Learning Objectives: At the conclusion of this presentation, the - PDF document

4/12/2018 CARING FOR THE DIABETIC FOOT ULCER/INFECTION IN RURAL OKLAHOMA Stephanie Mowdy, APRN,CNS,DNP, CWOCN,CDE, CFCN Learning Objectives: At the conclusion of this presentation, the participant will be able to: State the prevalence of diabetic foot ulcers/infections 1. within the nation, the state and rural Oklahoma regions. Identify evidenced-based recognized pathways for the 2. treatment of a diabetic foot ulcer/infection. Identify recommended antimicrobials and 3. administration recommendations for treatment of the diabetic foot infection. Identify supplemental treatments, including additional 4. pharmacological support for the management of a diabetic foot ulcer/infection. Diabetic Foot Ulcer (DFU) • Neuropathy • A foot with damage to • Loss of sensation, foot the vascular and deformities, increased risk of injury nervous systems • Peripheral Vascular Disease • Decreased blood flow, lack of oxygen • Ulceration • Infection • Decreased social, physical, and mental function Lipsky, et al. 2012, Searle, Campbell, Tallon, Fitzgerald & Vedhora, 2005 1

4/12/2018 BACKGROUND AND SIGNIFICANCE How Serious is a Diabetic Foot Ulcer? Diabetes Mellitus and Foot Ulcer Incidence • 29.1 million Americans affected • Incidence of 5.3% to 25% of the diabetic population • 1.4 million Americans diagnosed each year • Constant for 10 years • 73,000 Americans with a lower • Precedes lower extremity extremity amputation per year amputation in 60% to 85% of due to diabetes cases • Loss of one limb every 30 • Recurrence rates of 57.5% seconds within 3 years Hsu, Chang,Chen, Lin, & Chen, 2015 Kumari & Subash, 2013; American Diabetes Association (ADA), 2016 Madanchi et al. 2013 DFU Consequences • Overall mortality: 2% • Sepsis: 9.6% • 5-year mortality: 39%-80% • Hospital stays: More than any other diabetes related complication Skrepnek, Mills, & Armstrong, 2015 Yarwood-Ross & Randall, 2013 2

4/12/2018 The DFU in a Rural Setting Rural person with diabetes Oklahoma is at greater risk • 11.5% incidence of diabetes • 264.3% increase in incidence • Greater risk of development of DFU (1994-2013) • Greater risk of recurrence • 1,840 amputations per year • 51.3% greater risk of amputation • Rural Oklahoma • Limited access to care • 11.9% to 15.9% incidence • Decreased use of evidenced-based medicine Amputee Coalition, 2016 Lesens et al., 2010 Centers for Disease Control, n.d. Skrepnek, Mills, & Armstrong, 2015 Oklahoma State Department of Health, 2014 Poverty and the Underinsured in Southeastern Oklahoma 9 counties within service area • Poverty Level: 15.3% to 25.1% • Medicare: 65% • Medicaid: 18% • Private Insurance: 10% • Indigent: 7% Oklahoma State Department of Health , United States Census Bureau, n.d. Rural Populations • Wang, Balamurugan, Biddle, & • Lower levels of education Rollins (2011) • Poorer • Increased neuropathy in rural • Less preventative care activities population with underserved • Lack of health insurance provision of health care coverage • Increased risk for DFU • Inadequate health insurance development coverage • Hale et al., (2010) • Less interest in life-style • Extended healing time in rural alteration location • Increased manual labor with increased foot trauma Hale et al., 2010 Sriyani et al., 2013 • Bouldin et al., (2015) U. S. Department of Health and Human Services [HHS], 2013 • Less outpatient visits for care • More inpatient visits for care 3

4/12/2018 Improving Outcomes of Care in a Rural Setting • Early recognition • Standardized protocol • Multidisciplinary team • Evidenced-based clinical practice guidelines Nube, Veldoen, Frank, Bolton & Twigg, 2014 Sanders et al., 2013; Yan, Liu, Zhou & Sun, 2014 Clinical Practice Guidelines • Systemically • Provider belief in developed statements usefulness • Built upon evidenced- • Low adherence to based medicine usage • Designed to improve • Range of adherence quality of health care from 30% to 50% • Offer the best treatment possible for a specific condition Austad, Hetlevik, Mjolstad, & Helvick, 2016 Schiffen, 2016 Basdow, Runciman, Lipworth, & Easterman, 2016 Mahe, Chidia, Heifer, & Noble, 2016 Diabetic Foot Ulcer Treatment • Evidenced-based • Decrease time to clinical practice healing guidelines • Decreased risk of • Metabolism osteomyelitis • Infection • Reduction in lower • Circulation extremity amputations • Pressure • Pain Mehica, Gershater, & Raijer, 2013 Austad, Hetlevik, Mjolstad, & Helvik, 2016 Nube et al., 2014 Seroussi et al., 2013 Sanders, et al,, 2013 4

