diabetic foot

1. DIABETIC FOOT

2. Introduction: Diabetic Foot
Ulcers and Infections
• Most common problem in persons
with diabetes.
• Lifetime risk of a foot ulcer in
Diabetes patients: 25 %
• Account for approximately 25 percent of
all hospital stays for patients with
diabetes

3. Risk factors
• Local trauma and/or pressure
• Prior ulcers or amputations
• Infection
• Effects of chronic ischemia, due to
peripheral artery disease
• Patients with diabetes also have an
increased risk for nonhealing related to
mechanical and cytogenic factors

4. Aetiopathogenesis
• Peripheral neuropathy and peripheral
arterial disease (PAD) (or both) play a
central role

5. • Diabetic Foot Ulcers are classified as:
– Neuropathic
– Ischaemic
– Neuroischaemic

6. Typical features of DFUs according to
aetiology.

7. Neuropathic
DFU
Neuroischaemic
DFU
Ischaemic
DFU

8. Microbiology
• Most diabetic foot infections are
polymicrobial
• Superficial diabetic foot infections
:likely due to aerobic gram-positive cocci.
• Ulcers that are deep, chronically
infected and/or previously treated with
antibiotics are more likely to be
polymicrobial.

9. • Wounds with extensive local
inflammation, necrosis, malodorous
drainage, or gangrene with signs of
systemic toxicity should be presumed to
have anaerobic organisms in addition to
the above pathogens.

10. Ulcer classification
University of Texas system
Grade 0: Pre- or postulcerative
Grade 1:Full-thickness ulcer not involving tendon, capsule, or
bone
Grade 2: Tendon or capsular involvement without bone
palpable
Grade 3: Probes to bone

11. Grade0: Pre- or
postulcerative

12. Grade 1: Full-thickness ulcer not involving tendon, capsule, or
bone

13. Grade 2: Tendon or
capsular involvement
without bone palpable

14. Grade 3:
Probes to
bone

15. Wagner Classification:
• Grade 1: Skin and subcutaneous
tissue
• Grade 2: To bone
• Grade 3: Abscess or osteitis
• Grade 4: Partial foot gangrene
• Grade 5: Whole foot gangrene

17. WIFI Classification
• Measures 3
factors:
– Wound
– Ischemia
– Foot Infection

19. Clinical manifestation
Diabetic foot infections typically take one
of the following forms:
• Localized superficial skin involvement at
the site of a preexisting lesion
• Deep-skin and soft-tissue infections
• Acute osteomyelitis
• Chronic osteomyelitis

20. History
• Duration of diabetes
• Glycemic control
• Presence of micro- or macrovascular
disease
• History of prior foot ulcers, lower
limb bypasses or amputation
• Presence of claudication
• History of cigarette smoking

21. Physical examination
Assessment for the presence
of
• existing ulcers
• peripheral neuropathy
• loss of protective sensation
• peripheral artery disease,
and
• foot deformities
– claw toes and
– Charcot arthropathy

22. Examination of
Ulcer
• Predominantly neuropathic,
ischaemic or neuroischaemic?
• Is there critical limb ischaemia?
• Any musculoskeletal deformities?
• Ulcer Characteristics:
size/depth/location/wound
bed
• wound infection
• status of the wound edge

23. Semmes-Weinstein Monofilament
Test

24. • Procedure:
– Quiet Surrounding
– Eyes Closed for the test
– Supine position
– Testing in inner aspect of arm/hand
– Apply the monofilament perpendicular to the
skin surface with sufficient force to bend it
– Ask: whether they felt it?/Where they felt it?
– Duration: 2 secs
– 3 applications in each site with at least 1
mock

25. • Inference:
– Protective sensation is present at each site if
the patient correctly answers two out of
three applications
– Protective sensation is absent with two
out of three incorrect answers

26. Physical signs of peripheral artery
disease
• diminished foot pulses,
• decrease in skin
temperature,
• thin skin,
• lack of skin hair, and
• bluish skin color

27. Diagnosis of Diabetic Foot
Infection
• Primarily based on suggestive clinical
manifestations
• The presence of two or more features of
inflammation (erythema, warmth, tenderness,
swelling, induration and purulent secretions) can
establish the diagnosis
• Presence of microbial growth from a wound
culture in the absence of supportive clinical
findings is not sufficient to make the diagnosis of
infection

28. Diagnosis of underlying
osteomyelitis
• Grossly visible bone or ability to probe to
bone
• Ulcer size larger than 2 cm2
• Ulcer duration longer than one to two weeks
• Erythrocyte sedimentation rate (ESR) >70
mm/h
• A conventional radiograph with consistent
changes can be helpful in making the
diagnosis ((MRI), which is highly sensitive
and specific for osteomyelitis )
• Culture of bone biopsy specimens is also
important for identifying the causative
organisms

29. Differential diagnosis
• trauma
• crystal-associated
arthritis
• acute Charcot
arthropathy
• fracture
• thrombosis
• venous stasis

30. Infectious Diseases Society of America and International Working Group on the
Diabetic Foot Classifications of Diabetic Foot Infection

31. Management
Management of diabetic foot
infections requires:
• Attentive wound management
• Good nutrition
• Appropriate antimicrobial therapy
• Glycemic control, and
• fluid and electrolyte balance.

