Transcript Diabetic Foot Infection

•Of all the late complications of
diabetes, foot problems are
probably the most preventable.
Joslin, who wrote in 1934 that
“diabetic gangrene is not
heaven-sent, but earth-born
 Approximately 5% to 10% of
diabetic patients have had past
or present foot ulceration, and
1% have undergone amputation

Foot infections are among the
most common and serious complications of
diabetes mellitus.
Types of infection include
cellulitis, myositis, abscesses, necrotizing
fasciitis, septic arthritis, tendinitis, and
osteomyelitis.
Patients with diabetes are particularly susceptible
to foot infection primarily because
of neuropathy, vascular insufficiency, and
diminished neutrophil function.
Peripheral
neuropathy has a central role in the development
of a foot infection and it occurs in
about 30 to 50 percent of patientswith diabetes.
The most common pathogens in acute,
previously
untreated, superficial infected foot
wounds in patients with diabetes are aerobic
gram-positive bacteria, particularly
Staphylococcus
aureus and beta-hemolytic streptococci
(group A, B, and others).
Infection
in patients who have recently received antibiotics
or who have deep limb-threatening
infection or chronic wounds are usuallycaused by a
mixture of aerobic gram-positive, aerobic
gram-negative (e.g., Escherichia coli, Proteus
species,
Klebsiella species), and anaerobic organisms (e.g.,
Bacteroides
species, Clostridium species, Peptococcus and
Peptostreptococcus
species).

Dermatologic Skin status: color, thickness,
dryness, cracking
Sweating
Infection: check between toes for fungal
infection
Ulceration
Calluses/blistering: hemorrhage into callus?

Deformity (e.g., claw toes, prominent
metatarsal heads, Charcot joint)
Muscle wasting (guttering between
metatarsals)
Assess whether shoes are appropriate
for the feet (e.g., size, width)

Ability to perceive pressure from a 10-g
monofilament plus one of the
following: Vibration using 128-Hz tuning
fork
Pinprick sensation
Ankle reflexes
Vibratory perception threshold
Foot pulses
Ankle-brachial index, if indicated
existence, severity, and extent of infection, as well as vascular status, neuropathy,
and glycemic
control should be assessed in patients with a diabetic foot infection.
Visible bone and palpable bone on probing are suggestive of underlying
osteomyelitis in patients with
a diabetic foot infection.
Before an infected wound of a diabetic foot infection is cultured, any overlying
necrotic debris should
be removed to eliminate surface contamination and to provide more accurate
results.
Routine wound swabs and cultures of material from sinus tracts are unreliable and
strongly discouraged
in the management of diabetic foot infection.
The empiric antibiotic regimen for diabetic foot infection should always include an
agent active against
Staphylococcus aureus, including methicillin-resistant S. aureus if necessary, and
streptococci.
Meggitt–Wagner classification of
foot ulcers
Grade Description of the ulcer
Grade 0 Pre- or post-ulcerative lesion
completely epithelialized
Grade 1 Superficial, full thickness ulcer
limited to the dermis, not
extending to the subcutis
Grade 2 Ulcer of the skin extending
through the subcutis with
exposed tendon or bone and
without osteomyelitis or
abscess formation
Grade 3 Deep ulcers with osteomyelitis
or abscess formation
Grade 4 Localized gangrene of the toes
or the forefoot
Grade 5 Foot with extensive gangrene
must be diagnosed clinically rather
than bacteriologically
The clinical diagnosis of foot infection is basedon
Thepresence of purulent discharge from an
ulcer or the classic signs of inflammation (i.e.,
erythema,
pain, tenderness, warmth, or induration). Other
suggestive
features of infection include foul odor, the
presence
of necrosis, and failure of wound healing despite
optimal managment
Arterial inflow is adequate
Infection is treated appropriately.
Pressure is removed from the wound and
the immediate surrounding area.