Advancing Diabetic Foot Care: A Conversation With Gary M. Rothenberg, DPM

A close-up shot of a man's feet with diabetic foot complications.

(Adobe Stock 652340713 by Halfpoint)

Meet Gary M. Rothenberg, DPM, director of medical affairs for Podimetrics, is a podiatrist who is certified by the board and has over 20 years of experience, including academic work, clinical practice, and research. His research primarily focuses on preventing complications in the lower extremities that are related to diabetes. He also works as an associate professor of internal medicine in the Division of Metabolism, Endocrinology, and Diabetes at the University of Michigan.

Rothenberg speaks with Infection Control Today^® (ICT^®) about the critical link between diabetes, infections, and the risk of amputations. Rothenberg highlights preventive measures, the role of technology in remote patient monitoring, and the multidisciplinary approach to diabetic foot care. With a personal connection to diabetes as a father, he shares insights on the significant impact, morbidity, and mortality associated with diabetic foot infections.

Gary M. Rothenberg, DPM

(Photo courtesy of Gary M. Rothenberg, DPM)

Gary M. Rothenberg, DPM: I am the professor of internal medicine at the University of Michigan Medical School, where I practice podiatric medicine as well as run our [Limb Preservation, Wound Care, and Diabetic Lower Extremity Complications Fellowship] [and] hopefully avoiding complications associated with diabetes among people here in Michigan and the greater area. I'm also the director of medical Affairs for Podimetrics. We are a company with a mission of ending avoidable amputations for people living with diabetes. We have a program called the Smart Mat Program, and [which] we'll dive into that as well.

Probably the most important title that I have is Dad, and that is my 18-year-old son was diagnosed with type 1 diabetes at age 8, so we have been living as a family with diabetes. So, my professional career and my personal life collided. I say the universe spoke to me, and so my passion is the management of people with diabetes and, hopefully, avoiding complications.

ICT: Thank you so much. Please explain the correlation between diabetes and infection.

GMR: I can probably elaborate on what I call the “causal pathway” that leads to infections and, unfortunately, in a percentage of amputations, [in] people with diabetes over long periods of time and especially those who don't have as good control or management of their blood sugars level.

They develop neuropathy in their feet, which is the absence or the decrease of sensation and feeling in their feet, which predisposes people to potentially injuring their foot, for example, stepping on something and not knowing it. That open wound, which could result from that puncture, is a portal for infection in the presence of neuropathy because they…don't have that feedback that they're developing signs of infection.

Oftentimes, unfortunately, it's not [noticed] until the infection is very significant, with redness and swelling, bone involvement, and drainage coming from the foot. The bottom is a difficult place for these folks to see and to get to, so oftentimes, it's caregivers or people living in the home with people with diabetes who are the first to notice those potential complications. Again, it can be too late, and then folks will end up in the emergency room or in the hospital, potentially looking at a limb—or even a life-threatening—infection. So, it's that combination of neuropathy injury and then that lack of feedback that puts people at risk for developing infections in their lower extremities.

ICT: It's not just visual that you see that you notice the infection. It's also smell, from what I understand. Is that true?

GMR: It can be, and foot infections are noted to be multiorganism traditionally, so you have a very bad infection. There are multiple bacteria that set up shop, if you will, in the foot and frequently will develop abscesses plus pockets and collections, and that drainage can oftentimes have an odor, unfortunately. So that is nature's way of alerting us that something's going on if they don't have that feedback from feeling or it's again in a difficult spot to see.

ICT: What preventative measures or strategies are recommended to reduce the risk of infections and diabetic foot disease?

GMR: I'm glad you asked about prevention because that's our focus through my work with Podimetrics. We have this goal of all avoidable amputations. Again, that cascade of events starts with infection, leads to hospitalizations, and potentially can end up with infection. We know from the literature probably about 85% of amputations can be prevented, and there are a couple of things that we recommend at every patient visit that comes into my clinic for a comprehensive foot exam. What I am talking to them first is about patient education.

It is important to know the warning signs and check your feet every day. There are some techniques that, if you can't see the bottom of the foot, we recommend. We certainly recommend getting those who may live in the home with the patient to be involved in their care if you can't or if you have a significant other who can help look at your feet and make sure that there are no new bumps, bruises, blisters, or potential signs of infection.

