抗生素英文课件-ANTIBIOTICS-WITHIN-THE-MANAGEMENT-of-Dia

ANTIBIOTICSWITHINTHEMANAGEMENTofDiabeticfoot

Nice28-29avril2005ABDULMASSIHBassamMDEndocrinologistANTIBIOTICSWITHINTHEMANAGEM1DefinitionofaDiabeticFootinfectionEpidemiologyPathogenesisofaDiabeticFootInfectionclassificationAssessmentMicrobiologyPrincipleofantibiotictreatmentDefinitionofaDiabeticFoot2DefinitionofaDiabeticFootInfection(1)Nogenerally-accepteddefinitionFootinfectionsindiabeticscanbeulcer-ornon-ulcerrelatedAnatomiclocationofprimarysiteDepthofinfection(skin/softtissuevs.bone/joint)IsolationofpathogenicbacteriafromanappropriateculturespecimenDefinitionofaDiabeticFoot3entrance,growth,metabolicactivityandensuingpathophysiologiceffectsofmicroorganismsinthetissuesofapatientPurulentdischargefromtheulcerSignsofinflammationaroundtheulcerSystemicsigns(fever-leukocytosis)ThemanifestationoftheinflammatorysignsdependsonintactnervousandvascularsystemDefinitionofaDiabeticFootInfection(2)entrance,growth,metabolicac4EpidemiologylifetimeriskofDMpatient:15%14-20%willneedamputation1legislostevery30sec.Morethan80%arepotentiallypreventableSiteoffootulcers:

toes:51%

plantarmetatarsalhead:28%

dorsumoffoot:14%

multipleulcers:7%Epidemiologylifetimeriskof5抗生素英文课件-ANTIBIOTICS-WITHIN-THE-MANAGEMENT-of-Dia6Pathogenesisofdiabeticfootinfectiontriangleofdevil

infectionBad

sensationBadperfusionPathogenesisofdiabeticfoot7ClassificationSystemsforDiabeticFootInfectionsClassificationsystemsSeverityofInfectionFootUlcer(Wound)Nogenerally-acceptedclassificationDifferincriteria&complexityRequirevalidationforclinicaltrialsClassificationSystemsforDia8ClassificationSystemsforSeverityofDiabeticFootInfectionsLimb-threateningvs.non-limbthreateningMild,moderate,severeClassificationSystemsforSev9ClassificationSystemsfor

DiabeticFootUlcersWagnerUniv.ofTexas

Depth-ischemiaclass.ClassificationSystemsfor

Di10WagnerClassification0-Intactskin(mayhavebonydeformities.

1-Localizedsuperficialulcer.2-Deepulcertotendon,bone,ligamentorjoint.

3-Deepabscessorosteomyelitis.4-Gangreneoftoesorforefoot.5-Gangreneofwholefoot.WagnerFW:Thediabeticfootandamputationsofthefoot.InSurgeryoftheFoot.5thed.Mann,Reditor.StLouis,Mo.TheC.V.MosbyCompany.

WagnerClassification11SmallulcerwithbigproblemSmallulcerwithbigproblem12Depth-ischemiaclassificationGrade0

