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== Background ==
==Background==
*75% of patients have polymicrobial infection, usu 70% are [[gram positive]]
**Severe limb/life threatening infection are more likely to involve [[gram negative]] aerobic & [[anaerobic bacteria]] as well.
**[[MRSA]] is increasing in frequency
*Ulcer depth is important predictor of healing rate, [[osteomyelitis]] (OM) & risk of amputation.
*Failure of ulcer to heal by 50% or more after 1 month of treatment is a strong predictor that the ulcer is unlikely to heal after 3 months.
*Recurrence or amputation is 50-70% over 3-5 yrs. Overall, 50-80% will heal within 6 months with optimal care.


*1st key factor is to assess extent & depth of ulcer (typically more extensive than they appear)  
==Clinical Features==
**Ulcer depth is important predictor of healing rate, osteomyelitis (OM) & risk of amputation.
[[File:PMC2788600 vhrm-5-949f1.png|thumb|Infection in ulcer bed with mild surrounding erythema (''not'' probe-able to bone)]]
*Failure of ulcer to heal by 50% or more after 1 month of Rx is a strong predictor that the ulcer is unlikely to heal after 3 mos.
[[File:PMC3464072 DFA-3-18693-g011.png|thumb|Classic diabetic plantar ulcer overlying the third metatarsal head with purulent drainage. Ability to probe to bone confirmed osteomyelitis.]]
*75% of pts hv polymicrobial inf, usu 70% are g+. Severe limb/life threatening inf are more likely to involve g- aerobic & anaerobic bacteria w/ g+. MRSA is incr in freq.  
[[File:Neuropathic heel ulcer diabetic.jpg|thumb|Neuropathic diabetic foot ulcer.]]
*50% or more of pts w/ SEVERE diabetic foot inf have no s/s of systemic tox (ie fever, tachy, incr wbc or Lt shift)
*[[Diabetes mellitus]] ulcers usually occur at areas of increased pressure (sole of foot) or friction
**Venous ulcers usually present above malleoli with irregular borders
**Arterial ulcers usually found on the toes or shins, with pale, "punched-out" borders (typically painful)
*Often history of minor/unnoticed trauma such as ill-fitting footwear
*Note hair and nail growth, determine vascular status (palpate DP, PT, and popliteal pulse)  
*Probe ulceration site, note involvement of bone, joint, tendon, or sinus tract formation
**Often more extensive than initially appear
**Use sterile probe, if hit bone chance of OM 90% higher
*+/- systemic symptoms (e.g. [[fever]], malaise)
*50% or more of patients with SEVERE diabetic foot infections will have no systemic signs and symptoms of infection (i.e. fever, tachycardia, leukocytosis, left shift)
 
*[[Diabetes mellitus]] foot ulcer infection presumed if:
**2 or more of following: erythema, warmth, tenderness, or swelling
**OR if pus coming from ulcer site or nearby sinus tract
*Severe diabetes mellitus foot infection if:
**Abnormal vital signs
**Rim of erythema surrounding ulcer or ulcer >2 cm in diameter
**Lymphangitic streaking or signs of fasciitis (crepitus, skip lesions, severe tenderness, bullae), or if probe reaches bone/joint/tendon
 
==Differential Diagnosis==
{{Foot infection}}


== HPI ==
{{Hyperglycemia DDX}}


*Ask about recent trauma
==Evaluation==
*Duration of current lesions
===Workup===
*Associated systemic symptoms
*Obtain ABI on all patients with: nonpalpable DP/PT, claudication symptoms, ischemic foot pain
*Prior treatments
**Consider vascular consult if abnormal:
***ABI <0.4 (severe obstruction)
***ABI 0.4-0.69 (mod obstruction)


== Physical Exam ==
====Labs====
*Chem 10, CBC, Coags, A1c, consider ESR/CRP (useful for monitoring response to treatment)
*ESR >40 increased chance of OM 12 fold, an ESR >70 makes diagnosis nearly certain.


