diabetic foot infection - revised by ak
TRANSCRIPT
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Diabetic FootInfections
By: Lisa Kim
Alexander Kravitz
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Objectives
Revie case of !atient !resentin" it# diabeticinfection $DFI%
Disc&ss t#e e!idemiolo"y' etiolo"y' and clinical
!resentation of DFI
Revie a!!ro!riate t#era!ies for t#e mana"emDFI
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(atient )ase
K) is a *+ year old male ,as admitted to -aine.eneral on /0*
)): Ri"#t loer extremity le" o&nd on calcane
fo&l s&!!&rative disc#ar"e and bilateral loer ex
sellin" 1reated em!irically it# I2 vanco 3 zosyn
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Patient case, cont.2itals: 1em!455 6R457
B(48*90/ RR48; O+
stats45< room air
Labs:
Cultures: =o anaerobes
/3 "ram $>% bacilli
+3 Beta #emoloytic
Streptococcus"ro&
+3 coa" $>%Staphylococcus
/3 Di!#t#eroid bac
/3 Enterococcus
8//
?@
/
89+
+?
8@58
/5
88;
@7
/**87@;
+;
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(atient case' cont@ (ertinent st&dies:
>ray of ri"#t foot
1a""ed #ite blood
cell scan
(-6:
Admitted ;0+908/ fornecrotizin" faciitis 1reated it# I2 vanco'
Fla"yl' difl&can
A8) $+08?08?%: 5@;
Fhx: Mother: T2DM
2 brothers: T2
Shx: No EtOH or dr
!lleries: non
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-edications at 6ome Lant&s ins&lin: +* &nits
s&bc&taneo&sly CD )entr&m -ens m<ivitamin: 8 tab
CD
As!irin 8 m": 8 tab C
Lasix 9 m": + tabs BID
)arvedilol ;@+* m": 8 tab BID
)i!rofloxacin *99 m": 8 tab BID
Enoxa!arin ?9 m": ?9 m" s&bC BID
Levot#yroxine +* mc": 8 tab CD
Linezolid ;99 m": 8 tab BID
-etronidazole *99 m": 8 tab
)restor * m": 8 tab C6
ilver dressin" ?*: a!!ly C
!ironolactone +* m": 8 tab
1ams&losin 9@? m": 8 ca! C
(otassi&m )#loride +9mEC
tab CD
2itamin D *9'999 &nits: 8 ca
eeGly
-elatonin / m": 8 tab CD
Lisino!ril * m": 8 tab CD
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E!idemiolo"y Increasin"ly common
o In +99/: 889'999 #os!ital admissions for DFI
H! to ?9< of !atients it# DFI #ave !eri!#eral vasc&la
disease
Am!&tation d&e to DFI in t#e HA #as decreased by a
*9< in t#e last decadeo Latest: ?@; am!&tations !er 8999 diabetics
o -ost of t#e decrease #as been in above>t#e>anGle am!
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Etiolo"y
A DFI emer"es #en an infection occ&rs in an &lcerat
t#e foot from tra&ma or t#at is &ndetected beca&se of
!eri!#eral ne&ro!at#y
Infections can become more !rofo&nd and s!read to d
tiss&es' incl&din" bone
Often become com!licated by vasc&lar ins&fficiency 2ideo: #tt!:00yo&t&@be0lban.B"eccJt4/5s
http://youtu.be/ZlbanGBgecc?t=39shttp://youtu.be/ZlbanGBgecc?t=39s -
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Clinical Presentation (resence of infection defined by + classic findin"s of infla
or !&r&lenceo Redness' sellin"' armt#' tenderness' !ain
o (resence of !&r&lent or non>!&r&lent secretions
o Hndermined o&nd ed"es
o Fo&l odor
o Discolored "ran&lation tiss&e
F&rt#er classified:o -ild: s&!erficial and limited in size and de!t#
o -oderate: dee!er or more extensive
o evere: accom!anied by systemic si"ns or metabolic dist&rba
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)lassifications of DFI
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IDA International ,orGin" .ro&! on Diabetic Foo
)lassifications of DFI' cont@
Isc#emia may increase severity of infection ystemic infection may also manifest as #y!otens
conf&sion' vomitin"' or evidence of metabolic
dist&rbances
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Dianosis, cont. RisG factors for DFI
o (ositive !robe>to>bone $(1B% test
o ,o&nd !resent for /9 days
o 6istory of rec&rrent &lcers
o ,o&nd ca&sed by tra&ma
o
(resence of !eri!#eral vasc&lar disease in t#e affeco Loss of !rotective sensation
o (resence of renal ins&fficiency
o (atient Gnon to alG barefoot
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-ana"ement of infection
)lassify severity of infection based on its extende!t#' !resence of any systemic findin"s
Debride any o&nd t#at #as necrotic tiss&e or
s&rro&ndin" call&so Obtain c<&res !rior to em!iric antibiotic t#era!y by
!erformin" a bio!sy or c&retta"e after o&nd is cleadebride
Ima"in": radio"ra!# of affected foot' -RI'
radion&clide bone scan' labeled #ite blood ce
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-ana"ement of Infection
.ive antibiotic t#era!y for all infected o&nds b&combine it# a!!ro!riate o&nd care
Em!iric antibiotic re"imens are selected based o
severity and t#e liGely etiolo"ic a"ent -ild>moderate infection 3 no recent abx t#era!y 4 tar"
"ram $3% cocci
evere infection 4 broad s!ectr&m' !endin" c<&re re
antibiotic s&sce!tibility
)overa"e for P. aeruginosa is not necessary
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-ana"ement of Infection' co )onsider -RA covera"e in !atients it# !rior #
or if infection is clinically severe )ontin&e antibiotic t#era!y &ntil' b&t not beyond
resol&tion of t#e infectiono -ild:8>+ eeGs
o
-oderate>severe: +>/ eeGs
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-ana"ement of Infection'
Anaerobes are isolated from c#ronic' !revio&sly
or severe infectionso =ot major !at#o"ens in most mild to moderate infectio
o Little evidence to s&!!ort to cover for anaerobes in ade
debrided DFIs
E i i A tibi ti 1# B
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Em!iric Antibiotic 1#era!y Base
on )linical everityInfx severity Pathogens Abx agent Pearls
Mild MSS!"Stre#tococcus s## $Dicloxacillin
$Clinda%&cin
$Ce#halexin$'e(o)oxacin
$!%oxicillin$
cla(ulanate
$*+D dosinex#ens$co(ers C-TSS$*+D" ine$*D" subaureus$anaerob
co(eraes#ectru%
MS! $Dox&c&cline
$Tri%etho#ri%0sul1a%ethoxaole
$so%e runcertainstre#toco$*D suboaureus
Infx severity Pathogens Abx agent Pearls
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Infx severity Pathogens Abx agent Pearls
Moderate$Se(ere MSS!" Stre#tococcuss##"Enterobacteriaceae"obliate anaerobes
MS!
