Gas Gangrene in the Diabetic Foot. Dr. Brian Kline Dr. Anthony Malvasi

Transcription

1 Gas Gangrene in the Diabetic Foot Dr. Brian Kline Dr. Anthony Malvasi

2 Patient Patient is a 60 year old female that presents with wound on left foot for a few days Seen by her primary care doctor and started on Clindamycin along with referral back to podiatry. One day of outpatient Clindamycin before presenting to ER three days after first appointment with PCP She noticed that the foot was now black in color and that the wound has changed. She has now having drainage out of her foot. She had been having some pain in her foot from the infection but recently increased this morning. History of diabetes, hypertension, coronary artery disease, Chronic kidney disease, peripheral vascular disease and hyperlipidemia.

3 Physical Exam F F] F Heart Rate: [60-72] 60 Resp: [14-16] 14 BP: ( )/(70-85) 176/82 mmhg Constitutional: She is oriented to person, place, and time. She appears well-developed. Cardiovascular: Normal rate, regular rhythm and normal heart sounds. Exam reveals no gallop and no friction rub. No murmur heard. Pulmonary/Chest: Effort normal and breath sounds normal. No respiratory distress. She has no wheezes. She has no rhonchi. She has no rales. Abdominal: Soft. Bowel sounds are normal. She exhibits no distention. There is no tenderness. There is no rebound and no guarding. Skin: Skin is warm. Gangrenous left fifth digit with crepitus, wound is open but no active draining, necrotic left fifth digit

4 CT Scan lower extremity

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7 Wound Classification

8 Management Clinical Classification of Diabetic Foot Infection Not infected Wound lacking purulence or any manifestations of inflammation (i.e.,erythema, pain, tenderness, warmth, or induration) Mild Presence of purulence and/or two or more manifestations of inflammation, but any cellulitis or erythema extends 2 cm or less around the ulcer; infection is limited to the skin or superficial subcutaneous tissues; no other local complications or systemic illness Moderate Infection (purulence and/or two or more manifestations of inflammation) in a patient who is systemically well and metabolically stable, but who has at least one of the following characteristics: cellulitis extending more than 2 cm around the ulcer; lymphangitic streaking; spread beneath the superficial fascia; deep tissue abscess; gangrene; involvement of muscle, tendon, joint, or bone Severe Infection (purulence and/or two or more manifestations of inflammation) in a patient with systemic toxicity or metabolic instability (e.g., fever, chills, tachycardia, hypotension, confusion, vomiting, leukocytosis, acidosis, severe hyperglycemia, azotemia) Bader, Mazen S., MD,MPH. "Diabetic Foot Infection." Amereican Family Physician 78 (2008): Web.

9 Determining Severity Checking ABI on patients Neuropathy Plain x rays MRI Good for diabetics with no bone exposed or no improvement in symptoms after two weeks Bone scan

10 No Infection Off load pressure Consider wound healing agents Ensure proper footwear No antibiotic therapy

11 Mild infection Culture wound Wound care Empiric antibiotics Reassess wound every two days No improvement in two days consider hospital Better after two days narrow antibiotics

12 Antibiotic Considerations Empiric antibiotic to cover S. aureus and streptococci Aerobic gram negative pathogens coverage for severe infection, chronic infection or no response to treatment Gangrenous infections require antianaerobic therapy

13 Antibiotic Choices Dicloxacillin 500 mg Great for MSSA Cephalexin 500 mg Augmentin 875/125 mg Good for polymicrobial infections Clindamycin mg Doxycycline 100 mg Effective for MRSA Bactrim 160/800 mg

14 Severe infection Admit to hospital Plain x rays Surgical consult after plain films Antibiotics Consider hyperbaric oxygen

15 Antibiotic Choices No risk factor for polymicrobial infection Nafcillin Cefazolin Vancomycin Risk factor for polymicrobial infection Unasyn with Rocephin Levaquin Avelox Ertapenem Severe infection Cipro, Zosyn, Primaxin, Vancomycin

16 Signs of Gasgrene air under the skin pain in the area around a wound swelling in the area around a wound pale skin that quickly turns gray, dark red, purple, or black blisters with foul-smelling discharge

17 References 1. Capobianco, C. M., J. J. Stapleton, and T. Zgonis. "Surgical Management of Diabetic Foot and Ankle Infections." Foot & Ankle Specialist 3.5 (2010): Web. 2. Bader, Mazen S., MD,MPH. "Diabetic Foot Infection." Amereican Family Physician 78 (2008): Web. 3. Ramakrishnan, Kalyanakrishnan, MD, Robert C. Salinas, MD, and Nelson Higuita, MD. "Skin and Soft Tissue Infection." American Family Physician 92 (2015): Web