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

4/12/2018 1

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:

1.

State the prevalence of diabetic foot ulcers/infections within the nation, the state and rural Oklahoma regions.

2.

Identify evidenced-based recognized pathways for the treatment of a diabetic foot ulcer/infection.

3.

Identify recommended antimicrobials and administration recommendations for treatment of the diabetic foot infection.

4.

Identify supplemental treatments, including additional pharmacological support for the management of a diabetic foot ulcer/infection.

Diabetic Foot Ulcer (DFU)

• A foot with damage to

the vascular and nervous systems

• Neuropathy
• Loss of sensation, foot

deformities, increased risk of injury

• Peripheral Vascular Disease
• Decreased blood flow, lack
• f oxygen
• Ulceration
• Infection
• Decreased social, physical,

and mental function

Lipsky, et al. 2012, Searle, Campbell, Tallon, Fitzgerald & Vedhora, 2005

4/12/2018 2

BACKGROUND AND SIGNIFICANCE

How Serious is a Diabetic Foot Ulcer?

Diabetes Mellitus and Foot Ulcer Incidence

• 29.1 million Americans affected
• 1.4 million Americans diagnosed

each year

• 73,000 Americans with a lower

extremity amputation per year due to diabetes

• Loss of one limb every 30

seconds

American Diabetes Association (ADA), 2016

• Incidence of 5.3% to 25% of the

diabetic population

• Constant for 10 years
• Precedes lower extremity

amputation in 60% to 85% of cases

• Recurrence rates of 57.5%

within 3 years

Hsu, Chang,Chen, Lin, & Chen, 2015 Kumari & Subash, 2013; 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

4/12/2018 3 The DFU in a Rural Setting

Rural person with diabetes is at greater risk

• Greater risk of development of DFU
• Greater risk of recurrence
• 51.3% greater risk of amputation
• Limited access to care
• Decreased use of evidenced-based

medicine

Lesens et al., 2010 Skrepnek, Mills, & Armstrong, 2015

Oklahoma

• 11.5% incidence of diabetes
• 264.3% increase in incidence

(1994-2013)

• 1,840 amputations per year
• Rural Oklahoma
• 11.9% to 15.9% incidence

Amputee Coalition, 2016 Centers for Disease Control, n.d. 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, &

Rollins (2011)

• Increased neuropathy in rural

population with underserved provision of health care

• Increased risk for DFU

development

• Hale et al., (2010)
• Extended healing time in rural

location

• Increased manual labor with

increased foot trauma

• Bouldin et al., (2015)
• Less outpatient visits for care
• More inpatient visits for care
• Lower levels of education
• Poorer
• Less preventative care activities
• Lack of health insurance

coverage

• Inadequate health insurance

coverage

• Less interest in life-style

alteration

Hale et al., 2010 Sriyani et al., 2013

• U. S. Department of Health and Human Services [HHS],

2013

4/12/2018 4

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

developed statements

• Built upon evidenced-

based medicine

• Designed to improve

quality of health care

• Offer the best

treatment possible for a specific condition

Austad, Hetlevik, Mjolstad, & Helvick, 2016 Schiffen, 2016

• Provider belief in

usefulness

• Low adherence to

usage

• Range of adherence

from 30% to 50%

Basdow, Runciman, Lipworth, & Easterman, 2016 Mahe, Chidia, Heifer, & Noble, 2016

Diabetic Foot Ulcer Treatment

• Evidenced-based

clinical practice guidelines

• Metabolism
• Infection
• Circulation
• Pressure
• Pain

Austad, Hetlevik, Mjolstad, & Helvik, 2016 Seroussi et al., 2013

• Decrease time to

healing

• Decreased risk of
• steomyelitis
• Reduction in lower

extremity amputations

Mehica, Gershater, & Raijer, 2013 Nube et al., 2014 Sanders, et al,, 2013

4/12/2018 5 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

4/12/2018 6 Diabetic Foot Ulcer Pathophysiology

• Sensory Neuropathy
• Lack of sensation
• Motor Neuropathy
• Small muscle wasting,

atrophy

• Abnormal walking

patterns

• Limited joint mobility
• Subcutaneous

hemorrhages

• Autonomic Neuropathy
• Peripheral Vascular

Disease

• Calcification of small

vessels

• Poor collateral

circulation

Markakis, Bowling, & Boulton, 2016 Schaper et al., 2016 Tiaka, Papanas, manolakis, & Maltezos, 2012