P. aeruginosa
MS!,Enterobacteriaceae,Pseudomonas,
anaerobes
$'e(o)oxacin$Ce1oxitin$Ce1triaxone$!%#icillin$sulbacta%$Moxi)oxacin$Erta#ene%$+%i#ene%$cilastatin
'ineolid
$Da#to%&cin$3anco%&cin
Pi#eracillin$taobacta%
$3anco /ce1taidi%e,ce1#i%e, #i#0ta,atreona% or
carba#ene%
$*D$co(ers a$*D$i1 lo4 suaerugino$co(ers a
$5se onl&
$777" inc4ee8s$%onitor$chec8 M
T+D$*+D
$3er& broco(erae%#iric tse(ere in
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Reasons to Avoid Am!&tation
Red&ced mobility' very lo &ality of life
*>year mortality estimated Msimilar to t#at of some of t
deadly cancersN
i"ns of (ossible Imminently Limb
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i"ns of (ossible Imminently Limb>
1#reatenin" Infection
Evidence of systemic inflammatory res!onse
Ra!id !ro"ression of infection
Extensive "an"rene or necrosis
1iss&e "as on ima"in"
6emorr#a"ic b&llae (ain o&t of !ro!ortion to clinical findin"s
Extensive tiss&e loss
Fail&re to im!rove des!ite a!!ro!riate abx t#er
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)linical (earls
1enderness on !al!ation may be absent if s&ffi
ne&ro!at#y is !resent
)re!it&s can indicate "as and t#erefore anaero
,#en develo!in" a !lan for t#e !atients treatm
consider t#e !atients ability to com!ly it# antio &!!ort netorG
o )omorbid conditions $e@"@ !syc#%
o 1olerability of medication
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(atient case>6ome visit $?0+0
2itals:B(48+0+ mm6"' 1em!erat&re4 57@?' 6R45? B(-
Findin"s: =ot com!liant on c&rrent antibiotic re"imen
o )om!lainin" abo&t rec&rrent diarr#ea' na&sea' and vomitin
(atient did not #ave !ro!er slee!in" !atternso Hnderlyin" si"ns of de!ression
(atient as dividin" lant&s dose: 8+ &nits BID
o Learned from #os!ital
o )om!lained of bloatin"
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(atient case>6ome visit $?0+08?%cont@
)ons<ation for medical marij&ana
Didnt Gno t#e exact dates of f&t&re doctors a!!ointments
Delay in o&nd dressin" c#an"e to overorGed #ome #ealt# n
-<it&de of sym!toms@@
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(atient follo>&!
)alled !atient ?0508? P 5:?9 am
K) #ad to a!!ointments on ?0 re"ardin" t#e
of #is footo 8 a!!ointment cancelled d&e to -D !erformin" eme
s&r"ery
o (atient taGin" antibiotics a"ain: ants to "et bettero =o c#an"e in slee!in" !atterns
o Overall im!ression: K) did not ant to comm&nicate
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(atient follo>&!' cont@
Follo>&! note:o Ri"#t le" o&nd 4 f&ll of t#icGness' and &nc#an"ed f
!revio&s are
o Left le" 4 dec&bit&s &lcer
o evere malodor on ri"#t foot
)<&res it# s&sce!tibility !erformedo ?3 -or"anella mor"anii
o +3 2RE
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(ro"nosis after #ome visit' co
-D states t#at !atient as del&sional as to #a
effects t#ese o&nds can #aveo Ref&sed readmission
o Ref&sed 2A) dressin"
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C&estionsJJJJ
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ReferencesLi!sGy BA' Berendt AR' )ornia (B' et al@ +98+ Infectio&s Diseases
America clinical !ractice "&ideline for t#e dia"nosis and treatmediabetic foot infections@ Clin Infect Dis@ +98+Q*?$8+%:e8/+>7/@
abatine -@ (ocGet -edicine' 1#e -assac#&setts .eneral 6os!it
of Internal -edicine@ Li!!incott ,illiams ,ilGinsQ +98/@