WoundBedPreparationandInfectedWoundsinPatientsWithDiabetes

RobertJ.Snyder,DPM,MSc,CWSProfessorandDirectorofClinicalResearch,BarryUniversitySPM,MiamiShores,Florida

ImmediatePastPresident,AssociationfortheAdvancementofWoundCare

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

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

CoreHealingPrinciples

Patient factors

Physical aspects

MACROscopicenvironment

MICROscopicenvironment

“Thinklikeaninternist,beforeyouactlikeasurgeon”Wm.Ennis,DO

Woundmanagementoftenrequiresasubtlebalancebetweenmedicalandsurgicalinterventions.

STAIRWAYTOAMPUTATION

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

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

AccountforSpectrumofDFUPresentation

Probable contamination,no infection

Local infectionwith adjacent cellulitis

Progressive, necrotizingInfection

Snyder R. Podiatry ManagementNov-Dec 2013:119-120

~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

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

Saap LJ, Falanga V. Wound Rep Reg 2002; 10:354-359.

BiofilmandtheGlycocalyx

• Definition:– Anetworkofpolysaccharideorprotein-containingmaterialextendingoutsideofthecell.

• Theglycocalyxprotectsthebacteriafromantibioticsandaccountsforthepersistenceoftheinfection

KaniaRE(2007)ArchOtolaryHeadNeckSurg;133(2):115-21Glycocalyx

surrounding cells of Streptococcus species.

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

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

WoundBedPreparationinPractice

SnyderR,FifeC,MooreZ.TheDIMEandQualityMeasures.

AdvancesSkinWoundCareScheduledforPublication2015

Wound Bed Preparation

SibbaldRG, etal(2011)AdvSkinWoundCare.24:415-36SchultzGS,SibbaldRG,FalangaVetal.Woundbedpreparation: asystemicapproach towoundmanagement.WoundRepairandRegeneration, 2003;11:1-28

MoistWoundHealing

MoistWoundHealing

MoistWoundHealing

MoistWoundHealing

WoundBedPreparation

DesignedbyDr.RobertSnyder

Dyna-Flex®Multi-LayerCompression System®

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

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

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

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

Moisture

Wet Dry

Yes No

Fibracol

VAC/Veraflo

TielleNu-DermAlginate

Txbaseduponwound

appearance

Yes No

Nu-GelNu-Derm

HydrocolloidBioclusiveAdaptic

AdapticTouch

GraftJacket

Txbaseduponwound

appearance

DesignedbyDr.RobertSnyder

HyperproliferativeWoundEdge

IncreasedDepth

Yes No No Yes

ExcisionalDebridement

AdapticAdapticTouch

VAC/Veraflo

SelectiveDebridement

FibracolC-ORC

C-ORC/NAGraftJacket

AdapticAdapticTouch

VAC/Veraflo

GraftJacket

DesignedbyDr.RobertSnyder

ASurgicalPathwayShouldBeConsideredWhenAnAbscessorBoneInfectionisSuspected

SnyderR,etal.OWM2001

Surgicaldebridementisanimportantcomponentofboththeevaluationandidentificationofinfection

aswellastreatmentofinfection

SnyderRJetal.OWM.2001;47(3):24-41

Abscessedfootinaneuropathicpatientwithdiabetes:astepwiseapproach

Summary• Infectionrepresentsaserioussequelaeinacuteandchronicwoundsinpatientswithdiabetes

• Knowledgeofclinicalpathwaystomakingadiagnosisremainscritical:IDSAGuidelines

• Biofilmmayplayanimportantroleinresistantinfections

• Recentliteraturesupportstheuseofappropriatewoundbedpreparation,systemicantibiotics,sometopicalantiseptics,debridement,andsurgicalstrategiesinthetreatmentofwoundinfection

ThankYou