Lead Diabetes Podiatrist Consultant in Acute Medicine and Diabetes Diabetic Foot Lead Consultant

Transcription

1 Title: DIABETIC FOOT INFECTION Ref No: 1461 Version 3 Classification: Guideline Directorate: Organisation Wide Due for Review: Responsible for review: Lead Diabetes Podiatrist Consultant in Acute Medicine and Diabetes Diabetic Foot Lead Consultant Document Control Ratified by: Applicability: Service Delivery Unit Clinical Director of Pharmacy Care and Clinical Policies Group All patients as indicated 1. The Diabetic foot team This consists of:- Diabetologists: Tel: Mobile phone via Torbay Hospital switch board Lead Podiatrist: Tel: Inpatient Podiatrist: Mob: Vascular Surgeon: Tel: Vascular nurses: Bleep #253 and bleep #6293 Orthopaedic Surgeon: Tel: via switch Plus Tissue Viability: Tel: and Orthotics (based in TAIRU Tel: ) 1.1 Foot MDT clinics are held weekly in TAIRU on Tuesday morning between The diabetic foot clinic is attended on a regular basis by both the vascular and orthopaedic consultants. 1.3 There is an inpatient podiatrist and twice weekly inpatient ward rounds by the multidisciplinary foot team on Tuesday and Thursday. 1.4 Referral to the foot team should include all patients with a SINBAD score of 3 or more and all patients who have been admitted to hospital for an infected diabetic foot ulcer +/- surgery. Referral should be within 24 hours. 1.5 Appendix 1 Referral pathway 2. General Statement This guideline covers all patients with diabetes i.e. type 1 and type All diabetic foot ulcers should be assessed using the SINBAD score. A score of 3 or above indicates a severe foot ulcer. The SINBAD Score Please tick yes or no for each of the following: Site = Hindfoot No Yes Ischaemia: Clinical PVD? No Yes Neuropathy: Sensory loss? No Yes Bacterial Infection: Clinical? No Yes Area: 1cm 2 or more? No Yes Depth: to tendon or bone? No Yes 2.2 The diagnosis of diabetic foot infection should be achieved using a combination of clinical, valuation and laboratory investigations. 2.3 Wound swabs should only be taken if infection is indicated. The presence of infection is defined by the presence of at least 2 of the following clinical features: erythema, local tenderness or pain, (general pain may be present due to other causes such as neuropathic or ischaemic pain) Diabetic Foot Infection Version 3 (May 2017) Page 1 of 4

2 local warmth, Purulent discharge (thick, opaque to white or serosanguinous). Prior to taking the swab, the wound, if possible, should be debrided by a health professional qualified to do so. Any loose tissue or pus should be removed and the wound cleansed. The swab should be taken from the cleansed wound bed. 2.4 Infections may be classified clinically as mild, moderate or severe as below (ref IDSA): Mild Moderate Severe* Clinical features Local infection involving only the skin and subcutaneous tissues (without involvement of deeper tissues or systemic signs). If erythema must be >0.5cm to <2cm around ulcer. Local infection with erythema > 2cm or involving structures deeper than skin and subcutaneous tissues (eg abscess, osteomyelitis, septic arthritis, fasciitis) and no systemic inflammatory response. Local infection with signs of SIRS, (systemic inflammatory response signs) i.e. at least 2 of temperature >38 or <36, HR >90bpm, RR >20 breaths/min, WCC >12000 or <4000. *Ischemia may increase the severity of any infection and the presence of critical ischemia often makes the infection severe. Systemic infection may sometimes manifest with other clinical findings such as hypotension, confusion, vomiting or metabolic disturbance. 3 When should Osteomyelitis be suspected? 3.1 Clinically, the sausage toe deformity, is highly suggestive of underlying osteomyelitis (1). 3.2 Individuals with soft tissue infections that have been present for several weeks are at high risk of contiguous bone involvement, particularly if these lesions are located over a bony prominence (2). 3.3 The larger and deeper the ulceration, the more likely that an underlying osteomyelitis is present (3). 3.4 A wound with exposed bone or palpable bone on probing is highly indicative of osteomyelitis (4). 3.5 If a patient presents with a diabetic foot ulcer and osteomyelitis is suspected, the patient should be referred immediately to the multidisciplinary diabetic foot clinic at Torbay Hospital. 3.6 The wound should be assessed and photographed. 3.7 An x ray should be arranged and the wound swabbed as described in paragraph A blood test requesting CRP and full blood count (FBC), U&Es, and an up to date Hba1c (if not done within 3 months) should be arranged. Blood cultures should be taken prior to iv antibiotic administration in septic, hospitalised, patients. 4 Empirical Treatment of Diabetic Foot Infection 4.1 The majority of diabetic foot infections are caused by gram positive organisms particularly Staph aureus and Beta haemolytic streptococci (Group A and G). A high proportion of persistent or deep wounds will have polymicrobial infection, although it can be difficult to distinguish colonisation from infection. 4.2 Superficial wound swabs are a poor determinant of infection and should only be used in conjunction with clinical signs i.e. a positive wound swab does not need treating if there are no clinical features of infection. Whenever possible, deep samples should be taken, preferably tissue through biopsy or surgical debridement, and before antibiotics have been started. Debridement will shorten duration of antimicrobial therapy due to improved tissue penetration and removal of de-vitalised tissue. 4.3 Suggested oral antibiotic treatment (mild to moderate infection) see notes below and need to be guided by cultures whenever possible. Also check renal function for dose adjustments. Diabetic Foot Infection Version 3 (May 2017) Page 2 of 4

