Treatment of diabetic foot

Principles of conservative treatment of diabetic foot syndrome:

• compensation for diabetes mellitus;
• antibiotic therapy.

Principles of prevention of diabetic foot syndrome

• treatment of patients;
• regular wearing of orthopedic shoes;
• regular removal of hyperkeratoses

The amount of necessary medical care depends on the stage of the disease. Treatment of patients at the I stage of the diabetic foot syndrome consists in the adequate treatment of the wound defect and the affected area of the foot. Patients with the IA stage require a more detailed examination to assess the state of the circulation. At the II stage of the diabetic foot syndrome, the appointment of antibiotic therapy, local treatment and discharge of the limb is shown. Patients with IV-V stages of diabetic foot syndrome require immediate hospitalization in a surgical hospital, complex conservative and surgical treatment.

In the presence of critical ischemia, an urgent consultation with an angiosurgeon is indicated, and radiopaque angiography is performed to resolve the issue of the possibility of conducting a vascular reconstructive operation to restore blood flow. This can be either a distal bypass, or a percutaneous balloon angioplasty with stenting. Angio-surgical interventions are usually supported by conservative interventions, of which the suppression of infectious inflammation and local control of the wound process are of utmost importance. Conservative treatment can be supplemented by the introduction of prostaglandins (alprostadil) or heparin-like drugs (sulodexide).

Treatment of acute osteoarthropathy is in the early immobilization with the use of an individual discharge dressing (IRP).

In the presence of signs of chronic neuro-osteoarthropathy, the basis of treatment is therapeutic orthopedic footwear and compliance with the rules of foot care.

If necessary, the treatment of diabetic neuropathy.

Compensation for diabetes mellitus

Correction of hyperglycemia, arterial hypertension and dyslipidemia is the basis for the prevention of all late complications of diabetes mellitus. At the same time, it is necessary to be guided not by the advantages and disadvantages of individual medicines, but by the achievement and maintenance of the target values of these indicators.

Antibiotic therapy

Antibiotic therapy is prescribed in the presence of an infected wound or a high risk of infection. In the presence of systemic signs of wound infection, the need for antibiotic therapy is obvious; it should be carried out immediately and in adequate doses. However, given the hypoactivity of the immune system in diabetes mellitus (especially in elderly patients), these symptoms may be absent even in severe wound infection. Therefore, when prescribing antibiotic therapy, it is often necessary to focus on local manifestations of wound infection.

The choice of the optimal drug or combination of drugs is based on data on the causative agents of wound infection and their suspected sensitivity to antibiotics, as well as the pharmacokinetics of the drugs and the localization of the infectious process. Optimal selection of antibiotic therapy is based on the results of bacteriological examination of the wound detachable. Given the high prevalence of microorganisms resistant even to modern antibiotics, the probability of success when prescribing drugs "blindly" usually does not exceed 50-60%.

Bacteria most often sown in patients with diabetic foot syndrome:

• Gram-positive flora:
  • Staphylococcus aureus;
  • Streptococcus;
  • Enteroscocus;
• Gram-negative flora:
  • Klebsiella;
  • Escherichia colli;
  • Enterobacter;
  • Pseudomonas;
  • Citrobacter;
  • Morganella morganii;
  • Serratia;
  • Acinetobacter;
  • Proteus;
• anaerobes:
  • acteroides;
  • Clostridium;
  • Peptostreptococcus;
  • Peptococcus.

In severe forms of wound infection, life threatening or. Limbs such as phlegmon, deep abscesses, moist gangrene, sepsis, antibiotic therapy should be carried out only by parenteral medicines in a hospital in combination with full-fledged surgical drainage of purulent foci, detoxification and correction of carbohydrate metabolism.

With wound infection of mild and moderate severity (only local signs of wound infection and shallow purulent foci), antibacterial drugs can be taken internally in outpatient settings. With disrupted absorption of drugs in the digestive tract, which may be a manifestation of autonomic neuropathy, it is necessary to switch to the parenteral route of administration of drugs.

The duration of antibiotic therapy is determined individually in a particular case on the basis of the clinical picture and the data of bacteriological analysis. The most prolonged, for several months, antibiotic therapy can be applied when trying to conservatively treat osteomyelitis.

Antibiotic therapy

Antibacterial therapy for infection with staphylococci (Staphylococcus aureus):

• Gentamicin intravenously 5 mg / kg once a day before clinical and bacteriological improvement or
• Clindamycin inside 300 mg 3-4 times a day or intravenously 150-600 mg 4 times a day before clinical and bacteriological improvement or
• Rifampicin is administered orally 300 mg 3 times daily, prior to clinical and bacteriological improvement, or
• Flukloxacillin inside or intravenously 500 mg 4 times a day, before clinical and bacteriological improvement.

