Overview on diabetic foot management from IDSA guidelines and Wound international guidelines

1. Wound
Management In
Diabetic Foot Ulcers
• Dr. Hemat Afifi Sherif

2. Introduction
complex chronic wounds
5–7%
Of people with
diabetes
currently have
or have had a
DFU
25%
Of people with
diabetes will
develop a
DFU during
their lifetime
5% to 15%
Of diabetic
patients may
undergo limb
amputation

3. Every 20 Seconds A Lower
Limb Is Amputated Due To
Complications Of Diabetes.

4. Have a major long-term impact on :
The morbidity
Mortality
Quality of patients’ lives
Myocardial infarction
Fatal stroke

6. Etiology of DFUs

7. Neuropathic
Ischaemic
Neuro-ischaemic
peripheral arterial disease (PAD)
peripheral neuropathy
DFUs are commonly classified as :

9. Assessing DFUs
Multi-disciplinary Footcare Team (MDFT)

10. Medication
Comorbidities
Diabetes Status
The History Of The Wound
Previous DFUs Or Amputations
Any Symptoms Suggestive Of
Neuropathy Or PAD( Peripheral
Arterial Disease )
Full Patient History Including :
Take Into Consideration :

11. Is the wound predominantly neuropathic,
ischaemic or neuroischaemic?
If ischaemic is there critical limb
ischaemia?
What is the size/depth/location of the
wound?
Examination Of The Ulcer

12. What is the colour/status of the wound
bed?
— Black (necrosis)
— Yellow, red, pink
If so, are there systemic signs and
symptoms of infection such as :
Fevers
Chills
Rigors
metabolic instability
confusion
Is there any exposed bone?
Is there any necrosis or gangrene?
Is the wound infected?

13. color and consistency of
exudate, and is it purulent?
Is there any mal- odour?
Is there local pain?
Is there any exudate?
What is the level of production
 High
 Moderate
 Low
 None

14. What is the status of the wound edge:
Callus
Maceration
Erythema
Oedema
Undermining
Documenting ulcer characteristics
 Develop A Treatment Plan
 Monitor Any Response To Interventions
Digitally photographing DFUs at the first
consultation and periodically thereafter

15. carrying out the
monofilament
test
Where available:
1. Doppler ultrasound
2. Doppler waveform
3. Ankle brachial pressure index (ABPI)
Assessment for Peripheral Arterial
Disease

16. 1. Doppler ultrasound
2. Doppler waveform

17. Ankle Brachial Pressure
Index (ABPI)

18. 1.3 – 0.40

19. Include skin ulcers or gangrene.
If left untreated it will result in amputation of
the affected limb.
Common Terms Explained
This is a chronic manifestation of PAD
The arteries of the lower extremities are
severely blocked.
This results in ischaemic pain in the feet or
toes even at rest.
Critical limb ischaemia:
Complications of poor circulation

20. An embolism or thrombosis leads to sudden
lack of blood flow to a limb
Without surgical re-vascularisation,
complete acute ischemia leads to extensive
tissue necrosis within six hours.
Acute limb ischemia:

21. Classification according to :
Size
Depth
appearance
Location
CLASSIFICATION OF DFUs
They can help in :
The planning
Monitoring of treatment
predicting outcome

22. Necrosis
Gangrene
Identifying Infection
simple (mild) infection
Moderate to severe
with
Signs suggestive of infection
Wound undermining
Mal-odour
Wound exudate

23. Risk factors for infection
A positive probe-to-bone test
DFU present for more than 30 days
A history of recurrent DFUs
The presence of PAD in the affected limb
Loss of protective sensation
A previous lower extremity amputation
The presence of renal insufficiency
A history of walking barefoot.

24. Clinical Diagnosis And
Cultures
All open wounds will be colonized with
organisms
making the positive culture to be difficult
1. Soft tissue
2. Bone when osteomyelitis is suspected
3. Aspirations of purulent secretions

25. Inaccurate
As swab cultures grow surface
contaminants and miss the true
pathogen(s) causing the infection.
Deep Swabbing Technique
After the wound has been cleansed
and debrided
Superficial Swabbing Technique

26. Assessing Bone Involvement
Osteomyelitis can be difficult to diagnose in
the early stages.
Can diagnosed by :
A simple clinical test by inserting a sterile
blunt metal probe into the ulcer
Plain x-rays can help to confirm the
diagnosis
Magnetic resonance imaging (MRI)
white blood cell scanning combined with a
radio-nuclide bone scan

27. Osteomyelitis Imaging

28. Inspecting Feet For Deformities
A high-arch foot
Clawed lesser toes
the plantar arch and on the dorsum (a
‘hollowed-out’ appearance)
Typical presentations in patients with motor
neuropathy are:

29. Gait changes( the foot ‘slapping’ on the
ground)
Hallux valgus
Hallux rigidus
Fatty pad depletion.
Hallux valgus Hallux Rigidus Fatty Pad
Corrective Foot Surgery To Off-load Pressure
Areas

30. DFU Wound
Management

31. The essential components of
management are:
Treating underlying disease processes
Ensuring adequate blood supply
Local wound care, including infection control
Pressure off-loading.
The principle aim of DFU management is
Wound Closure.
Treat the DFU at an Early Stage to allow prompt
healing.

