Diabetic foot infection: Difference between revisions
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==Background== | ==Background== | ||
*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. | ||
==Diagnosis== | ==Diagnosis== | ||
#1st key factor is to assess extent & depth of ulcer (usu more extensive than they appear). Ulcer depth is imp predictor of healing rate, OM & risk of amputation. | |||
#Gently probe wound w/ sterile probe, if probe hits bone, chance of osteo is 90% higher. | |||
#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) | |||
#Inf of the wound is demonstrated by presence of purulent dc or 2 or more signs of inflammation (ttp, warmth, induration or erythema) around the ulcer. | |||
#Inf is severe if any of the following: abnl vs, rim of erythema around the ulcer is 2 cm or more in diameter, lymphangitic streaking or signs of fasciitis (such as crepitice or bullae), or if probe reaches bone/tendon/joint | |||
#ESR >40 incr chance of OM 12 fold, an ESR >70 makes dx nearly certain. | |||
#Charcot foot can look similar, but foot ulcer is usu absent, erythema & edema partially resolve w/ elevation of goot for 10 min. | |||
#Nd ABI if any of following: absence of DP & PT, claudication sx, isch foot pain. | |||
#Nd vascular surgeon if ABI <.4 (severe obst). .4-.69= mod obst, .7-.9 =mild obst, .9-1.3 =nl, >1.3 = med art ca (can see falsely high/nl ABI d/t medial calcification of the arteries). | |||
#Wound NOT likely to be infected if no systemic sx, no dc & no more than 1 s/s of local inflammation | |||
==Treatment== | ==Treatment== | ||
#Abx for mild= keflex or augmentin or diclox or clinda. Abx for severe= unasyn or clinda & quinolone or clinda & ceftaz, add vanco if life threat. | |||
#Focusing Rx on g+ aerobes w/ oral abx (1-2 wk) appears effective for most mild inf. Must eliminate pressure on wound until healed, nd to elminate or decr periph edema. Dress wound w/ warm/moist env after debridement, absorbant drsng if exudate present. | |||
#Recurrence of amp is 50-70% over 3-5 yrs. Overall, 50-80% will heal w/in 6 mos w/ optimal care. | |||
#Goal for best reults is A1c level <7%, BP <130/80, no Etoh or smoking & LDL <100. | |||
==Source== | ==Source== | ||
7/2/09 PANI | 7/2/09 PANI | ||
[[Category:ID]] | [[Category:ID]] | ||
Revision as of 14:22, 15 March 2011
Background
- 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.
Diagnosis
- 1st key factor is to assess extent & depth of ulcer (usu more extensive than they appear). Ulcer depth is imp predictor of healing rate, OM & risk of amputation.
- Gently probe wound w/ sterile probe, if probe hits bone, chance of osteo is 90% higher.
- 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)
- Inf of the wound is demonstrated by presence of purulent dc or 2 or more signs of inflammation (ttp, warmth, induration or erythema) around the ulcer.
- Inf is severe if any of the following: abnl vs, rim of erythema around the ulcer is 2 cm or more in diameter, lymphangitic streaking or signs of fasciitis (such as crepitice or bullae), or if probe reaches bone/tendon/joint
- ESR >40 incr chance of OM 12 fold, an ESR >70 makes dx nearly certain.
- Charcot foot can look similar, but foot ulcer is usu absent, erythema & edema partially resolve w/ elevation of goot for 10 min.
- Nd ABI if any of following: absence of DP & PT, claudication sx, isch foot pain.
- Nd vascular surgeon if ABI <.4 (severe obst). .4-.69= mod obst, .7-.9 =mild obst, .9-1.3 =nl, >1.3 = med art ca (can see falsely high/nl ABI d/t medial calcification of the arteries).
- Wound NOT likely to be infected if no systemic sx, no dc & no more than 1 s/s of local inflammation
Treatment
- Abx for mild= keflex or augmentin or diclox or clinda. Abx for severe= unasyn or clinda & quinolone or clinda & ceftaz, add vanco if life threat.
- Focusing Rx on g+ aerobes w/ oral abx (1-2 wk) appears effective for most mild inf. Must eliminate pressure on wound until healed, nd to elminate or decr periph edema. Dress wound w/ warm/moist env after debridement, absorbant drsng if exudate present.
- Recurrence of amp is 50-70% over 3-5 yrs. Overall, 50-80% will heal w/in 6 mos w/ optimal care.
- Goal for best reults is A1c level <7%, BP <130/80, no Etoh or smoking & LDL <100.
Source
7/2/09 PANI