4/12/2018 Time to Heal • Therapy Goal: 12 weeks or less • Index of Wound Healing: 50% reduction in size at 4 weeks • Average Time without specialty care: 49 weeks • Least Time: 21 days Sanders et al., 2013 Schaper, Van Netton, Apelqvist, Lipsky, & Baker, 2016 Warriner, Snyder, & Cardinal, 2011 REVIEW OF THE LITERATURE Clinical Practice Guidelines Recognized Evidenced-Based Clinical Practice Guidelines for Treatment of a DFU • Infectious Disease Society of America • International Working Group on the Diabetic Foot Ulcer • Society of Vascular Surgery • Registered Nurses’ Association of Ontario Hingorani et al., 2016 Lipsky et al., 2012 Markakis et al., 2016 Registered Nurses Association of Ontario, 2013 5

4/12/2018 Diabetic Foot Ulcer Pathophysiology • Sensory Neuropathy • Peripheral Vascular Disease • Lack of sensation • Calcification of small • Motor Neuropathy vessels • Small muscle wasting, • Poor collateral atrophy circulation • Abnormal walking patterns • Limited joint mobility • Subcutaneous hemorrhages • Autonomic Neuropathy Markakis, Bowling, & Boulton, 2016 Schaper et al., 2016 Tiaka, Papanas, manolakis, & Maltezos, 2012 Diabetic Foot Infection • Colonization of all DFUs • Diagnosis of osteomyelitis • Polymicrobial • MRI: highest sensitivity • Contiguous spread to and specificity bone • CT Scan • Development of • Nuclear Medicine Bone Scan osteomyelitis • Erythrosedimenation Rate: > 70 • C-reactive Protein: >14 • Ulcer size: > 2 cm • Bone culture Dunyach-Remy et al., 2016 Khodcee, Montoya, & Guthman, 2015 Markakis et al., 2016 Delayed Wound Healing Physiology • Hypoxic, inflammatory environment • Low growth factor activity • Reduced cellular proliferation • Elevated inflammatory markers • High levels of proteases • Bacterial virulence and host response Dunyach-Remy, 2016 6

4/12/2018 Evidenced-based Components of Wound Care • Offloading • Establishment of adequate perfusion • Aggressive treatment of infection • Sharp debridement • Wound bed Preparation • Advanced Topical Therapy • Overall metabolic control • Multidisciplinary Approach Game et al. , 2012 Hingorani et al., 2016 Schaper et al., 2016 Ulcer Classification • Wagner Scale • IDSA • Ulcer depth • Non infected • Osteomyelitis • Mild • Gangrene • Moderate Severe Chaun, Tang, Jiang, Zhou, & He, 2015 Lipsky, 2012 Infection Definitions: Culture Technique • Contaminated • Swab • Colonized • Deep Tissue • Critical colonization • Bone Biopsy • Infection • Percutaneous Bone • Biofilm Culture Lesens 2010 Lipsky et al., 2012 Pence et al., 2014 Chadwick 2015 7

4/12/2018 Antimicrobial Choice Assessment/Choice Length of Therapy : • Infection severity • Mild: 1 to 2 weeks • Previous antibiotic use • Deeper: 2 to 4 weeks • Wound pathophysiology • Osteomyelitis 6 weeks • Common area pathogens • Route: PO, IV, IM • Local resistance patterns • Avoid empiric coverage Banu, Hassan, Rajkumar, & Srivivasa, 2015 • Too broad Pence et al., 2014 • MRSA Schaper et al.,, 2013 Schaper et al., 2016 • Pseudomonas Antimicrobial Classes • Beta Lactams • Aminoglycosides • Cephalosporins • Sulfonamides • Carbapenems • Trimethoprim • Tetracyclines • Quinolones • Clindamycin • Rifampin Beta Lactams • Interfere with bacterial wall • Not often used alone in DFU synthesis • Inactivated by B-lactamases • Organisms: MSSA, • Renal Adjustment : Streptococci, Meningococci, • Renal Insufficiency enterococci, Non-B- • Adverse Reactions: lactamase producing • Relatively nontoxic staphylococci, gram-positive • Hypersensitivity Reactions rods • Cross-sensitizing and Cross • Route : Oral, IM, IV Reacting • Orally poorly absorbed • Nausea, vomiting, diarrhea • Dosage : 4 to 24 million • Secondary fungal infection units/day • Anaphylactic shock • Do not take within 1 to 2 hours • Less than 1% who claim reaction of eating are actually allergic Chambers 2007 Schlect & Bruno, 2018 8