Diabetic foot resident survival guide: Difference between revisions
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{{Resident | {| class="infobox" style="margin: 0 0 0 0; border: 0; float: right; width: 100px; background: #A8A8A8; position: fixed; top: 250px; right: 21px; border-radius: 0 0 10px 10px;" cellpadding="0" cellspacing="0"; | ||
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! style="padding: 0 5px; font-size: 85%; background: #A8A8A8" align=center| {{fontcolor|#2B3B44|Diabetic foot Resident Survival Guide Microchapters}} | |||
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Diabetic foot resident survival guide#Overview|Overview]] | |||
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Diabetic foot resident survival guide#Causes|Causes]] | |||
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Diabetic foot resident survival guide#Diagnosis|Diagnosis]] | |||
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Diabetic foot resident survival guide#Treatment|Treatment]] | |||
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Diabetic foot resident survival guide#Do's|Do's]] | |||
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! style="font-size: 80%; padding: 0 5px; background: #DCDCDC" align=left | [[Diabetic foot resident survival guide#Don'ts|Don'ts]] | |||
|} | |||
{{WikiDoc CMG}}; {{AE}} {{IF}} | {{WikiDoc CMG}}; {{AE}} {{IF}} | ||
{{SK}} [[Diabetic feet]]; [[Diabetic ulcer]]; [[Diabetic foot infection]]; [[Diabetic foot ulcer]] | |||
==Overview== | ==Overview== | ||
[[Diabetic foot]] is a [[Complication (medicine)|complication]] of long-standing and poorly controlled [[diabetes mellitus]]. Poor [[Glycemic Index|glycemic]] control, [[peripheral neuropathy]], improper [[foot]]wear, [[ischemia]] and possible [[foot]] [[Deformity|deformities]] including [[Charcot joint|charcot arthropathy]] are the main known causes of [[diabetic foot]]. A detailed [[history]] of the [[patient|patient]]'s [[diabetes]] status, [[foot]] care, [[deformity|deformities]], [[foot]] [[hygiene]], [[symptom|symptoms]] of [[ischemia]], and history of [[smoking]] is necessary to classify the [[wound]] or [[ulcer]] and treat the underlying cause. [[Physical examination]] includes an assessment of the [[ulcer]] and tests to detect the severity of [[peripheral neuropathy]] (such as Semmes-Weinstein monofilament test) and [[ischemia]] (such as [[Ankle-Brachial Index]] ([[Ankle-Brachial Index|ABI]])). Routine [[laboratory]] investigations are recommended, such as [[Glycosylated hemoglobin|HbA1c]]. If an [[infection]] is suspected, a [[wound]] [[Tissue culture|culture]] is necessary to guide [[antibiotic]] [[therapy]]. Mechanical offloading such as cast walkers, total contact casting or therapeutic shoes, and [[Podiatry|podiatric care]] are essential. [[surgery|Surgical]] interventions, such as [[revascularization surgery]]) may be considered for [[patient|patient's]] with [[ischemia]]. [[Antibiotic]] [[therapy]] is based on [[Tissue culture|culture]], risk of [[MRSA]] [[infection]], risk of [[pseudomonas]] [[infection]], presence or absence of [[complication|complications]], such as [[osteomyelitis]] and history of recent [[antibiotic]] use. [[Hyperbaric oxygen therapy]] is considered for a [[diabetic foot]] that persists despite [[treatment]] for more than 30 days. | |||
==Causes== | ==Causes== | ||
===Life Threatening Causes=== | ===Life Threatening Causes=== | ||
Life-threatening causes include conditions that may result in death or permanent [[disability]] within 24 hours if left untreated. [[Diabetic foot]] superseded with the following may result in [[sepsis]] and death. <ref name="pmid20535310">{{cite journal| author=Pendsey SP| title=Understanding diabetic foot. | journal=Int J Diabetes Dev Ctries | year= 2010 | volume= 30 | issue= 2 | pages= 75-9 | pmid=20535310 | doi=10.4103/0973-3930.62596 | pmc=2878694 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20535310 }} </ref> | Life-threatening causes include conditions that may result in death or permanent [[disability]] within 24 hours if left untreated. [[Diabetic foot]] superseded with the following may result in [[sepsis]] and death.<ref name="pmid20535310">{{cite journal| author=Pendsey SP| title=Understanding diabetic foot. | journal=Int J Diabetes Dev Ctries | year= 2010 | volume= 30 | issue= 2 | pages= 75-9 | pmid=20535310 | doi=10.4103/0973-3930.62596 | pmc=2878694 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20535310 }} </ref> | ||