32. Managing risk factors such as
 High blood pressure
 Hyperlipidaemia
 Smoking.
Nutritional deficiencies should also be
managed.
Treating The Underlying
Disease Processes
Treating any severe ischaemia
Achieving optimal diabetic control.

33. Examining the foot
Footwear for proper fit
The presence of any foreign bodies
Addressing the physical cause of the
trauma.

34. Careful moisture balance to prevent
maceration.
OPTIMISING LOCAL WOUND
CARE
The European Wound Management Association (EWMA)
Radical and repeated debridement
Frequent inspection and bacterial
control

35. Debridement Should Be Determined At Each
Dressing Change.
Tissue Debridement
Removes Necrotic Tissue and Callus
Reduces pressure
Allows full inspection of the underlying
tissues
Helps Drainage of secretions or pus
Helps optimize the effectiveness of topical
preparations
Stimulates Healing.
The benefits of debridement include:

37. Assess Severity of
Infection in the wound
Mild superficial and limited in size and
depth
Moderate Deeper or more extensive
Severe Accompanied by systemic signs

38.  Wounds without evidence of soft tissue or bone
infection ----------do not require antibiotic therapy
Obtain A Post-debridement Specimen
(Preferably Of Tissue)
Blood cultures should be sent if fever and
systemic toxicity are present

40. Most acute infections
in patients who have not
recently been treated with
antimicrobials are caused by
Aerobic Gram
+Ve cocci
especially
staphylococci
Chronic infections
, or those occurring after
antibiotic treatment
polymicrobial,
aerobic Gram- ve
bacilli
joining the aerobic
Gram+ve cocci.
In ischaemic or necrotic
wounds
Anaerobes may be
isolated as co-
pathogens with
aerobes

41. Penicillins And Cephalosporin Can Be
Effective In Most Cases.
 The choice between these agents should
be based on :
Tolerability cost

42.  Anaerobic organisms must be
considered if:
 Presence of an abscess
 Necrosis
 Foul-smelling tissue is present
 The infection is severe & long-standing
 The patient has recently treated with antibiotics
Metronidazole or Clindamycin should be
added to the regimen.

43. cause serious toxicity if used for long period
should be avoided in diabetic patients.
Aminoglycosides
provides similar coverage
offers the advantage of
mono-therapy.
A β-lactam– β-lactamase inhibitor
combination
ampicillin /
sulbactam
Amoxicillin
/clavulanic
Piperacillin
Tazobactam
Ticarcillin

44. Tigecycline
Other single-agent therapies :
These Agents Should be Limited in Their Use
To Patients Unresponsive To Other Therapies
Because of
Their cost is high
They have Broad Spectrum Activity
Carbapenem Ertapenem
Imipenem
Meropenem

45. Linezolid
could be used for patients with low likelihood
of gram-negative or anaerobic pathogens.
osteomyelitis
severe infection
The need for prolonged therapy with the
associated risk of linezolid-induced
myelosuppression and neuropathies
make other agents more desirable
BUT

46.  Empiric therapy directed at Pseudomonas
aeruginosa is usually unnecessary except for patients
with risk factors for true infection with this organism
Consider providing empiric therapy directed against
methicillin-resistant staphylococcus aureus (MRSA) in:
1. Patient with a prior history of MRSA infection
2. When the local prevalence of MRSA colonization or
infection is high
3. If the infection is clinically severe .

47.  Parenteral therapy for all severe, and some
moderate
 Switch to oral agents when the patient is systemically
well and culture results are available
 Continuing antibiotic therapy until resolution of
findings of infection, but not through complete
healing of the wound
 Initial antibiotic course for a soft tissue infection of
about 1–2 weeks for mild infections
 2–3 weeks for moderate to severe infections

50. Suggested Empiric
Antibiotic Regimens
(usually treated with oral agent[s])Mild
Clindamycin
Cephalexin
Levofloxacin
Amoxicillin-clavulanate
Trimethoprim/sulfamethoxazole

51. Moderate Severe
Levofloxacinb
Cefoxitin
Ceftriaxone
cephalosporin
Moxifloxacin
Ampicillin-sulbactam
ertapenem + vancomycin
Levofloxacinb or ciprofloxacin
with clindamycin
Imipenem-cilastatinb
To
Linezolidb
Daptomycinb
Vancomycin
Ertapenem
Tigecycline
Piperacillin-
tazobactam

