MANAGEMENT OF DIABETIC PATIENTS WITH FOOT CONDITIONS

DEPARTMENTS OF ENDOCRINOLOGY AND MICROBIOLOGY, BEAUMONT HOSPITAL -2011

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1. Management of the infected foot ulcer 2. Treatment of the infected foot ulcer 3. Infected foot ulcer with cellulitis 4.Treatment of an infected foot ulcer with suspected osteomyelitis 5.Management of the acute Charcot Foot 6.Investigations to be performed prior to coming to foot clinic 7.Miscellaneous foot conditions Appendix 1: Referral to the Diabetic Foot Clinic Appendix 2: Contact details: Diabetes Service, Microbiology Laboratory and Antibiotic Advice

These guidelines have been developed to improve diabetes foot care for both in and out-patients attending Beaumont Hospital. The guidelines were written by the Departments of Endocrinology and Microbiology in consultation with: Department of Vascular Surgery: Professor A Leahy; Mr D Moneley Department of Nephrology: Professor P Conlon Department of Podiatry: S Delaney and S Clifford

MANAGEMENT OF THE INFECTED FOOT ULCER

INVESTIGATIONS 1. Bloods FBC Urea & Electrolytes ESR C-RP Liver function Fasting lipids HbA1C Blood culture if evidence of systemic infection, pyrexia or cellulitis 2. Sample of Pus or Tissue Deep sample to be taken from the base of the ulcer and sent to microbiology The ulcer should be debrided and any tissue sent to microbiology for analysis Indicate in the clinical details that the specimen is a deep specimen from a diabetic patient. Otherwise the specimen will be processed as a superficial swab in the laboratory. Ulcer debridement to be performed by podiatry If the foot is very ischaemic (ABI < 0.4) then do not debride. Consult vascular surgery.

3. MRSA screening 4. Radiology Plain X-ray of the joint or affected foot* MRI of the foot +/or Bone scan *Plain X-Ray may be normal in the early stages, may take 14 days before osteomyelitis appears. MRI will detect early changes of osteomyelitis. 5. Vascular Assessment Ankle brachial index Doppler waveform Transcutaneous oxygen tension where available Vascular consult where appropriate 6. Neuropathic Assessment Clinical examination Nerve conduction studies MRI spine where appropriate

TREATMENT OF THE INFECTED FOOT ULCER

Admission to hospital may be necessary 1. Bed Rest may require crutches / wheelchair. Contact podiatrist if off-loading device (ie total contact cast) is required. 2. Debridement of foot ulcer (involve the vascular podiatry service) 3. Ulcer debridement and send tissue or pus sample to microbiology 4. Appropriate foot ulcer dressing 5. Intensify glycaemic control (may need to use insulin) 6. Treat surrounding oedema 7. Antibiotic Therapy Clinical presentation No sign of infection Infected superficial ulcer Antibiotic recommendations No antibiotic required Wound care (clean / debride / offload pressure) plus Co-Amoxiclav 625mg tds Penicillin allergy Clarithromycin 500mg BD PO
(if pseudomonas suspected, add Ciprofloxacin 500 750mg BD PO)

Duration (see follow-up below)

5 7 days

Infected deep ulcer

Co-Amoxiclav 625mg tds Debridement of ulcer antibiotics do not penetrate necrotic tissue

Duration depends on initial clinical presentation. Usually 10 14 days - continue until all infection has resolved. Duration depends on extent of tissue involvement, adequacy of debridement and wound vasculature.

Patient admitted to hospital

As above Patient may require IV antibiotics Contact microbiologists to discuss risk assessment regarding Ciprofloxacin use in case of suspected pseudomonal infection.

8. Other

Therapies* Consider GCSF Larvae therapy Hyperbaric oxygen therapy VAC pump Special dressings

* Decisions to be made by the Multidisciplinary Diabetes Foot team in consultation with tissue viability Follow Up

Daily / alternate day dressings Weekly review Rationalise antibiotics according to microbiology results liaise with clinical microbiology If on follow up the foot ulcer shows no sign of infection and the first or repeat swabs (base of ulcer) are negative then antibiotics can be stopped. In cases of a severe ischaemic foot ulcer (ABI < 0.4) antibiotic therapy may need to be prolonged (rationalise antibiotics according to swab results).