*[[Infection (disambiguation)|Infected]] diabetic foot | |||
*[[Osteomyelitis]] | *[[Infection (disambiguation)|Infected]] [[diabetic foot]]<ref name="pmid22577496">{{cite journal| author=Hobizal KB, Wukich DK| title=Diabetic foot infections: current concept review. | journal=Diabet Foot Ankle | year= 2012 | volume= 3 | issue= | pages= | pmid=22577496 | doi=10.3402/dfa.v3i0.18409 | pmc=3349147 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22577496 }} </ref> | ||
*[[Osteomyelitis]]<ref name="pmid20535310">{{cite journal| author=Pendsey SP| title=Understanding diabetic foot. | journal=Int J Diabetes Dev Ctries | year= 2010 | volume= 30 | issue= 2 | pages= 75-9 | pmid=20535310 | doi=10.4103/0973-3930.62596 | pmc=2878694 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20535310 }} </ref> | |||
===Common Causes=== | ===Common Causes=== | ||
* Poor [[Glycemic Index|glycemic]] control | |||
*Poor [[Glycemic Index|glycemic]] control | |||
*[[Peripheral neuropathy]] | *[[Peripheral neuropathy]] | ||
**[[Autonomic neuropathy]] | **[[Autonomic neuropathy]] | ||
Line 21: | Line 37: | ||
*[[Peripheral arterial disease]] | *[[Peripheral arterial disease]] | ||
*[[Peripheral ischemia]] | *[[Peripheral ischemia]] | ||
* Improper | *Improper [[foot]]wear | ||
* Foot deformities including | *[[Foot]] [[deformity|deformities]] including [[charcot joint|charcot arthropathy]] | ||
==Diagnosis== | ==Diagnosis== | ||
Assessment of diabetic foot includes evaluation of peripheral arterial disease, peripheral neuropathy, and foot deformities. Shown below is an algorithm summarizing the diagnosis of diabetic foot and diabetic foot ulcers according to the recommendations of the American Diabetes Association | Assessment of [[diabetic foot]] includes evaluation of [[peripheral arterial disease]], [[Peripheral neuropathy|peripheral neuropathy,]] and [[foot]] [[deformity|deformities]]. Shown below is an algorithm summarizing the [[diagnosis]] of [[diabetic foot]] and [[diabetic foot]] [[ulcer|ulcers]] according to the recommendations of the American Diabetes Association and International Diabetes Federation- Clinical Practice Recommendations on the Diabetic Foot 2017. <ref> {{cite web |url=https://www.idf.org/e-library/guidelines/119-idf-clinical-practice-recommendations-on-diabetic-foot-2017.html |title=Guidelines |format= |work= |accessdate=}} </ref><ref name="pmid20535310">{{cite journal| author=Pendsey SP| title=Understanding diabetic foot. | journal=Int J Diabetes Dev Ctries | year= 2010 | volume= 30 | issue= 2 | pages= 75-9 | pmid=20535310 | doi=10.4103/0973-3930.62596 | pmc=2878694 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20535310 }} </ref> | ||
{{familytree/start}} | {{familytree/start}} | ||
{{familytree | | | | A01 | |A01=<div style="float: left; text-align: left; line-height: 150% ">'''Characterize the symptoms:''' <br> ❑ Onset <br>❑ Type of sensation <br> ❑ Location <br> ❑ Nocturnal variation <br> ❑ Aggravating factors <br> ❑ Relieving factors <br> | {{familytree | | | | A01 | |A01=<div style="float: left; text-align: left; line-height: 150% ">'''Characterize the [[symptom|symptoms]]:''' <br> ❑ Onset <br>❑ Type of sensation <br> ❑ Location <br> ❑ Nocturnal variation <br> ❑ Aggravating factors <br> ❑ Relieving factors <br> | ||
---- | ---- | ||
'''Obtain a detailed history:''' <br> ❑ Onset of diabetes <br> ❑ Duration of diabetes <br> ❑ Compliance with medication <br> ❑ History of glycemic control <br> ❑ History of other diabetic | '''Obtain a detailed history:''' <br> ❑ Onset of [[diabetes]] <br> ❑ Duration of diabetes <br> ❑ Compliance with medication <br> ❑ History of glycemic control <br> ❑ History of other diabetic [[complications]] <br> ❑ Foot deformities/injuries/ulcers <br> ❑ History of lower limb amputation <br> ❑ Type of footwear <br> ❑ Foot hygiene <br> ❑ History of [[claudication]] <br> ❑ [[Smoking]] history <br> </div>}} | ||
{{familytree | | | | |!| | }} | {{familytree | | | | |!| | }} | ||
