Infected diabetic foot can be successfully treated by primary care physicians

Józef Drzewoski 1, Agata Drozdowska 1, Jacek Kasznicki 1, Marek Liniarski 2 CASE REPORT 1 Department of Internal Disease, Diabetology and Clinical Pharmacology, Medical University of Lodz, Poland 2 General Practice, Skierniewice, Poland Infected diabetic foot can be successfully treated by primary care physicians Abstract Diabetic foot complications are the most common cause of nontraumatic lower extremity amputations. The risk factors for diabetic ulcer formation include diabetic neuropathy, structural foot deformity and peripheral arterial occlusive disease. Foot ulcers are the principal portal of entry for infection in patients with diabetes. Infected foot ulcers are difficult to heal and successful management requires multidisciplinary approach. The appropriate treatment of this complication includes protecting the foot from pressure load, appropriate dressings, antibiotics, debridement and in some cases arterial revascularization. Family physicians play a key role in the prevention and early diagnosis of diabetic foot complications. It is suggested that infected diabetic foot should be treated in cooperation by general practitioners and specialists. The integration of services between primary and secondary care has been shown to improve outcomes and the effectiveness of such cooperation is proved by the case of a 52-year-old man with complicated diabetic foot. Diabet Dośw Klin 2009; 9, 1: 33 38 key words: diabetic foot, risk factors, infection, ambulatory treatment Introduction The lifetime incidence of foot ulcers in patients with diabetes mellitus may be as high as 25%. Many of them will require lower limb amputation [1 4]. It is estimated that up to two thirds of all diabetes-related lower-extremity amputations are preceded by foot ulcers [1]. The population of diabetic patients with foot ulceration is heterogenous. A number of studies demonstrated that majority of patients with foot ulcers present with profound peripheral polyneuropathy. There are several other causative factors that may vary among patients, such as excessive plantar pressure, the presence of atherosclerotic peripheral arterial disease, infection and co-morbidities [5]. Foot infections occurring in individuals with diabetes almost always follow trauma, especially when repetitive [6]. The etiology of diabetic foot infections is usually polymicrobial, mostly including aerobic Gram-positive cocci Address for correspondence: Józef Drzewoski, MD, PhD Klinika Chorób Wewnętrznych z Oddziałem Diabetologii i Farmakologii Klinicznej Uniwersytet Medyczny w Łodzi ul. Parzęczewska 35, 95 100 Zgierz Tel (+48 42) 714 45 51, e-mail: jdrzew@poczta.onet.pl Diabetologia Doświadczalna i Kliniczna 2009, 9, 1, 33 38 Copyright 2009 Via Medica, ISSN 1643 3165 (especially S. aureus) [7]. Patients with chronic wounds or those recently treated with antibiotics may also be infected with Gram-negative rods, while in those with foot ischemia or gangrene obligate anaerobic pathogens may be present [8]. It has been reported that foot complications were positively correlated with duration of diabetes, insulin treatment, presence of chronic diabetic complications, cigarette smoking, and low level of patient education [9]. It is regarded that infected diabetic foot ulcer should be treated only by those with sufficient experience and facilities. Therefore, it is suggested that general practitioner (GP) who rarely have enough experience in foot ulcer management should refer patients for foot specialist, and timely consultation with multidisciplinary team care is warranted. Such integration of services between primary and specialty care has been shown to improve outcomes [10]. To support this opinion we describe a man with infected diabetic foot ulcer successfully treated by the GP. Case description A 52 year-old man with type 2 diabetes mellitus, heavy tobacco smoker was first seen at the primary care practice in Skierniewice at the day of his discharge from the Surgical Department where he had been www.ddk.viamedica.pl 33

