Diabetic foot infection - Revision history

Rossdonaldson1: /* Clinical Features */

2020-09-10T16:29:08Z

Clinical Features

← Older revision		Revision as of 16:29, 10 September 2020
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	[[File:PMC2788600 vhrm-5-949f1.png\|thumb\|Infection in ulcer bed with mild surrounding erythema (''not'' probe-able to bone)]]		[[File:PMC2788600 vhrm-5-949f1.png\|thumb\|Infection in ulcer bed with mild surrounding erythema (''not'' probe-able to bone)]]
	[[File:PMC3464072 DFA-3-18693-g011.png\|thumb\|Classic diabetic plantar ulcer overlying the third metatarsal head with purulent drainage. Ability to probe to bone confirmed osteomyelitis.]]		[[File:PMC3464072 DFA-3-18693-g011.png\|thumb\|Classic diabetic plantar ulcer overlying the third metatarsal head with purulent drainage. Ability to probe to bone confirmed osteomyelitis.]]
			[[File:Neuropathic heel ulcer diabetic.jpg\|thumb\|Neuropathic diabetic foot ulcer.]]
	*[[Diabetes mellitus]] ulcers usually occur at areas of increased pressure (sole of foot) or friction		*[[Diabetes mellitus]] ulcers usually occur at areas of increased pressure (sole of foot) or friction
	**Venous ulcers usually present above malleoli with irregular borders		**Venous ulcers usually present above malleoli with irregular borders
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	**Abnormal vital signs		**Abnormal vital signs
	**Rim of erythema surrounding ulcer or ulcer >2 cm in diameter		**Rim of erythema surrounding ulcer or ulcer >2 cm in diameter
	**Lymphangitic streaking or signs of fasciitis (crepitus, skip lesions, severe tenderness, bullae), or if probe reaches bone/joint/tendon		**Lymphangitic streaking or signs of fasciitis (crepitus, skip lesions, severe tenderness, bullae), or if probe reaches bone/joint/tendon

	==Differential Diagnosis==		==Differential Diagnosis==

ClaireLewis at 15:50, 28 September 2019

2019-09-28T15:50:02Z

← Older revision		Revision as of 15:50, 28 September 2019
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	==Background==		==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 treatment is a strong predictor that the ulcer is unlikely to heal after 3 months.
	*75% of patients have polymicrobial infection, usu 70% are [[gram positive]]		*75% of patients have polymicrobial infection, usu 70% are [[gram positive]]
	**Severe limb/life threatening infection are more likely to involve [[gram negative]] aerobic & [[anaerobic bacteria]] as well.		**Severe limb/life threatening infection are more likely to involve [[gram negative]] aerobic & [[anaerobic bacteria]] as well.
	**[[MRSA]] is increasing in frequency		**[[MRSA]] is increasing in frequency
	*50% or more of ~~patients with SEVERE diabetic foot infections will have no systemic signs and symptoms of infection (i.e~~. ~~fever, tachycardia, leukocytosis, left shift)~~		*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 treatment is a strong predictor that the ulcer is unlikely to heal after 3 months.
	*Recurrence or amputation is 50-70% over 3-5 yrs. Overall, 50-80% will heal within 6 months with optimal care.		*Recurrence or amputation is 50-70% over 3-5 yrs. Overall, 50-80% will heal within 6 months with optimal care.
	*[[Diabetes mellitus]] 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)

	==Clinical Features==		==Clinical Features==
	[[File:PMC2788600 vhrm-5-949f1.png\|thumb\|Infection in ulcer bed with mild surrounding erythema (''not'' probe-able to bone)]]		[[File:PMC2788600 vhrm-5-949f1.png\|thumb\|Infection in ulcer bed with mild surrounding erythema (''not'' probe-able to bone)]]
	[[File:PMC3464072 DFA-3-18693-g011.png\|thumb\|Classic diabetic plantar ulcer overlying the third metatarsal head with purulent drainage. Ability to probe to bone confirmed osteomyelitis.]]		[[File:PMC3464072 DFA-3-18693-g011.png\|thumb\|Classic diabetic plantar ulcer overlying the third metatarsal head with purulent drainage. Ability to probe to bone confirmed osteomyelitis.]]
	~~===HPI===~~		*[[Diabetes mellitus]] ulcers usually occur at areas of increased pressure (sole of foot) or friction
	*~~Ask about recent trauma~~ (~~may have been unnoticed, and may include ill-fitting footwear~~)		**Venous ulcers usually present above malleoli with irregular borders
	*~~Duration of current lesions~~		**Arterial ulcers usually found on the toes or shins, with pale, "punched-out" borders (typically painful)
	*~~Associated systemic symptoms~~		*Often history of minor/unnoticed trauma such as ill-fitting footwear
	*~~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)		*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		*Probe ulceration site, note involvement of bone, joint, tendon, or sinus tract formation
			**Often more extensive than initially appear
	**Use sterile probe, if hit bone chance of OM 90% higher		**Use sterile probe, if hit bone chance of OM 90% higher
			*+/- systemic symptoms (e.g. [[fever]], malaise)
			*50% or more of patients with SEVERE diabetic foot infections will have no systemic signs and symptoms of infection (i.e. fever, tachycardia, leukocytosis, left shift)

			*[[Diabetes mellitus]] 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 diabetes mellitus 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 tenderness, bullae), or if probe reaches bone/joint/tendon

	==Differential Diagnosis==		==Differential Diagnosis==
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	**commonly missed diagnosis		**commonly missed diagnosis
	**requires different management (total contact cast, NWB)		**requires different management (total contact cast, NWB)
	*[[Diabetes mellitus]] 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 diabetes mellitus 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