{{familytree | | | | B01 | |B01=<div style="float: left; text-align: left; line-height: 150% ">'''Examine the patient:''' <br> '''Inspection'''<br> ❑ Location of ulcer <br> ❑ Integrity and charcteristic (dry/cracked) of skin <br> ❑ Sweating <br> '''Palpation''' <br> ❑ Pedal (dorsalis pedis) pulses <br> ❑ Vibration sensation <br> ❑ Ulcer site- warmth, tenderness, edema <br> '''Non-invasive tests''' <br> ❑ Semmes-Weinstein monofilament test <br> ❑ Probe-to-bone test if suspected osteomyelitis <br> ❑ Measure ABI (Ankle-Brachial Index) with a Arterial doppler </div>}} | {{familytree | | | | B01 | |B01=<div style="float: left; text-align: left; line-height: 150% ">'''Examine the [[patient]]:''' <br> '''Inspection'''<br> ❑ Location of [[ulcer]] <br> ❑ Integrity and charcteristic (dry/cracked) of skin <br> ❑ [[Sweating]] <br> '''[[Palpation]]''' <br> ❑ Pedal (dorsalis pedis) pulses <br> ❑ Vibration sensation <br> ❑ Ulcer site- warmth, tenderness, [[edema]] <br> '''Non-invasive tests''' <br> ❑ Semmes-Weinstein monofilament test <br> ❑ Probe-to-bone test if suspected [[osteomyelitis]] <br> ❑ Measure ABI (Ankle-Brachial Index) with a Arterial doppler </div>}} | ||
{{familytree | | | | |!| | }} | {{familytree | | | | |!| | }} | ||
{{familytree | | | | C01 | |C01= <div style="float: left; text-align: left; line-height: 150% "> '''Order tests:'''<br>❑ [[Glycosylated hemoglobin]]/ HbA1c <br> ❑ Fasting plasma glucose <br> ❑ [[Complete blood count]] <br> ❑ [[ESR]] and [[CRP]] <br> ❑ Deep tissue specimen for culture <br> </div>}} | {{familytree | | | | C01 | |C01= <div style="float: left; text-align: left; line-height: 150% "> '''Order tests:'''<br>❑ [[Glycosylated hemoglobin]]/ HbA1c <br> ❑ [[Fasting plasma glucose]] <br> ❑ [[Complete blood count]] <br> ❑ [[ESR]] and [[CRP]] <br> ❑ Deep tissue specimen for culture <br> </div>}} | ||
{{familytree/end}} | {{familytree/end}} | ||
==Treatment== | ==Treatment== | ||
Assessment of diabetic foot includes evaluation of peripheral arterial disease, peripheral neuropathy, and foot deformities. Shown below is an algorithm summarizing the diagnosis of diabetic foot and diabetic foot ulcers according to the recommendations of the American Diabetes Association | Assessment of [[diabetic foot]] includes evaluation of [[peripheral arterial disease]], [[peripheral neuropathy]], and foot deformities. Shown below is an algorithm summarizing the diagnosis of diabetic foot and diabetic foot ulcers according to the recommendations of the American Diabetes Association and International Diabetes Federation- Clinical Practice Recommendations on the Diabetic Foot 2017. <ref> {{cite web |url=https://www.idf.org/e-library/guidelines/119-idf-clinical-practice-recommendations-on-diabetic-foot-2017.html |title=Guidelines |format= |work= |accessdate=}}</ref> <ref name="pmid31862754">{{cite journal| author=American Diabetes Association| title=11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes-2020. | journal=Diabetes Care | year= 2020 | volume= 43 | issue= Suppl 1 | pages= S135-S151 | pmid=31862754 | doi=10.2337/dc20-S011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31862754 }} </ref> <ref name="pmid17276208">{{cite journal| author=Rathur HM, Boulton AJ| title=The diabetic foot. | journal=Clin Dermatol | year= 2007 | volume= 25 | issue= 1 | pages= 109-20 | pmid=17276208 | doi=10.1016/j.clindermatol.2006.09.015 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=17276208 }} </ref> <ref name="pmid20535310">{{cite journal| author=Pendsey SP| title=Understanding diabetic foot. | journal=Int J Diabetes Dev Ctries | year= 2010 | volume= 30 | issue= 2 | pages= 75-9 | pmid=20535310 | doi=10.4103/0973-3930.62596 | pmc=2878694 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20535310 }} </ref> | ||
<SMALL>Adapted from ''Diabetes Care. 2013;36(9):2862-71.'' and ''Clin Infect Dis. 2012;54(12):e132-73.''</SMALL> <ref name="pmid22619242">{{cite journal| author=Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG et al.| title=2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. | journal=Clin Infect Dis | year= 2012 | volume= 54 | issue= 12 | pages= e132-73 | pmid=22619242 | doi=10.1093/cid/cis346 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22619242 }} </ref> <ref name="pmid23970716">{{cite journal| author=Wukich DK, Armstrong DG, Attinger CE, Boulton AJ, Burns PR, Frykberg RG et al.| title=Inpatient management of diabetic foot disorders: a clinical guide. | journal=Diabetes Care | year= 2013 | volume= 36 | issue= 9 | pages= 2862-71 | pmid=23970716 | doi=10.2337/dc12-2712 | pmc=PMC3747877 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=23970716 }} </ref> | |||
{{familytree/start}} | {{familytree/start}} | ||
