Diabeticfoot

diabetic foot

1. DIABETIC F O O T

2. Introduction: Diabetic Foot Ulcers and Infections Most common problem in persons with diabetes. Lifetime risk of a foot ulcer in Diabetes patients: 25 % Account for approximately 25 percent of all hospital stays for patients with diabetes

3. Risk factors Local trauma and/or pressure Prior ulcers or amputations Infection Effects of chronic ischemia, due to peripheral artery disease Patients with diabetes also have an increased risk for nonhealing related to mechanical and cytogenic factors

4. Aetiopathogenesis Peripheral neuropathy and peripheral arterial disease (PAD) (or both) play a central role

5. Diabetic Foot Ulcers are classified as: Neuropathic Ischaemic Neuroischaemic

6. Typical features of DFUs according to aetiology.

7. Neuropathic DFU Neuroischaemic DFU Ischaemic DFU

8. Microbiology Most diabetic foot infections are polymicrobial Superficial diabetic foot infections :likely due to aerobic gram-positive cocci. Ulcers that are deep, chronically infected and/or previously treated with antibiotics are more likely to be polymicrobial.

9. Wounds with extensive local inflammation, necrosis, malodorous drainage, or gangrene with signs of systemic toxicity should be presumed to have anaerobic organisms in addition to the above pathogens.

10. Ulcer classification University of Texas system Grade 0: Pre- or postulcerative Grade 1:Full-thickness ulcer not involving tendon, capsule, or bone Grade 2: Tendon or capsular involvement without bone palpable Grade 3: Probes to bone

11. Grade0: Pre- or postulcerative

12. Grade 1: Full-thickness ulcer not involving tendon, capsule, or bone

13. Grade 2 : Tendon or capsular involvement without bone palpable

14. Grade 3: Probes to bone

15. Wagner Classification: Grade 1: Skin and subcutaneous tissue Grade 2: To bone Grade 3: Abscess or osteitis Grade 4: Partial foot gangrene Grade 5: Whole foot gangrene

16. WIFI Classification Measures 3 factors: Wound Ischemia Foot Infection

17. Clinical manifestation Diabetic foot infections typically take one of the following forms: Localized superficial skin involvement at the site of a preexisting lesion Deep-skin and soft-tissue infections Acute osteomyelitis Chronic osteomyelitis

18. Hi s t o r y Duration of diabetes Glycemic control Presence of micro- or macrovascular disease History of prior foot ulcers, lower limb bypasses or amputation Presence of claudication History of cigarette smoking

19. Physical examination Assessment for the presence of existing ulcers peripheral neuropathy loss of protective sensation peripheral artery disease, and foot deformities claw toes and Charcot arthropathy

20. Examination of Ulcer Predominantly neuropathic, ischaemic or neuroischaemic? Is there critical limb ischaemia? Any musculoskeletal deformities? Ulcer Characteristics: size/depth/location/wound bed wound infection status of the wound edge

21. Semmes-Weinstein Monofilament Test

22. Procedure: Quiet Surrounding Eyes Closed for the test Supine position Testing in inner aspect of arm/hand Apply the monofilament perpendicular to the skin surface with sufficient force to bend it Ask: whether they felt it?/Where they felt it? Duration: 2 secs 3 applications in each site with at least 1 mock

23. Inference: Protective sensation is present at each site if the patient correctly answers two out of three applications Protective sensation is absent with two out of three incorrect answers

24. Physical signs of peripheral artery disease diminished foot pulses, decrease in skin temperature, thin skin, lack of skin hair, and bluish skin color

25. Diagnosis of Diabetic Foot Infection Primarily based on suggestive clinical manifestations The presence of two or more features of inflammation (erythema, warmth, tenderness, swelling, induration and purulent secretions) can establish the diagnosis Presence of microbial growth from a wound culture in the absence of supportive clinical findings is not sufficient to make the diagnosis of infection

26. Diagnosis of underlying osteomyelitis Grossly visible bone or ability to probe to bone Ulcer size larger than 2 cm 2 Ulcer duration longer than one to two weeks Erythrocyte sedimentation rate (ESR) >70 mm/h A conventional radiograph with consistent changes can be helpful in making the diagnosis ((MRI), which is highly sensitive and specific for osteomyelitis ) Culture of bone biopsy specimens is also important for identifying the causative organisms

27. Differential diagnosis trauma crystal-associated arthritis acute Charcot arthropathy fracture thrombosis venous stasis

28. Infectious Diseases Society of America and International Working Group on the Diabetic Foot Classifications of Diabetic Foot Infection

29. Management Management of diabetic foot infections requires: Attentive wound management Good nutrition Appropriate antimicrobial therapy Glycemic control, and fluid and electrolyte balance.

