Diabetic foot resident survival guide: Difference between revisions
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{{familytree | | | | | | | | | C01 | | |C01= • Assess severity of infection according to the table below<br> • Treat with antiobiotics according to the table below }} | {{familytree | | | | | | | | | C01 | | |C01= • Assess severity of infection according to the table below<br> • Treat with antiobiotics according to the table below }} | ||
{{familytree/end}} | {{familytree/end}} | ||
:* DFI is classified based on its severity according to the Infectious Diseases Society of America (IDSA) guideline or the PEDIS grade developed by International Working Group on the Diabetic Foot (IWGDF). (see Table below) | |||
:* Selection of empiric antimicrobial regimen should be determined by the severity of DFI and the likely etiologic agents. | |||
::* '''Mild (grade 2) to moderate (grade 3) DFI without recent antibiotic treatment:''' | |||
:::* Highly bioavailable oral antibiotics against [[aerobic]] [[Gram-positive bacteria|Gram-positive cocci]] may be sufficient. | |||
::* '''Severe (grade 4) DFI:''' | |||
:::* Broad-spectrum antibiotics are recommended while culture results and susceptibility data are pending. | |||
{| | |||
| style="width: 15px;"| | |||
| | |||
{| style="border: 2px solid #A8A8A8; font-size: 90%;" | |||
! align="center" style="background: #A8A8A8;" | '''Clinical Manifestation''' | |||
! align="center" style="background: #A8A8A8; padding: 0 10px;" | '''PEDIS Grade''' | |||
! align="center" style="background: #A8A8A8; padding: 0 10px;" | '''IDSA Severity''' | |||
|- | |||
| style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" | Wound lacking [[purulent|purulence]] or any manifestations of [[inflammation]] | |||
! style="background: #DCDCDC; padding: 0 10px;" | 1 | |||
! style="background: #DCDCDC; padding: 0 10px;" | Uninfected | |||
|- | |||
| style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" | | |||
* Presence of ≥2 manifestations of [[inflammation]] ([[purulent|purulence]], or [[erythema]], [[pain]], [[tenderness]], [[calor|warmth]], or [[induration]]) | |||
* Any [[cellulitis]] or [[erythema]] extends ≤2 cm around the [[ulcer]] | |||
* Limited to the [[skin]] or superficial [[subcutaneous tissue]]s | |||
* <u>No</u> other local [[complication]]s (eg, [[trauma]], [[gout]], [[Neuropathic joint disease|acute Charcot neuro-osteoarthropathy]], [[fracture]], [[thrombosis]], [[venous stasis]]) or systemic illness | |||
! style="background: #F5F5F5; padding: 0 10px;" | 2 | |||
! style="background: #F5F5F5; padding: 0 10px;" | Mild | |||
|- | |||
| style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" | Infection in a patient who is metabolically stable and systemically well, but with ≥1 of the following characterisitics: | |||
* [[Cellulitis]] extending >2 cm | |||
* [[Lymphangitis|Lymphangitic streaking]] | |||
* Spread beneath the superficial [[fascia]] | |||
* Deep-tissue [[abscess]] | |||
* [[Gangrene]] | |||
* Involvement of [[muscle]], [[tendon]], [[joint]], or [[bone]] | |||
! style="background: #DCDCDC; padding: 0 10px;" | 3 | |||
! style="background: #DCDCDC; padding: 0 10px;" | Moderate | |||
|- | |||
| style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" | Infection in a patient with metabolic instability (eg, [[acidosis]], severe [[hyperglycemia]], or [[azotemia]]) or systemic toxicity as manifested by ≥2 of the following: | |||
* [[Fever|Temperature >38 °C]] or [[Hypothermia|<36 °C]] | |||
* [[Tachycardia|Heart rate >90 beats/min]] | |||
* [[Tachypnea|Respiratory rate >20 breaths/min]] or [[Respiratory alkalosis|PaCO2 <32 mm Hg]] | |||
* [[Leukocytosis|White blood cell count >12,000]] or [[Leukopenia|<4,000 cells/μL]] or [[bandemia|≥10% immature (band) forms]] | |||
