Diabetic foot ulcer

Question 1

diabetic foot ulcer overview

Answer 1

leading cause of non-traumatic amputation

-the major source of morbidity
- increase the incidence of ulcer

neuropathy, abnormal food biomechanics PAD, and poor wound healing

peripheral sensory neuropathy
interferes with normal protective mechanism
PAD and poor wound healing impeded the integrity

male DM > 10 ys smoking visual impairment poor glycemic control and Dialysis

Common areas:
great toe metatarsophalangeal, plantar
14-24% undergo amputation

Question 2

diabetic foot ulcer treatment

Answer 2

Imaging:
plain radiograph
MRI ( most specific)
Nuclear medicine tagged WBC.( if pt has metal in the body)

Laboratory:
CBC, CMP, wound, and blood cultures
- mild or non - limb-threatening infections
- oral ABX cover for staph and strep

• prior HX of MRSA
  cover with clindamycin (be careful with C- dif ), doxycycline ( DM can casuse AKI ), or Bactrim

Severe cases:
empiric coverage IV ABX
cover for staph, strep, gram-negative aerobic and anaerobes
vancomycin plus beta-lactam/beta-lactamase inhibitor ( zosyn and cefepime) or carbapenem

vancomycin plus fluoroquinolone plus Flagyl
- surgical debridement and wound care

Surgical debridement and wound care

Question 2

diabetic foot ulcer clinical findings

Answer 2

asymptomatic vs symptomatic
plantar surface
most common site

neuropathic vs. infection
gas gangrene w/o clostridial

Infectious etiology :
multiple organisms
- Aerobic-positive cocci are most common
- aerobic and anaerobic gram-negative bacilli

Question 3

clinical classification of DM foot infections

Answer 3

classification:
1 . uninfected _ wound lacking purulence or inflammation
2. mild -presence of 2 or more manifestations of inflammation, purulence, erythema, pain, tenderness, and infection limited to the skin

3. Moderate- infection as above pt is stable but has one or more of the following characteristics cellulitis > 2cm, lymphatic streaking spread beneath the superficial fascia - deep tissue gangrene, and involvement of joint, muscle, or bone
4. severe- systemic toxicity or metabolic instability

Question 5

Foot Osteomyelitis

Answer 5

diabeties , PAD , PN , and post surgery
20-60 % will get osteo

typically exogenous insult
the complication of deep pressure ulcers
impaired wound healing after surgery

incidence 30-40 cases /1000

most common pathogens :
- staph aureus
-anaerobes ( in chronic wounds)
- prevalent in chronic wounds
various gram-negative bacilli

Question 6

foot osteomyelitis diagnosis

Answer 6

clinical eval :
prob to bone test
- 90% predictive value

imaging
- MRI ( sensitivity 80-100 specificity 80-90%)

Question 7

antibiotic treatment for foot osteomyelitis

Answer 7

Antibiotics based on bone culture:
- empiric therapy if no culture
- gram-positive consider MRSA

-Risk for P aeruginosa
antipseudomonal coverage

antibiotics recieved within the past month
– empirically for gram-negative
- clindamycin plus fluoroquinolone

wound debridement plus 4-6 weeks of antibiotics
- reduce chances of amputation

2/3 of patients
dead bone still present
Long-term ABX for 3 months