Also, wearing what are called diabetic shoes or therapeutic shoes. Foot protection for people with diabetes is important. So, walking outside of the house, their feet should always be protected with shoes, and they don't have to be expensive. They can be house shoes with a nice firm sole, but protecting against those bumps in the night, even putting slippers on as these folks walk to the bathroom in the middle of the night or first thing in the morning, is important for protection.

At Podimetrics, we take that to the next level. We know from a historical perspective that temperature monitoring of feet is a useful tool and very sound science to predict potential complications. Just like any time anybody gets sick, you develop a fever, right? If you think you have the flu, one of the first signs is going to be developing a fever.

The foot does the same thing. So, it develops foot fever if there's a potential infection brewing because the patient has stepped on something and doesn't even know. Podimetrics has a program where we have patients monitor their foot temperatures by standing on a simple mat. There are thousands of temperature sensors, and through cellular-based technology, a scan that takes 20 seconds for the patient to step on the mat. That data is transmitted to the company, which is based out of Boston, and we have a team of nurses who are watching these patients for temperature escalations.

If [the nurses] notice something, then they call the patients, and they say, “Hey, Mr. Jones, that mat you're stepping on every morning, your right foot is lighting up like a Christmas tree. What's going on? Did you go to your grandson's baseball game? Did you do your Christmas shopping in July, or is there something potentially brewing in your foot?” Then it's that connection. I like to say we connect patients, providers, and data toward better outcomes. So, all of that is in the hopes of early detection and monitoring patients in between their usual visits with their providers.

ICT: You are the Director of Medical Affairs. How did you learn about Podimetrics?

GMR: I was introduced to Podimetrics. It was my time at the Miami Veterans Administration, and that's when I was introduced to the company. I was part of the original clinical trials, and we published the data in 2017 on early detection of foot ulcers or wounds through the use of remote temperature monitoring. I was very fortunate to be involved in that original research, where we showed that we could detect 97% of impending foot infections and ulcerations at a lead time of 35 days. When you have 5 weeks’ advance notice that something bad can happen, I like to say that you change destiny which is the course and the prevention that we want.

So, fast forward. It's now 6 years later, since we published that article and about 10 years into my journey with the company, and I am now full-time as the director of medical affairs. I have been very fortunate to be involved in a lot of continued research, which is a strong focus. We have active curiosity in helping this patient population, and veterans continue to be among the most important clients that we serve.

ICT: Can a person just purchase it? Or does it have the prescription?

GMR: It is by prescription. We have a wonderful website. That might be a really good resource. We're happy to send you all the information you're asking for, but the website has a lot of great information, too.

ICT: Would you explain the typical treatment approaches antibiotics use, challenges encountered, and managing infections related to diabetic foot ulcers?

GMR: We appreciate and subscribe to the multidisciplinary approach when it comes to the diabetic foot. So, as a podiatrist, oftentimes I am on the front line of treating these patients, especially their wounds, but typically, we will involve “the full village,” as we say, [family, health care workers, and caregivers] especially as it comes to infection. So, our infectious disease colleagues are among the first people that we contact in this multidisciplinary approach because they're antibiotic specialists. Typically, we will take a culture of the wound and the drainage and then work together with the infectious disease team. We may prescribe antibiotics or defer to them to do that. There have been wonderful advances in antibiotics, especially in oral versus IV, for the management of diabetic foot infections.

When I was in my training 25 years ago, everybody was admitted to the hospital and ended up on IV antibiotics with potentially a PICC line, and they were sent home or to a skilled nursing facility with these lines. So now we are fortunate, and sometimes, a lot of times, we can use orals [antibiotics], or these patients can go to an infusion center for an injection periodically for antibiotics.

It's also important to obviously have these patients manage their blood sugar levels. So, we need to involve the primate care physician or the endocrinologist oftentimes to help us support wound healing because, again, we know blood sugar management and control will significantly influence wound healing, and there, again, the multidisciplinary approach in these patients is really important. It can involve mental health care providers because, obviously, it can weigh heavy if you're asked to stay off your feet or you have to take an extended period of time off work. So that leads to issues with social determinants of health as we're talking about these days So the variety of people that we get involved, as I mentioned, the village, it's important to include everybody and put the patient at the middle of this multidisciplinary approach and then each of us with our particular expertise and passion comes to fulfill the patient's needs.

