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ANTIBIOTICS WITHIN THE MANAGEMENT of Diabetic foot. Nice 28-29avril2005 ABDULMASSIH Bassam MD Endocrinologist. Definition of a Diabetic Foot infection Epidemiology Pathogenesis of a Diabetic Foot Infection classification Assessment Microbiology Principle of antibiotic treatment.

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antibiotics within the management of diabetic foot

ANTIBIOTICS WITHIN THE MANAGEMENT of Diabetic foot

Nice 28-29avril2005

ABDULMASSIH Bassam MD

Endocrinologist

slide2
Definition of a Diabetic Foot infection

Epidemiology

Pathogenesis of a Diabetic Foot Infection

classification

Assessment

Microbiology

Principle of antibiotic treatment

definition of a diabetic foot infection 1
Definition of a Diabetic Foot Infection(1)
  • No generally-accepted definition
  • Foot infections in diabetics can be ulcer- or non-ulcer related
  • Anatomic location of primary site
  • Depth of infection

(skin/soft tissue vs. bone/joint)

  • Isolation of pathogenic bacteria from an appropriate culture specimen
slide4

Definition of a Diabetic Foot Infection(2)

  • entrance ,growth ,metabolic activity and ensuing pathophysiologic effects of microorganisms in the tissues of a patient
  • Purulent discharge from the ulcer
  • Signs of inflammation around the ulcer
  • Systemic signs (fever-leukocytosis)
  • The manifestation of the inflammatory signs depends on intact nervous and vascular system
epidemiology
Epidemiology
  • life time risk of DM patient : 15%
  • 14-20% will need amputation
  • 1 leg is lost every 30 sec.
  • More than 80% are potentially preventable
  • Site of foot ulcers: toes: 51%plantar metatarsal head: 28%dorsum of foot: 14%multiple ulcers: 7%
classification systems for diabetic foot infections
Classification Systems for Diabetic Foot Infections
  • Classification systems
    • Severity of Infection
    • Foot Ulcer (Wound)
  • No generally-accepted classification
  • Differ in criteria & complexity
  • Require validation for clinical trials
classification systems for severity of diabetic foot infections
Classification Systems for Severity of Diabetic Foot Infections
  • Limb-threatening vs. non-limb threatening
  • Mild, moderate, severe
classification systems for diabetic foot ulcers
Classification Systems for Diabetic Foot Ulcers
  • Wagner
  • Univ. of Texas
  • Depth-ischemia class.
slide11
Wagner Classification

0- Intact skin (may have bony deformities.

1- Localized superficial ulcer.

2- Deep ulcer to tendon, bone, ligament or joint.

3- Deep abscess or osteomyelitis.

4- Gangrene of toes or forefoot.

5- Gangrene of whole foot.

Wagner FW: The diabetic foot and amputations of the foot. In Surgery of the Foot. 5th ed.

Mann, R editor. St Louis, Mo. The C.V. Mosby Company.

depth ischemia classification
Depth- ischemia classification

Grade 0 no skin change

Grade 2exposed tendon, joint

Grade A no ischemia

Grade Cpartial gangrene

Grade 1 superficial ulcer

Grade 3 bone exposure

Grade Bischemia,no gangrene

GradeDcomplete gangrene

management based classification structure damage
Management based classificationstructuredamage
  • Skin
  • Subcutaneous tissues
  • Muscle and tendon
  • Bone
  • Articulation

Extention of infection

Perfusion of the foot

  • Good
  • Moderate
  • Poor
  • Able to correction or not
multidisciplinary team
Multidisciplinary team
  • 1-Diabetologist
  • 2-Vascular surgeon
  • 3-Orthopedics
  • 4-Infection disease
  • 5-Plastic surgeon
  • 6-Podiatrician
six intervention demonstrate efficacy in diabetic foot management
Six intervention demonstrate efficacy in diabetic foot management