noskinchangeGrade1

superficialulcer

Grade2

exposedtendon,

jointGrade3

boneexposure

GradeA

noischemia

GradeB

ischemia,

nogangrene

GradeC

partialgangreneGrade

D

complete

gangreneDepth-ischemiaclassification13Managementbasedclassification

structure

damage

SkinSubcutaneoustissuesMuscleandtendonBoneArticulationExtentionofinfectionPerfusionofthefootGoodModeratePoorAbletocorrectionornotManagementbasedclassificatio14Multidisciplinaryteam1-Diabetologist2-Vascularsurgeon3-Orthopedics4-Infectiondisease5-Plasticsurgeon6-PodiatricianMultidisciplinaryteam1-Diabet15Sixinterventiondemonstrateefficacyindiabeticfootmanagement1-offloading2-Debridementanddrainage3-wounddressing4-appropriateuseofantibiotic5-revascularization6-limitedamputationSixinterventiondemonstratee16BaselineAssessmentsLaboratoryhematologychemistryHgbA1CC-ReactiveProteinWound,tissue,andbloodculturesWoundorulcerdimensionsXrayimagingMRIIsotopescanDopplerPulseoxygenationmeasurement(toe)Arteriography1-Extensionofinfection2-Vascularassessment3-Generaldiabetesassess.BaselineAssessmentsLaboratory17DiagnosisofosteomylitisisveryimportantXRayispositiveafter30-50%ofbonedestruction(2weeks)MRICT.Scan3-phasebonescanLeukocytescanGuidedbonebiopsyDiagnosisofosteomylitisisv18EpidemiologyDefinitionofaDiabeticFootinfectionPathogenesisofaDiabeticFootInfectionclassificationAssessmentMicrobiologyPrincipleofantibiotictreatmentEpidemiology19MicrobesandChronicWoundsAllchronicwoundsarecontaminatedbybacteria.Woundhealingoccursinthepresenceofbacteria.Itisnotthepresenceoforganismsbuttheirinteractionwiththepatientthatdeterminestheirinfluenceonwoundhealing.MicrobesandChronicWoundsAll20LouisPasteur“Thegermisnothing.Itistheterraininwhichitisfoundthatiseverything.”Pasteur,L.(1880)Del’attenuationvirusducholeradespoules.CRAcad.Sci.91:673-680.LouisPasteur21DefinitionsWoundcontamination:thepresenceofnon-replicatingorganismsinthewound.Woundcolonization:thepresenceofreplicatingmicroorganismsadherenttothewoundintheabsenceofinjurytothehost.WoundInfection:thepresenceofreplicatingmicroorganismswithinawoundthatcausehostinjury.DefinitionsWoundcontaminat22MicrobiologyofWoundsThemicrobialflorainwoundsappeartochangeovertime.Earlyacutewound;Normalskinflorapredominate.S.aureus,andBeta-hemolyticStreptococcussoonfollow.(GroupBStreptococcusandS.aureusarecommonorganismsfoundindiabeticfootulcers)MicrobiologyofWoundsThemicr23MicrobiologyofWoundsAfterabout4weeksFacultativeanaerobicgramnegativerodswillcolonizethewound.Mostcommonones=Proteus,E.coli,andKlebsiella.Asthewounddeterioratesdeeperstructuresareaffected.Anaerobesbecomemorecommon.Oftentimesinfectionsarepolymicrobial(4-5).MicrobiologyofWoundsAfterab24MicrobiologyofWoundsInsummary:earlychronicwoundscontainmostlygram-positiveorganisms.Woundsofseveralmonthsdurationwithdeepstructureinvolvementwillhaveonaverage4-5microbialpathogens,includinganaerobes(seemoregram-negativeorganisms).MicrobiologyofWoundsInsumma25Howdoyouknowwhenawoundisinfected?Thiscanbeverydifficult.Acontinuumexistsbetweenwhenpathogenscolonizethewoundandthenstarttocausedamage.Thereisnoabsolutelyfoolprooflaboratorytestthatwillaidinthisdiagnosis.Howdoyouknowwhenawoundi26Howdoyouknowwhenawoundisinfected?Onefeatureiscommontoallinfectedchronicwounds;Thefailureofthewoundtohealandprogressivedeteriorationofthewound.Unfortunately,woundinfectionsarenottheonlyreasonsforpoorwoundhealing.Howdoyouknowwhenawoundi27Howdoyouknowwhenanulcerisinfected?Thetypicalfeaturesofwoundinfections:increasedexudateincreasedswellingincreasederythemaincreasedpainincreasedlocaltemperaturePeriwoundcellulitis,ascendinginfection,changeinappearanceofgranulationtissue(discoloration,pronetobleed,highlyfriable).Howdoyouknowwhenanulcer28Methicillin–resistantStaph.Au.

