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Diabetic Foot Infection:

A challenge for primary and secondary care?

Dr Tony Berendt
Consultant Physician
Bone Infection Unit
NOC NHS Trust, Oxford

Disclosure of Potential
Conflicts of Interest
Has received honoraria, travel expenses and
hospitality for serving on speakers bureaux and
advisory boards for RPR (Synercid), Pfizer (Linezolid)
MSD (Ertapenem) and MacroChem (Pexiganin)
Vice-Chair of IDSA Clinical Practice Guidelines
Committee for Diabetic Foot Infections; Chair of
IWGDF Osteomyelitis Sub-group
Member of Oxfordshire Priorities Forum and ORHNOC Medicines Advisory Committee
DIPC at NOC, Chair of TV (South Central) CHAIN
and Steering Group for pan-Oxfordshire C. difficile
intervention project

Infection and Healing


Healing

Infection
Replace
Lose
footwear
footwear
Offloading

Amputation
Wound

Learning objectives
Be able to discuss the epidemiological
importance of DFI
Know how to assess risk of diabetic foot
ulceration and infection
Be able to assess a patient with a diabetic foot
infection, in the context of published
guidelines, and make rational antibiotic choices

Epidemiology Pathophysiology Microbiology Assessment Biomechanics

General epidemiology
252 million diabetics worldwide

Epidemiology Pathophysiology Microbiology Assessment Biomechanics

General epidemiology
252 million diabetics worldwide
Foot problems account for largest number of
hospital bed days used for diabetic patients
1-4% of diabetics develop foot ulcer annually, 25%
in lifetime
45-75% of all lower extremity amputations are in
diabetics
85% of these preceded by foot ulcer
Two-thirds of elderly patients undergoing
amputation do not return to independent life
Studies have shown less costs for saving a limb cf.
amputation
Epidemiology Pathophysiology Microbiology Assessment Biomechanics

Pathophysiology: diabetic foot ulceration


Neuropathy

Pathophysiology: diabetic foot ulceration


Neuropathy

Motor

Sensory

Abnormal foot Loss of


biomechanics protective
sensation

Autonomic
Reduced skin
compliance
and
lubrication

Ulceration
Vascular
insufficienc

Infection

30-second foot examination

Any previous diabetes related foot problems?


Are both foot pulses palpable?
Is protective sensation intact?
Is there evidence of significant foot deformity?

Two-minute foot examination


Examine feet for ulcers, callus, blisters,
maceration, skin breaks, infection
Examine the toenails
Identify nature of any foot deformity
Examine the shoes
Observe patients ability to perform foot care
and examination (by observing them replace
socks and shoes)
Establish need for patient education

Standard ulcer care

Evaluate for infection


Debride ulcer, remove callosities
Check for sensation (monofilament)
Check for circulation (pulses, Dopplers)
Probe to bone?
Adequate offloading
Antibiotics if infected
Secondary prevention of ulcer and of major
diabetes related events

Epidemiology Pathophysiology Microbiology Assessment Biomechanics

Overview of Diabetic Foot Infections


7 % o f P o p u la t io n
D ia b e t ic
1 5 - 2 5 % D e v e lo p F o o t U lc e r
4 0 -8 0 % In fe c te d
(o r s u s p e c te d )
4 0 % M i ld

3 0 -4 0 % M o d e r a te

2 0 -3 0 % S e v e re

Slide courtesy of Ben Lipsky, Puget Sound VA, Seattle

Independent Risk Factors* for Foot


Infection:
Diabetex Prospective Trial

Variable
Risk Ratio (95%CI) p Value
Wound depth to bone
6.7 (2.319.9) 0.001
Wound duration >30 days 4.7 (1.613.4) 0.004
Recurrent foot wound
2.4 (1.34.5)
0.006
Traumatic wound etiology 2.4 (1.15.0)
0.02
Peripheral vascular disease 1.9 (1.03.6)
0.04
*stepwise logistic regression model, excluding ulceration
Lavery, Armstrong, Lipsky et al, Diabetes Care 2006;29:1288

Microbiology
Popular mythology = all infections are
polymicrobial

Epidemiology Pathophysiology Microbiology Assessment Biomechanics

Microbial complexity
Microbial burden
Clinical risk

Anaerobes
Aerobic Gram-negative rods
Gram positive cocci

Severity
Depth
Necrosis
Prior Rx

Treatment: myths
Treat uninfected ulcers to promote healing
Treat infected ulcers until the ulcer is healed
Treat all the organisms isolated from the
microbiological specimens
Hospitalise all infections
Give lots of intravenous therapy