Diabetologia Doświadczalna i Kliniczna 2009, Vol. 9, No. 1 hospitalized for 15 days because of ulceration of the right great toe with coexisting necrosis, which was surgically removed. Until hospitalisation, he was treated with oral hypoglycaemic drugs for 5 years and the patient had been controlling glycaemia every half a year. During hospitalization oral agents were replaced by premixed human insulin (30/70) injected twice daily. Physical examination during the first visit at primary care physician office revealed: brown melanosis of both feet up to shank with dry, desquamating skin; macerated epidermis around right great toe (due to moist dressings adhering undamaged skin); ulcer, which size was 4.5 cm by 2 cm, under the right great toe with unclean ground from necrosis and pus; redness, warmth, induration, and pain around the right great toe; hyperkeratosis of nails; lack of temperature differentiation; limited touch/compression sensation of the soles of both feet; vibration sensation: of great toes R0/8, L4/8; of medial ankle R4/8, L5/8; lack of differentiation between acute and dull pain; diabetic nonproliferative retinopathy on ophthalmologic examination. Medical record revealed the following results of laboratory measurements and additional tests: HbA 1c 10.4%; glycaemia range 11.3 and 14.5 mmol/l (204 261 mg/ /dl); Staphylococcus aureus sensitive to ciprofloxacin was found in swab culture (the antibiotic was introduced at the Surgical Department); presence of calcaneal spur and degenerative-forming changes of right metatarsus visible in the radiograph; lymphatic insufficiency of right shank without any pathologies within veins, such as dilatation or valvular failure; without evidence of past or active thrombosis; flow through arteries typical, low-resistant like in inflammation which indicated lymphangitis. During the first visit in the primary care practice the patient was educated on basic diabetes and foot care and was provided with personal glucometer. He was specifically asked to determine his blood glucose concentration before and 2 hours after the main meals. The principle of self-monitoring, decision making and goal setting were explained. The patient was also provided with a booklet describing the proper diet and smoking cessation was strongly recommended. Follow-up visits were scheduled initially every week and the patient was instructed to call his primary care physician for an appointment any time he had a concern about a foot problem. The initial pharmacological management was established and periodically, due to the clinical signs and symptoms, changed after consultation with the speciality team from the Department of Diabetology and Clinical Pharmacology, Medical University of Lodz. The management consisted of pre-mixed insulin bid and pentoxifiline 1200 mg/day, nadroparine: 5700 IU/0.6 ml/day, diosmine: 600 mg/day, ciprofloxacin: 500 mg bid, thioctic acid: 600 mg/day; benfotiamine: 50 mg tid; riboflavine: 3 mg tid; pyridoxine: 50 mg/day. It was recommended to apply Argentum sulfathiazolum cream directly into the wound alternately with povidone-iodine ointment in the morning. The patient was advised to change dressings twice a day using ointment with clostridiopeptidase in the evening, preceded by the following steps: washing the foot and wound with water and green soap, rinsing the wound with povidone-iodine solution, waiting 15 minutes, precise rinsing of the wound with aseptic 0.9% NaCl solution. The cream was also applied to the whole foot with paying special attention to interdigital spaces. The patient was instructed about the necessity of keeping the wound moist to promote optimal healing conditions, diminishing the bacterial population by regular changes of dressings, removing necrotic tissues using ointment with enzyme. Discordance between povidone-iodine and clostridiopeptidase associated with inhibition of enzyme activity which requires special preciseness during rinsing the wound with NaCl solution was also explained. The patient was informed about the most common pathogens isolated from feet wounds which had their origin in the area of perineum and anus. He was also learnt how to avoid transmission of pathogens (i.e. avoiding washing in shower cabin, bath with elevated foot on the edge of a bath-tub above the water surface). These information were given in order to help the patient to understand the need of keeping the correct hygiene of the whole body. To protect from excessive plantar pressure the patient was advised to wear the therapeutic shoe and walk only by means of elbow crutch. He was also encouraged to do careful physical exercises in horizontal position, involving different muscles groups of lower limbs which at the same time were increasing circulatory effectiveness. Education program was continued by GP during every patient visit. Follow-up period Day 28 Dripping from wound decreased (Fig. 1); better vibration sensation R5/8, L5/8. Analysis of the patient s glycemic profile indicated that blood glucose concentration 34 www.ddk.viamedica.pl