AnincreasingproblemRetrospectiveanalysisof63swabsfrominfectedfootulcerGram+aerobic84.2%staph.Au.79%30.2%MRSANotrelatedtopriorantibioticusage(dangandal.diab.med.20;2:159feb2003)InapriorstudyMRSAisassociatedwithpreviousantibiotictreatment(tentolourisandal.diab.med.16;9:767sep1999)Methicillin–resistantStaph29141microbesisolatedfrom93diabeticfootulcerStudydoneonsyrianpopulationpresentedinSDAsept2003B.hammadMDandH.JammalMD141microbesisolatedfrom9330抗生素英文课件-ANTIBIOTICS-WITHIN-THE-MANAGEMENT-of-Dia31EpidemiologyDefinitionofaDiabeticFootinfectionPathogenesisofaDiabeticFootInfectionclassificationAssessmentMicrobiologyPrincipleofantibiotictreatmentEpidemiology32TreatmentManagementofinfection:1-antibiotics.2-Incisionanddrainage.

3-softtissue,jointandboneresection4-amputationTreatmentManagementofinfect33Whatisthebestapproach?1-Oralantibioticfollowupafteroneweek2-IVantibioticinthehospitalandobservation3-Rapiddrainage+IVantibioticWhatisthebestapproach?1-Or34BedsidesurgeryBedsidesurgery35IschemicfootproblemIschemicfootproblem36SelfamputationSelfamputation37Shouldwecleanuncomplicatedfootulcerwithantibiotics?44ClinicallyuninfectedneuropathicfootulcerRandomizedtoamoxi+clavvs.placebo20daysfollow-upnodifferenceinoutcome

(chantelauandal.diab.Med.1996;13:156-159)64newfootulcerwithnoclinicalevidenceofinfectionRandomizedtoantibioticsvs.placeboPatientswithischemiaandpositiveulcerswabsshouldbeconsideredforearlyantibiotictreatment

(fosterandal.diab.Med.1998;15:suppl.2)Shouldwecleanuncomplicated38PrinciplesoftreatmentEvidence-basedregimesempiricaltherapyvsspecifictherapyOptimaldosageOptimaldurationIdentificationandremovalofinfectivefocusRecognitionofadverseeffectsPrinciplesoftreatmentEvidenc39The-lactams

PenicillinspenicillinV/G,ampicillin,amoxycillin,cloxacillin,ticarcillin,piperacillinCephalosporins1stgeneratione.g.cefazolin,cefalexin(Keflex)2ndgeneratione.g.cefuroxime(Zinacef,Zinnat)The-lactamsPenicillins40The-lactams3rdgeneratione.g.ceftriaxone(Rocephin),cefotaxime(Claforan),ceftazidime(Fortum),cefoperozone(Cefobid),ceftibuten(Cedax)4thgeneratione.g.cefepime(Maxipime)Carbapenemsimipenem,meropenemMonobactamaztreonamThe-lactams3rdgeneratione.41-lactam/-lactamaseinhibitorcombinations

-lactam/-lactamaseinhibitor42MacrolidesandQuinolonesMacrolideserythromycin,clarithromycin(Klacid),azithromycin(Zithromax)Quinolones(FQ)ofloxacin,levofloxacin(Cravit),Ciprofloxacin(Ciproxin)MacrolidesandQuinolonesMacro43OthersAminoglycosidesgentamicin,amikacin,netromycin*(NA)Tetracyclinesdoxycyline(Vibramycin),minocyclineGlycopeptidesvancomycin,teicoplaninNew:linezolid,ertapenem,moxifloxacinOthersAminoglycosides44LargecoverageswabswabLarge