3 Superficial 1 st Line Flucloxacillin 500mg -1g QDS PO OR Flucloxacillin 500mg QDS PO PLUS Amoxicillin 500mg TDS PO Alternative choices Co-amoxiclav 625mg TDS PO (limit duration to 2 weeks) Deep infection or osteomyelitis Assess patient for systemic symptoms (SIRS) and if present, admit to hospital and treat with IV antibiotics (see below). Arrange for orthopaedic assessment of wound. If patient is well and wound does not need debriding oral antibiotics may be used. It is essential that the foot team are involved in the decision. First line treatment of osteomyelitis is Clindamycin 450mg QDS PO. Flucloxacillin + Rifampicin 300mg BD PO, or Flucloxacillin + Sodium Fusidate 500mg TDS PO. Some patients may benefit from once daily IV antibiotics; examples include Daptomycin, Teicoplanin, Ertapenem and Piperacillin/Tazobactam or Flucloxacillin via 24 hour continuous infusion. These should only be initiated following discussion with a Consultant Microbiologist. Penicillin allergy Clindamycin 450mg QDS PO OR Doxycycline 100mg BD PO OR Clarithromycin 500mg BD PO Doxycycline 100mg BD PO PLUS Rifampicin 300mg BD PO A good initial antibiotic choice for superficial infection is Flucloxacillin on its own or in combination with amoxicillin (doxycycline or clarithromycin in penicillin allergic patients). Antibiotic choice may be influenced subsequently by swab results. If there is a poor response consider adding Metronidazole PLUS Levofloxacin (see note above). Resistant staphylococcal infection may respond to Doxycycline PLUS Rifampicin. Rifampicin is a strong enzyme inducer so may be omitted if risk of drug interactions (e.g. warfarin). If you are in doubt discuss with a Consultant Microbiologist. Monitoring of LFT s is required for patients on rifampicin and dose should be limited to a maximum of 300mg BD. For patients on high dose flucloxacillin and/or prolonged courses of flucloxacillin, monitoring of renal and liver function is also recommended. 4.5 Clindamycin has been linked to the development of C. difficile associated diarrhoea. However, all antibiotics can predispose to C. difficile and any patient with diarrhoea, who is currently on antibiotics, or recently received antibiotics, should have a stool sample tested for C.difficile. 4.6 Clindamycin should only be prescribed in the multidisciplinary diabetic foot clinic and the prescription preferably obtained from the hospital pharmacy. If written on an FP10 prescription then the prescription can be fulfilled by the hospital pharmacy or a community pharmacy. However if the patient is first treated by a community based diabetes specialist podiatrist, a 1 week course of Clindamycin should be arranged via the GP to prevent a delay in the treatment Avoid combinations of Clindamycin and Quinolones (Ciprofloxacin/Levofloxacin) unless there are no alternatives. This combination will significantly increase the risk of C. difficile associated diarrhoea - such patients should be risk assessed. 4.8 The duration of antimicrobial therapy should be at least 2 weeks for soft tissue infections. If osteomyelitis is suspected then antibiotics may need to be continued for 6 to 12 weeks or longer. These patients should receive specialist care within the diabetic foot MDT. Diabetic Foot Infection Version 3 (May 2017) Page 3 of 4