{{familytree | | | | A01 | |A01=<div style="float: left; text-align: left; line-height: 150% ">'''Prophylactic measures and Diabetic foot care in all patients''' <br> ❑ Glycemic control <br>❑ Apporpriate footwear and podiatric care <br> ❑ Mechanical offloading <br> • Cast Walkers <br> • Total contact casting <br> • Therapeutic shoes <br> ❑ Vascular care to prevent and treat peripheral arterial disease <br> | {{familytree | | | | | | | | | | | A01 | |A01=<div style="float: left; text-align: left; line-height: 150% ">'''Prophylactic measures and Diabetic foot care in all patients''' <br> ❑ Glycemic control <br>❑ Apporpriate footwear and podiatric care <br> • ❑ Mechanical offloading <br> • Cast Walkers <br> • Total contact casting <br> • Therapeutic shoes <br> ❑ Vascular care to prevent and treat peripheral arterial disease <br> | ||
</div>}} | </div>}} | ||
{{familytree | | | | |!| | }} | {{familytree | | | | | | | | | | | |!| | }} | ||
{{familytree | | | | C01 | |C01= <div style="float: left; text-align: left; line-height: 150% "> ❑ Local wound care <br> ❑ Debridement <br> </div>}} | {{familytree | | | | | | | | | | | C01 | |C01= <div style="float: left; text-align: left; line-height: 150% "> ❑ Local wound care <br> ❑ Debridement - Mechanical or chemical <br> </div>}} | ||
{{familytree | | | | | | | | | A01 |-|-| A02| | | | |A01=Peripheral arterial disease or signs of ischemia|A02=Medication/Surgical or endovascular revascularization}} | {{familytree | | | | | | | | | | | |!| | }} | ||
{{familytree | | | | | | | | | |!| | | | | | | | }} | {{familytree | | | | | | | | | | | A01 |-|-| A02| | | | |A01=[[Peripheral arterial disease]] or signs of [[ischemia]]|A02=[[Medication]]/[[Surgical]] or [[endovascular]] [[revascularization]]}} | ||
{{familytree | | | | | | | | | B01 |-|-| B02| | | | |B01=Presence of infection|B02= • Mechanical or chemical wound debridement <br>• Culture • Biopsy }} | {{familytree | | | | | | | | | | | |!| | | | | | | | }} | ||
{{familytree | | | | | | | | | |!| | | | | }} | {{familytree | | | | | | | | | | | B01 |-|-| B02| | | | |B01=Presence of infection|B02= • Mechanical or chemical wound debridement <br>• Culture • Biopsy }} | ||
{{familytree | | | | | | | | | C01 | | |C01= • Assess severity of infection according to the table below<br> • Treat with antiobiotics according to the table below }} | {{familytree | | | | | | | | | | | |!| | | | | }} | ||
{{familytree | | | | | | | | | | | C01 | | |C01= • Assess severity of [[infection]] according to the table below<br> • Treat with [[antiobiotics]] according to the table below }} | |||
{{familytree | | | | | | | | | | | |!| | | | | }} | |||
{{familytree | | | | | | | | | | | C01 | | |C01= If [[infection]] does not resolve within 30 days- <br> • Consider hyperbaric oxygen therapy}} | |||
{{familytree | | | | | | | | | | | |!| | | | | }} | |||
{{familytree | | | | | | | | | | | C01 | | |C01= • Observe foot <br> • Establish regular care <br> • Reassess in 2-3 months}} | |||
{{familytree/end}} | {{familytree/end}} | ||
:* DFI is classified based on its severity according to the Infectious Diseases Society of America (IDSA) guideline or the PEDIS grade developed by International Working Group on the Diabetic Foot (IWGDF). (see Table below) | :*DFI is classified based on its severity according to the Infectious Diseases Society of America (IDSA) guideline or the PEDIS grade developed by the International Working Group on the Diabetic Foot (IWGDF). (see Table below) | ||
:* Selection of empiric antimicrobial regimen should be determined by the severity of DFI and the likely etiologic agents | :*Selection of an empiric antimicrobial regimen should be determined by the severity of DFI and the likely etiologic agents. | ||
{| | {| | ||
| style="width: 15px;"| | | style="width: 15px;" | | ||
| | | | ||
{| style="border: 2px solid #A8A8A8; font-size: 90%;" | {| style="border: 2px solid #A8A8A8; font-size: 90%;" | ||
! | ! style="background: #A8A8A8;" align="center" |'''Clinical Manifestation''' | ||
! | ! style="background: #A8A8A8; padding: 0 10px;" align="center" |'''PEDIS Grade''' | ||
! | ! style="background: #A8A8A8; padding: 0 10px;" align="center" |'''IDSA Severity''' | ||
|- | |- | ||
| style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" | Wound lacking [[purulent|purulence]] or any manifestations of [[inflammation]] | | style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" |Wound lacking [[purulent|purulence]] or any manifestations of [[inflammation]] | ||