1- off loading

2- Debridement and drainage

3- wound dressing

4- appropriate use of antibiotic

5- revascularization

6- limited amputation

baseline assessments
Laboratory

hematology

chemistry

HgbA1C

C-Reactive Protein

Wound, tissue, and blood cultures

Wound or ulcer dimensions

X ray imaging

MRI

Isotope scan

Doppler

Pulse oxygenation measurement (toe)

Arteriography

Baseline Assessments

1-Extension of infection

2-Vascular assessment

3-General diabetes assess.

diagnosis of osteomylitis is very important
Diagnosis of osteomylitis is very important
  • X Ray is positive after 30-50%of bone destruction(2 weeks)
  • MRI
  • CT.Scan
  • 3-phase bone scan
  • Leukocyte scan
  • Guided bone biopsy
slide19
Epidemiology

Definition of a Diabetic Foot infection

Pathogenesis of a Diabetic Foot Infection

classification

Assessment

Microbiology

Principle of antibiotic treatment

microbes and chronic wounds
Microbes and Chronic Wounds
  • All chronic wounds are contaminated by bacteria.
  • Wound healing occurs in the presence of bacteria.
  • It is not the presence of organisms but their interaction with the patient that determines their influence on wound healing.
louis pasteur
Louis Pasteur

“ The germ is nothing. It is the terrain in which it is found that is everything.”

Pasteur, L. (1880) De l’attenuation virus du cholera des poules. CR Acad. Sci. 91: 673-680.

definitions
Definitions

Wound contamination: the presence of non-replicating organisms in the wound. Wound colonization: the presence of replicating microorganisms adherent to the wound in the absence of injury to the host. Wound Infection: the presence of replicating microorganisms within a wound that cause host injury.

microbiology of wounds
Microbiology of Wounds
  • The microbial flora in wounds appear to change over time.
  • Early acute wound; Normal skin flora predominate.
  • S. aureus, and Beta-hemolytic Streptococcus soon follow. (Group B Streptococcus and S. aureus are common organisms found in diabetic foot ulcers)
microbiology of wounds24
Microbiology of Wounds
  • After about 4 weeks
    • Facultative anaerobic gram negative rods will colonize the wound.
    • Most common ones= Proteus, E. coli, and Klebsiella.
  • As the wound deteriorates deeper structures are affected. Anaerobes become more common. Oftentimes infections are polymicrobial (4-5).
microbiology of wounds25
Microbiology of Wounds
  • In summary: early chronic wounds contain mostly gram-positive organisms.
  • Wounds of several months duration with deep structure involvement will have on average 4-5 microbial pathogens, including anaerobes (see more gram-negative organisms).
how do you know when a wound is infected
How do you know when a wound is infected?
  • This can be very difficult.
  • A continuum exists between when pathogens colonize the wound and then start to cause damage.
  • There is no absolutely foolproof laboratory test that will aid in this diagnosis.
how do you know when a wound is infected27
How do you know when a wound is infected?
  • One feature is common to all infected chronic wounds;
  • The failure of the wound to heal and progressive deterioration of the wound.
  • Unfortunately, wound infections are not the only reasons for poor wound healing.
how do you know when an ulcer is infected
How do you know when an ulcer is infected?
  • The typical features of wound infections:
  • increased exudate
  • increased swelling
  • increased erythema
  • increased pain
  • increased local temperature
  • Periwound cellulitis, ascending infection, change in appearance of granulation tissue (discoloration, prone to bleed, highly friable).
methicillin resistant staph au an increasing problem
Methicillin – resistant Staph. Au. An increasing problem
  • Retrospective analysis of 63 swabs from infected foot ulcer
  • Gram+ aerobic 84.2% staph. Au.79%
  • 30.2% MRSA
  • Not related to prior antibiotic usage

( dang and al. diab.med.20;2:159 feb2003)

  • In a prior study MRSA is associated with previous antibiotic treatment

(tentolouris and al. diab.med.16;9:767sep1999)

slide30

141 microbes isolated from 93 diabetic foot ulcer

Study done on syrian population presented in SDA sept2003 B.hammad MD and H.Jammal MD

slide32
Epidemiology

Definition of a Diabetic Foot infection

Pathogenesis of a Diabetic Foot Infection

classification

Assessment

Microbiology

Principle of antibiotic treatment

treatment
Treatment
  • Management of infection:

1- antibiotics.

