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#3 Surg > 45 - Diabetic Foot Infections > Flashcards

45 - Diabetic Foot Infections Flashcards

1
Q

What does caring for a diabetic foot infection require?

A
  • Requires a multidisciplinary team of healthcare professionals
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2
Q

What health care professionals will be included in the care of a diabetic foot infection?

A 
o	Vascular surgeon
o	Foot and ankle specialist
o	Internal Medicine
o	Infectious Disease specialist
o	Renal 
o	Orthotist
o	Nutrition
o	Physical Therapist
o	Nursing
o	Social services

This is a HUGE burden on health care

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3
Q

What do you do on initial evaluation of a diabetic foot infection?

A

o H&P, determine if patient needs hospital admission
o Baseline labs
o Cultures

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4
Q

What will you do for treatment of a diabetic foot infection?

A

o Antibiotics

o Surgery

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5
Q

What two concerns should you be assessing for in a diabetic foot infection?

A

MRSA & osteomyelitis

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6
Q

2012 Clinical Practice Guidelines for the “Diagnosis and Treatment of Diabetic Foot Infections”

A

o Developed by executive committee made up of panel of experts with special interest/expertise in the area of diabetic foot infections
o Multidisciplinary panel representing Internal Medicine, Infectious Disease, Podiatry, Vascular Surgery
o Performed extensive search and review of the literature
o Reviewed and discussed the available evidence
o Made recommendations based on their findings, discussions and overall consensus

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7
Q

How do you diagnose an infection clinically?

A
  • IMPORTANT - Not all wounds/ulcers are infected – NEED to diagnose infection CLINICALLY
  • Infection should be diagnosed clinically:
  • Presence of purulent secretions
  • Presence of at least 2 cardinal signs of inflammation:
    Erythema
    Edema
    Warmth
    Induration
    Pain or tenderness to the affected extremity
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8
Q

Describe the infection severity scale

A
  • Interchangeable four-level grading system specifically for infection
  • Combines the grading systems developed by the International Working Group on the Diabetic Foot (IWGDF) and the Infectious Diseases Society of America (IDSA)
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9
Q

IDSA = uninfected, IWGDF = 1

A

Wound lacking purulence or any manifestations of inflammation

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10
Q

ISDA = mild, IWGDF = 2

A

Presence of purulence or more than two manifestations of inflammation (pain, tenderness, erythema, warmth or induration) but any cellulitis/erythema extends less than 2 cm around the ulcer and the infection is limited to the skin or superficial subcutaneous tissues, no other local complications or systemic illness

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11
Q

ISDA = moderate, IWGDF = 3

A

Infection (as defined previously) in a patient who is systemically well and metabolically stable but that is associated with more than one of the following characteristics

  • Cellulitis extending more than 2 cm
  • Lymphangitic streaking
  • Spread beneath the superficial fascia
  • Deep tissue abscess
  • Gangrene
  • Involvement of muscle, tendon, joint or bone
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12
Q

ISDA = severe, IWGDF = 4

A

Infection in a patient with signs and symptoms of systemic toxicity (fever, chills and leukocytosis) or metabolic instability (tachycardia, hypotension, confusion, vomiting, acidosis, severe hyperglycemia or azotemia)

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13
Q

The patient should be evaluated in three areas

A
  • Patient as a whole
  • Affected limb/foot
  • Wound evaluation
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14
Q

Patient as a whole

A

o What is the patient’s systemic response to infection (fever, chills, HR, blood pressure)?
o What is the patient’s metabolic state?(lab workup – look at it TOGETHER with clinical)
o What is the patient’s social situation, cognitive state?

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15
Q

Affected limb/foot

A

o Are there any biomechanical manifestations (callus, Charcot deformity, hammertoes)?
o What is the patient’s vascular status to the lower extremity?
o Is there loss of protective sensation?

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16
Q

Wound evaluation

A

o Measurements
o Is infection present (redness, tracking under skin, probe to bone, discharge, etc.)?
o Radiologic studies (plain radiographs, CT – MRI is NOT appropriate)
o He will not document a certain grade, he will document what he sees – very detailed

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17
Q

Goals of the three level approach to patient evaluation

A
  • Determine the extent/severity of infection (radiographs, MRI, CT, etc., if infected, is hospitalization required?)
  • Determine the microbial etiology of the infection
  • Determine the cause of the wound/ulcer: Altered foot biomechanics? Improper shoe gear? Improperly fitted bracing?
  • Determine any contributing co-morbidities: Underlying vascular disease, Hyperglycemia, Renal disease
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18
Q

**Is hospital admission required? **

KNOW THIS

A
  • Patients with severe infections
  • Patients with critical limb ischemia
  • Patients with mild or moderate infections with complicating factors
19
Q

Laboratory data

A
  • Complete Blood Count (CBC)
  • Basic Metabolic Panel
  • Erythrocyte Sedimentation Rate
  • C-Reactive Protein (CRP)
  • He has started doing an A1c and blood glucose to evaluate metabolic status
20
Q

**Cultures – THIS IS IMPORTANT **

KNOW ALL OF THIS

A
  • How should cultures be collected?
  • When should cultures be obtained?
  • Why tissue culture/biopsy over swab cultures?
21
Q

How should cultures be collected?