4 4.9 If the patient is systemically unwell (severe infection) then admission to hospital for intravenous antibiotics should be arranged. On admission the patient should have all dressings removed from feet and both feet examined including an assessment of the peripheral circulation. Blood tests including FBC/U+Es/LFTs/glucose/CRP/HbA1c and cultures should be taken and the foot x-rayed. 5 Suggested Intravenous Antibiotic regime: Piperacillin/Tazobactam 4.5g TDS PLUS Metronidazole 500mg TDS Penicillin allergy: Define type of allergic reaction Rash only: Meropenem 1g TDS Anaphylaxis: Discuss with a Consultant Microbiologist 5.1 Use of gentamicin in diabetics should generally be restricted to 48h due to high incidence of CKD, particularly those with foot infection monitor levels/ renal function closely and always discuss alternatives with a Microbiologist if continuing beyond 48h. 5.2 Please inform a member of the foot MDT of all patients admitted to hospital with Diabetic foot infections within 24 hours of admission if possible by contacting the inpatient podiatrist. 6 Indications for surgery In all cases apart from critical ischaemia the initial surgical response should be sought from the on call orthopaedic team. In the acutely unwell hospitalised patient an urgent surgical opinion should be sought for: Patient with severe sepsis Patient with wet tissue loss Patient with critical ischaemia Patient with suspected collection. This may be indicated by the presence of air in the soft tissues on x-ray. 6.1 Other indications for surgery/surgical review Use the standard white request slip for the particular speciality required in addition to contacting the consultant or secretary directly. Failure of antibiotic therapy Evidence of PVD e.g.; non palpable foot pulses, monophasic Doppler signals, and an ABPI of below 0.8. Appendix 1 Diabetic Foot Referral Pathway Algorithm Appendix 2 Foot Screening Tool Diabetic Foot Infection Version 3 (May 2017) Page 4 of 4

5 Appendix 1 Diabetic Foot Referral Pathway Algorithm Urgent Medical Opinion New or Deteriorating Foot Ulcer/ suspected Charcot Medium or High Risk Foot Spreading cellulitis Patient systemically unwell, (eg shivers, headache, unusually high sugars) Extensive ulceration and Tissue necrosis Obvious abscess formation Mild to moderate infection, known PAD/neuropathy A hot, red, swollen foot or ankle where there is no known portal of entry for infection is highly indicative of Charcot arthropathy Foot screening has identified the presence of Neuropathy or PAD, +/- callus or deformity Urgent medical and surgical review required along with IV antibiotics If suspected Charcot, advise non-weight bearing as much as possible Non-urgent referral via letter, health professional referral or self referral to podiatry appointments office Refer to A&E or EAU immediately phone MDT Diabetes Team Urgent referral to Podiatry Appointments office ( ) t-sd.podappts@nhs.net Regular routine treatment and advice as per NICE guidelines To be seen by multidisciplinary foot team within 24 hours Urgent assessments within 2 working days Podiatry Appointments Office Castle Circus Health Centre Abbey Road, Torquay, TQ2 5YH Tel: t-sd.podappts@nhs.net Diabetic Foot Referral Pathway Algorithm