! style="background: #DCDCDC; padding: 0 10px;" | 1 | ! style="background: #DCDCDC; padding: 0 10px;" |1 | ||
! style="background: #DCDCDC; padding: 0 10px;" | Uninfected | ! style="background: #DCDCDC; padding: 0 10px;" |Uninfected | ||
|- | |- | ||
| style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" | | | style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" | | ||
* Presence of ≥2 manifestations of [[inflammation]] ([[purulent|purulence]], or [[erythema]], [[pain]], [[tenderness]], [[calor|warmth]], or [[induration]]) | *Presence of ≥2 manifestations of [[inflammation]] ([[purulent|purulence]], or [[erythema]], [[pain]], [[tenderness]], [[calor|warmth]], or [[induration]]) | ||
* Any [[cellulitis]] or [[erythema]] extends ≤2 cm around the [[ulcer]] | *Any [[cellulitis]] or [[erythema]] extends ≤2 cm around the [[ulcer]] | ||
* Limited to the [[skin]] or superficial [[subcutaneous tissue]]s | *Limited to the [[skin]] or superficial [[subcutaneous tissue]]s | ||
* <u>No</u> other local [[complication]]s (eg, [[trauma]], [[gout]], [[Neuropathic joint disease|acute Charcot neuro-osteoarthropathy]], [[fracture]], [[thrombosis]], [[venous stasis]]) or systemic illness | *<u>No</u> other local [[complication]]s (eg, [[trauma]], [[gout]], [[Neuropathic joint disease|acute Charcot neuro-osteoarthropathy]], [[fracture]], [[thrombosis]], [[venous stasis]]) or systemic illness | ||
! style="background: #F5F5F5; padding: 0 10px;" | 2 | ! style="background: #F5F5F5; padding: 0 10px;" |2 | ||
! style="background: #F5F5F5; padding: 0 10px;" | Mild | ! style="background: #F5F5F5; padding: 0 10px;" |Mild | ||
|- | |- | ||
| style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" | Infection in a patient who is metabolically stable and systemically well, but with ≥1 of the following characterisitics: | | style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" |Infection in a patient who is metabolically stable and systemically well, but with ≥1 of the following characterisitics: | ||
* [[Cellulitis]] extending >2 cm | |||
* [[Lymphangitis|Lymphangitic streaking]] | *[[Cellulitis]] extending >2 cm | ||
* Spread beneath the superficial [[fascia]] | *[[Lymphangitis|Lymphangitic streaking]] | ||
* Deep-tissue [[abscess]] | *Spread beneath the superficial [[fascia]] | ||
* [[Gangrene]] | *Deep-tissue [[abscess]] | ||
* Involvement of [[muscle]], [[tendon]], [[joint]], or [[bone]] | *[[Gangrene]] | ||
! style="background: #DCDCDC; padding: 0 10px;" | 3 | *Involvement of [[muscle]], [[tendon]], [[joint]], or [[bone]] | ||
! style="background: #DCDCDC; padding: 0 10px;" | Moderate | ! style="background: #DCDCDC; padding: 0 10px;" |3 | ||
! style="background: #DCDCDC; padding: 0 10px;" |Moderate | |||
|- | |- | ||
| style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" | Infection in a patient with metabolic instability (eg, [[acidosis]], severe [[hyperglycemia]], or [[azotemia]]) or systemic toxicity as manifested by ≥2 of the following: | | style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" |Infection in a patient with metabolic instability (eg, [[acidosis]], severe [[hyperglycemia]], or [[azotemia]]) or systemic toxicity as manifested by ≥2 of the following: | ||
* [[Fever|Temperature >38 °C]] or [[Hypothermia|<36 °C]] | |||
* [[Tachycardia|Heart rate >90 beats/min]] | *[[Fever|Temperature >38 °C]] or [[Hypothermia|<36 °C]] | ||
* [[Tachypnea|Respiratory rate >20 breaths/min]] or [[Respiratory alkalosis|PaCO2 <32 mm Hg]] | *[[Tachycardia|Heart rate >90 beats/min]] | ||
* [[Leukocytosis|White blood cell count >12,000]] or [[Leukopenia|<4,000 cells/μL]] or [[bandemia|≥10% immature (band) forms]] | *[[Tachypnea|Respiratory rate >20 breaths/min]] or [[Respiratory alkalosis|PaCO2 <32 mm Hg]] | ||
! style="background: #F5F5F5; padding: 0 10px;" | 4 | *[[Leukocytosis|White blood cell count >12,000]] or [[Leukopenia|<4,000 cells/μL]] or [[bandemia|≥10% immature (band) forms]] | ||
! style="background: #F5F5F5; padding: 0 10px;" | Severe | ! style="background: #F5F5F5; padding: 0 10px;" |4 | ||
! style="background: #F5F5F5; padding: 0 10px;" |Severe | |||
|} | |} | ||
|} | |} | ||
: '''5. What is the appropriate route, setting, and duration of antibiotic therapy?''' | :'''5. What is the appropriate route, setting, and duration of antibiotic therapy?''' | ||
