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MEDS 580 - Team - Final > Lecture 16 - Diabetic Feet Infections > Flashcards

Lecture 16 - Diabetic Feet Infections Flashcards

1
Q

Diabetic feet infections normally begin with ______ which is often secondary to ______ or _______

A

Neuropathic ulceration

Neuropathy or trauma

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2
Q

T/F: Diabetic foot complications are the main reason for diabetes-related hospitalizations and lower extremity amputations.

A

True

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3
Q

The principal pathogenic factors in diabetic foot disease are:

A

Sensory neuropathy
Ischemia
Infection

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4
Q

Ulceration is a consequence of…

A

The loss of awareness of trauma that can cause skin breakdown

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5
Q

What plays a central role in diabetic foot lesions?

A

Peripheral neuropathy

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6
Q

In order to test for neuropathy, clinicians use an inexpensive nylon monofilament test. It measures a patient’s risk for _______ and should be performed ______.

A

Ulceration

Annually

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7
Q

Local ulcer care includes:

A

sharp debridement and proper wound coverage which helps wound healing and removes bacteria

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8
Q

Management of ulcers consists of

A

Assessing ulcer for infection
local care
mechanical offloading

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9
Q

Name some of the inframalleolar infections common in diabetes patients.

A 
paronychia
cellulitis
myositis
abscesses
necrotizing fasciitis
septic arthritis
tendonitis
osteomyelitis
Mal perforans foot ulcer
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10
Q

Outline how a breach in skin integrity allows for deeper colonization and infection.

A
  1. Infection (ex. in nail bed) or bacteria on skin
  2. Broken skin = portal of entry
  3. Organism/infection penetrates muscle
  4. Organism grows and spreads
  5. Body responds to bacteria in deeper parts of muscle
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11
Q

What are the risk factors for foot ulceration and infection?

A 
peripheral motor neuropathy
peripheral sensory neuropathy
peripheral autonomic neuropathy
neuro-osteoarthritic deformities or limited joint mobility
vascular (arterial) insufficiency
hyperglycemia and other metabolic derangements
patient disabilities
maladaptive patient behaviors
health care system failures
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12
Q

peripheral motor neuropathy

A

abnormal foot anatomy and biomechanics (ex. clawing toes, high arch, etc.), may lead to excess pressure, callus formation, and ulcers
*may see a change in foot architecture from holding foot in awkward position, which puts pressure on areas that shouldn’t have pressure (slide 9)

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13
Q

peripheral sensory neuropathy

A

lack of protective sensation, leads to unattended minor injuries

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14
Q

peripheral autonomic neuropathy

A

deficient sweating, leads to drying and cracking skin

*risk for necrotizing fasciitis

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15
Q

neuro-osteoarthritic deformities or limited joint mobility

A

abnormal anatomy and biomechanics, may lead to excess pressure

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16
Q

vascular (arterial) insufficiency

A

impaired tissue viability, wound healing, and delivery of neutrophils

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17
Q

hyperglycemia and other metabolic derangements

A

impaired immunological function and wound healing and excess collagen cross-linking

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18
Q

patient disabilities

A

reduced vision, limited mobility, and previous amputations

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19
Q

maladaptive patient behaviors

A

inadequate adherence to precautionary measures and foot inspection and hygiene measures, poor medical care compliance, excessive weight bearing, inappropriate activities, and poor footwear

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20
Q

health care system failures

A

inadequate patient education and monitoring of glycemic control and foot care

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21
Q

Signs of infection:

A 
Redness
Warmth
Swelling/induration
Tenderness/pain
Purulence

Must have 2 or more symptoms according to IDSA DFI

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22
Q

Signs of infection in patients with neuropathy:

A

Nonpurulent secretions
Friable/discolored granulation tissue
Undermining of wound edges
Foul odor

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23
Q

IDSA Severity of Infection: Grade 1

A

Uninfected

No signs or symptoms

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24
Q

IDSA Severity of Infection: Grade 2

A

Mild
local infection only involving the skin and subcutaneous tissue
erythema around ulcer
exclude other cause of inflammation

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25
Q

IDSA Severity of Infection: Grade 3

A

Moderate
local infection with erythema > 2cm or in deeper than skin and subcutaneous tissue
no systemic inflammatory response signs

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26
Q

IDSA Severity of Infection: Grade 4

A

Severe
Local infection with signs of SIRS (must have more than 2: fever, elevated resting heart rate, rapid shallow breathing, elevated WBC)

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27
Q

Who to hospitalize:

A

Patients with severe infection
patients with a moderate infection and complicating features (severe PAD, no home support)
noncompliant patient w/ outpatient treatment
patients with mild infections

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28
Q

T/F: Patients with a moderate infection can be treated as outpatients.

A

TRUE as long as they are able to adhere to medical therapy and do not have critical limb ischemia or need surgical intervention.