*Determine ulcer location, dimensions, depth, and appearance
====Imaging====
*Note hair and nail growth, determine vascular status (palpate DP, PT, and popliteal pulse)
*X-rays to detect soft tissue gas, foreign body, OM, or structural foot deformities
*Probe ulceration note involvement of bone, joint, tendon, or sinus tract formation
**OM: x-ray changes occur late in disease, negative xrays do not exclude
**Use sterile probe, if hit bone chance of OM 90% higher
*MRI to eval for OM (not usually done in ED)
*DM foot ulcer infection presumed if:  
**2 or more of following: erythema, warmth, tenderness, or swelling
**OR if pus coming from ulcer site or nearby sinus tract
*Severe DM foot infection if:
**abnormal vital signs
**Rim of erythema surrounding ulcer or ulcer &gt;2 cm in diameter
**Lymphangitic streaking or signs of fasciitis (crepitus, skip lesions, severe TTP, bullae), or if probe reaches bone/joint/tendon
*Obtain ABI on all patients with: nonpalpable DP/PT, claudication sx, ischemic foot pain
**Call vascular if:
***ABI &lt;0.4 (severe obstruction)
***ABI 0.4-0.69 (mod obstruction)
*Reminder:
**DM ulcers usually occur at areas of increased pressure (sole of foot) or friction
**Venous ulcers usually present above malleoli with irregular borders
**Arterial ulcers usually found on the toes or shins, with pale, "punched-out" borders (typically painful)


== Diagnosis ==
===Diagnosis===
*Determine presence/extent of infection and likelihood of OM/fasciitis
*Consider Charcot arthropathy (diabetic neuropathic osteoarthropathy)
**commonly missed diagnosis
**requires different management (total contact cast, NWB)


Determine presence/extent of infection and likelihood of OM/fasciitis
====Likelihood of Osteomyelitis====
*Factors that increase likelihood of osteomyelitis:
**Visible bone or probe to bone
**Ulcer >2cm in size
**ESR >70
**Ulcer duration >2 weeks


=== Imaging ===
==Management==
===Non-infected chronic wounds<ref name="IDSA">2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections [http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/2012%20Diabetic%20Foot%20Infections%20Guideline.pdf full text]</ref>===
*Prophylactic antibiotics not indicated
*For clinically uninfected wounds, do not collect a specimen for culture
*Moist dressing to allow for healing and proper footwear to prevent worsening abrasions


*X-rays to detect soft tissue gas, FB, OM, or structural foot deformities
===Infected Wounds<ref name="IDSA"></ref>===
**OM x-ray changes occur late in dz, negative xrays do not exclude OM
*Consider wound culture prior to starting empiric antibiotic therapy. However cultures may be unnecessary for a mild infection in a patients who have not recently received antibiotic therapy.
*MRI to eval for OM (not usually done in ED)
*Coverage is targeted at [[MSSA]] + [[Streptococcus Genus|Strep]])
*Strict non-weight bearing, tight glycemic control, meticulous wound care


=== Labs ===
===Severe infection<ref name="IDSA"></ref>===
*Admit with surgical consult
*Empiric therapy directed at [[Pseudomonas aeruginosa]] is NOT necessary except for patients with risk factors for true infection with this organism
*[[MRSA]] coverage in a patient with a prior history of MRSA infection


*Chem 10, CBC, Coags, A1c, consider ESR/CRP (useful for monitoring response to Rx)
===[[Antibiotics]]===
*ESR &gt;40 incr chance of OM 12 fold, an ESR &gt;70 makes dx nearly certain.
{{Diabetic foot infection antibiotics}}


=== Likelihood of OM ===
==Disposition==
*Non-infected chronic wounds: outpatient management
*Infected Wounds: Low threshold for admission vs. outpatient management with antibiotics
*Severe infection: Admit with surgical consult


*Factors that increase likelihood of OM:
==See Also==
**Visible bone or probe to bone
*[[Foot diagnoses]]
**Ulcer &gt; 2cm in size
*[[Osteomyelitis]]
**ESR &gt;70
*[[Neuropathic pain]]
**Ulcer duration &gt; 2 weeks
*[[Wound care dressing basics]]