! style="background: #F5F5F5; padding: 0 10px;" | 4 | |||
! style="background: #F5F5F5; padding: 0 10px;" | Severe | |||
|} | |||
|} | |||
: '''5. What is the appropriate route, setting, and duration of antibiotic therapy?''' | |||
:* The table below describes the recommended route, setting, and duration of antibiotic therapy based on the extent and severity of DFI. | |||
{| | |||
| style="width: 15px;"| | |||
| | |||
{| style="border: 2px solid #A8A8A8; font-size: 90%;" | |||
! align="center" style="background: #A8A8A8; padding: 0 10px;" colspan=2 | '''Site of Infection, by Severity or Extent''' | |||
! align="center" style="background: #A8A8A8; padding: 0 10px;" | '''Route of Administration''' | |||
! align="center" style="background: #A8A8A8; padding: 0 10px;" | '''Setting''' | |||
! align="center" style="background: #A8A8A8; padding: 0 10px;" | '''Duration of Therapy''' | |||
|- | |||
! style="background: #DCDCDC; padding: 0 10px;" rowspan=3 | '''Soft-tissue only''' | |||
| style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" | Mild (Grade 2) | |||
| style="background: #DCDCDC; padding: 0 10px;" | Oral (or topical for superficial infections) | |||
| style="background: #DCDCDC; padding: 0 10px;" | Outpatient | |||
| style="background: #DCDCDC; padding: 0 10px; text-align: center;" | 1–2 wk | |||
|- | |||
| style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" | Moderate (Grade 3) | |||
| style="background: #DCDCDC; padding: 0 10px;" | Oral (or initial parenteral) | |||
| style="background: #DCDCDC; padding: 0 10px;" | Outpatient (or inpatient) | |||
| style="background: #DCDCDC; padding: 0 10px; text-align: center;" | 1–3 wk | |||
|- | |||
| style="background: #DCDCDC; padding: 0 10px; font-weight: bold;" | Severe (Grade 4) | |||
| style="background: #DCDCDC; padding: 0 10px;" | Initial parenteral, switch to oral when possible | |||
| style="background: #DCDCDC; padding: 0 10px;" | Inpatient, then outpatient | |||
| style="background: #DCDCDC; padding: 0 10px; text-align: center;" | 2–4 wk | |||
|- | |||
! style="background: #F5F5F5; padding: 0 10px;" rowspan=4 | '''Bone or joint''' | |||
| style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" | No residual infected tissue | |||
| style="background: #F5F5F5; padding: 0 10px;" | Parenteral or oral | |||
| style="background: #F5F5F5; padding: 0 10px;" | Inpatient, then outpatient | |||
| style="background: #F5F5F5; padding: 0 10px; text-align: center;" | 2–5 d | |||
|- | |||
| style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" | Residual infected soft tissue | |||
| style="background: #F5F5F5; padding: 0 10px;" | Parenteral or oral | |||
| style="background: #F5F5F5; padding: 0 10px;" | Inpatient, then outpatient | |||
| style="background: #F5F5F5; padding: 0 10px; text-align: center;" | 1–3 wk | |||
|- | |||
| style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" | Residual infected, viable bone | |||
| style="background: #F5F5F5; padding: 0 10px;" | Initial parenteral, switch to oral when possible | |||
| style="background: #F5F5F5; padding: 0 10px;" | Inpatient, then outpatient | |||
| style="background: #F5F5F5; padding: 0 10px; text-align: center;" | 4–6 wk | |||
|- | |||
| style="background: #F5F5F5; padding: 0 10px; font-weight: bold;" | Residual dead bone or no surgery | |||
| style="background: #F5F5F5; padding: 0 10px;" | Initial parenteral, switch to oral when possible | |||
| style="background: #F5F5F5; padding: 0 10px;" | Inpatient, then outpatient | |||
| style="background: #F5F5F5; padding: 0 10px; text-align: center;" | ≥3 mo | |||
|} | |||
|} | |||
===Empiric Therapy=== | |||
<SMALL><font color="#FF4C4C"> ▸ '''Click on the following categories to expand treatment regimens.'''</font></SMALL> | |||
{| | |||
| valign=top style="font-size: 80%;" | | |||
