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Diabetic Foot Infection

:
A challenge for primary and secondary care?

Dr Tony Berendt
Consultant Physician
Bone Infection Unit
NOC NHS Trust, Oxford

Disclosure of Potential
Conflicts of Interest
• Has received honoraria, travel expenses and
hospitality for serving on speakers bureaux and
advisory boards for RPR (Synercid), Pfizer (Linezolid)
MSD (Ertapenem) and MacroChem (Pexiganin)
• Vice-Chair of IDSA Clinical Practice Guidelines
Committee for Diabetic Foot Infections; Chair of
IWGDF Osteomyelitis Sub-group
• Member of Oxfordshire Priorities Forum and ORHNOC Medicines Advisory Committee
• DIPC at NOC, Chair of TV (South Central) CHAIN
and Steering Group for pan-Oxfordshire C. difficile
intervention project

Infection and Healing
Healing

Infection
Replace
Lose
footwear
footwear
Offloading

Amputation
Wound

Learning objectives
• Be able to discuss the epidemiological
importance of DFI
• Know how to assess risk of diabetic foot
ulceration and infection
• Be able to assess a patient with a diabetic foot
infection, in the context of published
guidelines, and make rational antibiotic choices

Epidemiology Pathophysiology Microbiology Assessment Biomechanics

General epidemiology  252 million diabetics worldwide Epidemiology Pathophysiology Microbiology Assessment Biomechanics .

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25% in lifetime  45-75% of all lower extremity amputations are in diabetics  85% of these preceded by foot ulcer  Two-thirds of elderly patients undergoing amputation do not return to independent life  Studies have shown less costs for saving a limb cf. amputation Epidemiology Pathophysiology Microbiology Assessment Biomechanics .General epidemiology  252 million diabetics worldwide  Foot problems account for largest number of hospital bed days used for diabetic patients  1-4% of diabetics develop foot ulcer annually.

Pathophysiology: diabetic foot ulceration Neuropathy .

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Pathophysiology: diabetic foot ulceration Neuropathy Motor Sensory Abnormal foot Loss of biomechanics protective sensation Autonomic Reduced skin compliance and lubrication Ulceration Vascular insufficienc Infection .

30-second foot examination • • • • Any previous diabetes related foot problems? Are both foot pulses palpable? Is protective sensation intact? Is there evidence of significant foot deformity? .

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callus. skin breaks. infection • Examine the toenails • Identify nature of any foot deformity • Examine the shoes • Observe patient’s ability to perform foot care and examination (by observing them replace socks and shoes) • Establish need for patient education . blisters.Two-minute foot examination • Examine feet for ulcers. maceration.

remove callosities Check for sensation (monofilament) Check for circulation (pulses.Standard ulcer care         Evaluate for infection Debride ulcer. Dopplers) Probe to bone? Adequate offloading Antibiotics if infected Secondary prevention of ulcer and of major diabetes related events Epidemiology Pathophysiology Microbiology Assessment Biomechanics .

Puget Sound VA.Overview of Diabetic Foot Infections 7 % o f P o p u la t io n D ia b e t ic 1 5 .2 5 % D e v e lo p F o o t U lc e r 4 0 -8 0 % In fe c te d (o r s u s p e c te d ) 4 0 % M i ld 3 0 -4 0 % M o d e r a te 2 0 -3 0 % S e v e re Slide courtesy of Ben Lipsky. Seattle .

excluding ulceration Lavery.9 (1.6) 0.0–3.02 Peripheral vascular disease 1.4 (1.7 (1.3–4.9) 0. Diabetes Care 2006.1–5.001 Wound duration >30 days 4.0) 0.004 Recurrent foot wound 2.4) 0.4 (1.5) 0.3–19. Armstrong.006 Traumatic wound etiology 2.29:1288 .6–13. Lipsky et al.7 (2.Independent Risk Factors* for Foot Infection: Diabetex Prospective Trial Variable Risk Ratio (95%CI) p Value Wound depth to bone 6.04 *stepwise logistic regression model.

Microbiology • Popular mythology = all infections are polymicrobial Epidemiology Pathophysiology Microbiology Assessment Biomechanics .

Microbial complexity Microbial burden Clinical risk Anaerobes Aerobic Gram-negative rods Gram positive cocci 1 2 3 4 Severity Depth Necrosis Prior Rx .

Treatment: myths • Treat uninfected ulcers to promote healing • Treat infected ulcers until the ulcer is healed • Treat all the organisms isolated from the microbiological specimens • Hospitalise all infections • Give lots of intravenous therapy .

