The Strategy of wound and

infection control in Diabetic

foot ulcer
Haryo Aribowo
Dept Bedah FK UGM/SMF Bedah RSUP Dr. Sarjito
Yogyakarta
Problems
Healing

Infection
Replace
Lose
footwear
footwear
Off-
loading

Amputation
Wound
General epidemiology

 252 million diabetics worldwide

 Foot problems account for largest number of
hospital bed days
 1-4% develop foot ulcer annually, 25% in
lifetime
 45-75% of all lower extremity amputations
 85% of these preceded by foot ulcer
 Two-thirds of elderly patients undergoing
amputation
 Studies have shown less costs for saving a
limb cf. amputation
Pathophysiology:
Neuropathy

Motor Sensory Autonomic

Abnormal foot Loss of protective Reduced skin
biomechanics sensation compliance and
lubrication

Ulceration
Vascular
insufficiency Infection
Overview of Diabetic Foot Infections
7% of Population
Diabetic

15-25% Develop Foot Ulcer

40-80% Infected
(or suspected)

40% Mild 30-40% Moderate 20-30% Severe

Microbial complexity
Microbial burden
Clinical risk

Anaerobes

Aerobic Gram-negative rods

Gram positive cocci

Severity
1 2 3 4 Depth
Necrosis
Prior Rx
Treatment: myths

Treat uninfected ulcers to promote healing

Treat infected ulcers until the ulcer is healed
Treat all the organisms isolated from the
microbiological specimens
Hospitalise all infections
Give lots of intravenous therapy
Management of Diabetic foot ulcer

Glucoses control
Nutrition
Debridement/wound care
Infections control
DEBRIDEMENT
1. Surgical : Anaestetic and non anaestetic
Sharp debridement

2. Non surgical : biological agent and non

biological agent
Larva, enzyme, modern dressing
1. Autolitik : aktivasi enzim autolitik tubuh dg
meningkatkan kelembaban jaringan luka,
dg produk seperti hirogel, hidrokoloid.
2. Enzimatik: produk enzim luar.
3. Biological: dg larva lalat emas, atau
keong hitam.
4. Mechanical Gauze Debridement: dresing luka
yg sesuai.
Evaluating the Patient with a DFI

Patient
Systemic response : Fever, chills, sweats
Metabolic status : Hyperglycaemia,
electrolyte imbalance, hyperosmolality, renal
impairment
 Cognitive function
Delirium, depression, dementia,
psychosis
Social situation
Support, self-neglect
· Limb/Foot
· Wound
Patient
Limb or Foot
Biomechanics
Vascular
Ischaemia
Venous insufficiency
Neuropathy
Infection
Wound
Size, depth
Necrosis, gangrene
Infection
 Clinical Classification of Diabetic Foot Infection

Wound without purulence or other

evidence of inflammation

More than 2 of purulence,

erythema, pain, tenderness,
warmth or induration. Any
cellulitis/erythema extends ≤2 cm
around ulcer and infection is
limited to skin/superficial subcut
tissues. No local complications or
systemic illness
Infection in patient who is systemically well &
metabolically stable but has any of:
cellulitis extending >2 cm; lymphangitis;
spread beneath fascia; deep tissue
abscess; gangrene; muscle, tendon, joint
or bone involved

Infection in a patient with systemic toxicity

or metabolic instability
Outcomes DFI Severity Classification
100%

89%
90%

80%

70%

60%
54%

50%

40%

30%

20%

10%
10% 6%

0%
None
No infection Mild
Mild Moderate
Moderate Severe
Severe
Antibiotic
Agent(s) Mild Moderate Severe
Advised Route Oral for Most Oral or IV Parenteral
Dicloxacillin Yes
Clindamycin Yes
Cephalexin Yes
TMP/SMX Yes Yes
Amoxicillin/clavulanate Yes Yes
Levofloxacin Yes Yes
Cefoxitin Yes
Ceftriaxone Yes
Ampicillin/sulbactam Yes
Linezolid (± aztreonam) Yes
Daptomycin (± aztreonam) Yes
Ertapenem Yes
Cefuroxime (± metronidazole) Yes
Ticarcillin/clavulanate Yes
Piperacillin/tazobactam Yes Yes
Levo- or Cipro- floxacin + Clindamycin Yes Yes
Imipenem-cilastatin Yes
Vanco + Ceftazidime ± metronidazole Yes
TERIMA KASIH