Diabetic Foot Infection

• Colonization of all DFUs
• Polymicrobial
• Contiguous spread to

bone

• Development of
• steomyelitis

Dunyach-Remy et al., 2016

• Diagnosis of
• steomyelitis
• MRI: highest sensitivity

and specificity

• CT Scan
• Nuclear Medicine Bone Scan
• Erythrosedimenation Rate:

> 70

• C-reactive Protein: >14
• Ulcer size: > 2 cm
• Bone culture

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

4/12/2018 7

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
• Ulcer depth
• Osteomyelitis
• Gangrene
• IDSA
• Non infected
• Mild
• Moderate Severe

Chaun, Tang, Jiang, Zhou, & He, 2015 Lipsky, 2012

Infection

Definitions:

• Contaminated
• Colonized
• Critical colonization
• Infection
• Biofilm

Chadwick 2015

Culture Technique

• Swab
• Deep Tissue
• Bone Biopsy
• Percutaneous Bone

Culture

Lesens 2010 Lipsky et al., 2012 Pence et al., 2014

4/12/2018 8 Antimicrobial Choice

Assessment/Choice

• Infection severity
• Previous antibiotic use
• Wound pathophysiology
• Common area pathogens
• Local resistance patterns
• Avoid empiric coverage
• Too broad
• MRSA
• Pseudomonas

Length of Therapy:

• Mild:

1 to 2 weeks

• Deeper:

2 to 4 weeks

• Osteomyelitis

6 weeks

• Route:

PO, IV, IM

Banu, Hassan, Rajkumar, & Srivivasa, 2015 Pence et al., 2014 Schaper et al.,, 2013 Schaper et al., 2016

Antimicrobial Classes

• Beta Lactams
• Cephalosporins
• Carbapenems
• Tetracyclines
• Clindamycin
• Aminoglycosides
• Sulfonamides
• Trimethoprim
• Quinolones
• Rifampin

Beta Lactams

• Interfere with bacterial wall

synthesis

• Organisms: MSSA,

Streptococci, Meningococci, enterococci, Non-B- lactamase producing staphylococci, gram-positive rods

• Route: Oral, IM, IV
• Orally poorly absorbed
• Dosage: 4 to 24 million

units/day

• Do not take within 1 to 2 hours
• f eating
• Not often used alone in DFU
• Inactivated by B-lactamases
• Renal Adjustment:
• Renal Insufficiency
• Adverse Reactions:
• Relatively nontoxic
• Hypersensitivity Reactions
• Cross-sensitizing and Cross

Reacting

• Nausea, vomiting, diarrhea
• Secondary fungal infection
• Anaphylactic shock
• Less than 1% who claim reaction

are actually allergic

Chambers 2007 Schlect & Bruno, 2018

4/12/2018 9 Extended-Spectrum Penicillins

• Mechanism of Action:

Interfere with bacterial wall synthesis

• Organisms: Same as

penicillins with more activity against gram negatives

• Route: PO or IV
• Drugs:
• Aminopenicillons
• Ampicillin (250 to 500mg four

times daily)

• Amoxicillin (250 to 500 mg three

times daily)

• Carboxypenecillins
• Ticarcillin 3 grams every 4 to 6

hours)

• Ureidopenicillins active

against gram negative bacilli

• Pipercillin (3 to4 grams every 4

to 6 hours)

