Diabetic Foot Infection - Revised by AK

7/24/2019 Diabetic Foot Infection - Revised by AK

1/28

Diabetic FootInfections

By: Lisa Kim

Alexander Kravitz


2/28

Objectives

Revie case of !atient !resentin" it# diabeticinfection $DFI%

Disc&ss t#e e!idemiolo"y' etiolo"y' and clinical

!resentation of DFI

Revie a!!ro!riate t#era!ies for t#e mana"emDFI


3/28

(atient )ase

K) is a *+ year old male ,as admitted to -aine.eneral on /0*

)): Ri"#t loer extremity le" o&nd on calcane

fo&l s&!!&rative disc#ar"e and bilateral loer ex

sellin" 1reated em!irically it# I2 vanco 3 zosyn


4/28

Patient case, cont.2itals: 1em!455 6R457

B(48*90/ RR48; O+

stats45< room air

Labs:

Cultures: =o anaerobes

/3 "ram $>% bacilli

+3 Beta #emoloytic

Streptococcus"ro&

+3 coa" $>%Staphylococcus

/3 Di!#t#eroid bac

/3 Enterococcus

8//

?@

/

89+

+?

8@58

/5

88;

@7

/**87@;

+;


5/28

(atient case' cont@ (ertinent st&dies:

>ray of ri"#t foot

1a""ed #ite blood

cell scan

(-6:

Admitted ;0+908/ fornecrotizin" faciitis 1reated it# I2 vanco'

Fla"yl' difl&can

A8) $+08?08?%: 5@;

Fhx: Mother: T2DM

2 brothers: T2

Shx: No EtOH or dr

!lleries: non


6/28

-edications at 6ome Lant&s ins&lin: +* &nits

s&bc&taneo&sly CD )entr&m -ens m&ltivitamin: 8 tab

CD

As!irin 8 m": 8 tab C

Lasix 9 m": + tabs BID

)arvedilol ;@+* m": 8 tab BID

)i!rofloxacin *99 m": 8 tab BID

Enoxa!arin ?9 m": ?9 m" s&bC BID

Levot#yroxine +* mc": 8 tab CD

Linezolid ;99 m": 8 tab BID

-etronidazole *99 m": 8 tab

)restor * m": 8 tab C6

ilver dressin" ?*: a!!ly C

!ironolactone +* m": 8 tab

1ams&losin 9@? m": 8 ca! C

(otassi&m )#loride +9mEC

tab CD

2itamin D *9'999 &nits: 8 ca

eeGly

-elatonin / m": 8 tab CD

Lisino!ril * m": 8 tab CD


7/28

E!idemiolo"y Increasin"ly common

o In +99/: 889'999 #os!ital admissions for DFI

H! to ?9< of !atients it# DFI #ave !eri!#eral vasc&la

disease

Am!&tation d&e to DFI in t#e HA #as decreased by a

*9< in t#e last decadeo Latest: ?@; am!&tations !er 8999 diabetics

o -ost of t#e decrease #as been in above>t#e>anGle am!


8/28

Etiolo"y

A DFI emer"es #en an infection occ&rs in an &lcerat

t#e foot from tra&ma or t#at is &ndetected beca&se of

!eri!#eral ne&ro!at#y

Infections can become more !rofo&nd and s!read to d

tiss&es' incl&din" bone

Often become com!licated by vasc&lar ins&fficiency 2ideo: #tt!:00yo&t&@be0lban.B"eccJt4/5s
http://youtu.be/ZlbanGBgecc?t=39shttp://youtu.be/ZlbanGBgecc?t=39s


9/28

Clinical Presentation (resence of infection defined by + classic findin"s of infla

or !&r&lenceo Redness' sellin"' armt#' tenderness' !ain

o (resence of !&r&lent or non>!&r&lent secretions

o Hndermined o&nd ed"es

o Fo&l odor

o Discolored "ran&lation tiss&e

F&rt#er classified:o -ild: s&!erficial and limited in size and de!t#

o -oderate: dee!er or more extensive

o evere: accom!anied by systemic si"ns or metabolic dist&rba


10/28

)lassifications of DFI


11/28

IDA International ,orGin" .ro&! on Diabetic Foo

)lassifications of DFI' cont@

Isc#emia may increase severity of infection ystemic infection may also manifest as #y!otens

conf&sion' vomitin"' or evidence of metabolic

dist&rbances


12/28

Dianosis, cont. RisG factors for DFI

o (ositive !robe>to>bone $(1B% test

o ,o&nd !resent for /9 days

o 6istory of rec&rrent &lcers

o ,o&nd ca&sed by tra&ma

o

(resence of !eri!#eral vasc&lar disease in t#e affeco Loss of !rotective sensation

o (resence of renal ins&fficiency

o (atient Gnon to alG barefoot


13/28

-ana"ement of infection

)lassify severity of infection based on its extende!t#' !resence of any systemic findin"s

Debride any o&nd t#at #as necrotic tiss&e or

s&rro&ndin" call&so Obtain c&lt&res !rior to em!iric antibiotic t#era!y by

!erformin" a bio!sy or c&retta"e after o&nd is cleadebride

Ima"in": radio"ra!# of affected foot' -RI'

radion&clide bone scan' labeled #ite blood ce


14/28

-ana"ement of Infection

.ive antibiotic t#era!y for all infected o&nds b&combine it# a!!ro!riate o&nd care

Em!iric antibiotic re"imens are selected based o

severity and t#e liGely etiolo"ic a"ent -ild>moderate infection 3 no recent abx t#era!y 4 tar"

