Wound Bed Preparation and Infected Wounds in Patients With Diabetes

Transcription

1 Wound Bed Preparation and Infected Wounds in Patients With Diabetes Robert J. Snyder, DPM, MSc, CWS Professor and Director of Clinical Research, Barry University SPM, Miami Shores, Florida Immediate Past President, Association for the Advancement of Wound Care

2 Diabetic Foot Ulcers One of the most common complications of diabetes Annual incidence 1% to 4% 1-2 Lifetime risk 15% to 25% 3-4 ~15% of diabetic foot ulcers result in lower extremity 1 million amputation 3,5 amputations globally in patients with diabetes (every 20 seconds ) ~85% of lower In the limb US; 1200 amputations in weekly patients with diabetes are proceeded by ulceration 6-7 Peripheral neuropathy is a major contributing factor in diabetic foot ulcers 1-7 Other factors: foot deformity, callus, trauma, infection, and peripheral vascular disease 1. Reiber and Ledoux. In The Evidence Base for Diabetes Care. Williams et al, eds. Hoboken, NJ: John Wiley & Sons; 2002: Boulton et al. NEJM. 2004;351: Sanders. J Am Podiatry Med Assoc. 1994;84: Boulton et al. Lancet. 2005;366: Ramsey et al. Diabetes Care 1999;22: Pecoraro et al. Diabetes Care. 1990;13: Apelqvist and Larsson. Diabetes Metab Res Rev. 2000:16:S75.

3 DFU Pathophysiology Final Common Pathways q Infection q Ischemia/hypoxia q Cellular failure All final common pathways q Pressure/trauma are implicated in DFU healing failure!! q Inflammation Snyder et al. Ostomy Wound Management. 2010;56(Suppl 4):S1-S24 Deep infection

4 Core Healing Principles Patient factors Physical aspects MACROscopic environment MICROscopic environment

5 Think like an internist, before you act like a surgeon Wm. Ennis, DO Wound management often requires a subtle balance between medical and surgical interventions.

6 STAIRWAY TO AMPUTATION

7 Classic Signs and Symptoms of Infection Heat Clinicians should diagnose infection based on the presence of at least 2 Pain classic symptoms or signs of inflammation Redness or purulent secretions Lipsky et al. Clinical Infectious Diseases. Swelling 2012;54(12): Clinically infected wounds usually require systemic antibiotics, while clinically uninfected wounds that are healing as expected do not require antimicrobials Lipsky B, Hoey C. Clinical Infectious Diseases. 2009;49:1541-9

8 Validity of Secondary Clinical Signs and Symptoms of Chronic Wound Infection Secondary clinical signs of infection with positive predictive value Serous drainage Clinicians with inflammation should consider Delayed the healing possibility of infection occurring in Discoloration any foot of wound granulation in a patient tissuewith diabetes Friable granulation tissue Lipsky et. Al. Clinical Infectious Diseases. Pocketing at base of wound 2012;54(12) Foul odor Wound breakdown Increasing pain Gardner, et al. Wound Rep Reg 2001; 9:

9 Account for Spectrum of DFU Presentation Probable contamination, no infection Local infection with adjacent cellulitis Progressive, necrotizing Infection Snyder R. Podiatry Management Nov-Dec 2013:

10 Infection Contributes to Various Complications Including Amputation ~60% of amputations due to infection Infection plays a role in about 60% of the DFU cases that result in amputation DFU = diabetic foot ulcer. Lipsky. Diabetes Metab Res Rev. 2004;24:S66. Lavery, Armstrong, et al. Diabetes Care. 2006;29:1288. Risk factors for infection: Wounds that penetrate to the bone Wounds with a duration > 30 days Recurrent foot wounds Wounds with a traumatic etiology Peripheral vascular disease Pain Deterioration of the wound Foul odor

11 Wound Bed Preparation Wound bed preparation is an important step in treating and protecting against wound infection DIME Sibbald RG, et al (2011) Adv Skin Wound Care. 24: Schultz GS, Sibbald RG, Falanga V et al. Wound bed preparation: a systemic approach to wound management. Wound Repair and Regeneration, 2003;11:1-28

12 Saap LJ, Falanga V. Wound Rep Reg 2002; 10:

13 Biofilm and the Glycocalyx Definition: A network of polysaccharide or protein-containing material extending outside of the cell. The glycocalyx protects the bacteria from antibiotics and accounts for the persistence of the infection Kania RE (2007) Arch Otolary Head Neck Surg; 133(2): Glycocalyx surrounding cells of Streptococcus species.