• Includes Klebsiella

pneumoniae

• Antipseudomonal penicillin
• Given in combination with

aminoglycoside or fluoroquinolone

• Adverse Reactions
• Similar to penicillin
• Renal Adjustment
• Similar to penicillin

Chambers 2007 Schlect & Bruno, 2018

B-Lactamase Inhibitors

• Addition to the Beta-

lactam drugs to extend activity against B- lactamase producing strains

• Clavulanic acid
• 500/125 ( 875-125 two times

daily)

• Sulbactam
• Tazobactam
• Inhibit the B-lactamase by

have very weak antibacterial action alone

Chambers 2007 Schlect & Bruno, 2018

Cephalosporins

• Similar to penicillin
• More stable to many bacterial B-lactamases
• Broader spectrum of activity
• E. coli and Klebsiella not expressing extended-spectrum

B-lactamases

• Not active against enterococci
• Lack of activity against gram-negative bacilli
• Lack of activity against MRSA (except for 5th generation

ceftaroline)

• Five generations

Chambers 2007 Schlect & Bruno, 2018

4/12/2018 10

Cephalosporin 1st and 2nd Generations

• 1st Generation:
• Gram positive cocci,

pneumococci, streptococci, staphylococci

• Sensitive for E. coli, Klebsiella

pneumoniae, and Proteus miralbus

• No activity for enterococci or

Pseudomonas aeruginosa

• Uncomplicated skin and soft

tissue infections

• Cephalexin, cefadroxil,

cefazolin

• Route: PO or IV
• 2nd Generation:
• Active against organisms

from 1st generation plus some extended gram negative coverage, Bacteroides coverage

• Marked individual differences

between drugs in this class

• No activity for enterococci or
• P. aeruginosa
• PO (Cefuroxime) or IV

(Cefoxitin, Cefotetan, Cefuroxime)

• Often used with polymicrobial

Chambers 2007 Schlect & Bruno, 2018

3rd and 4th Generation Cephalosporins

• 3rd Generation
• Organisms:Haemophilus influenzae and

some Enterobacteriaceae ( Escherichia coli, Klebsiella pneumoniae, Proteus mirabilis) that do not produce ampC β- lactamase or extended-spectrum β- lactamase (ESBL)

• Pseudomonas aeruginosa (Ceftazidime)
• IV only
• Varying half-lives between drugs
• Oral cefixime and ceftibuten have little activity

against S. aureus

• Most often used for : Polymicrobial infections

involving gram-negative bacilli and gram- positive cocci (e.g. intra-abdominal sepsis

• May begin to see decreasing activity against

gram positive organisms

• 4th generation
• Gram positive cocci, Gram-

negative bacilli (enhanced activity), including P. aeruginosa (similar to ceftazidime), ESBL- producing K. pneumoniae and E. coli, and ampC β-lactamase– producing Enterobacteriaceae, such as Enterobacter sp

• Most often used for :

Polymicrobial infections involving gram-negative bacilli and gram- positive cocci (eg, intra-abdominal sepsis

• May begin to see decreasing

activity against gram positive

• rganisms

Chambers 2007 Schlect & Bruno, 2018

5th Generation Cephalosporins

• Ceftaroline
• Effective against MRSA

and E. faecalis

• Not effective against

Pseudomonas

• Similar to 3rd and 4th

generations

• Adverse Reactions
• Hypersensitivity
• Rash most common
• Pain at injection site with

IM

• Cross reactions/cross

senility rare

• Leukopenia
• Thrombocytopenia
• Positive Coombs Test

Chambers 2007 Schlect & Bruno, 2018

4/12/2018 11 Cephalosporins by Generation

1st 2nd 3rd 4th 5th Cefadroxil (PO) Cefoxitin (IV) Cefotaxime (IV) Cefipime (IV) Ceftaroline Cephalexin (PO) Cefotetan (IV) Ceftazidime (IV) Cephradine(P O) Cefuroxime (IV) Cefriaxone (IV, IM) Cefazolin (IV) Cefprozil (PO) Ceftbuten (PO) Cefaclor(PO) Cefuroxmine (PO) Cefpodoxime (PO)