<div style="border-radius: 5px 5px 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #A1BCDD; text-align: center;"> | |||
<font color="#FFF"> | |||
'''Uninfected (Grade 1)''' | |||
</font> | |||
</div> | |||
<div class="mw-customtoggle-table00" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;"> | |||
<font color="#FFF"> | |||
▸ '''No Evidence of Infection''' | |||
</font> | |||
</div> | |||
<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #A1BCDD; text-align: center;"> | |||
<font color="#FFF"> | |||
'''Mild (Grade 2)''' | |||
</font> | |||
</div> | |||
<div class="mw-customtoggle-table01" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;"> | |||
<font color="#FFF"> | |||
▸ '''Acute Infection Without Recent Antibiotic Use''' | |||
</font> | |||
</div> | |||
<div class="mw-customtoggle-table02" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;"> | |||
<font color="#FFF"> | |||
▸ '''High Risk for MRSA''' | |||
</font> | |||
</div> | |||
<div style="border-radius: 0 0 0 0; border: solid 1px #20538D; border-bottom: 0px; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #A1BCDD; text-align: center;"> | |||
<font color="#FFF"> | |||
'''Moderate to Severe (Grade 3–4)''' | |||
</font> | |||
</div> | |||
<div class="mw-customtoggle-table03" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;"> | |||
<font color="#FFF"> | |||
▸ '''Chronic Infection or Recent Antibiotic Use''' | |||
</font> | |||
</div> | |||
<div class="mw-customtoggle-table04" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;"> | |||
<font color="#FFF"> | |||
▸ '''High Risk for MRSA''' | |||
</font> | |||
</div> | |||
<div class="mw-customtoggle-table05" style="cursor: pointer; border-radius: 0 0 0 0; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;"> | |||
<font color="#FFF"> | |||
▸ '''High Risk for ''Pseudomonas aureuginosa''''' | |||
</font> | |||
</div> | |||
<div class="mw-customtoggle-table06" style="cursor: pointer; border-radius: 0 0 5px 5px; border: solid 1px #20538D; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5); box-shadow: inset 0 1px 1px rgba(255, 255, 255, 0.5), 0 1px 1px rgba(0, 0, 0, 0.5); height: 30px; line-height: 30px; width: 325px; background: #4479BA;"> | |||
<font color="#FFF"> | |||
▸ '''Polymicrobial Infection''' | |||
</font> | |||
</div> | |||
| valign=top | | |||
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table00" style="background: #FFFFFF;" | |||
| valign=top | | |||
{| style="float: left; cellpadding=0; cellspacing= 0; width: 425px;" | |||
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Uninfected Wound, No Evidence of Infection}} | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''Uninfected wounds should be managed with appropriate wound care.'''''<BR> ▸ '''''Antibiotic therapy is <u>not</u> recommended.''''' | |||
|} | |||
|} | |||
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table01" style="background: #FFFFFF;" | |||
| valign=top | | |||
{| style="float: left; cellpadding=0; cellspacing= 0; width: 425px;" | |||
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Mild DFI, Acute Infection Without Recent Antibiotic Use}} | |||
|- | |||
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC;" align=left | ▸ '''''[[Dicloxacillin]] 125–250 mg PO qid'''''<BR> OR <BR> ▸ '''''[[Clindamycin]] 150–300 mg PO qid''''' <sup>†</sup><BR> OR <BR> ▸ '''''[[Cephalexin]] 500 mg PO qid'''''<BR> OR <BR> ▸ '''''[[Levofloxacin]] 750 mg PO qd'''''<BR> OR <BR> ▸ '''''[[Amoxicillin-Clavulanate]] 500 mg PO bid (or 250 mg PO tid)''''' <sup>‡</sup> | |||
|- | |||
| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" | <sup>†</sup> Usually active against community-associated MRSA, but check macrolide sensitivity and consider ordering a D-test before using for MRSA.<BR><sup>‡</sup> Relatively broad-spectrum oral agent that includes anaerobic coverage. | |||