Antibiotic therapy for infection with methicillin-resistant staphylococci (Staphylococcus aureus MRSA):

• Vancomycin intravenously 1 g 2 times a day until a clinical and bacteriological improvement or
• Doxycycline is administered 100 mg once a day, prior to clinical and bacteriological improvement, or
• Linezolid inside or intravenously 600 mg 2 times a day before clinical and bacteriological improvement or
• Rifampicin is administered orally 300 mg 3 times daily before clinical and bacteriological improvement or
• Trimethoprim 200 mg twice a day before clinical and bacteriological improvement.

Antibacterial therapy for streptococcal infection:

• Amoxicillin inside or intravenously 500 mg 3 times a day, before clinical and bacteriological improvement or
• Clindamycin inside 300 3-4 times a day or intravenously 150-600 mg 4 times a day, before clinical and bacteriological improvement or
• Flukloxacillin is administered orally 500 mg 4 times daily, prior to clinical and bacteriological improvement, or
• Erythromycin inside 500 mg 3 times a day, before the clinical and bacteriological improvement.

Antibacterial therapy for enterococci infection

• Amoxicillin inside or intravenously 500 mg 3 times a day, before clinical and bacteriological improvement.

Antibiotic therapy for anaerobic infection

• Clindamycin inside 300 mg 3 times a day or intravenously 150-600 mg 4 times a day, until a clinical and bacteriological improvement or
• Metronidazole is administered 250 mg 4 times a day or intravenously 500 mg 3 times a day, until clinical and bacteriological improvement.

Antibiotic therapy for infection with coliform bacteria (E. Coli, Proteus, Klebsiella, Enterobacter)

• Meropenem intravenously 0.5-1 g 3 times a day, until a clinical and bacteriological improvement or
• Tazobactam intravenously 4.5 g 3 times a day, until a clinical and bacteriological improvement or
• Ticarcillin / Clavulanate intravenously 3.2 g 3 times a day, before clinical and bacteriological improvement or
• Trimethoprim or intravenously 200 mg 2 times a day, before clinical and bacteriological improvement or
• Cefadroxil inside 1 g 2 times a day, before clinical and bacteriological improvement or
• Ceftazidime intravenously 1-2 g 3 times a day, before clinical and bacteriological improvement or
• Ceftriaxone intravenously 2 g once a day, before clinical and bacteriological improvement or
• Ciprofloxacin is administered orally 500 mg twice a day or intravenously 200 mg twice daily, before clinical and bacteriological improvement

Antibiotic therapy for infection with pseudomonas (P. Aeuginosa):

• Gentamicin intravenously 5 mg / kg 1 time per day, until clinical and bacteriological improvement or
• Meropenem intravenously 0.5-1 g 3 times a day, until a clinical and bacteriological improvement or
• Ticarcillin / Clavulanate intravenously 3.2 g 3 times a day, before clinical and bacteriological improvement or
• Ceftazidime intravenously 1-2 g 3 times a day, before clinical and bacteriological improvement or
• Ciprofloxacin inside 500 mg 2 times a day, before clinical and bacteriological improvement

Unloading foot and local treatment

The main principles of local treatment of trophic ulcers of the lower limbs in patients with diabetic foot syndrome are:

• unloading of the affected foot;
• local treatment of ulcerative defect;
• aseptic dressing.

The majority of ulcerative defects in diabetic foot syndrome are localized on the plantar surface or in the region of interdigital spaces. The mechanical pressure on the foot support surface during walking prevents the normal course of tissue repair processes. In this regard, an essential condition for the affective treatment of wound defects in the feet is the unloading of the affected foot. In the acute stage of the Sharko foot, discharge of the foot and shin is the main method of treatment.

The methods of unloading depend on the localization of the ulcerative defect (fingers, the area of the projection of metatarsal bones, the heel, the arch of the foot), as well as the forms of the lesion (neuroosteoarthropathy, neuropathic ulcer, neuroischemic ulcer). In the event that the wound is not located on the supporting surface (shin, rear of the foot), unloading the limb is not required.

To date, in clinical practice, there are three main types of unloading devices:

• individual relief dressing;
• multifunctional individual unloading dressing-shoes (MIRPO);
• medical-unloading shoes.

The IRP is used for the Charcot's foot, as well as for the localization of ulcerative defects in the heel and arch of the foot. Contraindications to the imposition of the SRI is the state of critical ischemia of the skin disease, the patient's disagreement.

MIRPO is applicable for the localization of ulcerative defects in the anterior part of the foot (fingers, interdigital spaces, projection area of the heads of metatarsal bones). MIRPO is the only means of unloading, applicable for bilateral defeat.