Footwear Neuropathic Foot Ulcer Discuss with multidisciplinary team Total contact cast Aircast Scotchcast boot Crutches/Wheelchair Neuroischaemic or Ischaemic Foot Ulcer Discuss with multidisciplinary team Wide fitting shoe (Drushoe) Crutches/Wheelchair Once the ulcer has healed refer to podiatrist for appropriate shoe wear

INFECTED FOOT ULCER WITH CELLULITIS

Investigations: 1.

As per Infected Foot Ulcer

Infected Foot Ulcer with Mild Cellulitis (< 2cm) May be able to manage as an out-patient * If patient is pyrexial or frail and unwell admit to hospital for IV therapy Empiric Antimicrobial Treatment: Co-Amoxiclav 625mg tds If penicillin allergy: replace Cefradine with Clarithromycin 500mg BD PO Duration: 1 2 weeks depending on clinical response. If the infection clears, consider stopping antibiotics. If a severely ischaemic foot ulcer, there may be a need to continue antibiotics until the ulcer heals. Rationalise antibiotics according to microbiology results liaise with clinical microbiology If MRSA is grown, liaise with microbiology regarding choice of antibiotic therapy *If patients are managed as out-patients, the ulcer needs to be reviewed on a regular basis by PHN or diabetes nurse specialist in DDC and if cellulitis is spreading then admit to hospital for intravenous antibiotics Infected Foot Ulcer with Severe Cellulitis (> 2cm) Admit for intravenous antibiotics (at least 2 weeks of treatment needed) Perform blood cultures Bed Rest may require crutches / wheelchair. Contact podiatrist if off-loading device is required. Daily review Empiric Antimicrobial Treatment: Flucloxacillin 2g QDS IV + Metronidazole 400mg TDS PO + Ciprofloxacin 400mg BD IV If the patient is colonised with MRSA, replace Flucloxacillin with Vancomycin 15mg/kg BD IV (adjust the dose according to pre-dose levels) maintain predose levels between 15 20mg/L. If the patient has a past history of C. Difficile, contact the microbiologists regarding an alternative to Ciprofloxacin for antibiotic therapy. Consider IV switch to oral Ciprofloxacin after 48 to 72 hours (dose: 500-750mg bd po. *renal dosing required)

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Duration of antibiotic therapy depends on initial clinical presentation. Usually 14 days continue until all infection has resolved. Duration may be longer than 14 days depending on extent of tissue involvement, adequacy of debridement and wound vasculature. 3. Debridement of foot ulcer Ulcer debridement and send tissue sample or pus to microbiology. Deep sample to be taken from the base of the ulcer and sent to microbiology Indicate in the clinical details that the specimen is a deep specimen from a diabetic patient. Otherwise the specimen will be processed as a superficial swab in the laboratory.

Appropriate foot ulcer dressing Intensify glycaemic control (may need to use insulin) Treat surrounding oedema Appropriate vascular and radiology investigations Rationalise antibiotics according to the results of the foot ulcer swab results. Contact podiatrist if off-loading device is required