Józef Drzewoski et al. Infected diabetic foot can be successfully treated by primary care physicians Day 42 The whole wound without necrosis, fibrin deposits visible on the surface (Fig. 2). Argentum sulfathiazolum cream and povidone-iodine ointment were administrated again. Doppler of feet arteries revealed monophasic curves illustrating rapidity of blood flow, retarded speed and high-resistant flow which at decreased pulsation rates, despite coexisting correct ankle-brachial ratios (ABI R 1.04; ABI L 1.19), allowed to diagnose difficulties of inflow due to macroangiopathy. Mean glycaemia was 7.8 mmol/l (140 mg/dl), 5.1 11.3 mmol/l (92 204 mg/dl); 47% values reached the established target goal. Figure 1. Day 28 oscillated from 5.5 to 12.4 mmol/l (99 223 mg/dl) with only 30% of measurements at target level. Glycemic profile of the patient during the follow-up period is presented in Table 1. Taking into account the importance of good metabolic control of diabetes and healing process the intensive insulin-therapy consisting of 18-10-6 units of regular insulin injected before the main meals and 10 units of NPH insulin at the bedtime was recommended. The scheme of insulin therapy during the whole period of the patient observation is presented in Table 2. The patient was consulted by the surgeon and sharp debridement was carried out twice at weekly intervals. Day 77 On the 77 th day the patient was told to apply moist applications with gentamicin (80 mg/2 ml, twice daily) and begin enzymatic debridement with clostridiopeptidase at noon. Day 107 Clean wound with shrunk edges and decreased area of unhealed surface (Fig. 3). Fibrin debris at the lower edge with incoming epidermis and granulation in the ground. Mean glycaemia was 6.9 mmol/l (124 mg/dl), 3.4 5.2 mmol/l (61 194 mg/dl). It is worth stressing that almost 64% measurements of blood glucose concentration were in optimal range. Day 133 The patent quitted smoking three days before the visit. Wound almost completely healed (Fig. 4). Visible new, gentle epidermis within the whole surface of the wound. The patient started intensive mobilization too early and that is why in the ground of the wound a small vessel ruptured with a slight haemorrhage in the new tissue (visible as bluish area at 2 nd hour; approxi- Table 1. Glycemic profile during the follow-up period Day of visit Mean glycemia Range of glycemia Optimal values [mmol/l; mg/dl] [mmol/l; mg/dl] of glycemia (%) 14 9.7 (175) 3.6 16.6 (64 299) 16 28 8.4 (151) 5.5 12.4 (99 223) 30 35 8.5 (153) 4.4 11.1 (79 200) 22 38 8.2 (147) 5.0 11.4 (90 205) 47 42 7.8 (140) 5.1 11.3 (92 204) 47 56 7.9 (143) 4.0 13.7 (76 247) 46 69 7.3 (131) 4.1 11.7 (73 211) 58 77 6.8 (123) 4.3 11.6 (77 208) 68 86 6.9 (124) 3.8 10.9 (69 196) 67 98 6.8 (122) 3.2 10.6 (58 191) 69 107 6.9 (124) 3.4 5.2 (61 194) 64 114 7.2 (129) 3.4 11.2 (61 202) 60 126 7.1 (127) 3.4 11.8 (62 212) 60 www.ddk.viamedica.pl 35

Diabetologia Doświadczalna i Kliniczna 2009, Vol. 9, No. 1 Table 2. Changes of insulin therapy during follow-up visits Day of visit Regular [U] NPH at Mix 30/70 before bedtime [U] supper [U] Before breakfast Before dinner Before supper 14 14 14 14 28 18 10 16 35 18 10 6 10 38 19 11 6 11 42 20 12 5 12 56 19 14 5 14 69 20 15 6 15 77 20 15 6 16 86 20 15 6 16 98 20 15 6 16 107 20 16 6 17 114 20 16 6 17 126 20 16 6 17 133 19 16 6 19 142 19 16 6 19 231 19 16 6 19 Figure 2. Day 42 Figure 3. Day 107 mately 1.5 mm in diameter). It turned out that the direct cause was not only connected with overpressure towards new tissue but also with needless use of selfmade support put into a shoe in order to replace the missing foot s tissue. The ulcer was completely healed 3 weeks later and the patient returned to his previous occupation (Fig. 5). Discussion Foot ulceration is a common complication of diabetes that has potentially disastrous consequences for patients. It should always be considered that the patient s quality of life decreases dramatically with the occurrence of diabetic foot ulcers. Fortunately, better control 36 www.ddk.viamedica.pl