coverage

superficialNormalperfusionNon-ischemicdeepBad

perfusionischemicNoantibioticsNosignsofinfectionsignsofinfectionGram+LargecoverageswabswabLargec45Recentandsuperficialulcerorcellulitis(nonischemic)Staph.Au.+strepCloxacillinAmoxi+with-lactamaseinhibitorsCefazolinCephalexinClindamycinRecentandsuperficialulcero46Deepulcerorneuroischemiculcerpolymicrobial:grampositivecocci,gramnegativebacilliandanaerobes-lactam+-lactamaseinhibitors+amikacin3rdGC+clindamycinciprofloxacin+clindamycinCiprofloxacin+linezolidcarbapenemsvancomyciniflifethreateningDeepulcerorneuroischemicul47mostulcerswillhealwiththetraditionalTherapyForlowgradeuninfectedwoundsaformofremovableorirremovableoffloadingdeviceshouldbeapartofanytreatmentplan.TheTCCisthemostestablished;

Wecannotrecommendanyonedressingoveranother;

DebridementshouldstillbedonetheoldfashionedwaybutcouldbefacilitatedbyusingHydrogelorMDTwhereavailable;

ifwoundsfailtoheal,treatingthemwithaskingraftoraddingbecaplermin(ortheplateletreleasate)notbeenvalidatedascosteffectiveinanyclinicaltrial.TheuseofsystemicHBOorIloprost,especiallyinhighgradeulcerswithasignificantischaemicelementmostulcerswillhealwiththe48Diabeticfootsuccessfullytreated!!Diabeticfootsuccessfullytre49ANTIBIOTICSWITHINTHEMANAGEMENTofDiabeticfoot

Nice28-29avril2005ABDULMASSIHBassamMDEndocrinologistANTIBIOTICSWITHINTHEMANAGEM50DefinitionofaDiabeticFootinfectionEpidemiologyPathogenesisofaDiabeticFootInfectionclassificationAssessmentMicrobiologyPrincipleofantibiotictreatmentDefinitionofaDiabeticFoot51DefinitionofaDiabeticFootInfection(1)Nogenerally-accepteddefinitionFootinfectionsindiabeticscanbeulcer-ornon-ulcerrelatedAnatomiclocationofprimarysiteDepthofinfection(skin/softtissuevs.bone/joint)IsolationofpathogenicbacteriafromanappropriateculturespecimenDefinitionofaDiabeticFoot52entrance,growth,metabolicactivityandensuingpathophysiologiceffectsofmicroorganismsinthetissuesofapatientPurulentdischargefromtheulcerSignsofinflammationaroundtheulcerSystemicsigns(fever-leukocytosis)ThemanifestationoftheinflammatorysignsdependsonintactnervousandvascularsystemDefinitionofaDiabeticFootInfection(2)entrance,growth,metabolicac53EpidemiologylifetimeriskofDMpatient:15%14-20%willneedamputation1legislostevery30sec.Morethan80%arepotentiallypreventableSiteoffootulcers:

toes:51%

plantarmetatarsalhead:28%

dorsumoffoot:14%

multipleulcers:7%Epidemiologylifetimeriskof54抗生素英文课件-ANTIBIOTICS-WITHIN-THE-MANAGEMENT-of-Dia55Pathogenesisofdiabeticfootinfectiontriangleofdevil

infectionBad

sensationBadperfusionPathogenesisofdiabeticfoot56ClassificationSystemsforDiabeticFootInfectionsClassificationsystemsSeverityofInfectionFootUlcer(Wound)Nogenerally-acceptedclassificationDifferincriteria&complexityRequirevalidationforclinicaltrialsClassificationSystemsforDia57ClassificationSystemsforSeverityofDiabeticFootInfectionsLimb-threateningvs.non-limbthreateningMild,moderate,severeClassificationSystemsforSev58ClassificationSystemsfor

DiabeticFootUlcersWagnerUniv.ofTexas

Depth-ischemiaclass.ClassificationSystemsfor

Di59WagnerClassification0-Intactskin(mayhavebonydeformities.

