For nternal Use Only

Diabetic foot
Infections
'Diabetics Should
Treat their Feet like they do their Face'
Introduction
Foot infections - among the most frequent and
serious consequences of diabetes mellitus
Responsible for more hospital days than any
other complication of diabetes
Dealing with this problem will require both, a
greater understanding of the pathophysiology of
these infections and better systems for
implementing proven effective measures
Lipsky BA. Diabetes Metab Res Rev 2004
Definition
nternational Consensus on Diagnosing and
Treating the nfected Diabetic Foot (2003)
ny infection invoIving the foot in a person with
diabetes originating in a chronic or acute injury to
the soft tissues of the foot, with evidence of pre-
existing neuropathy and/or ischemia
Berendt and Lipsky 2003, for FDA ADAC
!athogenesis of Diabetic foot
Multi-factorial, Complex and still poorly
understood
europathy
VascuIopathy
Immune dysfunction
Infection
!rolonged Hyperglycemia contributes to all the
above factors through different mechanisms
Lipsky B, Clinical nfectious Diseases 2004
europathy
Sensory
Loss of protective sensation
Loss of position sense
Motor
MuscIe weakness
Foot deformity
utonomic
!oor bIood fIow reguIation
Dry, stiff skin
Unaware of minor
cuts/bruises
!oor weight
distribution
Cracked skin
aIIows easy
entry of bacteria
Ulbrecht SJ, Clinical nfectious Diseases 2004
Forefoot uIcer due to europathy
InappropriateIy
high pressure
distribution
Ulbrecht SJ, Clinical nfectious Diseases 2004
VascuIopathy
Accelerated Atherosclerosis
Diabetes
Hypertension
Obesity
ge
DysIipidemia
Decreased
local blood flow
!oor
wound
healing
!oor
antibiotic
penetration
Watkins !J, BMJ 2003
%ypicaI uIcer due to poor circuIation
Watkins !J, BMJ 2003
HeeI uIcer is typicaI of poor bIood
circuIation due to vascuIopathy
MicrobioIogy of Diabetic foot
!oIymicrobiaI
Serious infections in hospitaIized patients are often caused by
3-5 bacteriaI species
erobes
Gram-positive cocci
S. aureus is the most important pathogen
nterococci in patients who have previousIy received a
cephaIosporin
Gram-negative baciIIi
39erobac9eriaceae in patients with chronic or previousIy treated
infections
!seudomo3as species in patients with wounds that have been
soaked or treated with wet dressings
naerobes
Wounds with ischemic necrosis or that invoIve deep tissues
Lipsky B, Clinical nfectious Diseases 2004
CIassification
Wagner's
CIassification of
Diabetic UIcer
Armstrong DG, Diabetes Care 1998
GRD 0-- I%C%
SKIImpending UIcer)
GRD 1- SU!RFICIL ULCRS
GRD 2- D! %O %DO
BO OR LIGM%
GRD 3- OS%OMYLI%IS
GRD 4- GGR OF %O
OR FOO%
GRD 5- GGR OF
%IR FOO%
!rincipIes of Management
Multidisciplinary approach
MedicaI
SurgicaI
Orthopedics
valuation of the patient
Look for danger signs needing urgent
intervention
Good Blood glucose control
Long term care after wound healing is complete
ducation and preventive foot care
Watkins !J, BMJ 2003
Danger signs for Urgent action
Redness and swelling of a foot indicates a
developing abscess, and urgent surgery may be
needed to save the leg
Cellulitis, discoloration, and crepitus (gas in soft
tissues)
!ink, painful, pulseless foot even without
gangrene indicates critical ischaemia that needs
urgent arterial investigation followed by surgical
intervention whenever possible
Foot can be saved only if there is good blood
supply
Watkins !J, BMJ 2003
!rincipIes of %reatment
SurgicaI debridement
Drain pus and abscess cavities and to remove all necrotic and
infected tissue including devitalised and infected bone resulting
from osteomyelitis
radication of infection
Antibiotic choices should optimally be based on results of culture
f empirical therapy is necessary, it should cover S. aureus and
anaerobes
Broader coverage should be considered based on the history &
clinical judgment
Reduction of weight bearing forces
Bed rest with foot raised
Lipsky BA, Diabetes Metab Res Rev 2004 Ulbrecht SJ, Clinical nfectious Diseases 2004
!revention
Regular foot exams and patient education can
prevent 85% of amputations
Four Basic Steps for !reventive Foot care
arIy identification of the high risk diabetic foot
arIy diagnosis of foot probIems
arIy intervention to prevent further deterioration
that may Iead to amputation
!atient education for proper care of the the feet
and footwear
Ulbrecht SJ, Clinical nfectious Diseases 2004
Care of feet in a diabetic
1 . Any injury has to be avoided
2 microcellular rubber (mcr) footwear must be
used
3 feet has to be kept clean and dry, especially
the toes and clefts
4 hyperkeratosis has to be avoided
Summary
Foot ulceration, sepsis, and amputation are
known and feared by almost every person who
has diabetes diagnosed
Yet these are potentially the most preventable of
all diabetic complications by the simplest
techniques of education and care
The majority can also be cured by immediate
and energetic treatment
Watkins !J, BMJ 2003
%HK YOU
!repared By
Dr. Shailendra Yadav
(JR-1 General Surgery)