|} | |||
|} | |||
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table02" style="background: #FFFFFF;" | |||
| valign=top | | |||
{| style="float: left; cellpadding=0; cellspacing= 0; width: 425px;" | |||
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Mild DFI, High Risk for MRSA}} | |||
|- | |||
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Doxycycline]] 100 mg PO q12h''''' <sup>†</sup><BR> OR <BR> ▸ '''''[[TMP-SMX|TMP–SMX]] 80-160 mg/400-800 mg PO q12h''''' <sup>†</sup> | |||
|- | |||
| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" | <sup>†</sup> Active against many MRSA & some gram-negatives; uncertain against streptococci. | |||
|} | |||
|} | |||
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table03" style="background: #FFFFFF;" | |||
| valign=top | | |||
{| style="float: left; cellpadding=0; cellspacing= 0; width: 425px;" | |||
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Moderate to Severe DFI, Chronic Infection or Recent Antibiotic Use}} | |||
|- | |||
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Levofloxacin]] 750 mg IV/PO q24h'''''<BR> OR <BR> ▸ '''''[[Cefoxitin]] 1 g IV q4h (or 2 g IV q6–8h)'''''<BR> OR <BR> ▸ '''''[[Ceftriaxone]] 1–2 g/day IV/IM q12–24h'''''<BR> OR <BR> ▸ '''''[[Ampicillin-Sulbactam|Ampicillin–Sulbactam]] 1.5–3 g IV/IM q6h'''''<BR> OR <BR> ▸ '''''[[Moxifloxacin]] 400 mg IV/PO q24h'''''<BR> OR <BR> ▸ '''''[[Ertapenem]] 1 g IV/IM q24h'''''<BR> OR <BR> ▸ '''''[[Tigecycline]] 100 mg IV, then 50 mg IV q12h''''' <sup>†</sup><BR> OR <BR> ▸ '''''[[Imipenem-Cilastatin|Imipenem–Cilastatin]] 0.5–1 g IV q6–8h''''' <sup>‡</sup> | |||
|- | |||
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Levofloxacin]] 750 mg IV/PO q24h'''''<BR> OR <BR> ▸ '''''[[Ciprofloxacin]] 600–1200 mg/day IV q6–12h'''''<BR> OR <BR> ▸ '''''[[Ciprofloxacin]] 1200–2700 mg IV q6–12h (for more severe cases)''''' | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]] 150–300 mg PO qid''''' | |||
|- | |||
| style="padding: 0 5px; font-size: 80%; background: #F5F5F5;" | <sup>†</sup> Active against MRSA.<BR> <sup>‡</sup> Not active against MRSA; consider when ESBL-producing pathogens suspected. | |||
|} | |||
|} | |||
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table04" style="background: #FFFFFF;" | |||
| valign=top | | |||
{| style="float: left; cellpadding=0; cellspacing= 0; width: 425px;" | |||
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Moderate to Severe DFI, High Risk for MRSA}} | |||
|- | |||
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Linezolid]] 600 mg IV/PO q12h'''''<BR> OR <BR> ▸ '''''[[Daptomycin]] 4 mg/kg IV q24h'''''<BR> OR <BR> ▸ '''''[[Vancomycin]] 15–20 mg/kg IV q8–12h (trough: 10–20 mg/L)''''' | |||
|} | |||
|} | |||
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table05" style="background: #FFFFFF;" | |||
| valign=top | | |||
{| style="float: left; cellpadding=0; cellspacing= 0; width: 425px;" | |||
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Moderate to Severe DFI, High Risk for ''Pseudomonas aeruginosa''}} | |||
|- | |||
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Piperacillin-Tazobactam|Piperacillin–Tazobactam]] 3.375 g IV q6–8h''''' | |||
|} | |||
|} | |||
{| class="mw-collapsible mw-collapsed" id="mw-customcollapsible-table06" style="background: #FFFFFF;" | |||
| valign=top | | |||
{| style="float: left; cellpadding=0; cellspacing= 0; width: 425px;" | |||
! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Moderate to Severe DFI, Polymicrobial Infection}} | |||
|- | |||