2-Incision and drainage.3-soft tissue, joint and bone resection

4-amputation

what is the best approach
What is the best approach?
  • 1-Oral antibiotic follow up after one week
  • 2-IV antibiotic in the hospital and observation
  • 3-Rapid drainage + IVantibiotic
should we clean uncomplicated foot ulcer with antibiotics
Should we clean uncomplicated foot ulcer with antibiotics?
  • 44 Clinically uninfected neuropathic foot ulcer
  • Randomized to amoxi+clav vs. placebo
  • 20 days follow-up no difference in outcome

(chantelau and al. diab. Med. 1996 ;13:156-159)

  • 64 new foot ulcer with no clinical evidence of infection
  • Randomized to antibiotics vs. placebo
  • Patients with ischemia and positive ulcer swabs should be considered for early antibiotic treatment

( foster and al. diab. Med.1998;15:suppl.2)

principles of treatment
Principles of treatment
  • Evidence-based regimes
    • empirical therapy vs specific therapy
  • Optimal dosage
  • Optimal duration
  • Identification and removal of infective focus
  • Recognition of adverse effects
the lactams
The -lactams
  • Penicillins
    • penicillin V/G, ampicillin, amoxycillin, cloxacillin, ticarcillin, piperacillin
  • Cephalosporins
    • 1st generation e.g. cefazolin, cefalexin (Keflex)
    • 2nd generation e.g. cefuroxime (Zinacef, Zinnat )
the lactams41
The -lactams
    • 3rd generation e.g. ceftriaxone (Rocephin ), cefotaxime (Claforan ), ceftazidime (Fortum ), cefoperozone (Cefobid ), ceftibuten (Cedax )
    • 4th generation e.g. cefepime (Maxipime )
  • Carbapenems
    • imipenem, meropenem
  • Monobactam
    • aztreonam
macrolides and quinolones
Macrolides and Quinolones
  • Macrolides
    • erythromycin, clarithromycin (Klacid ), azithromycin (Zithromax )
  • Quinolones (FQ)
    • ofloxacin, levofloxacin (Cravit ), Ciprofloxacin (Ciproxin )
others
Others
  • Aminoglycosides
    • gentamicin, amikacin, netromycin* (NA)
  • Tetracyclines
    • doxycyline (Vibramycin ), minocycline
  • Glycopeptides
    • vancomycin, teicoplanin
  • New: linezolid, ertapenem, moxifloxacin
slide45

Badperfusion

ischemic

Normal perfusion

Non-ischemic

deep

superficial

swab

signs of infection

No signs of infection

swab

Largecoverage

No antibiotics

Gram+

Large coverage

recent and superficial ulcer or cellulitis non ischemic
Recent and superficial ulcer or cellulitis (non ischemic)

Staph. Au. + strep

  • Cloxacillin
  • Amoxi+ with -lactamase inhibitors
  • Cefazolin
  • Cephalexin
  • Clindamycin
deep ulcer or neuroischemic ulcer
Deep ulcer or neuroischemic ulcer

polymicrobial: gram positive cocci, gram negative bacilli and anaerobes

  • -lactam + -lactamase inhibitors +amikacin
  • 3rd GC + clindamycin
  • ciprofloxacin + clindamycin
  • Ciprofloxacin + linezolid
  • carbapenems  vancomycin if life threatening
most ulcers will heal with the traditional therapy
most ulcers will heal with the traditional Therapy
  • For low grade uninfected wounds a form of removable or irremovable offloading device should be a part of any treatment plan. The TCC is the most established;  
  • We can not recommend any one dressing over another;  
  • Debridement should still be done the old fashioned way but could be facilitated by using Hydrogel or MDT where available;  
  • if wounds fail to heal, treating them with a skin graft or adding becaplermin (or the platelet releasate) not been validated as cost effective in any clinical trial.
  • The use of systemic HBO or Iloprost, especially in high grade ulcers with a significant ischaemic element