR), but not C-reactive protein (CRP), was found significantly higher in DFI group compared with NDFI group. The best cut-off value, sensitivity and specificity were 0.08 ng/ml, 77% and 100% for PCT, 32.1 mg/dl, 29% and 100% for CRP, 8.6 10(9)/L, 70% and 72% for WBC and 40.5 mm/h, 77% and 77% for ESR, respectively. The area under the receiver operating characteristic curve for infection identification was greatest for PCT (0.859; p < 0.001), followed by WBC (0.785; p = 0.001), ESR (0.752; p = 0.003), and finally CRP (0.625; p = 0.137). These results suggest that PCT may be a useful diagnostic marker for DFI. Additional research is needed to better define the role of PCT in DFI.

Value of white blood cell count with differential in the acute diabetic foot infection.

The authors reviewed the admission leukocyte indices of 338 consecutive admissions (203 males, 135 females, mean age of 60.2 +/- 12.9 years) with a primary diagnosis of diabetic foot infection in a multicenter retrospective study. The mean white blood cell count on admission for all subjects studied was calculated at 11.9 +/- 5.4 x 103 cells/mm3. Of all white blood cell counts secured for patients admitted with a diabetic foot infection, 56% (189 out of 338) were within normal limits. The average automated polymorphonuclear leukocyte percentage was calculated at 71.4 +/- 11.1% (normal range 40% to 80%). Normal polymorphonuclear leukocyte values were present in 83.7% of subjects. The authors stress that the diagnosis of a diabetic pedal infection is made primarily on the basis of clinical signs and symptoms, and that a normal white cell count and white cell differential should not deter the physician from taking appropriate action to mitigate the propagation of a potentially limb-threatening pedal infection.