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Preferred Regimen | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15–20 mg/kg IV q8–12h (trough: 10–20 mg/L)'''''<BR> OR <BR> ▸ '''''[[Linezolid]] 600 mg IV/PO q12h'''''<BR> OR <BR> ▸ '''''[[Daptomycin]] 4 mg/kg IV q24h''''' | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Piperacillin-Tazobactam|Piperacillin–Tazobactam]] 3.375 g IV q6–8h'''''<BR> OR <BR> ▸ '''''[[Imipenem-Cilastatin|Imipenem–Cilastatin]] 0.5–1 g IV q6–8h'''''<BR> OR <BR> ▸ '''''[[Ertapenem]] 1 g IV/IM q24h'''''<BR> OR <BR> ▸ '''''[[Meropenem]] 1 g IV q8h''''' | |||
|- | |||
| style="padding: 0 5px; font-size: 90%; background: #F5F5F5; font-weight: bold; font-style: italic;" align=center | Alternative Regimen | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Vancomycin]] 15–20 mg/kg IV q8–12h (trough: 10–20 mg/L)'''''<BR> OR <BR> ▸ '''''[[Linezolid]] 600 mg IV/PO q12h'''''<BR> OR <BR> ▸ '''''[[Daptomycin]] 4 mg/kg IV q24h''''' | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Ceftazidime]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Cefepime]] 2 g IV q8h'''''<BR> OR <BR> ▸ '''''[[Aztreonam]] 2 g IV q6–8h''''' | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | PLUS | |||
|- | |||
| style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Metronidazole]] 15 mg/kg IV, then 7.5 mg/kg IV q6h''''' | |||
|} | |||
|} | |||
|} | |||
==Do's== | ==Do's== |
Revision as of 02:16, 11 August 2020
Resident Survival Guide |
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ifrah Fatima, M.B.B.S[2]
Overview
This section provides a short and straight to the point overview of the disease or symptom. The first sentence of the overview must contain the name of the disease.
Causes
Life Threatening Causes
Life-threatening causes include conditions that may result in death or permanent disability within 24 hours if left untreated. Diabetic foot superseded with the following may result in sepsis and death. [1]
- Infected diabetic foot
- Osteomyelitis
Common Causes
- Poor glycemic control
- Peripheral neuropathy
- Peripheral arterial disease
- Peripheral ischemia
- Improper footwear
- Foot deformities including Charcot arthropathy [1] [2] [3]
Diagnosis
Assessment of diabetic foot includes evaluation of peripheral arterial disease, peripheral neuropathy, and foot deformities. Shown below is an algorithm summarizing the diagnosis of diabetic foot and diabetic foot ulcers according to the recommendations of the American Diabetes Association [4] [5] and International Diabetes Federation- Clinical Practice Recommendations on the Diabetic Foot 2017. "Guidelines".
Characterize the symptoms: ❑ Onset ❑ Type of sensation ❑ Location ❑ Nocturnal variation ❑ Aggravating factors ❑ Relieving factors Obtain a detailed history: ❑ Onset of diabetes ❑ Duration of diabetes ❑ Compliance with medication ❑ History of glycemic control ❑ History of other diabetic complcatios ❑ Foot deformities/injuries/ulcers ❑ History of lower limb amputation ❑ Type of footwear ❑ Foot hygiene ❑ History of claudication ❑ Smoking history | |||||||||||||
Examine the patient: Inspection ❑ Location of ulcer ❑ Integrity and charcteristic (dry/cracked) of skin ❑ Sweating Palpation ❑ Pedal (dorsalis pedis) pulses ❑ Vibration sensation ❑ Ulcer site- warmth, tenderness, edema Non-invasive tests ❑ Semmes-Weinstein monofilament test ❑ Probe-to-bone test if suspected osteomyelitis ❑ Measure ABI (Ankle-Brachial Index) with a Arterial doppler | |||||||||||||
Order tests: ❑ Glycosylated hemoglobin/ HbA1c ❑ Fasting plasma glucose ❑ Complete blood count ❑ ESR and CRP ❑ Deep tissue specimen for culture | |||||||||||||
Treatment
Assessment of diabetic foot includes evaluation of peripheral arterial disease, peripheral neuropathy, and foot deformities. Shown below is an algorithm summarizing the diagnosis of diabetic foot and diabetic foot ulcers according to the recommendations of the American Diabetes Association [4] [5] and International Diabetes Federation- Clinical Practice Recommendations on the Diabetic Foot 2017. "Guidelines".
