抗生素英文-ANTIBIOTICS-WITHIN-THE-MANAGEMENT-of-Diabe.ppt

ANTIBIOTICS WITHIN THE MANAGEMENT of Diabetic foot,Nice 28-29avril2005,ABDULMASSIH Bassam MD,Endocrinologist,Definition of a Diabetic Foot infection,Epidemiology,Pathogenesis of a Diabetic Foot Infection,classification,Assessment,Microbiology,Principle of antibiotic treatment,Definition,of a Diabetic Foot Infection(1),No generally-accepted definition,Foot,infections in diabetics can be ulcer-or non-ulcer related,Anatomic location of primary site,Depth of infection,(skin/soft tissue vs.bone/joint),Isolation of pathogenic bacteria from an appropriate culture specimen,entrance,growth,metabolic activity and ensuing pathophysiologic effects of microorganisms in the tissues of a patient,Purulent discharge from the ulcer,Signs of inflammation around the ulcer,Systemic signs(fever-leukocytosis),The manifestation of the inflammatory signs depends on intact nervous and vascular system,Definition,of a Diabetic Foot Infection(2),Pathogenesis of diabetic foot infection,triangle of devil,infection,Bad,sensation,Bad perfusion,Classification Systems for Diabetic Foot Infections,Classification systems,Severity of Infection,Foot Ulcer(Wound),No generally-accepted classification,Differ in criteriacomplexity,Require validation for clinical trials,Classification Systems for Diabetic Foot Ulcers,Wagner,Univ.of,Texas,Depth-ischemia class.,Wagner Classification,0-Intact skin(may have bony deformities.,1-Localized superficial ulcer.,2-Deep ulcer to tendon,bone,ligament or joint.,3-Deep abscess or osteomyelitis.,4-Gangrene of toes or forefoot.,5-Gangrene of whole foot.,Wagner FW:The diabetic foot and amputations of the foot.In Surgery of the Foot.5th ed.,Mann,R editor.St Louis,Mo.The C.V.Mosby Company.,Depth-ischemia classification,Grade 0 no skin change,Grade 1 superficial ulcer,Grade 2exposed tendon,joint,Grade 3 bone exposure,Grade A no ischemia,Grade Bischemia,no gangrene,Grade Cpartial gangrene,Grade,D,complete gangrene,Multidisciplinary team,1-Diabetologist,2-Vascular surgeon,3-Orthopedics,4-Infection disease,5-Plastic surgeon,6-Podiatrician,Six intervention demonstrate efficacy in diabetic foot management,1-off loading,2-Debridement and drainage,3-wound dressing,4-appropriate use of antibiotic,5-revascularization,6-limited amputation,Diagnosis of osteomylitis is very important,X Ray is positive after 30-50%of bone destruction(2 weeks),MRI,CT.Scan,3-phase bone scan,Leukocyte scan,Guided bone biopsy,Epidemiology,Definition of a Diabetic Foot infection,Pathogenesis of a Diabetic Foot Infection,classification,Assessment,Microbiology,Principle of antibiotic treatment,Microbes and Chronic Wounds,All chronic wounds are contaminated by bacteria.,Wound healing occurs in the presence of bacteria.,It is not the presence of organisms but their interaction with the patient that determines their influence on wound healing.,Louis Pasteur,“The germ is nothing.It is the terrain in which it is found that is everything.”,Pasteur,L.(1880)De lattenuation virus du cholera des poulesCR Acad.Sci.91:673-680.,Definitions,Wound contamination,:,the presence of non-replicating organisms in the wound.,Wound colonization:,the presence of replicating microorganisms adherent to the wound in the absence of injury to the host.,Wound Infection:,the presence of replicating microorganisms within a wound that cause host injury.,Microbiology of Wounds,After about 4 weeks,Facultative anaerobic gram negative rods will colonize the wound.,Most common ones=,Proteus,E.coli,and Klebsiella.,As the wound deteriorates,deeper structures are affected.Anaerobes become more common.Oftentimes infections are polymicrobial(4-5).,Microbiology of Wounds,In summary:,early chronic wounds contain mostly,gram-positive organisms.,Wounds of several months duration with deep structure involvement will have on average 4-5 microbial pathogens,including anaerobes(see more,gram-negative organisms,).,How do you know when a wound is infected?,This can be very difficult.,A continuum exists between when pathogens colonize the