Diabetic foot infection: Difference between revisions
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== Background == | == Background == | ||
*1st key factor is to assess extent and depth of ulcer (typically more extensive than they appear) | |||
*1st key factor is to assess extent | |||
**Ulcer depth is important predictor of healing rate, osteomyelitis (OM) & risk of amputation. | **Ulcer depth is important predictor of healing rate, osteomyelitis (OM) & risk of amputation. | ||
*Failure of ulcer to heal by 50% or more after 1 month of Rx is a strong predictor that the ulcer is unlikely to heal after 3 mos. | *Failure of ulcer to heal by 50% or more after 1 month of Rx is a strong predictor that the ulcer is unlikely to heal after 3 mos. | ||
*75% of pts hv polymicrobial inf, usu 70% are g+. Severe limb/life threatening inf are more likely to involve g- aerobic & anaerobic bacteria w/ g+. MRSA is incr in freq. | *75% of pts hv polymicrobial inf, usu 70% are g+. Severe limb/life threatening inf are more likely to involve g- aerobic & anaerobic bacteria w/ g+. MRSA is incr in freq. | ||
*50% or more of pts w/ SEVERE diabetic foot inf have no s/s of systemic tox (ie fever, tachy, incr wbc or Lt shift) | *50% or more of pts w/ SEVERE diabetic foot inf have no s/s of systemic tox (ie fever, tachy, incr wbc or Lt shift) | ||
*Recurrence of amputation is 50-70% over 3-5 yrs. Overall, 50-80% will heal w/in 6 mos w/ optimal care. | |||
== HPI == | == HPI == | ||
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== Treatment == | == Treatment == | ||
#For noninfected chronic wounds | #For noninfected chronic wounds | ||
##NWB, nonadherent padded dressing, ppx abx not indcated | ##NWB, nonadherent padded dressing, ppx abx not indcated | ||
#Empiric therapy for DM foot infections: | |||
##Mild infxn outpt Rx, non-limb-threatening ([[MSSA]] + strep): | |||
###'''[[Cephalexin]]''' 500mg Q6H OR '''[[Augmentin]]''' 875/125mg Q12H OR '''[[Dicloxacillin]]''' 500mg Q6H OR '''[[Clindamycin]]''' 450mg Q8H | |||
###Strict non-weight bearing, tight glycemic control, meticulous wound care | |||
##Severe infection, limb-threatening (admit): | |||
##'''[[Unasyn]]''' 3g IV Q6H OR '''[[Ticarcillin/Clavulanate]]''' 3.1g IV Q8H OR '''[[Clindamycin]]''' 900mg IV Q6H AND '''[[Ciprofloxacin]]''' 400mg IV Q12H OR '''[[Clindamycin]]''' 900mg IV Q6H AND '''[[Ceftriaxone]]''' 1g IV Q12H (add [[vancomycin]] if life threatening) | |||
#Goal for best reults is A1c level <7%, BP <130/80, no Etoh or smoking and LDL <100 | |||
#For DM foot infections @ HUCLA: | #For DM foot infections @ HUCLA: | ||
##Start pt on '''Diabetic Foot Infection with Wound (DFIW)''' pathway/order set '''(No ABX)''' | ##Start pt on '''Diabetic Foot Infection with Wound (DFIW)''' pathway/order set '''(No ABX)''' | ||
###Do not start pts on this pathway if have rapidly spreading infection or with severe sepsis/septic shock | ###Do not start pts on this pathway if have rapidly spreading infection or with severe sepsis/septic shock | ||
##Primary management is surgical debridement, consult trauma surgery | ##Primary management is surgical debridement, consult trauma surgery | ||
==See Also== | ==See Also== |
Revision as of 21:41, 15 April 2014
Background
- 1st key factor is to assess extent and depth of ulcer (typically more extensive than they appear)
- Ulcer depth is important predictor of healing rate, osteomyelitis (OM) & risk of amputation.
- Failure of ulcer to heal by 50% or more after 1 month of Rx is a strong predictor that the ulcer is unlikely to heal after 3 mos.