1-Localizedsuperficialulcer.2-Deepulcertotendon,bone,ligamentorjoint.

3-Deepabscessorosteomyelitis.4-Gangreneoftoesorforefoot.5-Gangreneofwholefoot.WagnerFW:Thediabeticfootandamputationsofthefoot.InSurgeryoftheFoot.5thed.Mann,Reditor.StLouis,Mo.TheC.V.MosbyCompany.

WagnerClassification60SmallulcerwithbigproblemSmallulcerwithbigproblem61Depth-ischemiaclassificationGrade0

noskinchangeGrade1

superficialulcer

Grade2

exposedtendon,

jointGrade3

boneexposure

GradeA

noischemia

GradeB

ischemia,

nogangrene

GradeC

partialgangreneGrade

D

complete

gangreneDepth-ischemiaclassification62Managementbasedclassification

structure

damage

SkinSubcutaneoustissuesMuscleandtendonBoneArticulationExtentionofinfectionPerfusionofthefootGoodModeratePoorAbletocorrectionornotManagementbasedclassificatio63Multidisciplinaryteam1-Diabetologist2-Vascularsurgeon3-Orthopedics4-Infectiondisease5-Plasticsurgeon6-PodiatricianMultidisciplinaryteam1-Diabet64Sixinterventiondemonstrateefficacyindiabeticfootmanagement1-offloading2-Debridementanddrainage3-wounddressing4-appropriateuseofantibiotic5-revascularization6-limitedamputationSixinterventiondemonstratee65BaselineAssessmentsLaboratoryhematologychemistryHgbA1CC-ReactiveProteinWound,tissue,andbloodculturesWoundorulcerdimensionsXrayimagingMRIIsotopescanDopplerPulseoxygenationmeasurement(toe)Arteriography1-Extensionofinfection2-Vascularassessment3-Generaldiabetesassess.BaselineAssessmentsLaboratory66DiagnosisofosteomylitisisveryimportantXRayispositiveafter30-50%ofbonedestruction(2weeks)MRICT.Scan3-phasebonescanLeukocytescanGuidedbonebiopsyDiagnosisofosteomylitisisv67EpidemiologyDefinitionofaDiabeticFootinfectionPathogenesisofaDiabeticFootInfectionclassificationAssessmentMicrobiologyPrincipleofantibiotictreatmentEpidemiology68MicrobesandChronicWoundsAllchronicwoundsarecontaminatedbybacteria.Woundhealingoccursinthepresenceofbacteria.Itisnotthepresenceoforganismsbuttheirinteractionwiththepatientthatdeterminestheirinfluenceonwoundhealing.MicrobesandChronicWoundsAll69LouisPasteur“Thegermisnothing.Itistheterraininwhichitisfoundthatiseverything.”Pasteur,L.(1880)Del’attenuationvirusducholeradespoules.CRAcad.Sci.91:673-680.LouisPasteur70DefinitionsWoundcontamination:thepresenceofnon-replicatingorganismsinthewound.Woundcolonization:thepresenceofreplicatingmicroorganismsadherenttothewoundintheabsenceofinjurytothehost.WoundInfection:thepresenceofreplicatingmicroorganismswithinawoundthatcausehostinjury.DefinitionsWoundcontaminat71MicrobiologyofWoundsThemicrobialflorainwoundsappeartochangeovertime.Earlyacutewound;Normalskinflorapredominate.S.aureus,andBeta-hemolyticStreptococcussoonfollow.(GroupBStreptococcusandS.aureusarecommonorganismsfoundindiabeticfootulcers)MicrobiologyofWoundsThemicr72MicrobiologyofWoundsAfterabout4weeksFacultativeanaerobicgramnegativerodswillcolonizethewound.Mostcommonones=Proteus,E.coli,andKlebsiella.Asthewounddeterioratesdeeperstructuresareaffected.Anaerobesbecomemorecommon.Oftentimesinfectionsarepolymicrobial(4-5).MicrobiologyofWoundsAfterab73MicrobiologyofWoundsInsummary:earlychronicwoundscontainmostlygram-positiveorganisms.Woundsofseveralmonthsdurationwithdeepstructureinvolvementwillhaveonaverage4-5microbialpathogens,includinganaerobes(seemoregram-negativeorganisms).MicrobiologyofWoundsInsumma74Howdoyouknowwhenawoundisinfected?Thiscanbeverydifficult.Acontinuumexistsbetweenwhenpathogenscolonizethewoundandthenstarttocausedamage.Thereisnoabsolutelyfoolprooflaboratorytestthatwillaidinthisdiagnosis.Howdoyouknowwhenawoundi75Howdoyouknowwhenawoundisinfected?Onefeatureiscommontoallinfectedchronicwounds;Thefailureofthewoundtohealandprogressivedeteriorationofthewound.Unfortunately,woundinfectionsarenottheonlyreasonsforpoorwoundhealing.Howdoyouknowwhenawoundi76Howdoyouknowwhenanulcerisinfected?Thetypicalfeaturesofwoundinfections:increasedexudateincreasedswellingincreasederythemaincreasedpainincreasedlocaltemperaturePeriwoundcellulitis,ascendinginfection,changeinappearanceofgranulationtissue(discoloration,pronetobleed,highlyfriable).Howdoyouknowwhenanulcer77Methicillin–resistantStaph.Au.