Clindamycin

• Bacteriostatic,

lincosamide antibiotic

• Similar to

macrolides(erythromycin)

• Mechanism of Action:

Inhibits bacterial protein synthesis; penetrates well into abscesses

• Previously common for

CA-MRSA

• Increasing resistance
• Anaerobic infections,

including bacteroides

• Route: PO or IV
• Dosage: 0.15-0.3

grams every 8 hours

• Renal Adjustment:
• No adjustment
• Adverse Reactions:
• Diarrhea, nausea
• Skin rash
• Impaired liver function
• Enterocolitis with

Clostridium difficile

Chambers 2007 Schlect & Bruno, 2018

Sulfonamides

• Mechanism of Action: Analog of

PABA, inhibit dyhdyropteroate and folate synthesis; Synthetic bacteriostatic

• Orally absorbed, widely distributed,

metabolized by liver, excreted by kidney

• Broad spectrum gram positive and

gram-negative

• Wide-spread resistance
• Most often used with other drugs
• Do not eradicate Strep A
• Sulfamethoxazole/trimethoprim;

Combined together enhances drug activity and inhibits folate synthesis

• Route:
• IV, Oral (sulfamethoxazole)
• Topical (Silvadene)
• Dosage: 1 or 2 tablets bid
• Renal Adjustment:
• Decrease by 50 percent
• Adverse Reactions:
• Hypersensitivity
• Stevens-Johnson Syndrome
• Toxic Epidermal Necrolysis
• Vasculitis
• Angioedema
• Crystalluria, oliguria, anuria
• Photosensitivity
• Thrombocytopenia, Agranulocytosis
• Insomnia, Headache

Chambers 2007 Schlect & Bruno, 2018

4/12/2018 12 Fluoroquinolones

• Mechanism of Action: Bactericidal

by blockage of DNA synthesis

• Metabolized in liver, excreted in urine,
• ften reach high levels in the urine
• Wide variety of gram positive and

gram negative

• Initially developed for gram-negative

bacteria (Cipro most active)

• Often not effective for MRSA
• Older: ciprofloxin, norfloxin, and
• floxin with little activity against

streptococci and anaerobes

• Increasing resistance to

Enterobacteriaceae, P. aeruginosa, S. pneumoniae, and Neisseria sp

• Newer: levofloxin, gemifloxin, and

moxifloxin will address streptococci and some anaerobes

• Levofloxin most active against gram-

positive

• Route: PO or IV
• Dosage:
• Older: Twice daily
• Newer: Once daily
• Renal Adjustment
• Reduce for impaired kidney function

creatinine clearance less than 50mL/min

• Dose based upon degree of impairment
• Adverse Reactions:
• Nausea, vomiting
• Peripheral neuropathy
• Strong association with Clostridium

difficile–associated

• Prolongation of QT interval

Chambers 2007 Schlect & Bruno, 2018

Doxycycline

• Bacteriostatic
• Mechanism of Action: bind to

the 30S subunit of RNA and inhibit protein synthesis

• Broad spectrum
• Aerobes
• Anaerobes
• Gram-positive
• Gram-negative
• Resistance due to efflux active

transport pump

• Doxycycline most often given for

MRSA, but minocycline most studied

• Route: PO
• Dosage: 100 mg two times daily
• Renal Adjustment
• None for doxycycline,
• Adjust for other tetracyclines
• Adverse Reactions:
• Will chelate with metals
• Do not give with milk, antacids, or

ferrous sulfate

• Food will not affect doxycycline

absorption

• Photosensitivity
• Candidiasis
• Do not give under age 8

Chambers 2007 Schlect & Bruno, 2018

Carbapenems

• Bactericidal
• B-lactams:imipenem, meropenem,

doripenem, and ertapenem

• Mechanism of Action: Broad spectrum:

Haemophilus influenzae, Anaerobes, Most Enterobacteriaceae (including those that produce ampC β-lactamase and extended- spectrum β-lactamase [ESBL], Methicillin- sensitive staphylococci and streptococci, S. pneumoniae

• methicillin-resistant staphylococci are

resistant

• Enterococcus faecalis and many P.

aeruginosa strains are resistant to ertapenem

• Often used with multidrug resistant

hospital-acquired bacteria

• Route: IV
• Dosage:
• Ertapenem longest half-life and may be given
• nce daily ( 1 gram)
• Merrum: 1.5 to 6 grams daily divided every 8

hours

• Adverse Reaction:
• Seizure activity
• Nausea, vomiting, diarrhea
• Skin Rash
• Reaction at injection site
• Renal Dosing
• Seizure activity
• Imipenem most likely to cause seizure activity

Chambers 2007 Schlect & Bruno, 2018

4/12/2018 13 Vancomycin

• Only effective against gram positive
• rganisms
• Mechanism of Action: Bactericidal,

Inhibits cell wall synthesis

• Drug of choice for:
• Methicillin-resistant S. aureus
• Methicillin-resistant coagulase-negative

staphylococci

• Certain β-lactam– and multidrug-resistant

Streptococcus pneumoniae

• β-Hemolytic streptococci (when β-lactams

cannot be used because of drug allergy or resistance)

• Corynebacterium group JK
• Viridans streptococci (when β-lactams cannot

be used because of drug allergy or resistance)

• Enterococci (when β-lactams cannot be used

because of drug allergy or resistance)

• Route: IV
• Dosage:
• Renal Dosing
• Excreted unchanged by glomerular filtration
• Decrease dose in renal insufficiency
• Adverse Effects:
• Hypersensitivity
• Red Man Syndrome
• Rash or fever when given for greater than 2

weeks

• Neutropenia and thrombocytopenia Usually

reversible)

• Nephrotoxicity (actually reported as rare)
• Ototoxicity
• Phlebitis

Chambers 2007 Schlect & Bruno, 2018

Daptomycin

• Similar to Vancomycin
• Mechanism of Action: Binds

and polarizes cell membrane resulting in rapid efflux of K+ from the cell and cell death

• More rapidly bactericidal
• Active against Vancomycin-

resistant strains of enterococci

• Active against intermediate-

and resistant-strains of S. aureus

• No cross-class resistance
• Route: IV
• Dosage 4mg/kg/day soft

tissue infection

• 6mg/kg/day bacteremia
• Renal Adjustment:
• Excreted through kidneys
• Every other day for CrCl less

than 30/mLmin

• Adverse reactions:
• Myopathy muscle weakness
• Creatinine kinase weekly
• Eosinophilic pneumonia

Chambers 2007 Schlect & Bruno, 2018

Linezolid

• Bacteriostatic, but bactericidal for

streptococci

• Mechanism of Action: Synthetic

antimicrobial, Inhibit protein synthesis

• Indicated for skin and soft tissue

infections

• Reserve for treatment of multi-drug

resistant gram-positive bacteria

• Approved for treatment of vancomycin-

resistant E faecium

• Route: PO or IV
• Dosage:
• 600 mg two times daily
• Dosage Adjustments:
• Do not use concurrently with persons
• n MAOI, SSRI or SNRI—serotonin

syndrome

• May stop if need linezolid, monitor for

serotonin syndrome for 2 weeks after stopping

• Do not give in uncontrolled

hypertension

• Adverse Reactions
• Serotonin syndrome
• Thrombocytopenia (reversible)
• Neutropenia, anemia
• Monitor CBC weekly with long term