:* The table below describes the recommended route, setting, and duration of antibiotic therapy based on the extent and severity of DFI. | :*The table below describes the recommended route, setting, and duration of antibiotic therapy based on the extent and severity of DFI. | ||
{| | {| | ||
| style="width: 15px;"| | | style="width: 15px;" | | ||
| | | | ||
{| style="border: 2px solid #A8A8A8; font-size: 90%;" | {| style="border: 2px solid #A8A8A8; font-size: 90%;" | ||
! | ! colspan="2" style="background: #A8A8A8; padding: 0 10px;" align="center" |'''Site of Infection, by Severity or Extent''' | ||
! | ! style="background: #A8A8A8; padding: 0 10px;" align="center" |'''Route of Administration''' | ||
! | ! style="background: #A8A8A8; padding: 0 10px;" align="center" |'''Setting''' | ||
! | ! style="background: #A8A8A8; padding: 0 10px;" align="center" |'''Duration of Therapy''' | ||
|- | |- | ||
! style="background: #DCDCDC; padding: 0 10px;" | ! rowspan="3" style="background: #DCDCDC; padding: 0 10px;" |'''Soft-tissue only''' | ||
| style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" | Mild (Grade 2) | | style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" |Mild (Grade 2) | ||
| style="background: #DCDCDC; padding: 0 10px;" | Oral (or topical for superficial infections) | | style="background: #DCDCDC; padding: 0 10px;" |Oral (or topical for superficial infections) | ||
| style="background: #DCDCDC; padding: 0 10px;" | Outpatient | | style="background: #DCDCDC; padding: 0 10px;" |Outpatient | ||
| style="background: #DCDCDC; padding: 0 10px; text-align: center;" | 1–2 wk | | style="background: #DCDCDC; padding: 0 10px; text-align: center;" |1–2 wk | ||
|- | |- | ||
| style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" | Moderate (Grade 3) | | style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" |Moderate (Grade 3) | ||
| style="background: #DCDCDC; padding: 0 10px;" | Oral (or initial parenteral) | | style="background: #DCDCDC; padding: 0 10px;" |Oral (or initial parenteral) | ||
| style="background: #DCDCDC; padding: 0 10px;" | Outpatient (or inpatient) | | style="background: #DCDCDC; padding: 0 10px;" |Outpatient (or inpatient) | ||
| style="background: #DCDCDC; padding: 0 10px; text-align: center;" | 1–3 wk | | style="background: #DCDCDC; padding: 0 10px; text-align: center;" |1–3 wk | ||
|- | |- | ||
| style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" | Severe (Grade 4) | | style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" |Severe (Grade 4) | ||
| style="background: #DCDCDC; padding: 0 10px;" | Initial parenteral, switch to oral when possible | | style="background: #DCDCDC; padding: 0 10px;" |Initial parenteral, switch to oral when possible | ||
| style="background: #DCDCDC; padding: 0 10px;" | Inpatient, then outpatient | | style="background: #DCDCDC; padding: 0 10px;" |Inpatient, then outpatient | ||
| style="background: #DCDCDC; padding: 0 10px; text-align: center;" | 2–4 wk | | style="background: #DCDCDC; padding: 0 10px; text-align: center;" |2–4 wk | ||
|- | |- | ||
! style="background: #F5F5F5; padding: 0 10px;" | ! rowspan="4" style="background: #F5F5F5; padding: 0 10px;" |'''Bone or joint''' | ||
| style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" | No residual infected tissue | | style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" |No residual infected tissue | ||
| style="background: #F5F5F5; padding: 0 10px;" | Parenteral or oral | | style="background: #F5F5F5; padding: 0 10px;" |Parenteral or oral | ||
| style="background: #F5F5F5; padding: 0 10px;" | Inpatient, then outpatient | | style="background: #F5F5F5; padding: 0 10px;" |Inpatient, then outpatient | ||
| style="background: #F5F5F5; padding: 0 10px; text-align: center;" | 2–5 d | | style="background: #F5F5F5; padding: 0 10px; text-align: center;" |2–5 d | ||
|- | |- | ||
| style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" | Residual infected soft tissue | | style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" |Residual infected soft tissue | ||
| style="background: #F5F5F5; padding: 0 10px;" | Parenteral or oral | | style="background: #F5F5F5; padding: 0 10px;" |Parenteral or oral | ||
| style="background: #F5F5F5; padding: 0 10px;" | Inpatient, then outpatient | | style="background: #F5F5F5; padding: 0 10px;" |Inpatient, then outpatient | ||
| style="background: #F5F5F5; padding: 0 10px; text-align: center;" | 1–3 wk | | style="background: #F5F5F5; padding: 0 10px; text-align: center;" |1–3 wk | ||
