8 - Surgical Management of Foot Infection Flashcards Preview

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Flashcards in 8 - Surgical Management of Foot Infection Deck (60):
1

Objectives

- Evaluation and management of foot infections requiring surgical treatment.
- Current IDSA guidelines for diabetic foot infections.

2

Indications for surgical interventions

- Abscess
- Osteomyelitis
- Gas Producing infection = Medical emergency

3

Good info to get in the history

o Speed of onset and duration
o Trauma
o Sources of contamination of wound
o Pain – particularly in insensate person
o If likely surgical case, when person last ate or drank

4

Good info to get in the ROS

o F/C/N/V
o Recent blood glucose

Review drug allergies

5

Physical exam

o Palpable fluctuance, or crepitance
o Lymphangitic streaking
o Mark leading edge of erythema
o Vitals

6

X-rays

o Look for gas, foreign bodies, signs of osteomyelitis

7

Labs to get

o WBC, CMP
o ESR or CRP

8

IDSA (infectious disease society of America) Diabetic Foot Infection Classification

- Uninfected
- Mild
- Moderate
- Severe

9

Uninfected

o Wound without purulence or any manifestations of inflammation

10

Mild

o Cellulitis or erythema > 0.5cm to ≤2 cm around ulcer or wound
o Infection is limited to skin or superficial subcutaneous tissue
o No local complications or systemic illness
o ***Should exclude other causes of inflammation (e.g., trauma, gout, acute Charcot, fracture, thrombosis, venous stasis)

11

Moderate

o Erythema >2 cm, OR involving deeper structures than skin or subcutaneous tissue (e.g. abscess, osteomyelitis, septic arthritis, fasciitis)
o AND no systemic inflammatory response syndrome (SIRS)

12

Severe

Local infection (as described previously) with signs of SIRS as manifested by ≥2 of the following:
- Temperature > 38°C or 90 beats/min
- Respiratory rate >20 breaths/min or PaCO2 12,000 or

13

IDSA validation - full thickness

This is how often each grade of the IDSA scale leads to a full thickness wound (no deeper):
- No infection: 88.7%
- Mild infection: 76.1%
- Moderate infection: 30.8%
- Severe infection: 22.2%

14

IDSA validation - fascia or tendon

This is how often each grade of the IDSA scale probes to fascia or tendon (no deeper)
- No infection: 7.2%
- Mild infection: 21.1%
- Moderate infection: 25.0%
- Severe infection: 11.1%

15

IDSA validation - bone or joint

This is how often each grade of the IDSA scale probes to bone or joint:
- No infection: 4.1%
- Mild infection: 2.8%
- Moderate infection: 44.2%
- Severe infection: 66.7%

16

IDSA validation - bone infection

This is how often each grade of the IDSA sale leads to bone infection
- No infection: 0%
- Mild infection: 0%
- Moderate infection: 38.5%
- Severe infection: 37%

17

Graph on hospitalization and amputation rates based on the IDSA grade of infection

- No infection: very few hospitalizations, very few amputations
- Mild infection: 10% are hospitalized, very few amputations
- Moderate infection: 55% are hospitalized, 45% have amputations
- Severe infection: 90% are hospitalized, 75% have amputations

18

Causative organism for cellulitis without open skin lesion

- Staph aureus
- Beta hemolytic strep

19

Causative organism for infected ulcer, antibiotically naive

- Staph aureus
- Beta hemolytic strep

20

Causative organism for infected ulcer, previously treated

- Staph aureus
- Beta hemolytic strep
- Enterobacter

21

Causative organism for macerated ulcer due to drainage or soaking

- Pseudomonas
- Polymycrobial

22

Causative organism for long standing ulcer with prolonged broad spectrum antibiotic use

- Polymycrobial
- Staph aureus
- Beta hemolytic
- Pseudomonas
- Gram negative rods
- Resistant bacteria

23

Causative organism for "fetid foot" - extensive necrosis or gangrene

- Gram positive cocci
- Gram negative rods
- Obligate anerobes

24

Causative organism for osteomyelitis

- Staph aureus
- Pseudomonas (puncture wounds)

25

Clinical signs of MSSA

o Thick, yellow, purulent drainage

26

Clinical signs of MRSA

o Usually quicker onset of purulent producing infection

27

Clinical signs of Strep

o Deeper red infection than staph and not as purulent

28

Clinical signs of pseudomonas

o Fruity smell
o Green tinge to wound

29

Clinical signs of anaerobes

o Extreme foul smell
o Brown, watery discharge

30

IDSA suggested antibiotics for moderate to severe foot infections with MSSA, streptococcus, enterobacteria and obligate anaerobes

1 = Ampicillin-sulbactam (Unasyn)
- This is adequate if low suspicion of pseudomonas

2 = Ertapenem
- Once daily dosing, relatively broad spectrum, not active against pseudomonas

3 = Imipenem-cislastin
- Very broad spectrum (no MRSA coverage) only use when needed

31

IDSA suggested antibiotics for moderate to severe foot infections with MRSA

Vancomycin

32

IDSA suggested antibiotics for moderate to severe foot infections with pseudomonas aeruginosa

Piperacillin-tazobactam (zosyn)
- TID or QID dosing, but good broad spectrum coverage

33

Case study HPI

o 53 year old female admitted to hospital by PCP for diabetic foot infection
o PCP noted larger bulla on plantar right midfoot with foul drainage
o Pain on foot and leg
o Fever (102 degrees F), chills, nausea, vomiting