A

o Whenever possible, cultures of deep tissue by means of curettage or biopsy is preferred over swab cultures***
o Cultures should be sent to laboratory in sterile container properly labeled as to the specimen/tissue type and anatomic location from which the specimen was obtained.
o Needle aspiration – Useful for obtaining purulent samples

22
Q

When should cultures be obtained?

A

o When wound is determined to be infected based on clinical assessment
o Cultures should be obtained to IDENTIFY organism causing clinical infection NOT to DIAGNOSE infection
o Whenever possible, obtain cultures prior to initiation of antibiotics
o If patient is stable but not responding to current therapy, stop antibiotics for short period of time (48-72 hrs) then re-culture – VERY IMPORTANT due to false negative result***

23
Q

Why tissue culture/biopsy over swab cultures?

A

o Generally provide more accurate culture result vs. swab
o Swab cultures yield a greater range of organisms but may not identify deeper organisms/flora
o Swab specimens yield fewer anaerobes
- If anaerobic swab is performed make certain it is properly collected (i.e. use swab designed for anaerobic collection)
- Note: Unless bacterial count is high, anaerobic organisms could be lost during collection process with exposure to room air

24
Q

Necessity of avoiding antibiotics in uninfected wounds

A

o Use of antibiotics for the purposes of prophylaxis against infection or for the enhancement of wound healing is NOT supported
o Do NOT put them on antibiotics unless an infection is presence
o Overuse encourages resistance – this is all it accomplishes, which can be dangerous
o Either frank resistance or an increase in the minimum inhibitory concentration (MIC) – He always picks the one with the lowest MIC
o Vancomycin Resistant S aureus
o Arise of multi-drug resistant gram-negative organisms
o Unnecessary financial burden
o Drug related adverse effects

25
Q

Antibiotic selection for initial emperical therapy

A

o Based on severity & available microbiological data (likely etiologic organism)
o Agents targeted for aerobic gram-positive cocci may be sufficient in mild infections
o Severe infections should be covered with broad-spectrum agents
o Cover for gram-positive cocci
o MRSA coverage based on prevalence (“Escalation and De-escalation theory”)
o You can start vancomycin prophylactically, but stop it if it comes back negative for MRSA

26
Q

Antibiotic selection for definitive antibiotic therapy

A 
o	Based on several factors 
o	Severity of infection
o	Culture results
o	Mild infections – 1 to 2 weeks of therapy
o	Moderate to severe infections – 2 to 4 weeks 
o	Depends on other factors
o	Adequacy of debridement
o	Soft tissue coverage
o	Wound vascularity

NOTE: Because diabetics have such bad vascular status, they will likely fail oral antibiotics due to the lack of circulation

27
Q

Considerations for surgical intervention

A 
o	Presence of deep abscess
o	Extensive bone or joint involvement
o	Crepitus
o	Necrosis or gangrene
o	Necrotizing fasciitis
o	NOTE: When considering surgery, patients should be evaluated for adequate vascular status/need for revascularization and consider vascular surgery consult when indicated
28
Q

Osteomyelitis

A
  • Challenging complication to treat
  • Presence of osteomyelitis increases likelihood of surgical intervention including amputation
  • Increases the duration of antibiotic therapy
  • Hinders healing of overlying tissue
  • S. aureus – Most common and most virulent gram positive organism
  • Pseudomonas – Most resistant gram negative organism
  • Fungi – Rare pathogens in cases of osteomyelitis
29
Q

Diagnosis of osteomyelitis includes…

A
  • Clinical
  • Laboratory
  • Imaging
  • Bone biopsy
30
Q

Clinical diagnosis of osteomyelitis

A

o Probe to bone (“if it probes to bone, it is osteomyelitis until proven otherwise)
o Overlying ulcer >2 cm²
o Ulcers of long duration (> 4 - 6weeks )

31
Q

Laboratory markers of osteomyelitis

A

o Leukocytosis – Infrequent in diabetic foot osteomyelitis
o Elevated C-reactive protein
o Elevated ESR (NOTE: there is controversy in the literature as to reliability)