|- | |- | ||
| style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" | Residual infected, viable bone | | style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" |Residual infected, viable bone | ||
| style="background: #F5F5F5; padding: 0 10px;" | Initial parenteral, switch to oral when possible | | style="background: #F5F5F5; padding: 0 10px;" |Initial parenteral, switch to oral when possible | ||
| style="background: #F5F5F5; padding: 0 10px;" | Inpatient, then outpatient | | style="background: #F5F5F5; padding: 0 10px;" |Inpatient, then outpatient | ||
| style="background: #F5F5F5; padding: 0 10px; text-align: center;" | 4–6 wk | | style="background: #F5F5F5; padding: 0 10px; text-align: center;" |4–6 wk | ||
|- | |- | ||
| style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" | Residual dead bone or no surgery | | style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" |Residual dead bone or no surgery | ||
| style="background: #F5F5F5; padding: 0 10px;" | Initial parenteral, switch to oral when possible | | style="background: #F5F5F5; padding: 0 10px;" |Initial parenteral, switch to oral when possible | ||
| style="background: #F5F5F5; padding: 0 10px;" | Inpatient, then outpatient | | style="background: #F5F5F5; padding: 0 10px;" |Inpatient, then outpatient | ||
| style="background: #F5F5F5; padding: 0 10px; text-align: center;" | ≥3 mo | | style="background: #F5F5F5; padding: 0 10px; text-align: center;" |≥3 mo | ||
|} | |} | ||
|} | |} | ||
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==Do's== | ==Do's== | ||
* | |||
*Check for [[signs]] of [[ischemia]]. | |||
*Check for [[Medical sign|signs]] of [[infection]]. | |||
*Always get a [[Culture media|wound culture]] to determine the type of [[organism]] and choice of an [[antibiotic]]. | |||
*[[Prophylactic]] [[Podiatry|podiatric]] care. | |||
*Mechanical offloading in all patients. <ref name="pmid31862754">{{cite journal| author=American Diabetes Association| title=11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes-2020. | journal=Diabetes Care | year= 2020 | volume= 43 | issue= Suppl 1 | pages= S135-S151 | pmid=31862754 | doi=10.2337/dc20-S011 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=31862754 }} </ref> | |||
==Don'ts== | ==Don'ts== | ||
* | |||
*Don't treat the [[ulcer]] without treating the underlying [[infection]], [[ischemia]], and appropriate glycemic control. | |||
==References== | ==References== | ||
{{Reflist|2}} | {{Reflist|2}} | ||
[[Category:Primary care]] | |||
[[Category: | |||
[[Category:Resident survival guide]] | [[Category:Resident survival guide]] | ||
[[Category: | [[Category:Up-To-Date]] | ||
Latest revision as of 20:45, 8 January 2021
Diabetic foot Resident Survival Guide Microchapters |
---|
Overview |
Causes |
Diagnosis |
Treatment |
Do's |
Don'ts |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ifrah Fatima, M.B.B.S[2]
Synonyms and keywords: Diabetic feet; Diabetic ulcer; Diabetic foot infection; Diabetic foot ulcer
Overview
Diabetic foot is a complication of long-standing and poorly controlled diabetes mellitus. Poor glycemic control, peripheral neuropathy, improper footwear, ischemia and possible foot deformities including charcot arthropathy are the main known causes of diabetic foot. A detailed history of the patient's diabetes status, foot care, deformities, foot hygiene, symptoms of ischemia, and history of smoking is necessary to classify the wound or ulcer and treat the underlying cause. Physical examination includes an assessment of the ulcer and tests to detect the severity of peripheral neuropathy (such as Semmes-Weinstein monofilament test) and ischemia (such as Ankle-Brachial Index (ABI)). Routine laboratory investigations are recommended, such as HbA1c. If an infection is suspected, a wound culture is necessary to guide antibiotic therapy. Mechanical offloading such as cast walkers, total contact casting or therapeutic shoes, and podiatric care are essential. Surgical interventions, such as revascularization surgery) may be considered for patient's with ischemia. Antibiotic therapy is based on culture, risk of MRSA infection, risk of pseudomonas infection, presence or absence of complications, such as osteomyelitis and history of recent antibiotic use. Hyperbaric oxygen therapy is considered for a diabetic foot that persists despite treatment for more than 30 days.