TREATMENT OF AN INFECTED FOOT ULCER WITH SUSPECTED OSTEOMYELITIS 1. Admit to hospital for Bed Rest 2. Investigations If osteomyelitis is suspected the following investigations should be performed urgently FBC ESR/C-RP Urea & Electrolytes Liver function tests Blood cultures Foot X-Ray MRI of the affected foot MRSA screen 3. Ulcer Debridement Debridement of the ulcer should be performed with gentle probing (probe to bone test) to determine whether bony involvement present 4. Vascular assessment 5. Intensify glucose control (may need insulin) 6. Treat surrounding oedema 7. Bed Rest may require crutches / wheelchair. Contact podiatrist if off-loading device is required. 8. Orthopaedic consult regarding the need for bone biopsy and bone culture. Bone biopsy is the gold standard for the diagnosis of osteomyelitis and helps to guide effective and appropriate antimicrobial therapy 9. Empiric Antimicrobial Treatment: Flucloxacillin 2g QDS IV + Metronidazole 400mg TDS PO + Ciprofloxacin 400mg BD IV If the patient is colonised with MRSA, replace Flucloxacillin with Vancomycin 15mg/kg BD IV (adjust the dose according to pre-dose levels) maintain pre-dose levels between 15 20mg/L. If the patient has a past history of C.Difficile, contact the microbiologists regarding an alternative to Ciprofloxacin for antibiotic therapy. Consider IV switch to oral Ciprofloxacin after 72 hours (dose: 500-750mg bd po: *renal dosing required) If S. Aureus isolated add Sodium Fusidate 500mg TDS PO if susceptible (Watch liver function, if abnormal discuss with clinical microbiology)

DO NOT USE SODIUM FUSIDATE WITH SIMVASTAIN or ATORVASTATIN THERE IS AN INCREASED RISK OF MYOPATHY STOP THE STATIN FOR THE DURATION OF SODIUM FUSIDATE THERAPY Liaise with microbiology regarding results of cultures and rationalise antibiotics accordingly Duration will depend on extent of bone debridement. If no debridement usually 6 weeks (if acute osteomyelitis) however liaise with microbiology as a longer duration of therapy may be required (e.g. chronic osteomyelitis)

10. Contact podiatrist if specialist footwear required 11. Post discharge - If for follow up in Diabetes Foot Clinic, sent letter of referral plus discharge summary to Diabetes Day Centre.

MANAGEMENT OF THE ACUTE CHARCOT FOOT Patients may present with an acute swollen foot the foot may look cellulitic. Therefore it is important to differentiate between an Acute Charcot foot and a diabetic foot with cellulitis. CLINICAL PRESENTATION Can present either with or without a foot ulcer (neuropathic foot ulcer) A history of recent injury may precede the presentation The entire foot may be erythematous, oedematous, warm to touch, anhidrosis, bounding foot pulses and have a temperature difference of 2-5o C between the affected and contralateral foot. Neurological examination will show sensory loss. On inspection the foot may have no deformity or may only have prominence of the medial border of the foot or may have the gross deformities associated with Charcot foot such as a rocker bottom foot. On moving the foot, there will be a degree of hypermobility and crepitus.

INVESTIGATIONS Blood tests as for an infected foot ulcer Foot X-Ray may be normal in the acute stages of a Charcot joint MRI scan of the foot If a foot ulcer is present then perform an Indium Labelled White Cell Scan to differentiate between an Acute Charcot foot and osteomyelitis

TREATMENT Avoid further trauma STRICT BED REST and non-weight bearing is critical Total contact cast or Aircast to be used Treat with bisphosphonate infusion (60 - 90mg of IV Pamidronate discuss with endocrine team) Treat ulcer if present as above Podiatry involvement footwear needs to be addressed. Protect the unaffected foot (bilateral Charcot foot can occur in 30% of cases)

Serial plain radiographs of the affected foot Consider orthopaedic consult Liaise with physiotherapy regarding leg strengthening exercises

Once adequate resolution of the acute changes occur (oedema, aching and temperature reduction and there is X-ray evidence of bone healing) then gradual protected weightbearing can commence with the support of total contact casts. The casts need to be checked weekly as the rapid resolution of oedema may require the cast to be changed weekly or bi-weekly.

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INVESTIGATIONS TO BE PERFORMED PRIOR TO COMING TO FOOT CLINIC 1. Bloods FBC Urea & Electrolytes ESR C-RP Liver function Fasting lipids HbA1C 2. Sample of Pus or Tissue (if relevant) Send a deep sample of pus or tissue where possible. Indicate in the clinical details that the specimen is a deep specimen from a diabetic patient. Otherwise the specimen will be processed as a superficial swab in the laboratory. A superficial swab reflects superficial colonisation only and is not indicative of deeper organisms. 3. Radiology Plain X-Ray of the foot if ulcer or cellulitis present MRI scan of the foot if concern re osteomyelitis and foot X-Ray is normal If there is a hot swollen foot then urgent MRI foot and consider Acute Charcot Foot 4. Ankle Brachial Index ABI to be performed in ALL patients attending the foot clinic and repeated 6 12 monthly 5. Neuropathic Foot Ulcers Clinical examination is vital to ensure no spinal cord pathology. If there is a concern that the neuropathy is not due to diabetes, order nerve conduction studies and perform appropriate imaging studies of the back.