32
Q

Imaging for osteomyelitis

A

Plain radiographs

  • Poor sensitivity in early stages
  • Infection can precede radiologic changes by up to 4 weeks
  • May be difficult to distinguish from Charcot

MRI

  • Imaging modality of choice (very helpful for surgical planning of excision border)
  • Sensitivity reported in literature to be 90% - 100%
  • High positive and negative predictive values
33
Q

Bone biopsy

A

o Gold Standard diagnostic test
o Should be taken aseptically through non-ulcerated area or intraoperatively
o Sent for histology and microbiology
o Ideally performed prior to initiation of antibiotics (beware of false negative results)

34
Q

Treatment of osteomyelitis - antibiotics alone vs surgical debridement/resection

A

o Four scenarios for consideration of non-surgical management
o No acceptable surgical target (resection would lead to unacceptable loss of function)
o Vascular disease for which reconstruction is not an option but patient wants to refrain from amputation
o Infection restricted to forefoot with minimal soft tissue loss
o Risk outweighs benefit

35
Q

Combined surgical resection and antibiotic therapy

A

o If resection is performed obtain specimen from surgical margin for microbiology and pathology
o Determines if residual infection is present and will also help distinguish acute vs. chronic process and therefore determine length & route of antibiotic therapy

36
Q

Treatment principles for diabetic foot infections

** KNOW THIS ***

A

Eradicate bacterial load with incision and drainage and debridement
o This step must be done regardless of vascular supply
o Must remove ALL Non-Viable Bone and Soft tissue. Worry about closure of wound when infection eradicated
o **Do NOT CLOSE an infected wound **

Start with empirical antibiotics and focus therapy based on reliable deep cultures
o Length of antibiotics depends on severity of infection, response of infection to treatment (typically 2 to 8 weeks)
o Oral
o Intravenous (In-patient or out-patient (via PICC line, central line))
o Antibiotic beads

Closure of wounds

37
Q

Treatment of non-limb threatening infections

A
  • Debride necrotic tissue
  • Start with broad spectrum antibiotic
  • Deep culture should be taken
  • Adjust antibiotic according to culture and patient response
  • Local wound care and plan for closure
38
Q

Treatment of limb/life threatening infections

A

EMERGENT SURGERY REQUIRED

  • Admission to hospital
  • Incision and drainage of abscess and debridement of all necrotic soft tissue and bone
  • May require surgical debridement every 48 hours until necrotic tissue is eradicated
  • Start with broad spectrum antibiotic
  • Deep culture should be taken
  • Adjust antibiotic according to culture and patient response
  • Assess for vascular disease
  • Optimize medical and nutritional status
  • Local wound care and plan for final closure when infection is eradicated
39
Q

CASE STUDY I

A
  • 1 week history of swelling and drainage after utilizing a medicated corn pad
  • Worsening symptoms of pain in 5th toe and swelling and drainage

Labs
o WBC – normal
o Temp – 98 F
o X-rays – negative for gas or bone destruction

40
Q

Diagnosis and treatment for CASE STUDY I

A

Diagnosis: non-limb threatening infection

Treatment: I&D in the office, culture , local wound care
o Treatment
o Debride superficial abscess
o Oral antibiotic
o Culture of purulence
o MSSA – Methicillin Sensitive Staph Aureus
o Local wound care

41
Q

CASE STUDY II

A
  • 5 day history of swelling, drainage and erythema in the 1st inner space after stepping on a roofing nail at work
  • Worsening symptoms of malaise and pain in forefoot

Labs
o WBC -17.00
o Temp – 100 F
o X-rays – negative for gas or bone destruction

42
Q

Diagnosis and treatment for CASE STUDY III

A

Diagnosis: deep abscess

o	Admitted to hospital
o	IV Unasyn 
o	I&D performed that day
o	Deep cultures taken
o	2 weeks of IV antibiotics  
o	You continue to debride until you see HEALTHY, BLEEDING TISSUE ***
43
Q

CASE STUDY III

A
  • Patient with increased malodor and pain in the arch over the last 2 days.
  • Presented to Emergency room
  • Worsening symptoms of malaise and pain in midfoot. Extreme malodor from ulcer
Labs
o	WBC -25.00
o	Temp – 102 F
o	Vitals not stable 
o	X-rays – positive for gas
44
Q

Diagnosis and treatment for CASE STUDY III

A

Diagnosis: sepsis, limb/life threatening wound, need to go to OR emergently

o Blood cultures positive for Staph Aureaus
o Patient in sepsis
o This moves very rapidly, so you will need to emergently take patient to OR
o Will need to go back to OR to debride numerous times to remove more necrotic tissue
o Can put wound VAC on the wound to get good granulation tissue
o Skin graft will be needed to cover

#3 Surg (12 decks)

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