DIABETIC FOOT

INFECTION

Prepared by :

1- Hosam bakhsh 1512040

2- Hassan alshamrani 1512035

Supervisor:
1
16/2/2022
Dr. Asma Alasmari


Outline: – Overview and Definition .

– Associated risk factor.

– Sings and symptoms.

– Case Scenario .

– SOAP.

– Reference

Overview and Definition :

Overview

and Definition :

Diabetes

is characterized by hyperglycemia due to decreased insulin, secretion (from the

pancreas), decreased insulin sensitivity or both. Chronic hyperglycemia leads to many

complications,

including organ and nerve damage

e

Diabetes and foot infection

– Patients with diabetes are at high risk for foot infections because of
neuropathic damage and compromised blood flow to the lower extremities.

– Foot infections are the most common cause of amputation. Ulcers are

evaluated for the presence of inflammation and purulence and then classified

by severity, which guides management (e.g., surgery or antibiotics).

I
Staphylococcus and Streptococcus. are the predominant pathogens in diabetic
foot infections.

go

Diabetes and foot infection

Eta

– For people with diabetes, common foot problems can develop and lead to

serious complication these problems can lead to numbness or loss of feeling in

the foot, and, in severe cases, amputation.

– Foot problems for people with diabetes most often happen when there is nerve

damage also called diabetic neuropathy, which usually affects the feet and legs

first, then the hands and arms

– To avoid serious foot problems, it is advisable to manage your blood sugar levels

and follow diabetes foot care guidelines.

§ Loss of sensation:

The effect of a
It can lessen the ability to feel pain, heat, and coldness: if a diabetic
has lost sensation in the feet, it means they may not feel a foot
injury. For example, they could have a stone in their shoe and walk

Diabetes on on it all day without knowing.

the Feet: § Skin changes:

diabetes can cause changes in the skin of the foot it may become
very dry and the skin may peel and crack.

HyWin

– Foot Ulcers:

me
The effect of
Ulcers most often occur on the ball of the foot or on the bottom of
the big toe. Ulcers on the sides of the foot are usually a result of

poorly fitted shoes.

Diabetes on – Poor circulation:

the Feet: Poor circulation can make the foot less able to fight infections and

heal from them because diabetes causes blood vessels of the foot

and leg to narrow and harden.

i 2161 of

sat

• Gangrene:

Gangrene is a serious condition that refers to the death of body

The effect of tissue. It is caused by lack of blood flow to the tissues or from a
serious bacterial infection.

Diabetes on
– Amputation:

the Feet: Advanced stages of infected ulcers could result in amputation.

Signs and Symptoms of Diabetic Peripheral Neuropathy:

54 – It often affects the feet and legs first, followed by the hands and arms.

Fi.gg
saw

– Are often worse at night, and may include:

Ø• Numbness or reduced ability to feel pain or temperature changes.

Ø• Tingling sensation.

Ø• Muscle weakness.

then

Ø• Loss of reflexes, (especially in the ankle).

Ø• Loss of balance and coordination.

ØSerious foot problems

Øsuch as: ulcers, infections, deformation, and bone and joint pain).

Ø• Skin discoloration.

Case Scenario :

M.L 67 Years old female she present to the Emergency department complaining from sore and

swallowing foot past medical history with Diabetes mellitus type 2 from 18 years ago ,

hypertension and depression After her husband death and she was hospitalised for hyperosmotic

syndrome with history of diabetic foot V.S was BP 122/76 temp:37.4 Cْ wt : 95kg Ht: 5’1’

as

t 10


Subjective : 1- Patient demographics :

Name: M.L

Gender : female

Age: 67 years old

2- Chief complaint (CC) :

She stepped on a piece of metal and now her foot is swollen Sore

3- History of present illness (HPI) :

Complaining of sore and swollen foot from five days ago she is

stepped on a piece of metal and later noted redness and soreness

in the area

11


Subjective :

4-

Past medical history (PMH):

DM

(type 2) 18 years ago

Hospitalised 2 month ago for hyperosmolar hyperglycaemic syndrome

Hospitalised 9 months ago with MI.