6 Appendix 2 Diabetic Foot Screening Tool All people with diabetes should have their feet checked on an annual basis, searching for the risk factors of ulceration. The foot should then be classified as being at either low, medium or high risk, the risk status documented and the patient informed. Neuropathy This is detected with a 10g monofilament. Test 5 sites on each foot. If the patient is unable to feel 1 out of 5 sites tested, this would indicate neuropathy. Peripheral Arterial Disease (PAD) Palpate the dorsalis pedis and posterior tibial arteries. If unable to palpate, this could indicate PAD. If Doppler ultrasound available, a monophasic signal would indicate PAD. Callus and/or Deformity Whilst not necessarily a complication of diabetes, the presence of callus and deformity indicates high pressure areas. High pressure areas in addition to neuropathy or PAD put the foot at high risk of ulceration. LOW RISK No neuropathy, no peripheral arterial disease Issue foot care leaflet and re-screen in 1 year Agree self management plan MEDIIUM RISK Neuropathy and/or peripheral arterial disease Issue foot care leaflet. Refer to podiatry for regular follow up every 3 to 6 months Foot inspection Footwear inspection Enhanced education Skin and nail care HIGH RISK History of previous ulceration and/or neuropathy/ peripheral arterial disease and callus/deformity. Issue foot care leaflet. Refer to podiatry for regular follow up every 1 to 3 months As above ACTIVE ULCER Urgent referral to podiatry, tel: Or tsdpodappts@nhs.net Investigate vascular insufficiency. Initiate and supervise wound management. Debridement of wound. Antibiotics if required. Provision of specialist footwear and casting. Foot Screening Tool

7 Protocols & Guidelines Document Control This is a controlled document. It should not be altered in any way without the express permission of the author or their representative. On receipt of a new version, please destroy all previous versions. Ref: 1461 Title: Diabetic Foot Infection Date of Issue: 5 May 2017 Next Review Date: 5 May 2020 Version: 3 Diabetes Specialist Podiatrist, Author: Consultant in Acute Medicine and Diabetes Diabetic Foot Lead Consultant Index: Allied Health Professionals Classification: Guideline Applicability: As indicated The guidance contained in this document is intended to be inclusive for all Equality Impact: patients within the clinical group specified, regardless of age, disability, gender, gender identity, sexual orientation, race and ethnicity & religion or belief. Evidence based: Yes 1. Rajbhandari et al, (2000) sausage toe : a reliable sign of underlying osteomyelitis. Diabetic medicine 17: Lipsky BA (1997) Osteomyelitis of the foot in diabetic patients. Clinical infectious Diseases. 25: Newman LG, Waller J, palastro CJ et al (1991) Unsuspected osteomyelitis in diabetic foot ulcers: diagnosis and monitoring leococyte scanning with indium References: oxyquinolone. Journal of the American medical Association. 266: Grayson ML et al (1995) Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis in diabetic foot ulcers. Journal of the American Medical Association 27: Venkatesan P, Jeffcoate WJ (1997) Conservative management of osteomyelitis in the feet of diabetic patients. Diabetic Medicine 14: IDSA Guideline for Diabetic Foot Infections CID 2012:54 (15 June) Produced following audit: No Audited No Approval Route: See ratification Date Approved: 3 May 2017 Clinical Director of Pharmacy Service Delivery Unit Care and Clinical Policies Group Links or overlaps with other policies: All TSDFT Trust strategies, policies and procedure documents. PUBLICATION HISTORY: Issue Date Status Authorised 1 27 January 2012 New Consultant Physician in Diabetes and Endocrinology, Clinical Director of Pharmacy 2 17 July 2014 Revised Consultant in Acute Medicine and Diabetes Diabetic Foot Lead Consultant Consultant Microbiologist Clinical Director of Pharmacy 3 5 May 2017 Revised Clinical Director of Pharmacy Service Delivery Unit Care and Clinical Policies Group 3 20 February 2018 Review Date Extended 2 Years to 3 Years Diabetic Foot Infection Document Control Information

8 The Mental Capacity Act 2005 The Mental Capacity Act provides a statutory framework for people who lack capacity to make decisions for themselves, or who have capacity and want to make preparations for a time when they lack capacity in the future. It sets out who can take decisions, in which situations, and how they should go about this. It covers a wide range of decision making from health and welfare decisions to finance and property decisions Enshrined in the Mental Capacity Act is the principle that people must be assumed to have capacity unless it is established that they do not. This is an important aspect of law that all health and social care practitioners must implement when proposing to undertake any act in connection with care and treatment that requires consent. In circumstances where there is an element of doubt about a person s ability to make a decision due to an impairment of or disturbance in the functioning of the mind or brain the practitioner must implement the Mental Capacity Act. The legal framework provided by the Mental Capacity Act 2005 is supported by a Code of Practice, which provides guidance and information about how the Act works in practice. The Code of Practice has statutory force which means that health and social care practitioners have a legal duty to have regard to it when working with or caring for adults who may lack capacity to make decisions for themselves. The Act is intended to assist and support people who may lack capacity and to discourage anyone who is involved in caring for someone who lacks capacity from being overly restrictive or controlling. It aims to balance an individual s right to make decisions for themselves with their right to be protected from harm if they lack the capacity to make decisions to protect themselves. (3) All Trust workers can access the Code of Practice, Mental Capacity Act 2005 Policy, Mental Capacity Act 2005 Practice Guidance, information booklets and all assessment, checklists and Independent Mental Capacity Advocate referral forms on icare Infection Control All staff will have access to Infection Control Policies and comply with the standards within them in the work place. All staff will attend Infection Control Training annually as part of their mandatory training programme. Diabetic Foot Infection The Mental Capacity Act 2005