therapy

• Irreversible periperpheral neuropathy
• Reversible optic neuropathy

Chambers 2007 Schlect & Bruno, 2018

4/12/2018 14 Gentamycin

• Aminoglycoside
• Bactericidal
• Mechanism of Action: Irreversible

inhibitor of protein synthesis

• Gram negative bacillary enteric bacteria
• Almost always used with B-lactam

antimicrobial to cover gram positive and increase synergism

• Little activity against anaerobes
• Route: IV
• One to three times daily
• Dosage:
• 5 mg/kg dose
• Achieve drug level of 1mcg/mL 18 to 24

hours after infusion

• Concentration-dependent killings
• Post antibiotic effect
• Must monitor trough levels: > 2mcg/ml

predictive of toxicity

• Renal Adjustment:
• Decrease dose based upon creatinine

clearance

• Avoid use with other nephrotoxic

antimicrobials and loop diuretics

• Adverse Reactions:
• Toxicity is both time and concentration

dependent

• Ototoxicity (hearing and balance)
• Nephrotoxicity

Chambers 2007 Schlect & Bruno, 2018

Flagyl

• Bactericidal
• Mechanism of Action:

Enters cell wall and disrupts DNA synthesis

• Effective against

anaerobes, bacteroides, and clostridium species

• Consider gas gangrene
• Often used for obligate

anaerobes

• Given with other

antimicrobials

• Route: PO or IV
• Dose: 500 mg three times

daily

• Dosage Adjustment:
• Not indicated in renal

insufficiency

• May also use for odor control

with dressing change

• Adverse Reactions:
• Nausea, diarrhea
• Stomatitis
• Peripheral neuropathy with

prolonged use

Chambers 2007 Schlect & Bruno, 2018

Rifampin

• Bactericidal
• Mechanism of Action:

Suppress RNA synthesis

• Active against gram-positive

and gram-negative bacteria, some enteric, mycobacteria, chlamydia

• Staph infections, osteomyelitis
• Resistance develops rapidly,

do not use alone

• Route: PO
• Dose: 600 mg daily
• Renal Adjustment
• No adjustment for renal

insufficiency

• Interacts with many other

medications and may need to decrease the dosages of other medications

• Adverse Reactions:
• Hepatitis
• Heartburn, nausea, vomiting,

diarrhea

• Headache, drowsiness, ataxia,

confusion

• Colors body fluids orange
• Will stain contact lenses

Chambers 2007 Schlect & Bruno, 2018

4/12/2018 15 Topical Antimicrobial Considerations

• Mupirocin
• MRSA and MSSA
• Bacitracin
• Gram positive staph

aureus

• Gentamycin
• Absorbed especially well in

denuded skin

• Ciprofloxin
• Do not use for

prevention

• Usually not sufficient

enough alone

• Consider if mild infection
• Close monitoring
• Use over large infected

ulcers may help lead to resistance

• Addressing local

bioburden

• Avoid systemic effects

Chambers 2007 Schlect & Bruno, 2018

Mild Diabetic Foot Infection

Ulcer Severity Organism Route Drug (Choose One for each organism unless

• therwise specified)

Mild MSSA Streptococcus spp Oral Cephalexin Clindamycin MSSA with suspected anaerobe Amoxicillin-clavulanate MRSA Oral Bactrim Doxycycline

Moderate Diabetic Foot Infection

Ulcer Severity Organism Route Drug (Choose One for each organism unless

• therwise specified)

Moderate MSSA Streptococcus spp Enterobacteriaceae Obligate anaerobes Intramuscular Ceftriaxone Ciprofloxin with Clindamycin Levofloxin with Clindamycin Intramuscular Ceftriaxone Intravenous Ertapenem Ciprofloxin Levofloxin MRSA Oral Linezolid Intravenous Vancomycin Daptomycin Pseudomonas aeruginosa Intravenous Piperacillin-tazobactam

