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WoundBedPreparationandInfectedWoundsinPatientsWithDiabetes
RobertJ.Snyder,DPM,MSc,CWSProfessorandDirectorofClinicalResearch,BarryUniversitySPM,MiamiShores,Florida
ImmediatePastPresident,AssociationfortheAdvancementofWoundCare
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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 amputation3,5
■ ~85% of lower limb amputations in patients with diabetes are proceeded by ulceration6-7
■ Peripheral neuropathy is a major contributing factor in diabetic foot ulcers1-7
❑ 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; 2002:641–665.
2. Boulton et al. NEJM. 2004;351:48.3. Sanders. J Am Podiatry Med Assoc. 1994;84:322.
4. Boulton et al. Lancet. 2005;366:1719.5. Ramsey et al. Diabetes Care 1999;22:382.6. Pecoraro et al. Diabetes Care. 1990;13:513.7. Apelqvist and Larsson. Diabetes Metab Res Rev.
2000:16:S75.
1 million amputations globally in patients with diabetes (every 20 seconds )
In the US; 1200 amputations weekly
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DFU…PathophysiologyFinalCommonPathways
q Infectionq Ischemia/hypoxiaq Cellularfailureq Pressure/traumaq Inflammation
Snyderetal.OstomyWoundManagement.2010;56(Suppl4):S1-S24
All final common pathways are implicated in DFU healing failure!!
Deep infection
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CoreHealingPrinciples
Patient factors
Physical aspects
MACROscopicenvironment
MICROscopicenvironment
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“Thinklikeaninternist,beforeyouactlikeasurgeon”Wm.Ennis,DO
Woundmanagementoftenrequiresasubtlebalancebetweenmedicalandsurgicalinterventions.
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STAIRWAYTOAMPUTATION
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ClassicSignsandSymptomsofInfection
• Heat• Pain• Redness• Swelling
Clinicians should diagnose infection based on the presence of at least 2
classic symptoms or signs of inflammation or purulent secretions
Lipsky et al. Clinical Infectious Diseases. 2012;54(12):132-173
Clinicallyinfectedwoundsusuallyrequiresystemicantibiotics,whileclinicallyuninfectedwounds thatarehealingasexpecteddonot
requireantimicrobialsLipskyB,Hoey C.ClinicalInfectiousDiseases.2009;49:1541-9
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ValidityofSecondaryClinicalSignsandSymptomsofChronicWoundInfection
• Secondaryclinicalsignsofinfectionwithpositivepredictivevalue…– Serousdrainagewithinflammation– Delayedhealing– Discolorationofgranulationtissue– Friablegranulationtissue– Pocketingatbaseofwound– Foulodor– Woundbreakdown– Increasingpain
Gardner, et al. Wound Rep Reg 2001; 9:178-186
Cliniciansshouldconsiderthepossibilityofinfectionoccurringin
any footwoundinapatientwithdiabetes
Lipsky et.Al.Clinical InfectiousDiseases.2012;54(12)”132-173
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AccountforSpectrumofDFUPresentation
Probable contamination,no infection
Local infectionwith adjacent cellulitis
Progressive, necrotizingInfection
Snyder R. Podiatry ManagementNov-Dec 2013:119-120
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~60% of amputations
due to infection
• Riskfactorsforinfection:– Woundsthatpenetratetothebone
– Woundswithaduration>30days
– Recurrentfootwounds– Woundswithatraumaticetiology
Infection plays a role in about 60% of theDFU 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.
Infection Contributes to Various Complications Including Amputation
Peripheral vascular diseasePain
Deterioration of the woundFoul odor
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Wound bed preparation isan important step in treating and
protecting againstwound infection
DIME
Wound Bed Preparation
SibbaldRG, etal(2011)AdvSkinWoundCare.24:415-36SchultzGS,SibbaldRG,FalangaVetal.Woundbedpreparation: asystemicapproach towoundmanagement.WoundRepairandRegeneration, 2003;11:1-28
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Saap LJ, Falanga V. Wound Rep Reg 2002; 10:354-359.
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BiofilmandtheGlycocalyx
• Definition:– Anetworkofpolysaccharideorprotein-containingmaterialextendingoutsideofthecell.
• Theglycocalyxprotectsthebacteriafromantibioticsandaccountsforthepersistenceoftheinfection
KaniaRE(2007)ArchOtolaryHeadNeckSurg;133(2):115-21Glycocalyx
surrounding cells of Streptococcus species.
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BiofilmsareProblematic:
• Resistanttohostimmuneresponses• Markedlyresistanttopenetrationbytopicalantibioticsandbactericidals
• Mixedbacterialspeciesmayenhancethevirulence-synergistically
• Commonindevitalizedtissue
Costerton JW, Lewandowski Z, Caldwell DE, Korber DR, Lappin-Scott HM. Microbial biofilms. Annu Rev Microbiol. 1995;49:711-745.Xu KD, McFeter GA, Stewart PS. Biofilm resistance to antimicrobial agents. Microbiology. 2000;146:547-549.
Biofilmcanbe500xmoreresistanttoantibacterialagents
Costerton JW,etal.Annu RevMicrobiol1995;49:711-745
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APotentialModelforDisruptingProblematicBiofilm
(Theoretical)• SharpDebridement andutilizationoftopicalantimicrobialstolowerplanktonic bacteriallevels;thiswilldecreasenewbiofilm colonies
• Continuesharpdebridementonaregularbasistocontinuallydisruptandpotentiallyweakenthebiofilm/glycocalyx.(i.e.Biofilm canpotentiallyreturnwithin3-24hours.)