30. Wound management Local wound care for diabetic foot infections typically includes debridement of callus and necrotic tissue, wound cleansing , and relief of pressure on the ulcer DEBRIDMENT: Debridement is essential for ulcer healing choice of debridement sharp, enzymatic, autolytic, mechanical, and biological) Fig: Neuropathic ulcer Top: Pre debridement Bottom: Post debridement

31. DRESSINGS After debridement, ulcers should be kept clean and moist but free of excess fluids Dressings should be selected based upon ulcer characteristics, such as the extent of exudate, desiccation, or necrotic tissue Adjunctive local therapies : negative pressure wound therapy (NPWT) use of custom-fit semipermeable polymeric membrane dressings cultured human dermal grafts application of growth factors

32. Wound Management Dressing Guide International Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers.

33. Wound Management Dressing Guide Continued...

34. Su r g e r y Required for cure of infections complicated by abscess, extensive bone or joint involvement, crepitus, necrosis, gangrene or necrotizing fasciitis And for source control in patients with severe sepsis In addition to surgical debridement, revascularization (via angioplasty or bypass grafting) and/or amputation may be necessary.

35. Antimicrobial therapy EMPERIC THERAPY: Mild infection: Outpatient oral antimicrobial therapy. Should include activity against skin flora including streptococci and S. aureus Agents with activity against methicillin-resistant S. aureus (MRSA) should be used in patients with purulent infections and those at risk for MRSA infection

36. Moderate infection : D eep ulcers with extension to fascia. Should include activity against streptococci, S. aureus (and MRSA if risk factors are present), aerobic gram-negative bacilli and anaerobes – can be administered orally Empiric coverage for P. aeruginosa may not always be necessary unless the patient has particular risk for involvement with this organism, such as a macerated wound or one with significant water exposure

37. Severe infection: Limb-threatening diabetic foot infections and those that are associated with systemic toxicity should be treated with broad-spectrum parenteral antibiotic therapy In most cases, surgical debridement is also necessary.

38. Duration of therapy Mild infection should receive oral antibiotic therapy in conjunction with attentive wound care until there is evidence that the infection has resolved (usually about one to two weeks) Patients with infection also requiring surgical debridement or amputation should receive intravenous antibiotic therapy perioperatively

39. In case of osteomyelitis: No data support the superiority of specific antimicrobial agents for osteomyelitis Appropriate regimens for empiric therapy are similar to that for moderate to severe diabetic foot infections Therapy should be tailored to culture and sensitivity results, ideally from bone biopsy. Patients who were initiated on parenteral therapy, a switch to an oral regimen is reasonable following clinical improvement

40. Extensive surgical debridement or resection is preferable in the following clinical circumstances Persistent sepsis without an alternate source Inability to receive or tolerate appropriate antibiotic therapy Progressive bone deterioration despite appropriate antibiotic therapy Mechanics of the foot are compromised by extensive bony destruction requiring correction Surgery is needed to achieve soft tissue wound or primary closure

41. Adjunctive therapies vacuum-assisted wound closure, hyperbaric oxygen and granulocyte colony-stimulating factor (G-CSF)

42. Follow-up Close follow-up is important to ensure continued improvement and to evaluate the need for modification of antimicrobial therapy, further imaging, or additional surgical intervention

43. S umma r y Hyperglycemia, sensory and autonomic neuropathy, and peripheral arterial disease all contribute to the pathogenesis of lower extremity infections in diabetic patients Evaluation of a patient with a diabetic foot infection involves determining the extent and severity of infection through clinical and radiographic assessment

44. The presence of two or more features of inflammation (erythema, warmth, tenderness, swelling, induration, or purulent secretions) can establish the diagnosis of a diabetic foot infection. The definitive diagnosis of osteomyelitis is made through histologic and microbiologic evaluation of a bone biopsy sample Management of diabetic foot infections requires attentive wound management, good nutrition, antimicrobial therapy, glycemic control, and fluid and electrolyte balance

45. References:: Lipsky BA, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2012; 54:e132. International Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers. Wounds International, 2013. Gulf Diabetic Foot Working Group. Identification and management of infection in diabetic foot ulcers: International consensus. Wounds International 2017. www.uptodate.com Internet

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