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MISCELLANEOUS FOOT CONDITIONS 1. Dry Skin Apply emollients to feet at least once daily Tinea Pedis (Athletes foot) Apply Terbinafine (Lamisil) cream to the feet for 1 week Subungual Haematoma Refer to Podiatry for drainage of haematoma Ingrown Toe-Nail (Onychocryptosis) Refer to podiatry for appropriate treatment Infected Ingrown Toe-Nail Refer to podiatry for appropriate treatment Swab nail bed. Treat with antibiotics Cefradine 1g TDS PO for 1 week Follow up with podiatry (doctor review if necessary). Onychomycosis (Fungal nail infection) Eradication is difficult Swab nail bed and send nail clippings for fungal culture If localised to one nail and not upsetting the patient then control the fungal nail disease with regular debulking of the nail bed. If localised to one nail but is cosmetically disturbing to the patient then for trial of topical Loceryl (Amorolfine). Apply to infected nail 1 2 times per week after filing and cleansing; allow to dry (approx. 3 minutes). Treat fingernails for 6 months, toe-nails for up to 9 months (review at intervals of 3 months). Arrange podiatry review to ensure effective treatment. If fungal infection is spreading or painful or not responding to topical antifungal agents then for trial of Terbinafine (250mg daily) for 6 weeks to treat finger-nails and 12 weeks to treat toe-nails. Side effects include GI upset, hepatitis, loss of taste, urticaria and Stevens-Johnson syndrome. Arrange podiatry review to ensure effective treatment. * Loceryl will only be effective for superficial white onychomycosis. Severe yellow dystrophic onychomycosis will need oral treatment

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Appendix 1: Patients to be Referred to the Diabetic Foot Clinic*

1. Active Diabetic Foot Ulcer

OR OR OR

2. History of a Diabetic Foot Ulcer 3. History of a lower limb amputation 4. Charcot foot 5. History of cellulitis of the foot
OR OR

6. High Risk Diabetic Foot (Absent monofilament absent dorsalis pedis pulse with ABI < 0.7) 7. Structural deformity of the foot

OR

*Patients can be referred to the Diabetic Foot Clinic by the endocrine and vascular services directly as long as the patient fits the above criteria. This clinic is held on the 4th Tuesday of every month. Patients from other services need to be referred to the general diabetes service first.

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Appendix 2: Contact details: Diabetic Service, Microbiology Laboratory and Antibiotic Advice If you have any queries regarding antibiotic therapy, please contact the microbiologists. If the patient has had a recent hospital admission or recent antibiotics, please contact the microbiologist for advice, as antibiotic therapy may have to be modified. Laboratory enquires Medical enquiries Dr Diarmuid Smith S/N Amanda Ledwith Dept of Podiatry S Delaney S Clifford Consultant Microbiologists Dr E Smyth Ext 2847 Diabetes Day Centre Ext 2744 / 2745

Ext 2599

Ext 2017 edmondsmyth@beaumont.ie Ext 3312 hilaryhumphreys@beaumont.ie Ext 2938 fidelmafitzpatrick@beaumont.ie Ext 2667/3320/3321 Bleep 319/443 Consultant-on-call via switch

Prof H Humphreys

Dr F Fitzpatrick

Registrars office

Out of hours

Pharmacy enquiries Antimicrobial Senior Pharmacist Ms. Sarah Foley

Bleep 046 Sarahfoley2@beaumont.ie

Any comments or suggestions on these guidelines, please feedback to Dr. Diarmuid Smith or the Department of Microbiology

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