• Thereisin-vitroevidenceusingbiofilmmodelswhichdemonstratestheabilityofsometopicalantimicrobialdressingstodisruptbiofilm(i.e.iodine,silver)
Hill et. al 2010
Rememberthatitisstillnotknownwhetherallbiofilm are“bad”
Muchmoreresearchisrequiredinthisfield
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WoundBedPreparationinPractice
SnyderR,FifeC,MooreZ.TheDIMEandQualityMeasures.
AdvancesSkinWoundCareScheduledforPublication2015
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Wound Bed Preparation
SibbaldRG, etal(2011)AdvSkinWoundCare.24:415-36SchultzGS,SibbaldRG,FalangaVetal.Woundbedpreparation: asystemicapproach towoundmanagement.WoundRepairandRegeneration, 2003;11:1-28
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MoistWoundHealing
MoistWoundHealing
MoistWoundHealing
MoistWoundHealing
WoundBedPreparation
DesignedbyDr.RobertSnyder
Dyna-Flex®Multi-LayerCompression System®
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DevitalizedTissue
Evaluatepatientandwound
AdequateVascularity Orthopedic Dermatological
Yes No
Debride VascularConsult
Sharp Mechanical Autolytic
NuGelHydrocolloidBio
ousiveTielle
VACVeraflo
+ProbeToBone
Yes No
X-ray+OsteoYes No
SystemicABXIDConsultTopicals(ie.SNA)
F/UX-rayC-ORC
C-ORC/SilverFibracol
MeasureLengthWidthDepth
EvaluateGranulationUnderminingPeriwound
Infection
Yes No
SeeInfectionAlgorithm
NuGelHydrocolloidBiocclusive
Tielle
Epithealization:(CelluTome)
No
DesignedbyDr.RobertSnyder
VersionA
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DevitalizedTissue
Evaluatepatientandwound
AdequateVascularity Dermatological
Yes
Debride
VascularConsult
Sharp Mechanical Autolytic
NuGelHydrocolloidBioo
usiveTielle
VACVeraflo
MeasureLengthWidthDepth
EvaluateGranulationUnderminingPeriwound
Infection
Yes No
SeeInfectionAlgorithm
NuGelHydrocolloidBiocclusive
Tielle
Epithealization:(CelluTome)
No
DesignedbyDr.RobertSnyder
VersionB
No
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Orthopedic
+ProbeToBone
X-rayMRI
+Osteomyelitis
Yes
SystemicABXIDConsultTopicals(ie.SNA)
F/UX-rayC-ORC
C-ORC/SilverFibracol
Dermatological
See algorithm
DesignedbyDr.RobertSnyder
VersionA-1
No
Yes No
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Infection
PrimarySignsandSymptoms(Heat,Pain,RednessSwelling)
Yes
SecondarySignsandSymptoms(ie:wound
deterioration, pain)
No
Considerinflammatory
causesor
CriticalColonization
SharpDebridement
Culture andSensitivity X-ray
SNA C/ORC SystemicABX VACVeraflo
EvaluateCause
Malignancy Vasculitis PyodermaGangrenosumVasculopathy
+BiopsyYes No
FurtherEvaluation
DiagnosisofExclusion
C/ORC
VACVeraflo
NegativePathergy
Other
CBCESRVDRL,HIV,PPDC-reactiveproteinGramstainSpecialstainsforAFB,fungusRoutine cultureAFB,anaerobic, fungalcultureX-rays,nuclearmedstudies,CT,MRI(osteomyelitis, deepabscess,infectedprosthesis)
ESRVDRLAntinuclear antibodiesRheumatoid factorProtein electrophoresisImmunecomplexComplement (CH50, C3,C4)a-ANCA,p-ANCA(Anti-neutrophilcytoplasmicantibodies)Hepatitis panelCoagulopathy(antithrombin III,protein C,S,Sicklecellorother hemoglobinopathyCryoglobulinemia (cryoglobulins, C2,C4, endorgandysfunction)
Inflammation
DesignedbyDr.RobertSnyder
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Moisture
Wet Dry
Yes No
Fibracol
VAC/Veraflo
TielleNu-DermAlginate
Txbaseduponwound
appearance
Yes No
Nu-GelNu-Derm
HydrocolloidBioclusiveAdaptic
AdapticTouch
GraftJacket
Txbaseduponwound
appearance
DesignedbyDr.RobertSnyder
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HyperproliferativeWoundEdge
IncreasedDepth
Yes No No Yes
ExcisionalDebridement
AdapticAdapticTouch
VAC/Veraflo
SelectiveDebridement
FibracolC-ORC
C-ORC/NAGraftJacket
AdapticAdapticTouch
VAC/Veraflo
GraftJacket
DesignedbyDr.RobertSnyder
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ASurgicalPathwayShouldBeConsideredWhenAnAbscessorBoneInfectionisSuspected
SnyderR,etal.OWM2001
Surgicaldebridementisanimportantcomponentofboththeevaluationandidentificationofinfection
aswellastreatmentofinfection
SnyderRJetal.OWM.2001;47(3):24-41
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Abscessedfootinaneuropathicpatientwithdiabetes:astepwiseapproach
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Summary• Infectionrepresentsaserioussequelaeinacuteandchronicwoundsinpatientswithdiabetes
• Knowledgeofclinicalpathwaystomakingadiagnosisremainscritical:IDSAGuidelines
• Biofilmmayplayanimportantroleinresistantinfections
• Recentliteraturesupportstheuseofappropriatewoundbedpreparation,systemicantibiotics,sometopicalantiseptics,debridement,andsurgicalstrategiesinthetreatmentofwoundinfection