9 Quality Impact Assessment (QIA) Please select Who may be affected by this document? Patient / Service Users Visitors / Relatives General Public Voluntary / Community Groups Trade Unions GPs NHS Organisations Police Councils Carers Staff Other Statutory Agencies Others (please state): Does this document require a service redesign, or substantial amendments to an existing process? NO. If you answer yes to this question, please complete a full Quality Impact Assessment. Are there concerns that the document could adversely impact on people and aspects of the Trust under one of the nine strands of diversity? No. Age Disability Gender re-assignment Pregnancy and maternity Marriage and Civil Partnership Race, including nationality and ethnicity Religion or Belief Sex Sexual orientation If you answer yes to any of these strands, please complete a full Quality Impact Assessment. If applicable, what action has been taken to mitigate any concerns? Who have you consulted with in the creation of this document? Note - It may not be sufficient to just speak to other health & social care professionals. Patients / Service Users Visitors / Relatives General Public Voluntary / Community Groups Trade Unions GPs NHS Organisations Police Councils Carers Staff Details (please state): Other Statutory Agencies Lead diabetic foot consultant and microbiologist. Diabetic Foot Infection Quality Impact Assessment

10 Rapid Equality Impact Assessment (for use when writing policies and procedures) Policy Title (and number) Diabetic Foot Infection Version and Date Version 3 Nov Policy Author Diabetes Specialist Podiatrist An equality impact assessment (EIA) is a process designed to ensure that a policy, project or scheme does not discriminate or disadvantage people. EIAs also improve and promote equality. Consider the nature and extent of the impact, not the number of people affected. EQUALITY ANALYSIS: How well do people from protected groups fare in relation to the general population? PLEASE NOTE: Any Yes answers may trigger a full EIA and must be referred to the equality leads below Is it likely that the policy/procedure could treat people from protected groups less favorably than the general population? (see below) Age Yes No Disability Yes No Sexual Orientation Yes No Race Yes No Gender Yes No Religion/Belief (non) Yes No Gender Reassignment Yes No Pregnancy/ Maternity Yes No Marriage/ Civil Partnership Yes No Is it likely that the policy/procedure could affect particular Inclusion Health groups less Yes No favorably than the general population? (substance misuse; teenage mums; carers 1 ; travellers 2 ; homeless 3 ; convictions; social isolation 4 ; refugees) Please provide details for each protected group where you have indicated Yes. VISION AND VALUES: Policies must aim to remove unintentional barriers and promote inclusion Is inclusive language 5 used throughout? Are the services outlined in the policy/procedure fully accessible 6? Does the policy/procedure encourage individualised and person-centered care? Could there be an adverse impact on an individual s independence or autonomy 7? If Yes, how will you mitigate this risk to ensure fair and equal access? Yes No Yes No Yes No Yes No EXTERNAL FACTORS Is the policy/procedure a result of national legislation which cannot be modified in any way? Yes No What is the reason for writing this policy? (Is it a result in a change of legislation/ national research?) It is recommended by NICE guidelines Who was consulted when drafting this policy/procedure? What were the recommendations/suggestions? The diabetic foot multidisciplinary team including microbiology. ACTION PLAN: Please list all actions identified to address any impacts Action Person responsible Completion date AUTHORISATION: By signing below, I confirm that the named person responsible above is aware of the actions assigned to them Name of person completing the form Diabetes Specialist Podiatrist Signature Validated by (line manager) Consultant in Diabetes and Endocrinology Signature Diabetic Foot Infection Rapid Equality Impact Assessment