Prophylactic measures and Diabetic foot care in all patients ❑ Glycemic control ❑ Apporpriate footwear and podiatric care ❑ Mechanical offloading • Cast Walkers • Total contact casting • Therapeutic shoes ❑ Vascular care to prevent and treat peripheral arterial disease | |||||||||||||||||||||||||||||||||||||||
❑ Local wound care ❑ Debridement | |||||||||||||||||||||||||||||||||||||||
Peripheral arterial disease or signs of ischemia | Medication/Surgical or endovascular revascularization | ||||||||||||||||||||||||||||||||||||||
Presence of infection | • Mechanical or chemical wound debridement • Culture • Biopsy | ||||||||||||||||||||||||||||||||||||||
• Assess severity of infection according to the table below • Treat with antiobiotics according to the table below | |||||||||||||||||||||||||||||||||||||||
- DFI is classified based on its severity according to the Infectious Diseases Society of America (IDSA) guideline or the PEDIS grade developed by International Working Group on the Diabetic Foot (IWGDF). (see Table below)
- Selection of empiric antimicrobial regimen should be determined by the severity of DFI and the likely etiologic agents.
- Mild (grade 2) to moderate (grade 3) DFI without recent antibiotic treatment:
- Highly bioavailable oral antibiotics against aerobic Gram-positive cocci may be sufficient.
- Severe (grade 4) DFI:
- Broad-spectrum antibiotics are recommended while culture results and susceptibility data are pending.
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- 5. What is the appropriate route, setting, and duration of antibiotic therapy?
- The table below describes the recommended route, setting, and duration of antibiotic therapy based on the extent and severity of DFI.
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Empiric Therapy
▸ Click on the following categories to expand treatment regimens.
Uninfected (Grade 1) ▸ No Evidence of Infection Mild (Grade 2) ▸ Acute Infection Without Recent Antibiotic Use ▸ High Risk for MRSA
Moderate to Severe (Grade 3–4) ▸ Chronic Infection or Recent Antibiotic Use ▸ High Risk for MRSA ▸ High Risk for Pseudomonas aureuginosa ▸ Polymicrobial Infection |
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Do's
- The content in this section is in bullet points.
Don'ts
- The content in this section is in bullet points.
References
- ↑ 1.0 1.1 Pendsey SP (2010). "Understanding diabetic foot". Int J Diabetes Dev Ctries. 30 (2): 75–9. doi:10.4103/0973-3930.62596. PMC 2878694. PMID 20535310.
- ↑ Mishra SC, Chhatbar KC, Kashikar A, Mehndiratta A (2017). "Diabetic foot". BMJ. 359: j5064. doi:10.1136/bmj.j5064. PMC 5688746. PMID 29146579.
- ↑ Rathur HM, Boulton AJ (2007). "The diabetic foot". Clin Dermatol. 25 (1): 109–20. doi:10.1016/j.clindermatol.2006.09.015. PMID 17276208.
- ↑ 4.0 4.1 Pop-Busui R, Boulton AJ, Feldman EL, Bril V, Freeman R, Malik RA; et al. (2017). "Diabetic Neuropathy: A Position Statement by the American Diabetes Association". Diabetes Care. 40 (1): 136–154. doi:10.2337/dc16-2042. PMC 6977405 Check
|pmc=
value (help). PMID 27999003. - ↑ 5.0 5.1 American Diabetes Association (2020). "11. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes-2020". Diabetes Care. 43 (Suppl 1): S135–S151. doi:10.2337/dc20-S011. PMID 31862754.