Timeline of Staphylococcal antibiotic resistance Penicillin-resistance Sporadic MRSA Epidemic MRSA GISA CA-MRSA VRSA 194 195 196 197 198 199 200 201 .

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org Clinical Infectious Diseases 2004.39:885-910 .idsociety.www.

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dementia. depression.Evaluating the Patient with a DFI • Patient – Systemic response • Fever. electrolyte imbalance. cardiovascular status – Metabolic status • Hyperglycaemia. chills. sweats. hyperosmolality. psychosis – Social situation • Support. self-neglect · Limb/Foot · Wound Epidemiology Pathophysiology Microbiology Assessment Biomechanics . renal impairment – Cognitive function • Delirium.

gangrene – Infection Epidemiology Pathophysiology Microbiology Assessment Biomechanics . depth – Necrosis.Evaluating the Patient with a DFI • Patient • Limb or Foot – Biomechanics – Vascular • Ischaemia • Venous insufficiency – Neuropathy – Infection • Wound – Size.

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tendon. spread beneath fascia. erythema. tenderness. deep tissue abscess. pain. Any cellulitis/erythema extends ≤2 cm around ulcer and infection is limited to skin/superficial subcut tissues. joint or bone involved Infection in a patient with systemic toxicity or metabolic instability Epidemiology Pathophysiology Microbiology Assessment Biomechanics . lymphangitis.Clinical Classification of Diabetic Foot Infection Clinical Manifestations of Infection Wound without purulence or other evidence of inflammation Uninfected 1 More than 2 of purulence. No local complications or systemic illness Mild 2 Moderate 3 Severe 4 Infection in patient who is systemically well & metabolically stable but has any of: cellulitis extending >2 cm. muscle. warmth or induration. gangrene.

p < 0.6. <0.Outcomes By IDSA DFI Severity Classification 100% 90% 80% 100% 1666 patients enrolled in prospective diabetic foot study 89% 90% Hospitalization X2 trend = 118. Peters.0001 80% X2 trend = 108. Clin Infect Dis 2007 .0001 78% 70% 70% 60% 54% 60% 50% 50% 40% 40% 30% 30% 20% 20% 10% LE Amputation 10% 46% 10% 6% 3% 0% 3% 0% No infection None Mild Moderate Severe Mild Moderate Severe No infection None Mild Mild Moderate Severe Moderate Severe Armstrong. Lipsky. Lavery.

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Table 8: Suggested Antibiotic Regimens: DFI Agent(s) Mild Advised Route Moderate Oral for Most Severe Oral or IV Dicloxacillin Yes Clindamycin Yes Cephalexin Yes TMP/SMX Yes Yes Amoxicillin/clavulanate Yes Yes Levofloxacin Yes Yes Cefoxitin Yes Ceftriaxone Yes Ampicillin/sulbactam Yes Linezolid (± aztreonam) Yes Daptomycin (± aztreonam) Yes Ertapenem Yes Cefuroxime (± metronidazole) Yes Parenteral .

Moderate Oral (or initial parenteral) Outpatient/ inpatient 2-4 weeks Severe Initial IV. or residual dead bone post-op. post amputation) Residual infected soft tissue only Residual infected (but viable) bone No surgery.Site Severity Route Location Duration Soft tissue only Mild Topical or oral Outpatient 7-14 days. then consider oral switch Initial IV. to outpatient 2-4 weeks Extent of surgery No residual infected tissue (e. switch to oral when possible Inpatient. then consider oral switch 4-6 weeks Bone or joint extend up to 28 d if slow to resolve >3 months . Route Duration Parenteral or oral 2-5 days Parenteral or oral 2-4 weeks Initial IV.g.

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The diabetic foot: Charcot foot with “rocker bottom” deformity .

• Charcot foot – grossly disordered architecture and biomechanics – midfoot ulceration – instability of midfoot – note previous minor amputations – still well-vascularised .

Bone resorption and destruction .

Bone regeneration on antibiotic therapy .

health service management and audit are required . understand the pathophysiology and biomechanics • Infection (DFI) is a common and frequently serious consequence of diabetic foot ulceration (DFU) • A structured approach to assessment and treatment. using international or local guidelines. agreed pathways. provides a means to rationalise care and improve outcomes • Care must be multidisciplinary to achieve this.Conclusions • Ulceration is a common consequence of diabetic neuropathy • To understand and treat ulceration.

Does it need antibiotics. after Teniers the younger (by kind permission of National Gallery. they won’t be discovered for another 300 years! You must be joking mate! Debridement and offloading more like it! Doctor treating a patient in his surgery: 17th Century. London) . doctor? Besides.