34

Case study ROS

o Last blood glucose 200-300
o A1c 8-10
o Numbness in hands and feet
o Blurred vision secondary to retinopathy
o Heart palpitations for 2 days

35

Case study PMHx

o Type 2 diabetes
o Renal failure with dialysis

36

Case study physical exam

o Vascular: pedal pulses palpable
o Neuro: diminished
o Foot: hot, swollen, erythematous foot
o Derm: large bulla the width of the plantar arch with gray/black in color with small opening centrally. Erythema to surrounding tissue, no purulent drainage
o Musculoskeletal: pain with palpation

X-ray
o Gas gangrene in the medial arch
o Make sure it isn’t tracking up into the leg (this stays mostly in the arch, medial to lateral)

Culture
o Either culture drainage in the ER or do it in the OR

37

Labs yesterday and labs today

- Labs yesterday (CRP, ESR, WBCs)
o WBC = 29.5 (10 is normal)
o H/H = 10.6/31
o Bun/Cr = 86/6.2
o Blood glucose = 294
o Albumin = 3.2
o C-reactive protein = 24.1 (1 or less is normal)

38

Treatment

Emergency I & D
o Infections will more commonly track up tendons
o Less commonly it will track across the arch
o Can see the plantar fascia
o Use bag of 300 mL of saline and wash it out with pressure lavage

39

Dressing

o Pack the wound
o Do not close the wound because it would increase an anaerobic environment
o Let it drain then go back a few days later

40

Cultures

o Staph aureus
o Strep (GBS)
o Bacteroides
o MRSA
o Enterobacter

41

Repeat I & D

o Back to OR for repeat
o Continued purulent drainage
o Intraoperative findings = necrotic tissue found within wound
o Purulent drainage from multiple deep pockets
o Wound VAC applied in OR

42

Management going forward

o Diabetes
o Living situation with help
o WB, antibiotics

43

Discharge from hospital

o Patient sent to SNF for wound vac therapy and 4 weeks IV abx (vanc, zosyn) per ID recommendation
o Wound eventually healed

44

CASE STUDY 2

o 51 year old male presents to clinic with ulcer plantar left hallux
o Went on fishing trip 1 month ago, ulcer formed from wet, rubbing boots
o 10 days ago noticed erythema and edema
o 4 days ago went to ED and was put on ED

45

Case study PMHx

o T2D, HTN
o Heart murmur
o High cholesterol, colon cancer hx

46

Case study social

o Denies tobacco, alcohol, drug use
o Counselor at prison system

47

Case study ROS

o Denies fever, chills, nausea, vomiting
o Blood glucose around 120, does not check often due to
o Some numbness and tingling in the feet
o Does not feel like feet are hot or cold (vascular)
o Denies claudication
o Had ulcers before? Did they heal?

48

Case study physical exam

o Pedal hair present
o Pedal pulses are not palpable but are biphasic with Doppler and pedal hair is present
o Cannot feel monofilament (2/10)
o Size of ulcer is 2 mm in diameter
o Derm: erythema noted to lef hallux with slight purpule discoloration
o Ulcer plantar hallux IPJ with yellow fibrotic base
o Edema present to hallux and foot
o Musculoskeletal: ROM is somewhat limitied to 1st MPJ, pain to palpation of the hallux, no fluctuance or crepitus

49

Case study initial visit

o Purple discoloration from infection
o Get x-ray, take culture, get bloodwork
o Antibiotics are not currently helping
o Vascular studies (did not get them because circulation was pretty good)
o Offloading (total contact cast, boot, post-op shoe, cutout over 1st ray)
o Dress the wound, does not meet criteria to put in the hospital

50

Cultures

o Group G strep
o MSSA

Bactrim
o Bactrim only covers staph and usually MRSA
o Bactrim does NOT cover strep very well – not great

51

X-rays

o No gas present
o No erosive changes in bones (no osteo)

52

1 week later

o Toe started turning gray 2 days after being seen
o Presents with completely black toe
o Needs amputation right away
o Progressed so quickly so be suspicious of necrotizing fasciitis

53

Hospital

o Admit to hospital
o X-rays
o Labs
o Amputation

54

Labs at hospital

o WBC = 12.7
o Sed rate = 100
o CRP = 7.5
o AbA1c = 8.1

55

Treatment

o Hallux amputation performed
o Cultures came back as skin flora
o Patient send home non-weight bearing

56

4 weeks post op

o Sutures removed because they were loose
o Minimal drainage
o No pain
o Would like to go back to work

57

6 weeks post op

o Patient called in stating he can see bone
o Instructed to use betadine and call if redness or signs of systemic
o Wound came open 1-2 weeks after going back to work

58

How to manage now

o X-rays
o 1st ray amputation or partial first ray amputation
o Admit to hospital
o MRI to see extent of bone involvement (1st met head is destroyed, Edema goes back to base of 1st met head, Infectious disease wanted the whole 1st ray to be gone)
o Biomechanics (If you take off the whole first ray, he will have no attachment for Lis francs TA, more pressure on other metatarsals)

59

2 weeks later

Healing well at this time

60

Case study 3

- 52-year-old diabetic male with new ulcer plantar 2nd metatarsal head
- Chills nausea
- Vascular -= DP palpable, PT not, glucose 765
- 2nd ray is already missing
- High BP, high pulse, high respirations
- Admitted to hospital right away
- X-rays – Soft tissue gas