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29
Q

T/F: There is NO evidence-based admission or discharge criteria for patients with DFI.

A

TRUE

30
Q

What are the benefits of fo imaging for diabetic feet?

A

Lets you know if there is a secondary complication

  • helps better define soft tissues purulent collections
  • can identify soft tissue findings (bony abnormalities, foreign bodies, calcified arteries or soft tissue gas)
  • can aid in finding pathological bone findings (ie osteomyelitis-slide 14)
31
Q

Ulcer Risk Factors: General or systemic (image on slide 16)

A 
uncontrolled hyperglycemia
duration of diabetes
peripheral vascular disease
blindness or visual loss
chronic renal disease
older age
32
Q

Local issues

A 
peripheral neuropathy
structural foot deformity
trauma and improperly fitted shoes
callus
history of prior ulcer amputation
prolonged elevated pressures
limited joint mobility
33
Q

Risk Factors for infection

A 
wound depth to bone
wound duration >30 days
recurrent foot wound
traumatic wound etiology
peripheral vascular disease
34
Q

What does ulcer evaluation entail?

A

classification based on extent and depth of ulcer + presence of infection or ischemia

35
Q

How do clinicians assess diabetic patients with Diabetic foot ulcers for ischemia?

A

ankle-brachial index and toe pressure measurements

36
Q

Texas Ulcer Classification (study images on slides 20-27)

A

Grade 0: Pre- or postulcerative (stages A to D)
Grade 1: Full-thickness ulcer not involving tendon, capsule or bone (stages A to D)
Grade 2: Tendon or capsular involvement without bone palpable (Stages A to D)
Grade 3: Probes to bone (Stages A to D)

37
Q

Texas Ulcer Classification Staging

A

A: noninfected
B: Infected
C: Ischemic
D:Infected and ischemic

38
Q

Wound/Ischemia/Foot Infection (WIFI) System

A

proposed by Society for Vascular Surgery
goal: provide a more quantitative assessment of peripheral artery disease (PAD) as a predictor and contributor to lower extremity pathology
scoring (none/mild/moderate/severe) using specified criteria similar to Texas system

39
Q

WIFI Wound Scoring

A

0: no ulcer and no gangrene
1: Small ulcer and no gangrene
2: Deep ulcer or gangrene limited to toes
3: Extensive ulcer or extensive gangrene

40
Q

WIFI Ischemia Scoring

A

Toe pressure/TCPO2

0: > 60 mmHg
1: 40 to 59
2: 30 to 39
3: <30

41
Q

WIFI Foot Infection Scoring

A

0: noninfected
1. Mild (<2 cm cellulitis)
2. Moderate (> 2 cm cellulitis/purulence)
3. Severe (systemic response/sepsis)

42
Q

Infection management

A
  • clinical diagnosis, especially if see signs of infection
  • treat based on severity
  • Obtain tissue samples for culture and sensitivity via wounder curettage (ideally after debridement and before abx)
43
Q

Rules for DFI treatment

A

Don’t treat uninfected wound
Tailor to culture data
no evidence fo subclinical colonization impairing wound healing

44
Q

Antibiotic Use Principles

A

Empiric therapy: starts based on clinical evaluation
Tailoring Therapy: change abx in response to clinical data
Convert from IV to PO: minimizes complications and saves money
Use the shortest effective duration of therapy
Monitor Pharmacokinetics: Vancomycin trough and dose adjusting

45
Q

The most common infecting organisms in western nations are

A

staphylococci
streptococci

(skin-dwelling bacteria)

46
Q

T/F: Second organisms to cause infection are often aerobic gram-negative bacilli and anaerobes.

A

TRUE

47
Q

The most common pathogens in acute, previously untreated, superficial infected foot wounds DM patients are aerobic gram-positive bacteria like

A

Staphylococcus aureus and beta-hemolytic streptococci

48
Q

What pathogen(s) is/are likely to cause infection in patients who recently received abx or who have deep limb-threatening infection or chronic wounds?

A

aerobic gram-positive or aerobic gram-negative (E. coli, Proteus sp., Klebsiella sp.) and anerobic organisms

NEVER obligate anaerobes as the sole identified species

49
Q

Signs of systemic toxicity from pathogens

A

extensive local inflammation
necrosis
malodorous drainage or
gangrene

50
Q

How may Staphylococus aureus and Streptococcus* contribute to foot infections?

A

cellulitis without an open skin wound*
infected ulcer and abx naïve*
chronic infected ulcer previously treated with abx therapy*
long duration non-healing wounds
fetid foot (extensive necrosis, gangrene or malodorous)*

51
Q

**If a patient has a history of _____ infection or colonization within one year, they are at an _____ risk of reinfection, especially due to the pathogen _______. Failing to empirically cover it can pose an unacceptable risk of treatment. Clinicians can use an ______ to determine the strain of bacteria present.