- 75% of pts hv polymicrobial inf, usu 70% are g+. Severe limb/life threatening inf are more likely to involve g- aerobic & anaerobic bacteria w/ g+. MRSA is incr in freq.
- 50% or more of pts w/ SEVERE diabetic foot inf have no s/s of systemic tox (ie fever, tachy, incr wbc or Lt shift)
- Recurrence of amputation is 50-70% over 3-5 yrs. Overall, 50-80% will heal w/in 6 mos w/ optimal care.
HPI
- Ask about recent trauma
- Duration of current lesions
- Associated systemic symptoms
- Prior treatments
Physical Exam
- Determine ulcer location, dimensions, depth, and appearance
- Note hair and nail growth, determine vascular status (palpate DP, PT, and popliteal pulse)
- Probe ulceration site, note involvement of bone, joint, tendon, or sinus tract formation
- Use sterile probe, if hit bone chance of OM 90% higher
- DM foot ulcer infection presumed if:
- 2 or more of following: erythema, warmth, tenderness, or swelling
- OR if pus coming from ulcer site or nearby sinus tract
- Severe DM foot infection if:
- Abnormal vital signs
- Rim of erythema surrounding ulcer or ulcer >2 cm in diameter
- Lymphangitic streaking or signs of fasciitis (crepitus, skip lesions, severe TTP, bullae), or if probe reaches bone/joint/tendon
- Obtain ABI on all patients with: nonpalpable DP/PT, claudication sx, ischemic foot pain
- Call vascular if:
- ABI <0.4 (severe obstruction)
- ABI 0.4-0.69 (mod obstruction)
- Call vascular if:
- Reminder:
- DM ulcers usually occur at areas of increased pressure (sole of foot) or friction
- Venous ulcers usually present above malleoli with irregular borders
- Arterial ulcers usually found on the toes or shins, with pale, "punched-out" borders (typically painful)
Diagnosis
Determine presence/extent of infection and likelihood of OM/fasciitis
Imaging
- X-rays to detect soft tissue gas, FB, OM, or structural foot deformities
- OM x-ray changes occur late in dz, negative xrays do not exclude OM
- MRI to eval for OM (not usually done in ED)
Labs
- Chem 10, CBC, Coags, A1c, consider ESR/CRP (useful for monitoring response to Rx)
- ESR >40 incr chance of OM 12 fold, an ESR >70 makes dx nearly certain.
Likelihood of OM
- Factors that increase likelihood of OM:
- Visible bone or probe to bone
- Ulcer > 2cm in size
- ESR >70
- Ulcer duration > 2 weeks
Treatment
- For noninfected chronic wounds
- NWB, nonadherent padded dressing, ppx abx not indcated
- Empiric therapy for DM foot infections:
- Mild infxn outpt Rx, non-limb-threatening (MSSA + strep):
- Cephalexin 500mg Q6H OR Augmentin 875/125mg Q12H OR Dicloxacillin 500mg Q6H OR Clindamycin 450mg Q8H
- Strict non-weight bearing, tight glycemic control, meticulous wound care
- Severe infection, limb-threatening (admit):
- Unasyn 3g IV Q6H OR Ticarcillin/Clavulanate 3.1g IV Q8H OR Clindamycin 900mg IV Q6H AND Ciprofloxacin 400mg IV Q12H OR Clindamycin 900mg IV Q6H AND Ceftriaxone 1g IV Q12H (add vancomycin if life threatening)
- Mild infxn outpt Rx, non-limb-threatening (MSSA + strep):
- Goal for best reults is A1c level <7%, BP <130/80, no Etoh or smoking and LDL <100
- For DM foot infections @ HUCLA:
- Start pt on Diabetic Foot Infection with Wound (DFIW) pathway/order set (No ABX)
- Do not start pts on this pathway if have rapidly spreading infection or with severe sepsis/septic shock
- Primary management is surgical debridement, consult trauma surgery
- Start pt on Diabetic Foot Infection with Wound (DFIW) pathway/order set (No ABX)
See Also
Source
- Tintinalli
- UpToDate
- PANI