14 Biofilms are Problematic: Resistant to host immune responses Markedly resistant to penetration by topical antibiotics Biofilm and can bactericidals be 500x more resistant to antibacterial agents Mixed bacterial species may enhance the Costerton JW, et al. Annu Rev Microbiol 1995;49: virulence-synergistically Common in devitalized tissue Costerton JW, Lewandowski Z, Caldwell DE, Korber DR, Lappin-Scott HM. Microbial biofilms. Annu Rev Microbiol. 1995;49: Xu KD, McFeter GA, Stewart PS. Biofilm resistance to antimicrobial agents. Microbiology. 2000;146:

15 Hill et. al 2010 A Potential Model for Disrupting Problematic Biofilm (Theoretical) Sharp Debridement and utilization of topical antimicrobials to lower planktonic bacterial levels; this will decrease new biofilm colonies Continue Remember sharp that debridement it is still not on known a regular whether basis to continually disrupt all biofilmare and potentially bad weaken the biofilm/glycocalyx. Much more research (i.e. Biofilm is required can potentially in this fieldreturn within 3-24 hours.) There is in-vitro evidence using biofilm models which demonstrates the ability of some topical antimicrobial dressings to disrupt biofilm (i.e. iodine, silver)

16 Wound Bed Preparation in Practice Snyder R, Fife C, Moore Z. The DIME and Quality Measures. Advances Skin Wound Care Scheduled for Publication 2015

17 Wound Bed Preparation Sibbald RG, et al (2011) Adv Skin Wound Care. 24: Schultz GS, Sibbald RG, Falanga V et al. Wound bed preparation: a systemic approach to wound management. Wound Repair and Regeneration, 2003;11:1-28

18 Wound Bed Preparation Moist Wound Healing Moist Wound Healing Dyna-Flex Multi-Layer Compression System Moist Wound Healing Moist Wound Healing Designed by Dr. Robert Snyder

19 Version A Devitalized Tissue No Adequate Vascularity Evaluate patient and wound Orthopedic Epithealization: (CelluTome) Dermatological Yes Debride No Sharp Mechanical Autolytic Designed by Dr. Robert Snyder VAC Veraflo NuGel HydrocolloidBio ousive Tielle Vascular Consult Yes Systemic ABX ID Consult Topicals (ie. SNA) Yes + Probe To Bone X-ray + Osteo No No F/U X-ray C-ORC C-ORC/Silver Fibracol Measure Length Width Depth Yes See Infection Algorithm Infection Evaluate Granulation Undermining Periwound No NuGel Hydrocolloid Biocclusive Tielle

20 Version B Devitalized Tissue No Evaluate patient and wound Epithealization: (CelluTome) Adequate Vascularity Dermatological Yes Debride No Vascular Consult Measure Length Width Depth Evaluate Granulation Undermining Periwound Infection Sharp Mechanical Autolytic Yes No Designed by Dr. Robert Snyder VAC Veraflo NuGel HydrocolloidBioo usive Tielle See Infection Algorithm NuGel Hydrocolloid Biocclusive Tielle

21 Version A-1 Orthopedic + Probe To Bone Yes No Dermatological X-ray MRI See algorithm + Osteomyelitis Yes No Systemic ABX ID Consult Topicals (ie. SNA) F/U X-ray C-ORC C-ORC/Silver Fibracol Designed by Dr. Robert Snyder

22 CBC ESR VDRL, HIV, PPD C-reactive protein Gram stain Special stains for AFB, fungus Routine culture AFB, anaerobic, fungal culture X-rays, nuclear med studies, CT, MRI (osteomyelitis, deep abscess, infected prosthesis) Infection Inflammation ESR VDRL Antinuclear antibodies Rheumatoid factor Protein electrophoresis Immune complex Complement (CH50, C3, C4) a-anca, p-anca (Anti-neutrophil cytoplasmic antibodies) Hepatitis panel Coagulopathy (antithrombin III, protein C, S, Sickle cell or other hemoglobinopathy Cryoglobulinemia (cryoglobulins, C2, C4, end organ dysfunction) Primary Signs and Symptoms (Heat, Pain, Redness Swelling ) Evaluate Cause Yes Sharp Debridement Culture and Sensitivity Secondary Signs and Symptoms (ie: wound deterioration, pain) X-ray SNA C/ORC Systemic ABX No Consider inflammatory causes or Critical Colonization VAC Veraflo Other Malignancy Yes Vasculitis Further Evaluation Designed by Dr. Robert Snyder + Biopsy Vasculopathy No C/ORC VAC Veraflo Pyoderma Gangrenosum Diagnosis of Exclusion Negative Pathergy

23 Moisture Wet Dry Yes No Yes No Fibracol VAC/ Veraflo Tielle Nu-Derm Alginate Tx based upon wound appearance Nu-Gel Nu-Derm Hydrocolloid Bioclusive Adaptic Adaptic Touch Tx based upon wound appearance GraftJacket Designed by Dr. Robert Snyder

24 Hyper proliferative Wound Edge Increased Depth Yes No No Yes Excisional Debridement Selective Debridement Adaptic Adaptic Touch VAC/ Veraflo Fibracol C-ORC C-ORC/NA GraftJacket Adaptic Adaptic Touch VAC/ Veraflo GraftJacket Designed by Dr. Robert Snyder

25 A Surgical Pathway Should Be Considered When An Abscess or Surgical debridement is an important component Bone Infection is Suspected of both the evaluation and identification of infection as well as Snyder treatment R, et al. OWM of 2001 infection Snyder RJ et al. OWM. 2001;47(3):24-41

26 Abscessed foot in a neuropathic patient with diabetes: a stepwise approach

27 Summary Infection represents a serious sequelae in acute and chronic wounds in patients with diabetes Knowledge of clinical pathways to making a diagnosis remains critical: IDSA Guidelines Biofilm may play an important role in resistant infections Recent literature supports the use of appropriate wound bed preparation, systemic antibiotics, some topical antiseptics, debridement, and surgical strategies in the treatment of wound infection

28 Thank You