AnincreasingproblemRetrospectiveanalysisof63swabsfrominfectedfootulcerGram+aerobic84.2%staph.Au.79%30.2%MRSANotrelatedtopriorantibioticusage(dangandal.diab.med.20;2:159feb2003)InapriorstudyMRSAisassociatedwithpreviousantibiotictreatment(tentolourisandal.diab.med.16;9:767sep1999)Methicillin–resistantStaph78141microbesisolatedfrom93diabeticfootulcerStudydoneonsyrianpopulationpresentedinSDAsept2003B.hammadMDandH.JammalMD141microbesisolatedfrom9379抗生素英文课件-ANTIBIOTICS-WITHIN-THE-MANAGEMENT-of-Dia80EpidemiologyDefinitionofaDiabeticFootinfectionPathogenesisofaDiabeticFootInfectionclassificationAssessmentMicrobiologyPrincipleofantibiotictreatmentEpidemiology81TreatmentManagementofinfection:1-antibiotics.2-Incisionanddrainage.

3-softtissue,jointandboneresection4-amputationTreatmentManagementofinfect82Whatisthebestapproach?1-Oralantibioticfollowupafteroneweek2-IVantibioticinthehospitalandobservation3-Rapiddrainage+IVantibioticWhatisthebestapproach?1-Or83BedsidesurgeryBedsidesurgery84IschemicfootproblemIschemicfootproblem85SelfamputationSelfamputation86Shouldwecleanuncomplicatedfootulcerwithantibiotics?44ClinicallyuninfectedneuropathicfootulcerRandomizedtoamoxi+clavvs.placebo20daysfollow-upnodifferenceinoutcome

(chantelauandal.diab.Med.1996;13:156-159)64newfootulcerwithnoclinicalevidenceofinfectionRandomizedtoantibioticsvs.placeboPatientswithischemiaandpositiveulcerswabsshouldbeconsideredforearlyantibiotictreatment

(fosterandal.diab.Med.1998;15:suppl.2)Shouldwecleanuncomplicated87PrinciplesoftreatmentEvidence-basedregimesempiricaltherapyvsspecifictherapyOptimaldosageOptimaldurationIdentificationandremovalofinfectivefocusRecognitionofadverseeffectsPrinciplesoftreatmentEvidenc88The-lactams

PenicillinspenicillinV/G,ampicillin,amoxycillin,cloxacillin,ticarcillin,piperacillinCephalosporins1stgeneratione.g.cefazolin,cefalexin(Keflex)2ndgeneratione.g.cefuroxime