A

MRSA
Increased
Staphylococcus aureus
Antibiogram

52
Q

T/F: P. aeruginosa is prevalent in diabetic foot infections in warm climates.

A

TRUE

53
Q

What factors increase the risk of infection caused by P. aeruginosa?

A

macerated ulcers
foot soaking
exposure to water or moist environments

54
Q

Mild Infection Treatment

A

outpatient oral antimicrobial therapy

  • empiric therapy against skin flora (i.e streptococci and S. aureus)
  • agents against methicillin-resistant S. aureus (MRSA) if they have a purulent infection and are at risk
55
Q

Moderate Infection Treatment

A

empiric therapy of deep ulcers that extend to the fascia that work against the activity of Streptococci, S. aureus, and MRSA (if at risk)

  • can use oral regimen
  • if have an extensive infection in deep tissue can treat with empiric parenteral therapy
56
Q

Single-drug regimens for mild/moderate treatment against streptococci and staphylococci

A

cephalexin
dicloxacillin
amoxicillin-clavulanate or clindamycin

57
Q

What medications can be used to treat MRSA?*

*must know at least one for the exam

A

Trimethoprim-sulfamethoxazole PLUS amoxicillin-clavulanate
-OR-
Clindamycin PLUS Ciprofloxacin/levofloxacin/moxifloxacin

58
Q

Moderate/Severe treatment agents

A

Beta-lactam: Ampicillin-sulbactam, piperacillin-tazobactam
Carbapenems: Impenem-cilastatin, meropenem, ertapenem
fluoroquinolones: moxifloxacin
Other: metronidazole (IV) plus one fo the following: ceftriaxone, ceftazidime, cefepime, ciprofloxacin, levofloxacin, aztreonam

PLUS one of the following if need MRSA coverage:
Vancomycin (use for cephalosporin and penicillin-resistant organisms)
Linezolid
Daptomycin

  • Assume MRSA for severely infected persons
59
Q

Severe Infection Treatment

A

if limb-threatening DFI or systemic toxicity treat w/ broad-spectrum parenteral abx therapy
surgical debridement
empiric therapy against streptococci, MRSA, aerobic gram-negative bacilli, and anaerobes

60
Q

How is agent selection determined and what are the problems with it?

A

-Based on clinical trials

Problems:

  • lack of standardization
  • no single drug or combination is superior
  • while the FDA has approved drugs for one symptom (i.e abx for complicated skin/skin infections) but not for accompanying ones such as osteomyelitis
61
Q

Should topical antimicrobials be used to treat DFI? Why or why not?

A

Uncertain.
Antiseptics like povidone-iodine are not recommended for open wounds due to cytotoxic effects
No published data for agents such as silver, neomycin, polymyxin B, gentamycin, or muciprocin for DFI
No evidence to recommend silver-containing dressings

62
Q

Surgical intervention should be considered in what classification(s) of DFIs?

A

moderate and severe

63
Q

Examples of surgical intervention include:

A

debridement
abscess drainage
opening of infected compartments
major amputation

64
Q

What are the indications of amputation?

A

extensive gangrene
long, unsuccessful course of therapy
life-threatening soft tissue infection
extensive osteomyelitis

65
Q

T/F: DFIs constitute a significant cause of morbidity and mortality.

A

TRUE

66
Q

T/F: You can treat clinically uninfected ulcers.

A

FALSE. Only treat if infected.

67
Q

T/F: Mild/moderate infections can be treated PO without hospital admittance.

A

TRUE

68
Q

T/F: Empiric therapy should always cover for staphylococcus and MRSA.

A

FALSE. Always cover for staphylococcus, but only for MRSA if the infection is severe or the patient has a history of MRSA (infection or colonization)

69
Q

How can a multidisciplinary team help patients with DFIs and who should make up the team?

A

Teams help reduce the likelihood and extent of lower extremity amputations; The team should be composed of experienced medical, surgical or nursing providers that use specified evidence-based procedure. An optimal example would be a foot specialist, vascular surgeon, and wound care specialist with access to ID specialists or microbiologists and other disciplines (diabetes, pharmacy, etc.)
If not practical, providers should use telemedicine consultations from experts or form consulting relationships to ensure prompt evaluation and treatment

70
Q

What does the multidisciplinary approach look like?

A

Primary care: gatekeeper, yearly monofilament exam, patients 50 y.o. should have ankle-brachial index (ABI) testing
Infectious Disease if patient has a complicated infection
Podiatry: proper footwear per ADA recommendations, insoles for patients with peripheral neuropathy with or without deformity, see patients with PAD and neuropathy, history of diabetic foot ulceration or amputations
orthopedic surgery: when amputation is necessary

MEDS 580 - Team - Final (10 decks)

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