Causes
Life Threatening Causes
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated. Diabetic foot superseded with the following may result in sepsis and death.[1]
Common Causes
- Poor glycemic control
- Peripheral neuropathy
- Peripheral arterial disease
- Peripheral ischemia
- Improper footwear
- Foot deformities including charcot arthropathy
Diagnosis
Assessment of diabetic foot includes evaluation of peripheral arterial disease, peripheral neuropathy, and foot deformities. Shown below is an algorithm summarizing the diagnosis of diabetic foot and diabetic foot ulcers according to the recommendations of the American Diabetes Association and International Diabetes Federation- Clinical Practice Recommendations on the Diabetic Foot 2017. [3][1]
Characterize the symptoms: ❑ Onset ❑ Type of sensation ❑ Location ❑ Nocturnal variation ❑ Aggravating factors ❑ Relieving factors Obtain a detailed history: ❑ Onset of diabetes ❑ Duration of diabetes ❑ Compliance with medication ❑ History of glycemic control ❑ History of other diabetic complications ❑ Foot deformities/injuries/ulcers ❑ History of lower limb amputation ❑ Type of footwear ❑ Foot hygiene ❑ History of claudication ❑ Smoking history | |||||||||||||
Examine the patient: Inspection ❑ Location of ulcer ❑ Integrity and charcteristic (dry/cracked) of skin ❑ Sweating Palpation ❑ Pedal (dorsalis pedis) pulses ❑ Vibration sensation ❑ Ulcer site- warmth, tenderness, edema Non-invasive tests ❑ Semmes-Weinstein monofilament test ❑ Probe-to-bone test if suspected osteomyelitis ❑ Measure ABI (Ankle-Brachial Index) with a Arterial doppler | |||||||||||||
Order tests: ❑ Glycosylated hemoglobin/ HbA1c ❑ Fasting plasma glucose ❑ Complete blood count ❑ ESR and CRP ❑ Deep tissue specimen for culture | |||||||||||||
Treatment
Assessment of diabetic foot includes evaluation of peripheral arterial disease, peripheral neuropathy, and foot deformities. Shown below is an algorithm summarizing the diagnosis of diabetic foot and diabetic foot ulcers according to the recommendations of the American Diabetes Association and International Diabetes Federation- Clinical Practice Recommendations on the Diabetic Foot 2017. [4] [5] [6] [1]
Adapted from Diabetes Care. 2013;36(9):2862-71. and Clin Infect Dis. 2012;54(12):e132-73. [7] [8]
Prophylactic measures and Diabetic foot care in all patients ❑ Glycemic control ❑ Apporpriate footwear and podiatric care • ❑ Mechanical offloading • Cast Walkers • Total contact casting • Therapeutic shoes ❑ Vascular care to prevent and treat peripheral arterial disease | |||||||||||||||||||||||||||||||||||||||||||
❑ Local wound care ❑ Debridement - Mechanical or chemical | |||||||||||||||||||||||||||||||||||||||||||
Peripheral arterial disease or signs of ischemia | Medication/Surgical or endovascular revascularization | ||||||||||||||||||||||||||||||||||||||||||
Presence of infection | • Mechanical or chemical wound debridement • Culture • Biopsy | ||||||||||||||||||||||||||||||||||||||||||
• Assess severity of infection according to the table below • Treat with antiobiotics according to the table below | |||||||||||||||||||||||||||||||||||||||||||
If infection does not resolve within 30 days- • Consider hyperbaric oxygen therapy | |||||||||||||||||||||||||||||||||||||||||||
• Observe foot • Establish regular care • Reassess in 2-3 months | |||||||||||||||||||||||||||||||||||||||||||
- DFI is classified based on its severity according to the Infectious Diseases Society of America (IDSA) guideline or the PEDIS grade developed by the International Working Group on the Diabetic Foot (IWGDF). (see Table below)
- Selection of an empiric antimicrobial regimen should be determined by the severity of DFI and the likely etiologic agents.
|
- 5. What is the appropriate route, setting, and duration of antibiotic therapy?
- The table below describes the recommended route, setting, and duration of antibiotic therapy based on the extent and severity of DFI.
|
Empiric Therapy
▸ Click on the following categories to expand treatment regimens.
Uninfected (Grade 1) ▸ No Evidence of Infection Mild (Grade 2) ▸ Acute Infection Without Recent Antibiotic Use ▸ High Risk for MRSA
Moderate to Severe (Grade 3–4) ▸ Chronic Infection or Recent Antibiotic Use ▸ High Risk for MRSA ▸ High Risk for Pseudomonas aureuginosa ▸ Polymicrobial Infection |
|
Do's
- Check for signs of ischemia.
- Check for signs of infection.
- Always get a wound culture to determine the type of organism and choice of an antibiotic.
- Prophylactic podiatric care.
- Mechanical offloading in all patients. [5]
Don'ts
- Don't treat the ulcer without treating the underlying infection, ischemia, and appropriate glycemic control.
References
- ↑ 1.0 1.1 1.2 1.3 Pendsey SP (2010). "Understanding diabetic foot". Int J Diabetes Dev Ctries. 30 (2): 75–9. doi:10.4103/0973-3930.62596. PMC 2878694. PMID 20535310.
- ↑ Hobizal KB, Wukich DK (2012). "Diabetic foot infections: current concept review". Diabet Foot Ankle. 3. doi:10.3402/dfa.v3i0.18409. PMC 3349147. PMID 22577496.
- ↑ "Guidelines".
- ↑ "Guidelines".
- ↑ 5.0 5.1 American Diabetes Association (2020). "11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes-2020". Diabetes Care. 43 (Suppl 1): S135–S151. doi:10.2337/dc20-S011. PMID 31862754.
- ↑ Rathur HM, Boulton AJ (2007). "The diabetic foot". Clin Dermatol. 25 (1): 109–20. doi:10.1016/j.clindermatol.2006.09.015. PMID 17276208.
- ↑ Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG; et al. (2012). "2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections". Clin Infect Dis. 54 (12): e132–73. doi:10.1093/cid/cis346. PMID 22619242.
- ↑ Wukich DK, Armstrong DG, Attinger CE, Boulton AJ, Burns PR, Frykberg RG; et al. (2013). "Inpatient management of diabetic foot disorders: a clinical guide". Diabetes Care. 36 (9): 2862–71. doi:10.2337/dc12-2712. PMC 3747877. PMID 23970716.