ICT: What impact do diabetic foot infections have on the overall prognosis and quality of life for infection for individuals with diabetes, and how are severe infections managed to prevent complications like amputations?

GMR: Unfortunately, there is significant morbidity and mortality associated with diabetic foot infections. Breast cancer…we all know about and support the pink ribbon. not to take anything away from that, but 5 years survival rates from breast cancer are about 11% at 5 years. If a patient with diabetes and a lower extremity amputation, their 5-year mortality is just under 50%, so all the media and Hollywood coverage around breast cancer is wonderful. We don't really have that in diabetic foot disease, which is unfortunate because, again, the morbidity and mortality are about 3 times of breast cancer.

So, it's really understated and underappreciated the significant mortality and the quality-of-life impairment. Obviously, it's not only the reality that in 5 years, these patients may also not be alive. But how are they experiencing those last five years of their life, not being able to be ambulatory? We know being ambulatory is a huge surrogate marker of quality of life and people doing the things that they need to do and want to do.

I mentioned again that with patients, sometimes the motivation to heal a wound or to prevent infection is to walk their daughter down the aisle at a wedding. When we can partner and understand what the patient’s goals are, that is helpful and motivating for the patient as well, on my end as a provider to help them, but prevention is the key to avoiding that quality-of-life impairment and significant morbidity and mortality associated with diabetic foot disease.

We talk about poorly managed diabetes as the leading cause of amputations. Frankly, it's also the leading cause of kidney disease and why people are on dialysis. So, it is the duration of diabetes as well as the control of those blood sugars.

I mentioned I have a son with type 1 diabetes who was diagnosed at 8 [years old], and one of the most significant things in the space that I heard from his endocrinologist is what he told my son. He said, “Now Evan, well-controlled diabetes is the leading cause of nothing.”

So, the idea is you have to acknowledge it and accept it using technology, which is a wonderful thing to add to diabetes management today, whether it be telemedicine devices like the Smart Mat [technology] or continuous glucose monitoring devices that can help with blood sugar management. Nobody is saying it's easy, but the key is to manage those blood sugars. We don't have a cure for diabetes., so it's a management situation.

There's a program through the Joslin Diabetes Center in Boston, Massachusetts is probably the most famous center in the US, and they have a medalist program, and for the professors, it's a research project. But it's also a congratulatory program for people who live successfully, and they get these medals at 25 years and 50 years and increments in [between]. As I mentioned using it as a study tool to figure out why some people live very successfully with diabetes for many years and then others, unfortunately, succumb to complications very early. And again, I think today we have a better appreciation for social determinants of health care and equities and genetic predisposition, and then I think overall, how do you individuals take responsibility and manage their own health?

ICT: Is there an age that these diabetic and foot infections come on more rapidly or more often, or is it just across the board?

GMR: I think it's probably again more about how long you are living with diabetes. Do you have neuropathy? So again, bring It full circle to what we talked about at the beginning of the conversation. I think it is more about neuropathy. You can live for 50 years without developing neuropathy. Then those folks are at much less risk for developing foot infections; of course, injuries can always happen, trauma or stepping on something. We all do it whether we have diabetes or not, but it's then what happens after you get the injury, so I wouldn't say there's a specific age. It's more related to how long you have diabetes and then the control of that diabetes over time.

ICT: Do you have anything else you'd like to add?

GMR: I'm appreciative again for spending a little bit and sharing some time. We emphasize that prevention is the key to avoiding these complications. We want folks to be active and involved in this process as we embrace technology and all the new Is that are out there. I think in this post-COVID-19 era. We also really understand that telemedicine is an important tool in health care, and keeping eyes on our patients in between their usual physical visits with us is too. So remote patient monitoring, whether again it is continuous glucose monitoring or temperature monitoring of feet with a Smart Mat device. Those are important in connecting the dots between the patient and the provider and then utilizing data in that process toward prevention.