Left second toe amputation one year ago secondary two diabetic foot infection

Hyperlipidaemia

Hypertension

Depression

Chronic

renal insufficiency

Obese

* DM : diabetic mellitus .
• MI : myocardial infraction . 12


Subjective :

Social history (SH) :

6-

She is depressed since her husband’s death

None adherence with her medication and glucometer

7- Allergy (All) :

Sulfa

– sever rash

13


Subjective : 8-Medication history :

Drug Used for

Bloodegulate
Sagen
Metformin Bigman type 2 DM

1000 mg P.O BID/day

Aspirin NSAID Prophylactic Dose for MI

81 mg PO once daily
Cortez

Premixed NPH,regular insulin 70/30 Type 2 DM

60 unit Q A.M and Q PM
NaturalProtamine

hagedorn Lisinopril Hypertension

20 mg PO once dailyActitheppen

Simvastatin Hyperlipidaemia
40 mg po once dailyHMGCoAreductase

inheritor

SSR Citalopram Depression
20 mg po once daily

SAR Trazodone Depression

t 50 mg po at bedtime 14
 Unst
subningndr
e Objective :
Physical Examination :
Abdominal :
Obese class || with BMI 39.6
Heart :
normal S1, and S2
Skin :
Warm , coase and very dry
Ext :
2+ edema with diminished sensation of right foot area of redness and induration
4-5 cm poor care with some fungus and overgrown toenails

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 Objective:
Physical Examination :
Vital signs Result Normal range

BP 122/76 SBP <120 mmgh &DBP <80

HR 92 60-100 beat/minute

RR 20 12-20 breath/minute

T 37.4 Cْ 37.2

Weight 95

Hight 5’1’
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LABORATORY TEST RESULTS AND NORMAL
VALUES :
Biochemistry test Patient results Normal values

Na 136 mEq/L 135-145 mEq/L

K L/3.6 mEg 3.5-5 mEq/L

Cl 98 mEq/L 95-106 mEq/L

CO2 24 mEq/L 22 to 28 mEq/L

BUN 30 mg/dL 7-20 mg/dL

SCr 1.7 mg/dL 0.6 – 1.3 mg/dL

Fasting blood glucose 181 mg/dL dL/110 mg<

CrCl 23.07 mL/min 88-128 mL/min

A1C 11.8 % < 6.5 %

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HEMATOLOGICAL TESTS Patient results Normal values

Hgb 12.6 g/dL dl/12 to 16 g

Hct 37.8% 38 % to 50%

WBC 16.4 x 103/mm3 4.000-11.000 cells/mm3

Plt 390 x 103/mm³ 150,000 – 450,000/mm3

Bands 8% 3 to 5 %

Lymphs 15% 20 to 40 %

Monos 6% 2 to 8 %
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 Assessment :

– Based on patient past medical history as well as laboratory tests M.L had
poorly controlled diabetes mellitus besides History of present
– Illness ( sore and swollen due to stepped on a piece of metal ) and rise in
White Blood Cell Count in addition to physical examination on extremities
she is now suffering from Diabetic Foot Infection.

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 – Eradicate the bacteria.
– Prevent the development of osteomyelitis and the need for
amputation.
– Preserve as much normal limb function as possible.
Therapeutic – Prevent infectious complications.
goals – Improve control of diabetes mellitus.( discontinue NPH,regular
insulin 70/30 and Metformin and initiate Aspart rapid acting,
Detemir long acting and Empagliflozin.
– Discontinue one of antidepressants drug (citalopram).

– *NPH: Neutral Protamine Hagedorn

 – Appropriate wound care by experienced podiatrists (incision
and drainage, debridement of the wound, toenail clipping),
nurses (wound care, dressing changes of wound, foot care
Non pharmacotherapy teaching).
– Bedrest, minimal weight-bearing, leg elevation, and control of
edema.
 – Initiate broad-spectrum coverage for Gram positive, negative
bacteria and Pseudomonas aeruginosa as Well as
anaerobes due to the location of the wound (bottom of foot), its
size and severity, and the patient’s diabetes.
ØPiperacillin/tazobactam 2.25 g IV Q 6 h

Pharmacotherapy – This patient does have risk factors for MRSA infection (recent
hospitalizations, existing chronic illnesses), and empiric coverage
of this organism should be considered as well.
Cyclic ØDaptomycin < 30 CrCl 4mg/kg
liPo
peptide
andbiotic Therapy should be continued for at least 1-2weeks.

*MRSA: Methicillin-resistant Staphylococcus aureus

 – According to her medication history and insufficient controlled
DM.
Shifting NPH, Regular Insulin To Aspart rapid acting, Detemir
long acting And discontinued metformin due to Their
contraindicated in high SCr and start Empagliflozin 10mg daily in
the morning.
SGLT z
Pharmacotherapy dotransport
(cont) where
– In depression medication Take SSRI and TCA can cause dual
action and Serotonin syndrome so discontinue Trazodone and
continue in Citalopram 20mg once daily.