	====Likelihood of ~~Osteomyolysis~~====		====Likelihood of Osteomyelitis====
	*Factors that increase likelihood of ~~osteomyolysis~~:		*Factors that increase likelihood of osteomyelitis:
	**Visible bone or probe to bone		**Visible bone or probe to bone
	**Ulcer >2cm in size		**Ulcer >2cm in size
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	==Management==		==Management==
	===~~Noninfected~~ chronic wounds<ref name="IDSA">2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections [http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/2012%20Diabetic%20Foot%20Infections%20Guideline.pdf full text]</ref>===		===Non-infected chronic wounds<ref name="IDSA">2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections [http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/2012%20Diabetic%20Foot%20Infections%20Guideline.pdf full text]</ref>===
	*Prophylactic antibiotics not ~~indcated~~		*Prophylactic antibiotics not indicated
	*For clinically uninfected wounds, do not collect a specimen for culture		*For clinically uninfected wounds, do not collect a specimen for culture
	*Moist dressing to allow for healing and proper footwear to prevent worsening abrasions		*Moist dressing to allow for healing and proper footwear to prevent worsening abrasions
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	==Disposition==		==Disposition==
	*~~Noninfected~~ chronic wounds: outpatient management		*Non-infected chronic wounds: outpatient management
	*Infected Wounds: Low threshold for admission vs. outpatient management with antibiotics		*Infected Wounds: Low threshold for admission vs. outpatient management with antibiotics
	*Severe infection: Admit with surgical consult		*Severe infection: Admit with surgical consult

Rossdonaldson1: /* Disposition */

2019-02-27T06:48:49Z

Disposition

← Older revision		Revision as of 06:48, 27 February 2019
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	==Disposition==		==Disposition==
	*Noninfected chronic wounds: outpatient management		*Noninfected chronic wounds: outpatient management
			*Infected Wounds: Low threshold for admission vs. outpatient management with antibiotics
			*Severe infection: Admit with surgical consult

	==See Also==		==See Also==

Rossdonaldson1: /* Disposition */

2019-02-27T06:46:29Z

Disposition

← Older revision		Revision as of 06:46, 27 February 2019
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	==Disposition==		==Disposition==
			*Noninfected chronic wounds: outpatient management

	==See Also==		==See Also==

Rossdonaldson1: /* Workup */

2019-02-27T06:45:22Z

Workup

← Older revision		Revision as of 06:45, 27 February 2019
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	===Workup===		===Workup===
	*Obtain ABI on all patients with: nonpalpable DP/PT, claudication symptoms, ischemic foot pain		*Obtain ABI on all patients with: nonpalpable DP/PT, claudication symptoms, ischemic foot pain
	**~~Call~~ vascular if:		**Consider vascular consult if abnormal:
	***ABI <0.4 (severe obstruction)		***ABI <0.4 (severe obstruction)
	***ABI 0.4-0.69 (mod obstruction)		***ABI 0.4-0.69 (mod obstruction)

Rossdonaldson1: /* Workup */

2019-02-27T06:29:56Z

Workup

← Older revision		Revision as of 06:29, 27 February 2019
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	==Evaluation==		==Evaluation==
	===Workup===		===Workup===
			*Obtain ABI on all patients with: nonpalpable DP/PT, claudication symptoms, ischemic foot pain
			**Call vascular if:
			***ABI <0.4 (severe obstruction)
			***ABI 0.4-0.69 (mod obstruction)

	====Labs====		====Labs====
	*Chem 10, CBC, Coags, A1c, consider ESR/CRP (useful for monitoring response to treatment)		*Chem 10, CBC, Coags, A1c, consider ESR/CRP (useful for monitoring response to treatment)

Rossdonaldson1: /* Diagnosis */

2019-02-27T06:29:44Z

Diagnosis

← Older revision		Revision as of 06:29, 27 February 2019
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	**Rim of erythema surrounding ulcer or ulcer >2 cm in diameter		**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		**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 symptoms, ischemic foot pain
	**Call vascular if:
	***ABI <0.4 (severe obstruction)
	***ABI 0.4-0.69 (mod obstruction)

	====Likelihood of Osteomyolysis====		====Likelihood of Osteomyolysis====

Rossdonaldson1: /* Likelihood of OM */

2019-02-27T06:29:15Z

Likelihood of OM

← Older revision		Revision as of 06:29, 27 February 2019
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	***ABI 0.4-0.69 (mod obstruction)		***ABI 0.4-0.69 (mod obstruction)

	====Likelihood of OM====		====Likelihood of Osteomyolysis====
	*Factors that increase likelihood of OM:		*Factors that increase likelihood of osteomyolysis:
	**Visible bone or probe to bone		**Visible bone or probe to bone
	**Ulcer >2cm in size		**Ulcer >2cm in size

Rossdonaldson1: /* Likelihood of OM */

2019-02-27T06:28:47Z

Likelihood of OM

← Older revision		Revision as of 06:28, 27 February 2019
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	***ABI 0.4-0.69 (mod obstruction)		***ABI 0.4-0.69 (mod obstruction)

	===Likelihood of OM===		====Likelihood of OM====
	*Factors that increase likelihood of OM:		*Factors that increase likelihood of OM:
	**Visible bone or probe to bone		**Visible bone or probe to bone

Rossdonaldson1: /* Evaluation */

2019-02-27T06:28:30Z

Evaluation

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 ==Evaluation==
 *Determine presence/extent of infection and likelihood of OM/fasciitis
 *Consider Charcot arthropathy (diabetic neuropathic osteoarthropathy)
@@ Line 48: / Line 59: @@
 ***ABI <0.4 (severe obstruction)
 ***ABI 0.4-0.69 (mod obstruction)
 ===Likelihood of OM===