Józef Drzewoski et al. Infected diabetic foot can be successfully treated by primary care physicians Figure 4. Day 133 Figure 5. Day 157 of glycemia, early recognition of complications of peripheral neuropathy and ischemia, as well as a multidisciplinary approach to the therapy when an ulcer develops can dramatically reduce this problem [11, 12]. Diabetic foot infections require attention to local (foot) and systemic (metabolic) issues and coordinated management, which in our case was also secured by GP being in permanent contact with the department of diabetology. Efforts to prevent infections should be targeted at people with traumatic foot wounds, especially chronic, deep, recurrent, or associated with peripheral vascular disease [6, 8]. Management of ulcers consists of three elements: removal of callus, eradication of infection, and reduction of weight bearing forces, often requiring bed rest with the foot raised [10]. Having patients use a wheelchair or crutches to completely halt weight bearing on the affected foot is the most effective method of offloading to heal a foot ulceration [13, 14]. Multidisciplinary diabetic foot care including early detection, patient education (proper foot care and footwear), effective management of foot problems and scheduled follow-up must be emphasized to prevent diabetes-related lower extremities amputation [15]. The case of our patient clearly demonstrates that mild to moderate infections can be effectively treated in the outpatient setting by GPs. It has been established that empirical antibiotic-therapy must cover mainly gram-positive cocci the pathogens presumed to be present. However, definitive therapy depends on culture results and the clinical response [16]. It was shown that treatment of infected diabetic-foot is safe and effective in the out-patient setting. Penicillins together with beta-lactamase inhibitors and fluoroquinolones are the most frequent choice [6]. Interestingly enough, more than 50% of the diabetic patients reported that they had not had their feet examined by their physician and 28% referred that they had not received foot education. Patients with lower levels of school education and income, as well as overweight individuals, were less likely to receive foot education. Foot self-examination is not carried out by 33% of the patients. Those individuals who had received foot education or had had their feet examined were more likely to check their feet regularly. GPs perform foot examination more often in males, low-income patients, those with foot complications, and those treated with insulin, but not in patients with the highest risk of foot complications, that is, those with diabetic neuropathy or peripheral vascular disease. Unfortunately, GPs tended to perform foot examination less frequently than diabetologists did [9]. It should be emphasized that pain sensation, being the primary natural warning signal, is faulty in patients with diabetic neuropathy and that is why injuries are not recognized until they are so severe that full-thickness wounds occurs [17 19]. Lavery et al. [17] suggested that infrared temperature monitoring, serving as early warning sign, appears to be a simple and useful adjunct in the prevention of diabetic foot ulceration. Of note study of Clemensen et al. [12] indicates that treatment of diabetic ulcers at home can be effectively supported by means of telemedicine. From the point of view of all three stakeholders (patient, visiting nurse, and expert), the simultaneous dialog facilitates satisfactory means for handling the cooperation and treatment. www.ddk.viamedica.pl 37

Diabetologia Doświadczalna i Kliniczna 2009, Vol. 9, No. 1 Foot problems remain one of the main challenge associated with management of diabetic patients. It has been reported that GPs who provide ongoing diabetic foot care education, prescribe appropriate shoes, and take an aggressive multidisciplinary approach to wound care can reduce the lower extremity amputation rate in their patient populations by 44% to 85% [4, 20, 21]. To increase the chance of infected foot ulcer healing the appropriate metabolic control of diabetes is obligatory. It is worth pointing out that in case of our patient the number of normal values of glycemia reached 60% after implementation of intensive insulin therapy. Although it is recommended to treat diabetic