Diploma in Medicine Endocrinology Unit Dr.

Kimberly Oman

Poorly characterized defects in host immunity ... make them more susceptible to certain types of infections including bacterial infections of the skin and soft tissue (CID 1997;25:1318) Impaired wound healing in diabetics (ibid) Decreased cell mediated immunity (Mandell 1990 p. 129) Decreased neutrophil chemotaxis and phagocytosis (Mandell p. 145)

Mild diabetic decompensation Does not seem to be deleterious to the phagocytic

Severe diabetic decompensation Poor chemotaxis, ingestion and killing by PMNs (? Staphylococcus aureus in diabetes mellitus (Mandell - 1990 p. 1496) Increased nasopharyngeal colonization of diabetic

system

Partly due to hyperosmolar state)

patients on insulin ? Increased frequency of infection More likely to be severe and protracted

Crepitant soft tissue wounds (p. 809): nonclostridial anaerobic cellulitis, necrotizing fasciitis, synergistic necrotizing cellulitis (Gas gangrene) Forniers gangrene (necrotizing fasciitis of the male genitals) - if the abdominal wall becomes involved in an obese patient with diabetes, the process can spread like wildfire (p. 810)

Candida vaginitis (p. 1946) Chronic or persistent bacterial pneumonia (p. 566) Infectious arthritis (p. 912) Rhinocerebral mucormycosis (DM esp. acidosis, leukemia, renal transplant) : facial pain, headache, involvement of orbit & braintreat with radicaldebridement (p.1964) ? Cryptococcosis (fungal meningitis, pneumonia) p. 1982

Clinical presentation

Not uncommon in Fiji but not described in the literature

Unwell Minimal or no localizing signs Often confused +/- fever Often high white count Respond to cloxacillin and gentamicin May do poorly if antibiotics withheld

Ischemia
Arterial insufficiency in 60% with non-healing

ulcers and 46% with major amputations

Infection
Superficial fungal infections leading to

maceration or broken skin Increased nasal and skin colonization with Staphylococcus aureus

Peripheral neuropathy present in over 80% of diabetics with foot lesions Sensory neuropathy Motor neuropathy:
Gait disturbances, foot deformities (such as claw

Unperceived injury

Autonomic neuropathy
Interference with sweating can lead to dry,

toe)

cracked skin

Good glycemic control No smoking Early detection of loss of protective sensation

Vibration Monofilament testing

Regular foot inspection by clinicians Education in foot care and proper footwear

Wash and dry your feet thoroughly every day, especially between the toes Inspect your feet daily for blister, skin breaks and infection Apply cream to the skin Cut your toenails carefully Wear well-fitting shoes that dont rub or hurt your feet or cause blisters Dont go barefoot

Seek medical care if you have an infection or skin breakdown on your feet. Tell patients that preventing foot problems and treating foot problems early can prevent amputations

Most common
Unperceived, excessive and repetitive pressure on

Others

plantar bony prominences such as metatarsal heads

Foot deformities (elevated focal pressure) Small foreign bodies in footwear Pressure necrosis from poorly fitting footwear Puncture wounds Pacific Islands: going barefoot

History Prior ulceration Prior surgery involving the metatarsal bones Physical findings Callus or hemorrhagic callus Blister or macerated skin Limited hallux dorsiflexion (<30 degrees) Prominent metatarsal heads inadequately covered

Radiographic findings: Charcots fracture

with soft tissue Other plantar bony prominences

No apparent infection
(No signs of inflammation or drainage or evidence

of osteomyelitis on plain xray)

Mild infection

Superficial, < 2 cm of cellulitis No serious ischemia No bone or joint involvement Patient reliable, good home support

Limb-threatening infections

Full-thickness ulcer >2 cm of cellulitis with or without lymphangitis Bone or joint involvement Systemic toxicity Serious ischemia Patient unreliable or poor home support

Major problem: determining if osteomyelitis is present

Often difficult / problematic Early osteomyelitis

Similar to soft tissue infection No changes on radiographs Hard to distinguish on xray from diabetic

osteopathy (Charcots changes)

History:
Ulcer present for more than one week Previous osteomyelitis History of other foot complications secondary to

Physical exam:

peripheral neuropathy

Many are not febrile Increased risk if ulcer over bony prominence Larger or deeper ulcer Bone visible or can be touched with a sterile blunt probe

Laboratory tests
ESR
>70 mm/hr: 100% have osteomyelitis >40 mm/hr: 12x risk of osteomyelitis

Radiography

WBC, other tests not helpful

Findings: focal osteopenia; lucencies in cortex or

medullary bone bony abnormalities not present on plain films for 10-20 days Overseas: bone scans / gallium scans / indium labeled leukocytes / MRI

Bone culture
Sensitivity 95% / Specificity 99% Surgical approach OR Percutaneous through uninfected tissue Gram stain and culture Histopathology

Laboratory studies

Not always done due to expense

Some skip if osteomyelitis highly likely Consider for suspected unusual organisms

Similar for soft tissue infection and osteomyelitis Soft tissue cultures often grow different organisms from bone cultures in the same patient Most infections are polymicrobial
Average: 2.2 pathogens in osteomyelitis, twice that in

soft tissue infections

Staphylococcus aureus most common

Other gram +: Streptococcus spp., Enterococcus spp.