== Treatment ==
==External Links==


#For noninfected chronic wounds
##NWB, nonadherent padded dressing, ppx abx not indcated
#For DM foot infections @ HUCLA:
##Start pt on '''Diabetic Foot Infection with Wound (DFIW)''' pathway/order set '''(No ABX)'''
###Do not start pts on this pathway if have rapidly spreading infection or with severe sepsis/septic shock
##Primary management is surgical debridement, consult trauma surgery
#Empiric therapy for DM foot infections:
##Mild infxn outpt Rx, non-limb-threatening (MSSA + strep):
###'''Keflex''' 500mg Q6H OR '''Augmentin''' 875/125mg Q12H OR '''Dicloxacillin''' 500mg Q6H OR '''Clinda''' 450mg Q8H
###Strict NWB, tight glycemic control, meticulous wound care
##Severe infxn, limb-threatening (admit):
##'''Unasyn''' 3g IV Q6H OR '''Ticarcillin-clavulanate''' 3.1g IV Q8H OR '''Clinda''' 900mg IV Q6H AND '''Ciprofloxacin''' 400mg IV Q12H OR '''Clinda''' 900mg IV Q6H and '''Ceftriaxone''' 1g IV Q12H (add vanco if life threat)
#Recurrence of amp is 50-70% over 3-5 yrs. Overall, 50-80% will heal w/in 6 mos w/ optimal care.
#Goal for best reults is A1c level &lt;7%, BP &lt;130/80, no Etoh or smoking &amp; LDL &lt;100.


== Source ==
==References==
<references/>


*Tintinalli
[[Category:ID]]
*UpToDate
[[Category:Endocrinology]]
*PANI

Revisión actual - 16:29 10 sep 2020

Background

  • 75% of patients have polymicrobial infection, usu 70% are gram positive
  • Ulcer depth is important predictor of healing rate, osteomyelitis (OM) & risk of amputation.
  • Failure of ulcer to heal by 50% or more after 1 month of treatment is a strong predictor that the ulcer is unlikely to heal after 3 months.
  • Recurrence or amputation is 50-70% over 3-5 yrs. Overall, 50-80% will heal within 6 months with optimal care.

Clinical Features

Infection in ulcer bed with mild surrounding erythema (not probe-able to bone)
Classic diabetic plantar ulcer overlying the third metatarsal head with purulent drainage. Ability to probe to bone confirmed osteomyelitis.
Neuropathic diabetic foot ulcer.
  • Diabetes mellitus ulcers usually occur at areas of increased pressure (sole of foot) or friction
    • Venous ulcers usually present above malleoli with irregular borders
    • Arterial ulcers usually found on the toes or shins, with pale, "punched-out" borders (typically painful)
  • Often history of minor/unnoticed trauma such as ill-fitting footwear
  • Note hair and nail growth, determine vascular status (palpate DP, PT, and popliteal pulse)
  • Probe ulceration site, note involvement of bone, joint, tendon, or sinus tract formation
    • Often more extensive than initially appear
    • Use sterile probe, if hit bone chance of OM 90% higher
  • +/- systemic symptoms (e.g. fever, malaise)
  • 50% or more of patients with SEVERE diabetic foot infections will have no systemic signs and symptoms of infection (i.e. fever, tachycardia, leukocytosis, left shift)
  • Diabetes mellitus foot ulcer infection presumed if:
    • 2 or more of following: erythema, warmth, tenderness, or swelling
    • OR if pus coming from ulcer site or nearby sinus tract
  • Severe diabetes mellitus foot infection if:
    • Abnormal vital signs
    • Rim of erythema surrounding ulcer or ulcer >2 cm in diameter
    • Lymphangitic streaking or signs of fasciitis (crepitus, skip lesions, severe tenderness, bullae), or if probe reaches bone/joint/tendon

Differential Diagnosis

Foot infection

Skin and Soft Tissue

Deep Tissue / Limb-Threatening

Bone and Joint

Look A-Likes

Hyperglycemia

Diabetic Emergencies

Diabetes Mellitus (New or Known)