Timeline of Staphylococcal antibiotic


resistance
Penicillin-resistance
Sporadic MRSA

Epidemic MRSA
GISA
CA-MRSA
VRSA

194

195

196

197

198

199

200

201

www.idsociety.org

Clinical Infectious Diseases 2004;39:885-910

Evaluating the Patient with a DFI


Patient

Systemic response

Fever, chills, sweats, cardiovascular status


Metabolic status

Hyperglycaemia, electrolyte imbalance,


hyperosmolality, renal impairment
Cognitive function

Delirium, depression, dementia, psychosis


Social situation

Support, self-neglect
Limb/Foot
Wound
Epidemiology Pathophysiology Microbiology Assessment Biomechanics

Evaluating the Patient with a DFI


Patient
Limb or Foot

Biomechanics
Vascular

Ischaemia
Venous insufficiency
Neuropathy
Infection
Wound

Size, depth
Necrosis, gangrene
Infection
Epidemiology Pathophysiology Microbiology Assessment Biomechanics

Clinical Classification of Diabetic Foot Infection


Clinical Manifestations of Infection
Wound without purulence or other evidence of
inflammation

Uninfected

More than 2 of purulence, erythema, pain,


tenderness, warmth or induration. Any
cellulitis/erythema extends 2 cm around ulcer and
infection is limited to skin/superficial subcut tissues.
No local complications or systemic illness

Mild

Moderate

Severe

Infection in patient who is systemically well &


metabolically stable but has any of: cellulitis
extending >2 cm; lymphangitis; spread beneath
fascia; deep tissue abscess; gangrene; muscle,
tendon, joint or bone involved
Infection in a patient with systemic toxicity or
metabolic instability

Epidemiology Pathophysiology Microbiology Assessment Biomechanics

Outcomes By IDSA DFI Severity Classification


100%
90%
80%

100%
1666 patients enrolled in prospective
diabetic foot study
89%
90%

Hospitalization
X2 trend = 118.6, <0.0001

80%

X2 trend = 108, p < 0.0001

78%

70%

70%
60%

54%

60%

50%

50%

40%

40%

30%

30%

20%

20%

10%

LE Amputation

10%

46%

10%

6%

3%

0%

3%

0%
No infection

None

Mild

Moderate

Severe

Mild Moderate Severe

No infection

None

Mild
Mild

Moderate
Severe
Moderate
Severe

Armstrong, Lavery, Peters, Lipsky. Clin Infect Dis 2007

Table 8: Suggested Antibiotic Regimens: DFI


Agent(s)

Mild

Advised Route

Moderate
Oral for Most

Severe
Oral or IV

Dicloxacillin

Yes

Clindamycin

Yes

Cephalexin

Yes

TMP/SMX

Yes

Yes

Amoxicillin/clavulanate

Yes

Yes

Levofloxacin

Yes

Yes

Cefoxitin

Yes

Ceftriaxone

Yes

Ampicillin/sulbactam

Yes

Linezolid ( aztreonam)

Yes

Daptomycin ( aztreonam)

Yes

Ertapenem

Yes

Cefuroxime ( metronidazole)

Yes

Parenteral

Site

Severity

Route

Location

Duration

Soft
tissue
only

Mild

Topical or oral

Outpatient

7-14 days;

Moderate

Oral (or initial


parenteral)

Outpatient/
inpatient

2-4 weeks

Severe

Initial IV, switch to


oral when
possible

Inpatient,
to
outpatient

2-4 weeks

Extent of
surgery
No residual
infected tissue
(e.g. post
amputation)
Residual
infected soft
tissue only
Residual
infected (but
viable) bone
No surgery, or
residual dead
bone post-op.

Route

Duration

Parenteral or oral

2-5 days

Parenteral or oral

2-4 weeks

Initial IV, then


consider oral
switch
Initial IV, then
consider oral
switch

4-6 weeks

Bone
or joint

extend up
to 28 d if
slow to
resolve

>3 months

The diabetic foot: Charcot foot with


rocker bottom deformity

Charcot foot
grossly disordered
architecture and
biomechanics
midfoot ulceration
instability of midfoot
note previous minor
amputations
still well-vascularised

Bone resorption and destruction

Bone regeneration on antibiotic therapy

Conclusions
Ulceration is a common consequence of diabetic
neuropathy
To understand and treat ulceration, understand the
pathophysiology and biomechanics
Infection (DFI) is a common and frequently serious
consequence of diabetic foot ulceration (DFU)
A structured approach to assessment and
treatment, using international or local guidelines,
provides a means to rationalise care and improve
outcomes
Care must be multidisciplinary to achieve this;
agreed pathways, health service management and
audit are required

Does it need
antibiotics, doctor?

Besides, they wont be


discovered for another 300
years!

You must be joking mate!


Debridement and offloading
more like it!
Doctor treating a patient in his surgery: 17th Century, after Teniers the
younger (by kind permission of National Gallery, London)