32. Wound management
• Local wound care for diabetic foot infections typically
includes debridement of callus and necrotic tissue,
wound cleansing, and relief of pressure on the
ulcer
DEBRIDMENT:
• Debridement is essential for
ulcer healing
• choice of debridement
– sharp,
– enzymatic,
– autolytic,
– mechanical, and
– biological)
Fig: Neuropathic ulcer
Top: Pre debridement

33. DRESSINGS
• After debridement, ulcers should be kept
clean and moist but free of excess fluids
• Dressings should be selected based upon
ulcer characteristics, such as the extent of
exudate, desiccation, or necrotic tissue
Adjunctive local therapies :
• negative pressure wound therapy (NPWT)
• use of custom-fit semipermeable
polymeric membrane dressings
• cultured human dermal grafts
• application of growth factors

34. • Wound Management Dressing
Guide
International Best Practice Guidelines: Wound Management in Diabetic Foot Ulcers.

35. • Wound Management Dressing Guide
Continued...

36. Surgery
Required for cure of infections complicated by
• abscess,
• extensive bone or joint involvement,
• crepitus, necrosis, gangrene or necrotizing fasciitis
• And for source control in patients with severe
sepsis
In addition to surgical debridement, revascularization
(via angioplasty or bypass grafting) and/or
amputation may be necessary.

37. Antimicrobial therapy
EMPERIC THERAPY:
Mild infection: Outpatient oral
antimicrobial therapy.
Should include activity against skin
flora including streptococci and S.
aureus
Agents with activity against methicillin-
resistant S. aureus (MRSA) should be used
in patients with purulent infections and those
at risk for MRSA infection

38. • Moderate infection: Deep ulcers with
extension to fascia. Should include activity
against streptococci, S. aureus (and MRSA
if risk factors are present), aerobic gram-
negative bacilli and anaerobes
– can be administered orally
• Empiric coverage for P. aeruginosa may not
always be necessary unless the patient has
particular risk for involvement with this
organism, such as a macerated wound or
one with significant water exposure

39. Severe infection: Limb-threatening diabetic
foot infections and those that are
associated with systemic toxicity should
be treated with broad-spectrum
parenteral antibiotic therapyIn most cases, surgical debridement is
also necessary.

41. Duration of therapy
• Mild infection should receive oral antibiotic
therapy in conjunction with attentive
wound care until there is evidence that
the infection has resolved (usually about
one to two weeks)
• Patients with infection also requiring
surgical debridement or amputation
should receive intravenous antibiotic
therapy perioperatively

42. • In case of osteomyelitis:
• No data support the superiority of
specific antimicrobial agents for
osteomyelitis
• Appropriate regimens for empiric therapy
are similar to that for moderate to severe
diabetic foot infections
• Therapy should be tailored to culture
and sensitivity results, ideally from
bone biopsy.
• Patients who were initiated on
parenteral therapy, a switch to an oral
regimen is reasonable following

43. Extensive surgical debridement or resection is
preferable in the following clinical
circumstances
• Persistent sepsis without an alternate source
• Inability to receive or tolerate
appropriate antibiotic therapy
• Progressive bone deterioration
despite appropriate antibiotic
therapy
• Mechanics of the foot are compromised by
extensive bony destruction requiring
correction
• Surgery is needed to achieve soft tissue
wound or primary closure

44. Adjunctive
therapies
• vacuum-assisted wound closure,
• hyperbaric oxygen and
• granulocyte colony-stimulating factor (G-
CSF)

45. Follow-
up
• Close follow-up is important to ensure
continued improvement and to evaluate
the need for modification of antimicrobial
therapy, further imaging, or additional
surgical intervention

46. Summar
y• Hyperglycemia, sensory and autonomic
neuropathy, and peripheral arterial
disease all contribute to the pathogenesis
of lower extremity infections in diabetic
patients
• Evaluation of a patient with a diabetic foot
infection involves determining the extent
and severity of infection through clinical
and radiographic assessment

47. • The presence of two or more features of
inflammation (erythema, warmth, tenderness,
swelling, induration, or purulent secretions) can
establish the diagnosis of a diabetic foot
infection. The definitive diagnosis of osteomyelitis
is made through histologic and microbiologic
evaluation of a bone biopsy sample
• Management of diabetic foot infections requires
attentive wound management, good nutrition,
antimicrobial therapy, glycemic control, and fluid
and electrolyte balance

48. Reference
s::• Lipsky BA, et al. 2012 Infectious Diseases Society
of America clinical practice guideline for the
diagnosis and treatment of diabetic foot infections.
Clin Infect Dis 2012; 54:e132.
• International Best Practice Guidelines:
Wound Management in Diabetic Foot
Ulcers. Wounds International, 2013.
• Gulf Diabetic Foot Working Group. Identification
and management of infection in diabetic foot
ulcers: International consensus. Wounds
International 2017.
• www.uptodate.com
• Internet

49. THANK
YOU!!!!