Medication/Drug-Induced

Physiologic Stress Response

  • Sepsis / critical illness (stress hyperglycemia — very common in the ED)
  • Trauma / major surgery / burns
  • Acute coronary syndrome / myocardial infarction
  • Stroke (especially hemorrhagic)
  • Pancreatitis (both a cause and consequence)
  • Shock (any etiology)
  • Pain (catecholamine surge)
  • Seizure (postictal)
  • Physiologic stress alone rarely causes glucose >200 mg/dL in non-diabetics; glucose >200 in a "stress response" should prompt evaluation for undiagnosed diabetes or prediabetes

Endocrine

Pancreatic

  • Pancreatitis (acute or chronic — destruction of islet cells)
  • Pancreatic malignancy (adenocarcinoma, neuroendocrine tumors)
  • Post-pancreatectomy
  • Cystic fibrosis-related diabetes
  • Hemochromatosis (iron deposition in pancreas — "bronze diabetes")

Toxic/Overdose

Other

  • Renal failure (chronic kidney disease, acute kidney injury — impaired insulin clearance AND insulin resistance)
  • Cirrhosis / hepatic failure (impaired glycogenolysis regulation)
  • Pregnancy (gestational diabetes, steroid administration for fetal lung maturity)
  • Parenteral nutrition (TPN, dextrose-containing fluids)
  • Post-transplant diabetes (immunosuppressants)

Complications of Diabetes (Not Causes of Hyperglycemia)

These are associated conditions that may be present alongside hyperglycemia but do not themselves cause elevated glucose:

Evaluation

Workup

  • Obtain ABI on all patients with: nonpalpable DP/PT, claudication symptoms, ischemic foot pain
    • Consider vascular consult if abnormal:
      • ABI <0.4 (severe obstruction)
      • ABI 0.4-0.69 (mod obstruction)

Labs

  • Chem 10, CBC, Coags, A1c, consider ESR/CRP (useful for monitoring response to treatment)
  • ESR >40 increased chance of OM 12 fold, an ESR >70 makes diagnosis nearly certain.

Imaging

  • X-rays to detect soft tissue gas, foreign body, OM, or structural foot deformities
    • OM: x-ray changes occur late in disease, negative xrays do not exclude
  • MRI to eval for OM (not usually done in ED)

Diagnosis

  • Determine presence/extent of infection and likelihood of OM/fasciitis
  • Consider Charcot arthropathy (diabetic neuropathic osteoarthropathy)
    • commonly missed diagnosis
    • requires different management (total contact cast, NWB)

Likelihood of Osteomyelitis

  • Factors that increase likelihood of osteomyelitis:
    • Visible bone or probe to bone
    • Ulcer >2cm in size
    • ESR >70
    • Ulcer duration >2 weeks

Management

Non-infected chronic wounds[1]

  • Prophylactic antibiotics not indicated
  • For clinically uninfected wounds, do not collect a specimen for culture
  • Moist dressing to allow for healing and proper footwear to prevent worsening abrasions

Infected Wounds[1]

  • Consider wound culture prior to starting empiric antibiotic therapy. However cultures may be unnecessary for a mild infection in a patients who have not recently received antibiotic therapy.
  • Coverage is targeted at MSSA + Strep)
  • Strict non-weight bearing, tight glycemic control, meticulous wound care

Severe infection[1]

  • Admit with surgical consult
  • Empiric therapy directed at Pseudomonas aeruginosa is NOT necessary except for patients with risk factors for true infection with this organism
  • MRSA coverage in a patient with a prior history of MRSA infection

Antibiotics

Associated organisms include Staphylococcus, Streptococcus, Enterococcus, Enterobacteriaceae, Proteus, Bacteroides, and Pseudomonas, and Klebsiella

Superficial Mild Infections

Prior antibiotic treatment or moderate infections

Inpatient Treatment

Disposition

  • Non-infected chronic wounds: outpatient management
  • Infected Wounds: Low threshold for admission vs. outpatient management with antibiotics
  • Severe infection: Admit with surgical consult

See Also

External Links

References

  1. ↑ 1.0 1.1 1.2 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections full text
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