This document discusses some pitfalls in the treatment of diabetic foot ulcers. It begins by stating that no lesion should be underestimated. It then covers diabetic foot infection, describing the differences between contamination, colonization, and infection. Grading of foot wound infection from mild to severe is explained using the IDSA IWGDF classification system. The importance of debriding wounds with necrotic tissue is highlighted. Different dressings are discussed, noting that keeping wounds dry is no longer the preferred treatment and that some older antiseptics like Mercurochrome are no longer recommended. The concept of wound bed preparation focusing on issues of non-viable tissue, infection, moisture balance, and non-advancing edges is introduced

1. Some Pitfalls in DF
Prof Hanan Gawish, MD, PhD
Diabetes and Endocrinology, Mansoura University
Chairman of the Egyptian Society of DF
IDF/ DF Consultative Section Board Secretary

2. Agenda
• Underestimation of the lesion

27. Agenda
• No Underestimation of any trivial lesion

28. Agenda
• No Underestimation of any lesion
• DF infection

29. Contamination: the presence of non-replicating
organisms in the wound
All chronic wounds are contaminated
Colonization: the presence of replicating microorganisms
adherent to the wound in the absence of injury to the
host
Infection: the presence of replicating microorganisms
within a wound that cause host injury

30. Diagnosis of infection
1. Classic signs of inflammation (redness, warmth, swelling,
tenderness, or pain or purulent secretions,
2. Secondary signs (eg, nonpurulent secretions, friable or
discolored granulation tissue, undermining of wound edges,
foul odor)

31. HOW DO YOU KNOW WHEN A WOUND
IS INFECTED?
• Often asymptomatic - no pain due to
diabetic polyneuropathy
• May cause mild discomfort
• Disturbance of blood glucose control may be
early evidence of a local infection.
• The failure of the wound to heal and
progressive deterioration of the wound

32. Debride any wound that has necrotic tissue or
surrounding callus.
Assess Infected wound

33. • Mild infections are relatively easily
treated
• Moderate infections may be limb
threatening
• Severe infections may be life
threatening
WHY WE ARE IN NEED TO GRADE
INFECTION

34. •Guides selection and route of
administration of an antibiotic regimen.
•Decide the duration of treatment
•Helps to determine the need for
hospitalization.
WHY WE ARE IN NEED TO GRADE
INFECTION

35. Classification of foot wound infection
IDSA IWGDF
No symptoms , no signs of infectionGrade1
(no
infection)
Infection involving the skin and the
subcutaneous tissue
Presence of ≥2 of local manifestation of
inflammation
NO local or systemic complication
Grade2
(mild
infection)
≥ 1 of the following: Cellulitis extending >2cm,
Lymangitis, spread to deeper tissuees
NO systemic complication
Grade3
( moderate
infection)
Systemic toxicity and metabolic instabilityGrade4
(severe
infection)

36. No symptoms or signs of infection
GRADE 1(NO INFECTION)

37. • Infection involving the skin and the
subcutaneous tissue only
•
• Erythema > 0.5 - 2 cm around the
ulcer.
• NO involvement of deeper tissues
• NO systemic signs.
GRADE 2 (MILD INFECTION)

38. Infection involving structures deeper than
skin and subcutaneous tissues such as
abscess, osteomyelitis,
septic arthritis, fasciitis.
Erythema > 2 cm
No systemic inflammatory response
signs.
GRADE 3 (MODERATE INFECTION)

39. Any foot infection with signs of a systemic
inflammatory response syndrome (SIRS)
2 or more of the following :
1. Temperature > 38 or < 36°Celsius
2. Heart rate > 90 beats/min
3. Respiratory rate > 20 breaths/min
4. White blood cell count > 12.000 or <
4.000/cu mm
5. 10% immature (band) forms
GRADE 4 (SEVERE INFECTION)

40. 0 1 2 3
Pre or Post
ulcerative
lesion
(epithelialized)
Superficial
(not involving
tendons,
capsules or
bone).
Penetrates to
tendon or
capsule
Penetrates to
Bone.
Infection Infection Infection Infection
Ischemia Ischemia Ischemia Ischemia
Infection &
Ischemia
Infection &
Ischemia
Infection &
Ischemia
Infection &
Ischemia
A
B
C
D
University of Texas classification

41. Agenda
• No Underestimation of any lesion
• DF infection
• Dressings

42. Dressings have the
potential to deceive
both the doctor and
patient into
thinking that by
covering a wound
they were curing it
Dr. Paul Brand

43. • The old edict of keeping a wound dry and painting it with
antiseptics is no longer thought to be the treatment of choice

44. Mercurochrome
Topical antiseptic used for minor cuts
and scrapes.
No longer sold in the USA Mercury
content.
FDA ineffective, no longer
approved.
Dark red colour stains the skin
difficult detection of erythema or
inflammation

45. Wound Bed preparation
•Tissue non-viable
T
•InfectionI
•Moisture Balance
M
•Edges non-advancing
E

46. Moisture Balance
Insufficient moisture Excessive moisture
prevent epithelial
migration and matrix
deposition
inhibit cell proliferation and
breaks down matrix
components

47. What to put on a wound ?

48. •It is not what you put on the wound.
It is what you take Off
•Offloading is much more important
than dressing
•Even saline dressing can work well if
patient is properly offloaded

49. The Greatest Catastrophe
No Internist was there for this diabetic patient

50. THANK YOU