Diabetic foot infection: Difference between revisions

Revision as of 21:59, 23 August 2013

Background

1st key factor is to assess extent & 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)

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 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
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)
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)

Diagnosis

ESR >40 incr chance of OM 12 fold, an ESR >70 makes dx nearly certain.

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

Authors:

@@ Line 1: / Line 1: @@
 ==Background==
-*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.
+*1st key factor is to assess extent & 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.
@@ Line 14: / Line 15: @@
 *Note hair and nail growth, determine vascular status (palpate DP, PT, and popliteal pulse)
 *Probe ulceration 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
 *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)
+*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)
 ==Diagnosis==
+#ESR >40 incr chance of OM 12 fold, an ESR >70 makes dx nearly certain.
-#Gently probe wound w/ sterile probe, if probe hits bone, chance of osteo is 90% higher.
-#
-#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