Gram negative bacilli Enterobacteriaceae; Pseudomonas (puncture

Anaerobes Relatively frequent in serious soft tissue infections Less common in osteomyelitis More frequent in long-standing infections,
? Role of Staph epi and Corynebacterium spp.

wound especially with rubber-soled shoes; soaking feet)

infections not eradicated by previous antibiotics or necrotic tissue / foul odor

Guided by soft tissue or bone cultures Some treat all organisms cultured, others do not Less serious: anti-Staphylococcal cover is often sufficient More serious: Staphylococcal, gram negative and anaerobe cover

Traditional: 4 - 6 weeks IV antibiotics Basis: animal models and anecdotes No reliable data on: Duration of antibiotic therapy When to switch to oral agents Approach (CID 1997;25:1310) Consider bone biopsy for culture and histopathology Remove entire section of infected bone plus 2 weeks of

antibiotics OR 4-6 weeks of culture-guided antibiotic therapy without bony resection

Approach (NEJM 1994;13:854)

Traditional 4 - 6 week IV therapy OR Remove entire section of infected bone plus 2 - 3

Also mentioned (CID and NEJM)

approach

weeks of antibiotics - at least one week IV (longer for tarsal or calcaneal bone which must be removed piecemeal)

10 - 12 weeks antibiotics without surgical debridement Chronic suppression without cure can be a valid

Probe to bone? - Osteomyelitis Suggestive xray? - Osteomyelitis Unclear? (Too early for xray changes?)
Treat as for soft tissue infection (culture-directed)

for 2 weeks Repeat xray in 2 weeks to look for osteomyelitis

Soft tissue infections: beware gas gangrene and necrotizing soft tissue infections

Mild to moderate infections (not defined)

Severe infections

Metronidazole 400mg po 8/24 PLUS Flucloxacillin 500mg po 6/24 metronidazole 400mg po 8/24 PLUS cloxacillin 1-2g IV 6/24 PLUS Gentamicin 80mg IV 8/24 (adjust as needed) metronidazole 400mg po 8/24 PLUS cephalothin 1-2 gm IV 4/24

Alternative

Change to oral therapy when infection is under control Duration of treatment depends on response Adjust therapy based on culture results

Surgical debridement is often necessary Surgical advice should be sought (often not necessary in mild cases) Proper dressings and wound care very important

Clindamycin (old antibiotic) po/IV

Staphylococcus aureus, other gram positives,

anaerobes, excellent in necrotizing Streptococcal or anaerobic infections

Fluoroquinolones (Ciprofloxacin)
Staphylococcus aureus & gram negatives Not anaerobes Newer quinolones cover other gram positives (but

not Ciprofloxacin)

B-lactam / B-lactamase combinations po/IV: gram negative, S. aureus, anaerobes Amoxicillin - clavulanate - po Ampicillin - sulbactam - IV Ticarcillin - clavulanate - IV Piperacillin - tazobactam - IV Cefoxitin or cefotetan (2nd generation cephalosporins) IV S. aureus, anaerobes, gram - with holes Carbapenems (imipenem / meropenem) - IV gram negative, S. aureus, anaerobes

Debridement of infected tissue (diabetics do not tolerate undrained suppuration) Remove infected bone if possible (ie. digital or ray amputation) When to amputate? Revascularization procedures if needed (overseas)

2-year mortality rate:

35-50%

1-3 year cumulative amputation rate:

40%

High morbidity and mortality Often hard to distinguish soft tissue infection from osteomyelitis Little data on optimal duration of treatment Little data on IV vs. oral antibiotics Many valid approaches Therefore best treatment is still uncertain

Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW, Karchmer AW. Assessment and management of foot disease in patients with diabetes. N Engl J Med 1994;331:854-60. Lipsky BA. Osteomyelitis of the foot in diabetic patients. Clin Infect Dis 1997;25:1318-26. MandellGL, Douglas RG, Bennett JE eds. Principles of Infectious Diseases 3rd Edition. Churchill Livingstone: New York; 1990.