wound and then start to cause damage.,There is no absolutely foolproof laboratory test that will aid in this diagnosis.,How do you know when an ulcer is infected?,The typical features of wound infections:,increased exudate,increased swelling,increased erythema,increased pain,increased local temperature,Periwound cellulitis,ascending infection,change in appearance of granulation tissue(discoloration,prone to bleed,highly friable).,Methicillin resistant Staph.Au.An increasing problem,Retrospective analysis of 63 swabs from infected foot ulcer,Gram+aerobic 84.2%staph.Au.79%,30.2%MRSA,Not related to prior antibiotic usage,(dang and al.diab.med.20;2:159 feb2003),In a prior study MRSA is associated with previous antibiotic treatment,(,tentolouris and al.diab.med.16;9:767sep1999),Epidemiology,Definition of a Diabetic Foot infection,Pathogenesis of a Diabetic Foot Infection,classification,Assessment,Microbiology,Principle of antibiotic treatment,Treatment,Management of infection:,1-antibiotics.,2-Incision and drainage.3-soft tissue,joint and bone resection,4-amputation,What is the best approach?,1-Oral antibiotic follow up after one week,2-IV antibiotic in the hospital and observation,3-Rapid drainage+IVantibiotic,Bed side surgery,Ischemic foot problem,Self amputation,Should we clean uncomplicated foot ulcer with antibiotics?,44 Clinically uninfected neuropathic foot ulcer,Randomized to amoxi+clav vs.placebo,20 days follow-up no difference in outcome,(chantelau and al.diab.Med.1996;13:156-159),64 new foot ulcer with no clinical evidence of infection,Randomized to antibiotics vs.placebo,Patients with ischemia and positive ulcer swabs should be considered for early antibiotic treatment,(foster and al.diab.Med.1998;15:suppl.2),Principles of treatment,Evidence-based regimes,empirical therapy vs specific therapy,Optimal dosage,Optimal duration,Identification and removal of infective focus,Recognition of adverse effects,The-lactams,Penicillins,penicillin V/G,ampicillin,amoxycillin,cloxacillin,ticarcillin,piperacillin,Cephalosporins,1,st,generation e.g.cefazolin,cefalexin(,Keflex,),2,nd,generation e.g.cefuroxime (,Zinacef,Zinnat,),The-lactams,3,rd,generation e.g.ceftriaxone(,Rocephin,),cefotaxime(,Claforan,),ceftazidime(,Fortum,),cefoperozone(,Cefobid,),ceftibuten(,Cedax,),4,th,generation e.g.cefepime(,Maxipime,),Carbapenems,imipenem,meropenem,Monobactam,aztreonam,-lactam/,-lactamase inhibitor combinations,Macrolides and Quinolones,Macrolides,erythromycin,clarithromycin(,Klacid,),azithromycin(,Zithromax,),Quinolones(FQ),ofloxacin,levofloxacin(,Cravit,),Ciprofloxacin(,Ciproxin,),Others,Aminoglycosides,gentamicin,amikacin,netromycin*(NA),Tetracyclines,doxycyline(,Vibramycin,),minocycline,Glycopeptides,vancomycin,teicoplanin,New:linezolid,ertapenem,moxifloxacin,Large coverage,swab,swab,Large,coverage,superficial,Normal perfusion,Non-ischemic,deep,Bad,perfusion,ischemic,No antibiotics,No signs of infection,signs of infection,Gram+,Recent and superficial ulcer or cellulitis(non ischemic),Staph.Au.+strep,Cloxacillin,Amoxi+with,-lactamase inhibitors,Cefazolin,Cephalexin,Clindamycin,Deep ulcer or neuroischemic ulcer,polymicrobial:gram positive cocci,gram negative bacilli and anaerobes,-,lactam,+-,lactamase,inhibitors+,amikacin,3rd GC+,clindamycin,ciprofloxacin+,clindamycin,Ciprofloxacin+,linezolid,carbapenems,vancomycin,if life threatening,most ulcers will heal with the traditional Therapy,For low grade uninfected wounds a form of removable or irremovable offloading device should be a part of any treatment plan.The TCC is the most established;,We can not recommend any one dressing over another;,Debridement should still be done the old fashioned way but could be facilitated by using Hydrogel or MDT where available;,if wounds fail to heal,treating them with a skin graft or adding becaplermin(or the platelet releasate)not been validated as cost effective in any clinical trial.,The use of systemic HBO or Iloprost,especially in high grade ulcers with a significant ischaemic element,Diabetic foot successfully treated !,