foot ulcers at highly specialized centers, in the real life the majority of patients are treated by GPs. It is because of relatively poor access to diabetologists especially in smaller towns (like Skierniewice in case of our patient) or in the country [11] Therefore, GPs are nowadays the key players in identifying patients at risk for foot ulceration and implementing an appropriate management plans. However, it is worth stressing that referral for specialty care should be considered for more complicated or unresponsive lesions [22 24]. In conclusion, the case we describe demonstrates that GPs may successfully treat infected diabetic foot. The increasing prevalence of diabetes, the insufficient number of diabetic foot specialists in our country, and high incidence of diabetic foot indicate that the health care organizers should establish efficacious system of cooperation between GPs and specialties to decrease enormous economical burden of this common diabetes- -related complication. The paper was support by grant 503 0077 9 Medical University of Lodz, Poland. References 1. Frykberg RG. Diabetic foot ulcers: pathogenesis and management. Am Family Phys 2002; 66: 1655 1662. 2. Frykberg RG, Armstrong DG, Giurini J. et al. Diabetic foot disorders; a clinical practice guideline. American College of Foot and Ankle Surgeons. J Foot Ankle Surg 2000; 39 (suppl. 5): S1 S60. 3. American Diabetes Association. Consensus Development Conference on Diabetic Foot Wound Care. 7 8 April 1999, Boston, Massachusetts. Diabetes Care 1999; 22: 1354 1360. 4. Al-Maskari F, El-Sadig M. Prevalence of risk factors for diabetic foot complications. BMC Family Practice 2007; 8: 59 67. 5. Prompers L, Schaper N, Apelqvist J. et al. Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE Study. Diabetologia 2008; 51: 747 755. 6. Lavery LA, Armstrong DG, Wunderlich RP. et al. Risk factors for foot infections in individuals with diabetes. Diabetes Care 2006; 29: 1288 1293. 7. Esposito S, Leone S, Noviello S. et al. Foot infections in diabetes (DFIs) in the out-patient setting: an Italian multicentre observational survey. Diab Med 2008; 25: 979 984. 8. Lipsky BA, Berendt AR, Deery HG. et al. Diagnosis and treatment of diabetic foot infections. Plast Reconstr Surg 2006; 117 (suppl. 7): S212 S238. 9. De Berardis G, Pellegrini F, Franciosi M. et al. Are type 2 diabetic patients offered adequate foot care? The role of physician and patient characteristics. J Diab Compl 2005; 19: 319 327. 10. Watkins PJ. ABC of diabetes. The diabetic foot. BMJ 2003; 326: 977 979. 11. Bowering CK. Diabetic foot ulcers. Pathophysiology, assessment, and therapy. Can Fam Physician 2001; 47: 1007 1016. 12. Clemensen J, Larsen SB, Kirkevold M. et al. Treatment of diabetic foot ulcers in the home: video consultations as an alternative to outpatient hospital care. Intern J Telemed Appl 2008; ID 132890: doi: 10.1155/2008/132890. 13. Kruse I, Edelman S. Evaluation and treatment of diabetic foot ulcers. Clin Diab 2006; 24: 91 93. 14. Armstrong DG, Lavery LA, Kimbriel HR. et al. Activity patterns of patients with diabetic foot ulceration. Diabetes Care 2003; 26: 2595 2597. 15. Tantisiriwat N, Janchai S. Common foot problems in diabetic foot clinic. J Med Assoc Thai 2008; 91: 1097 1101. 16. Lipsky BA. Medical treatment of diabetic foot infections. Clin Infect Dis 2004; 39 (suppl. 2): S104 S114. 17. Lavery LA, Higgins KR, Lanctot DR. et al. Preventing diabetic foot ulcer recurrence in high-risk patients. Diabetes Care 2007; 30: 14 20. 18. Armstrong DG, Lavery LA, Quebedeaux TL. et al. Surgical morbidity and the risk of amputation due to infected puncture wounds in diabetic versus nondiabetic adults. South Med J 1997; 90: 384 389. 19. Fowler MJ. Microvascular and macrovascular complications of diabetes. Clin Diab 2008; 26: 77 82. 20. Nesbitt JAA. Approach to managing diabetic foot ulcers. Can Fam Physician 2004; 50: 561 567. 21. Boulton AJM. Management of diabetic peripheral neuropathy. Clin Diab 2005; 23: 9 15. 22. Donohoe ME, Fletton JA, Hook A. et al. Improving foot care for people with diabetes mellitus a randomized controlled trial of an integrated care approach. Diabet Med 2000; 17, 581 587. 23. Boulton AJM, Kirsner RS, Vileikyte L. Neuropathic diabetic foot ulcers. NEJM 2004; 351: 48 55. 24. Koblik T. Zespół stopy cukrzycowej. In: Sieradzki J. ed. Cukrzyca. Via Media, Gdańsk 2006. 38 www.ddk.viamedica.pl