"ram $3% cocci

evere infection 4 broad s!ectr&m' !endin" c&lt&re re

antibiotic s&sce!tibility

)overa"e for P. aeruginosa is not necessary


15/28

-ana"ement of Infection' co )onsider -RA covera"e in !atients it# !rior #

or if infection is clinically severe )ontin&e antibiotic t#era!y &ntil' b&t not beyond

resol&tion of t#e infectiono -ild:8>+ eeGs

o

-oderate>severe: +>/ eeGs


16/28

-ana"ement of Infection'

Anaerobes are isolated from c#ronic' !revio&sly

or severe infectionso =ot major !at#o"ens in most mild to moderate infectio

o Little evidence to s&!!ort to cover for anaerobes in ade

debrided DFIs

E i i A tibi ti 1# B


17/28

Em!iric Antibiotic 1#era!y Base

on )linical everityInfx severity Pathogens Abx agent Pearls

Mild MSS!"Stre#tococcus s## $Dicloxacillin

$Clinda%&cin

$Ce#halexin$'e(o)oxacin

$!%oxicillin$

cla(ulanate

$*+D dosinex#ens$co(ers C-TSS$*+D" ine$*D" subaureus$anaerob

co(eraes#ectru%

MS! $Dox&c&cline

$Tri%etho#ri%0sul1a%ethoxaole

$so%e runcertainstre#toco$*D suboaureus

Infx severity Pathogens Abx agent Pearls


18/28

Infx severity Pathogens Abx agent Pearls

Moderate$Se(ere MSS!" Stre#tococcuss##"Enterobacteriaceae"obliate anaerobes

MS!

P. aeruginosa

MS!,Enterobacteriaceae,Pseudomonas,

anaerobes

$'e(o)oxacin$Ce1oxitin$Ce1triaxone$!%#icillin$sulbacta%$Moxi)oxacin$Erta#ene%$+%i#ene%$cilastatin

'ineolid

$Da#to%&cin$3anco%&cin

Pi#eracillin$taobacta%

$3anco /ce1taidi%e,ce1#i%e, #i#0ta,atreona% or

carba#ene%

$*D$co(ers a$*D$i1 lo4 suaerugino$co(ers a

$5se onl&

$777" inc4ee8s$%onitor$chec8 M

T+D$*+D

$3er& broco(erae%#iric tse(ere in


19/28

Reasons to Avoid Am!&tation

Red&ced mobility' very lo &ality of life

*>year mortality estimated Msimilar to t#at of some of t

deadly cancersN

i"ns of (ossible Imminently Limb


20/28

i"ns of (ossible Imminently Limb>

1#reatenin" Infection

Evidence of systemic inflammatory res!onse

Ra!id !ro"ression of infection

Extensive "an"rene or necrosis

1iss&e "as on ima"in"

6emorr#a"ic b&llae (ain o&t of !ro!ortion to clinical findin"s

Extensive tiss&e loss

Fail&re to im!rove des!ite a!!ro!riate abx t#er


21/28

)linical (earls

1enderness on !al!ation may be absent if s&ffi

ne&ro!at#y is !resent

)re!it&s can indicate "as and t#erefore anaero

,#en develo!in" a !lan for t#e !atients treatm

consider t#e !atients ability to com!ly it# antio &!!ort netorG

o )omorbid conditions $e@"@ !syc#%

o 1olerability of medication


22/28

(atient case>6ome visit $?0+0

2itals:B(48+0+ mm6"' 1em!erat&re4 57@?' 6R45? B(-

Findin"s: =ot com!liant on c&rrent antibiotic re"imen

o )om!lainin" abo&t rec&rrent diarr#ea' na&sea' and vomitin

(atient did not #ave !ro!er slee!in" !atternso Hnderlyin" si"ns of de!ression

(atient as dividin" lant&s dose: 8+ &nits BID

o Learned from #os!ital

o )om!lained of bloatin"


23/28

(atient case>6ome visit $?0+08?%cont@

)ons&ltation for medical marij&ana

Didnt Gno t#e exact dates of f&t&re doctors a!!ointments

Delay in o&nd dressin" c#an"e to overorGed #ome #ealt# n

-&ltit&de of sym!toms@@


24/28

(atient follo>&!

)alled !atient ?0508? P 5:?9 am

K) #ad to a!!ointments on ?0 re"ardin" t#e

of #is footo 8 a!!ointment cancelled d&e to -D !erformin" eme

s&r"ery

o (atient taGin" antibiotics a"ain: ants to "et bettero =o c#an"e in slee!in" !atterns

o Overall im!ression: K) did not ant to comm&nicate


25/28

(atient follo>&!' cont@

Follo>&! note:o Ri"#t le" o&nd 4 f&ll of t#icGness' and &nc#an"ed f

!revio&s are

o Left le" 4 dec&bit&s &lcer

o evere malodor on ri"#t foot

)&lt&res it# s&sce!tibility !erformedo ?3 -or"anella mor"anii

o +3 2RE


26/28

(ro"nosis after #ome visit' co

-D states t#at !atient as del&sional as to #a

effects t#ese o&nds can #aveo Ref&sed readmission

o Ref&sed 2A) dressin"


27/28

C&estionsJJJJ


28/28

ReferencesLi!sGy BA' Berendt AR' )ornia (B' et al@ +98+ Infectio&s Diseases

America clinical !ractice "&ideline for t#e dia"nosis and treatmediabetic foot infections@ Clin Infect Dis@ +98+Q*?$8+%:e8/+>7/@

abatine -@ (ocGet -edicine' 1#e -assac#&setts .eneral 6os!it

of Internal -edicine@ Li!!incott ,illiams ,ilGinsQ +98/@

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Diabetic Foot Infection - Revised by AK

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