4/12/2018 16 Severe Diabetic Foot Infection

Ulcer Severity Organism Route Drug (Choose One for each organism unless otherwise specified) Severe MSSA Streptococcus spp Enterobacteriaceae Obligate anaerobes Intramuscular Ceftriaxone Intravenous Ertapenem Ciprofloxin Levofloxin MRSA Vancomycin Daptomycin Pseudomonas aeruginosa Intravenous Piperacillin-tazobactam MRSA Enterobacteriaceae Pseudomonas aeruginosa Obligate anaerobes Intravenous (May choose more than one) Vancomycin Ceftazidime Cefipime Piperacillin-tazobactam Ertapenem

Osteomyelitis

Ulcer Severity Organism Route Drug (Choose One for each

• rganism unless otherwise

specified) Osteomyelitis Identified by bone culture Specific to culture Unidentified organism Intravenous Vancomycin Daptomycin Oral Bactrim Doxycycline Ciprofloxin Rifampicin (add as secondary)

Length of Treatment

• Mild infection: 1 to 2 weeks
• Moderate infection: 3 weeks
• Severe infection: 2 to 4 weeks
• Osteomyelitis: 6 weeks with remaining viable

bone

• Osteomyelitis: 3 months with no surgery and

devitalized bone

• Amputation for osteomyelitis with clear margin:

2 to 5 days

4/12/2018 17

PERIPHERAL VASCULAR DISEASE (PVD)

• Multisegmental
• Arterial rigidity
• Medial calcification of vessels
• Poor development of collateral circulation
• Decreased function of progenitor cells

Baker & Kenny, 2016 Markakis et al., 2016

PVD Assessment and treatment

• Assessment
• ABI
• Doppler Ultrasound
• MRI angiography
• CT angiography
• Arterial catheterization

Markakis et al., 2016

• Treatment
• Hyperbaric Oxygen

Therapy

• Medication
• Revascularization

Lipsky et al., 2012 Tiaka et al., 2012

Pharmacologic Support of PVD

• Antiplatelet/Modification
• f Atherogenesis
• Aspirin: 81 to 162

mg/daily

• Aspirin 25 mg plus

dipyridamole 200 mg/daily

• Clopridogel: 75 mg/daily
• Ticlopidine: 250 mg bid
• Relief of Claudication
• Pentoxifyline: 400

mg/daily

• Cilostazol: 100mg bid

Teo 2018

4/12/2018 18 Hyperbaric Oxygen Therapy

• The use of 100% oxygen

at pressures greater than atmospheric pressure

• The patient breathes 100%
• xygen intermittently while

the pressure of the treatment chamber is increased to greater than 1 atmosphere absolute (ATA).

• Mechanism of Action:

Hyperoxygenation and decrease in bubble size; result of increased partial pressure of arterial oxygen

• Secondary Actions:
• Vasoconstriction
• Angiogenesis
• Fibroblast proliferation
• Leukocyte oxidative killing
• Toxin inhibition
• Antibiotic synergy
• Bhutani & Vishwanath, 2012

Debridement

• Removal of devitalized

tissue

• Wound stimulus
• Wound healing cascade

Lipsky et al., 2012 Tian, Liang, Song, Zhao, & Yang, 2013

• Pharmacological/Enzym

atic

• Collagenase
• Dakin’s Solution
• Acetic Acid
• Hypochlorous Acid

Offloading

• Total Contact Cast
• 90% healing rate
• Removable Devices
• 28% Adherence Rate
• Fall Risk
• Mobility

Game et al., 2012 Lipsky et al., 2012 Markakis et al., 2016

4/12/2018 19 Wound Bed Preparation

Debridement

• Advanced topical

therapy

• No RCT in support of one

topical dressing

Research supports:

• Growth factors
• Cellular-based tissue

products

• Granulocyte colony-

stimulating factors

• Negative pressure wound

therapy

Game et al., 2012 Lipsky et al., 2012

Guideline Implementation

• Support provider in care
• Easy, accessible format
• Facilitator present at point of care
• Adult learning principles
• Tools to support adoption of guideline

Basedow, Runciman, Lipworth, & Esterman, 2016 Harrison et al., 2010 Gifford, 2011

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