52. Effective combination that will provide coverage
against most potential pathogens
Gram-positive
Gram negative
Anaerobes
No “best” regimens exist to treat diabetic soft tissue
infections
Clindamycin 600 mg IV
every 8 hours
ciprofloxacin
400 mg
Third-generation
cephalosporinor

53. Studies of Antibiotic Therapy for Diabetic
Foot Infections Published Since 2004
Antibiotic Agent(s) (Route) Type/Severity of
Infection
Metronidazole + ceftriaxone vs
ticarcillin/clavulanate (IV)
Older men,
Wagner
grades 1–3
Ceftobiprole vs vancomycin +
ceftazidime (IV)
complicated skin
and skin structure
infection
Piperacillin/tazobactam vs
ampicillin/ sulbactam (IV)
Moderate/severe
infected DFU

54. Antibiotic Agent(s) (Route) Type/Severity of
Infection
Daptomycin vs vancomycin or
Semisynthetic penicillin (IV)
Gram+ DFI
Ertapenem vs
piperacillin/tazobactam (IV)
Moderate/severe
DFI
Moxifloxacin (IV to PO) vs
piperacillin/tazobactam (IV) to
amoxicillin/clavulanate (PO)
complicated skin
and skin structure
infection
Pexiganan (topical) vs ofloxacin
(PO)
Mildly infected
Ceftriaxone vs fluoroquinolone
(IV)
Severe
limbthreatening“
DFI

55. Antibiotic Agent(s) (Route) Type/Severity of
Infection
Moxifloxacin vs amoxicillin/
clavulanate (IV to PO)
complicated skin
and skin structure
infection
Tigecycline vs ertapenem (IV) Qualifying DFI±
osteomyelitis
Piperacillin/tazobactam vs
imipenem/cilastatin (IV)
Severe DFI,
including
osteomyelitis

60. Biofilms And Chronic Persistent
Infection

61. Biofilms are complex polymicrobial
communities that develop on the surface of
chronic wounds,
May lack the overt clinical signs of infection

62. This matrix acts as a thick, slimy
protective barrier, making it very difficult
for antimicrobial agents to penetrate it
They are not visible to the naked eye and
cannot be detected by routine cultures
The microbes produce an extra-polymeric
substance that contributes to the structure
of the biofilm.

63. Using Antimicrobial
Dressings.
Treatment should aim to :
Disrupt the biofilm burden
Regular, Repeated
Debridement
Vigorous Wound
Cleansing
Prevent reformation and attachment

64. Amputation and post-
amputation care

65. Amputation should not be considered
unless a detailed vascular assessment
has been performed by vascular staff
Of patients who
undergo an amputation
will develop a further
DFU on the
contralateral limb
within 18 months of
amputation.
50%
The three–
year mortality
rate
after a first
amputation
20-50%

66. Ischaemic rest pain that cannot be managed
by analgesia or revascularisation
Foot infection that cannot be managed by
other measures
A non-healing ulcer that is accompanied by
a higher burden of disease .
Complications in a diabetic foot that
amputation is a better alternative for the
patient.
Amputation may be indicated in
the following circumstances:

67. Increased Patient Awareness:
Patient should be reviewed 1–3 monthly by
a foot protection team
At each review
patients' feet
should be inspected
the need for vascular
assessment reviewed.
Footcare
Education

68. Patient Foot-care
Education

69. Patient Foot-care Education
Patients should know who to contact if a
DFU develops or recurs
Patient education should be provided in
Several Sessions using a Variety Of
Methods

70. Recognize the need for
treatment of new wounds
It Is Essential To Evaluate
Is the patient understand the messages
Is he motivated to act and has sufficient
self-care skills
Understand the aims of treatment
How to recognize and report
the signs and symptoms of
(worsening) infection

71. Steps to avoid
amputation

72. Good glycaemic control
Pressure offloading
Ensure regular review and provide patient
education
ffective local wound care
Restoring pulsatile blood flow.
Infection control.
Consider therapy directed at biofilm in wounds
that are slow to heal

73. CASE

74. T.U., a 67-year-old man with diabetes
presents to his general practitioner
for a routine checkup and has no
specific complaints
Past History
15-year history of poorly controlled type 2 diabetes
3-year history of recurrent foot ulcers.

75. He is afebrile and demonstrates no other signs of
a systemic infection.
On examination
The physician observes that
An ulcer on the underside of the foot, (which had
previously healed over) , is open and inflamed
purulent fluid can be expressed from the wound.
T.U. reports no pain around the
area and was unaware that the
ulcer had worsened.

76. Does T.U. have an active
infection, and is antibiotic
therapy required?

77. What treatment
should T.U.
receive?

78. Ampicillin / sulbactam
Amoxicillin / clavulinic acid
piperacillin–tazobactam
Cefotaxim
ceftriaxone
Cefoperazone
Ceftazidime

79. An Amputation Is
Required
Despite aggressive antibiotic
therapy and debridement
T.U.’s infection spreads

80. How long should
antibiotics be prescribed
for T.U. after surgery?