diabetic foot infection - swedish
TRANSCRIPT
DIABETIC FOOT INFECTIONISABELLE TREPICCIONE, MD
OUTLINEScope of problem
Predisposition
PreventionDiagnosis
Treatment
SCOPE OF THE PROBLEMLifetime incidence of foot ulcer is 25%
50% are infected
50% of non-traumatic lower extremity amputations are due to DFI
131 million diabetics worldwide in 2000
366 million diabetics by 2030
COST OF THE PROBLEMMean annual cost of treatment in 2001:
$9,000 for an uninfected foot ulcer
$25,000 for an infected foot ulcer
$45,000 for a foot ulcer with osteomyelitis
PREDISPOSING FACTORS
NEUROPATHY VASCULAR DISEASE
IMMUNE DYSFUNCTION
NEUROPATHY VASCULAR DISEASE IMMUNE DYSFUNCTION
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NEUROPATHY Sensory neuropathy: Wounds go undetected and worsen with exposure to repetitive trauma
Autonomic neuropathy: Gland dysfunction makes skin dry and susceptible to tearing
Motor neuropathy: Atrophy of intrinsic foot muscles leads to anatomic deformities
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VASCULAR DISEASEHyperglycemia causes endothelial cell dysfunction and smooth muscle cell abnormalities
Hyperglycemia is associated with an increase in thromboxane A2 contributing to hypercoagulability
Co-existing hypertension and hyperlipidemia
IMMUNE DYSFUNCTIONFewer inflammatory cytokines
Impaired neutrophil chemotaxis
Impaired neutrophil phagocytosis
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IDENTIFYING THOSE AT RISKHemoglobin a1c >9% (OR 3.2)
>10 years with diabetes (OR 3.0)
Prior lower extremity amputation (RR 2.8)
Visual acuity less than 20/40 (RR 1.9)
Prior foot ulceration (RR 1.6)
PREVENTIONPatient education: Improvement in patient knowledge and behavior. No ulcer or amputation prevention.
Yearly screening foot exam: Decreased ulcer recurrence at 1 year if referred to podiatry. No reduction in amputation.
Diabetic footwear: Custom footwear prevents ulcer recurrence.
Optimize glycemic control: Improves neuropathy. Nonsignificant reduction in amputation.
Smoking cessation: Nonsmoking diabetics have lower rates of foot ulceration and amputation.
Not studied: Callus debridement, treatment of tinea pedis or onychomycosis, and lower extremity revascularization.
Infection indicated by presence of 2 or more of: Swelling or induration Erythema Tenderness Warmth Purulent discharge
Lavery LA, Armstrong DG, Murdoch DP, Peters EJ, Lipsky BA. (2007). Validation of the Infectious Diseases Society of America’s diabetic foot classification system. Clin Infect Dis
UNINFECTED MILD INFECTION-Local infection confined to skin
and subcutaneous tissue
-Circumference of erythema >0.5cm
and <2cm
MODERATE INFECTION
-Local infection with involvement
of deeper structures
-Circumference of erythema >2cm
SEVERE INFECTION-Local infection plus systemic inflammatory
response syndrome
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IDENTIFYING INFECTED ULCERSProbe to bone, RR 6.7
Ulceration present >30 days, RR 4.7
History of recurrent ulcers, RR 2.4
Traumatic foot wound, RR 2.4
Presence of vascular disease in same limb, RR 1.9
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WOUND CULTURE INDICATIONS
Culture and gram stain moderate to severely infected wounds
Consider culture of mild infection if there are MRSA or pseudomonas risk factors
Don’t culture uninfected wounds
TECHNIQUE
Clean and debride wound
Obtain culture specimen from base
Aspirate purulence if present
Do not send superficial swabs or swabs of wound drainagef wound or wound drainage for culture
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IMAGINGXrays of all new diabetic foot infections
MRI if there is concern for other deep space infection
MRI when a chronic ulceration becomes infected
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TREATMENT OF THE INFECTED ULCERAntibiotics
Wound care
Sometimes surgery
Does anything else make a difference?
ANTIBIOTICSMILD infection: target gram positive cocci, maybe MRSA (ORAL)
MODERATE infection: target gram positive cocci, maybe MRSA (ORAL)
SEVERE infection: target gram positive cocci, gram negative and obligate anaerobes, MRSA and pseudomonas (PARENTERAL)
WHEN DO I NEED TO COVER FOR MRSA?When the patient has a history of MRSA or MRSA colonization within the
past yearWhen the infection is severeWhen local MRSA prevalence is 50% (for mild) or 30% (for moderate)
WHEN DO I NEED TO COVER FOR MRSA?
25% MRSA
40% MRSA
DO NOT ROUTINELY NEED TO COVER (UNLESS SEVERE)
COVER IN MODERATE AND SEVERE INFECTION
WHEN DO I NEED TO COVER FOR PSEUDOMONAS?Not as common a pathogen in DFI as previously thoughtIncreasing evidence that it may be a wound colonizerThe IDSA recommends coverage in:Severe infectionsTropical climatesFrequent exposure of the foot to water
WOUND CARE
Debridement Off-loadingMoist wound environment
No topical antimicrobials
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WHEN SHOULD I CONSULT A SURGEON?Evidence of life or limb threatening infection
Evidence of critical ischemia
Evidence of deep-space infection or abscess
Failure to improve with otherwise appropriate treatment
OTHER TREATMENTSNegative-pressure wound therapy AKA wound vac
Hyperbaric oxygen
Granulocyte colony stimulating factors (G-CSF)
Stem cell
Not studied: intensive glycemic control limb revascularization
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LEARNING POINTSWhen it comes to prevention; focus on appropriate footwear, a1c control, and smoking cessation
Send a tissue culture in all but mild diabetic foot infections
Most mild and moderate infections do not require MRSA or pseudomonas coverage
Wound care is critical to complete healing
Call a podiatrist or orthopedic surgeon when the infection is deep or severe
QUESTIONS?
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