*SSRI: Selective serotonin reuptake inhibitors. * TCA: Tricyclic antidepressants.

 Continue on:
ØAspirin 81mg one daily.
Pharmacotherapy ØLisinopril 20mg once daily.
(cont) ØSimvastatin 40mg once daily.
ØCitalopram 20mg once daily.
 – Daptomycin
CPK levels should be monitored weekly. Daptomycin should
be discontinued in patients with unexplained signs and
symptoms of myopathy in conjuction with CPK elevation >
1000U/L .

Monitoring • Piperacillin/tazobactam
Therapeutic: Culture and sensitivities, serum levels, signs and
symptoms of infection, white blood cell count.

*CPK: Creatine phosphokinase.

 – Obtain every 6 months in patients at goal A1C and every 3
months in those over goal.
Follow up – If the patient above the goal may need to increase the dose of
insulin.
PAT I E N T C O U N S E L L I N G

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 PAT I E N T C O U N S E L L I N G

Insulin Counselling :
• Check Insulin for discoloration and particles. Discard ifpresent.
• Clean injection site (area of the skin) with an alcohol swab.
• Use a new needle for each injection. Prior to each injection
• Insert the needle all the way in. Pens are injected straight down (at a 90 degree angle)
• Press the injection button (pen) Count 5 - 10 seconds before removing the needle.
• Rotate injection sites around the abdomen regularly toprevent skin damage.
• dispose of needles.
• Do not store pens with needle attached.

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 PAT I E N T C O U N S E L L I N G

Empagliflozin Counselling :
• It is usually taken once a day in the morning with or without food.

• Take empagliflozin at around the same time every day.

• Do not take more or less of it or take it more often than prescribed by your doctor.

• Do not stop taking empagliflozin without talking to your doctor.

• Take the missed dose as soon as you remember it.

• If it is almost time for the next dose skip the missed dose and continue your regular dosing schedule.

• Do not take a double dose to make up for a missed one.

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 PAT I E N T C O U N S E L L I N G

Aspirin Counselling :
• Swallow the tablets whole with a full glass of water.

• Do not break, crush, or chew them.

• Do not take more or less of it or take it more often.

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 PAT I E N T C O U N S E L L I N G

Lisinopril Counselling :
• take by mouth It is usually taken once a day.

• To help you remember to take lisinopril, take it around the same time every day.

• Do not take more or less of it or take it more often than prescribed

• by your doctor.

• Continue to take lisinopril even if you feel well. Do not stop taking lisinopril without talking to your
doctor.

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 PAT I E N T C O U N S E L L I N G

Simvastatin counselling :
• He tablets are usually taken once a day in the evening.

• Take simvastatin at around the same time every day.

• Do not take more or less of it or take it more often than prescribed by your doctor.

• Continue to take simvastatin even if you feel well.

• Do not stop taking simvastatin without talking to your doctor.

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 PAT I E N T C O U N S E L L I N G

Citalopram counselling :
• have raised the chance of suicidal thoughts need to watch patient closely.
• Tablet to take by mouth.
• The tablet is usually taken with a meal or light snack two or more times a day.
• To help you remember to take Citalopram , take it around the same time(s) every day.
• Do not take more or less of it
• Continue to take Citalopram even if you feel well.
• Do not stop taking Citalopram without talking to your doctor.
• If you suddenly stop taking Citalopram , you may experience withdrawal symptoms such as dizziness
nausea; headache; confusion; anxiety; agitation; difficulty falling asleep or staying asleep; extreme
tiredness or tingling in the hands or feet abnormally excited mood;

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 Health maintenance vaccine:

• Herpes zoster vaccine :

• Shingrix: age > 50 years, 2 doses, 2-6 months apart .
• Annual influenza vaccine .
• Pneumococcal vaccine (age >65 years)
• Prevnar 13 x 1 if not received previously
• Pneumovax 23 x 1 (Wait at least one year after prevnar 13 And at least
Five years after any prior doses of pneumovax 23

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 Reference :

• American diabetes association.

• 44th ed. 2021.Shapiro K, Bombatch C, Garrett S, Veverka A.

• RxPrep course book. 2020.Accp. 2nd ed. 2021.

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