Healing-unloading shoes (LRO) are used in one-sided lesions, when ulcerative defects are localized in the anterior part of the foot. Contraindication for the use of LRO is the presence of signs of osteoarthropathy.

IRP and MIRPO are made of fixing polymeric materials Soft-cast and Scotch-cast, in the conditions of the clinic. LRO is an orthopedic product manufactured in the conditions of an orthopedic enterprise.

Unloading of the limb can be supplemented with the appointment of bisphosphonates, for example pamidronate:

• Pamidronate intravenously 90 mg once every 3 months, prolonged.

In the case of an ischemic or neuroischemic form of lesion injury, local treatment of a defect should necessarily be accompanied by measures aimed at correcting hemodynamic disorders in the affected limb and antibiotic therapy.

Local treatment of the ulcerative defect is performed in a specially equipped office or purulent dressing. Surgical treatment of the wound chamber comprises removing necrotic tissue, blood clots, foreign bodies, as well as complete release of the wound edges of hyperkeratotic lesions dense scab defect is closed or fibrin coating, application of ointments with collagenase and proteinase activity to complete cleansing surface. After surgical treatment, the surface of the trophic ulcer should be thoroughly rinsed. To this end, you can use both liquid antiseptics and sterile saline.

The general requirements for a modern aseptic dressing is atraumatic (not sticking to the wound) and the possibility of creating an optimal, moist environment in the wound.

Each phase of the wound process dictates its requirements for local treatment.

In the first phase (synonyms - recovery phase, exudation phase and purification) needed atraumatic dressing with a high absorbency, allowing as soon as possible to achieve complete purification wound surface from necrotic masses and exudate At this stage, the treatment may be combined total antibiotic therapy with topical application of antibiotics and proteolytic enzymes. In the event that there is a deep wounded small diameter, it is advisable to use drugs in the form of powder, granules or gel, to facilitate and speed up the process of removing anesthetized tissues and to avoid a violation of outflow of exudate.

Change of dressings in the phase of exudation should be conducted at least once in 24 hours, and with a large volume of detachable - every 8 hours. During this period, it is necessary to strictly control the level of glycemia, since persistent hyperglycemia creates additional difficulties in combating the infectious process and the ability of its generalization .

In the second (synonyms, regeneration stage, granulation stage) and third (synonyms, phase of scar organization and epithelization) phases, various atraumatic bandages can be used.

In the presence of signs of ischemia, it is recommended to apply bandages that accelerate the healing of the wound.

[1], [2], [3], [4], [5],

Patient Education

In most patients with trophic ulcers, the development of this complication can be prevented. It is known that the formation of a neuropathic ulcer occurs only after mechanical or other damage to the skin of the foot. With neuroischemic or ischemic form of the diabetic foot syndrome, damage also often becomes a factor provoking the development of skin necrosis.

The complex of preventive measures that allow to sufficiently reduce the risk of injury to the lower extremities can be represented in the form of "prohibiting" and "permissive" rules.

"Prohibitive" rules are aimed at excluding factors that can damage foot tissues:

• with the care of the skin of the feet, the use of sharp cutting objects is categorically excluded;
• if the patient has decreased sensitivity of the feet, poor eyesight, or skin lesions occur while treating the nails - he should not cut them themselves with scissors. It is possible to treat the nails with a saw or help from relatives. In the absence of these "risk factors," the use of scissors is possible, but one should not cut off the nails too short and shear the corners.
• if the feet are cold, do not warm them with heaters, electric heaters or steam heating batteries. If the temperature sensitivity of the patient is reduced, he will not feel a burn;
• for the same reason, you can not take hot foot baths (the water temperature should not be above 37 C). In addition, foot baths should not be long - this makes the skin flabby, more vulnerable to various damaging factors;
• It is not recommended to walk without shoes (including at home). With a significant increase in plantar pressure, and there is a risk of injury or infection of the affected area. On the beach you need to wear bathing slippers, and also protect your feet from sunburn;
• should abandon the uncomfortable tight shoes, do not wear high-heeled shoes, as thus there are zones of increased pressure on the foot. Care must be given to new shoes: the first time to wear it for not more than one hour and in no case to use such methods of wearing as dressing on a wet sock. Additional opportunities for injuries create open shoes, especially shoes with a strap running between the fingers,
• if you have corns on your feet, you can not try to get rid of them with a corn plaster or keratolytic ointments and liquids, since these products contain substances that damage the skin;
• should pay attention to the elastic bands of socks: too tight elastic bands squeeze the skin of the lower legs, which makes blood circulation

"Permissive" recommendations contain a description of the proper conduct of hygiene measures:

• when diabetes is necessary to regularly inspect the legs - it allows you to detect damage to the feet in the early stages, even in patients with a sensitivity disorder;
• Nail treatment should be done in a safe way (preferably with a saw). The edge of the nail needs to be cut along straight lines, leaving corners intact;
• pumice is the most suitable means for removing corns and areas of hyperkeratosis. It should be used while washing your feet and do not try to remove the calluses at one time;
• Dry areas of the coyote should be lubricated with a water-based cream containing urea. This will prevent the formation of fissure - possible entrance gate infection;
• after washing your feet you should wipe it dry, do not rub it, but damp your skin, especially in the interdigital spaces. The increased humidity in these areas contributes to the development of diaper rash and fungal diseases. For the same reason, using a foot cream, do not apply it to the skin between the fingers;
• if the feet are cold, they should be warmed with warm socks of the appropriate size, without tight elastic bands. It is necessary to make sure that the socks do not get lost in shoes;
• it is necessary to take it as a rule to touch the inside surface of the shoe each time before handing it on, whether any foreign objects that could injure the leg, whether the insole has wrapped around, or if sharp nails do not come out;
• daily diabetics should carefully examine the feet, especially the plantar surface and interdigital spaces. Elderly people and people with overweight can experience some difficulties at the same time. They can be recommended to use a mirror installed on the floor, or ask for help from relatives. This procedure allows you to quickly detect wounds, cracks, scrapes. Even minor damage to the patient should be shown to the doctor, however, he must be able to provide first aid on his own;
• A wound or a crack found during examination of the foot should be washed with a disinfectant solution. To do this, you can use 1% solution of dioxidine, solutions of miramistine, chlorhexidine, acebine. The washed wound should be closed with a sterile dressing or bactericidal adhesive plaster. Do not use a regular adhesive plaster, apply alcohol solutions or a concentrated solution of potassium permanganate. It is undesirable to use oil bandages or fat-based creams that create a good nutrient medium for the development of infection and make it difficult to drain the discharge from the wound. If there is no positive effect for 1-2 days, you should consult a doctor in the office "Diabetic Stop".

All the necessary means (sterile wipes, bactericidal plaster, solutions of antiseptics) is recommended to be included in the first aid kit of the patient.

When there are signs of inflammation (redness, local edema, purulent discharge), urgent medical attention is needed. It may require surgical cleansing of the wound, the appointment of antibacterial agents. In such a situation it is important to provide the foot with complete peace. The patient is shown a bed mode if necessary, use a wheelchair, special unloading devices.

Compliance with these simple rules allows patients to reduce the risk of gangrene development and subsequent amputation.

All the "prohibiting" and "permissive" rules should be discussed in detail in the session devoted to the rules of foot care as part of the self-monitoring program.

Wearing orthopedic shoes

In half of the patients, the examination of the feet makes it possible to predict the site of the development of the ulcer (the risk zone) long before it occurs. Predyazvennogo causes skin damage and subsequent development of trophic strain CBA are feet (toes beak and Hammer, Hallux valgus, flat foot, amputation within the foot and the like), and thickening of the nail plate, close footwear and others.

Each deformation leads to the formation of a "risk zone" in typical places for it. If such a zone experiences high blood pressure when walking, it causes premalignant skin changes: hyperkeratosis and subcutaneous hemorrhage. In the absence of timely intervention - the removal of scalpel sites of hyperkeratosis in these zones, trophic ulcers are formed.

The main preventive tool, allowing 2-3 times to reduce the likelihood of ulcerative defect formation, is orthopedic footwear. The main requirements for such shoes are the lack of a toe cap, which makes them soft and pliable in the upper surface of the shoe; rigid sole, significantly reduces the pressure in the area of the anterior plantar surface of the foot, the seamless inner space of the shoe, which eliminates the possibility of scuffing.

Removal of hyperkeratosis sites

Another direction of prevention of diabetic foot syndrome, as mentioned above, is the timely removal of hyperkeratosis sites with special tools (scalpel and scaler) in the Diabetic Foot cabinet. Since pathological hyperkeratosis creates additional pressure on the skin, this measure is not cosmetic, but therapeutic and preventive. But, until the causes of the formation of hyperkeratosis are eliminated, this measure gives a temporary effect - corn is quickly formed again. Orthopedic footwear eliminates the formation of hyperkeratosis completely. Thus, the mechanical removal of hyperkeratosis sites should be of a regular nature.

A similar situation occurs when the nail plates thicken, which create pressure on the soft tissues of the subungual space of the finger. If the thickening of the nail is caused by mycosis, it is advisable to administer local therapy with antifungal lacquer in combination with the mechanical processing of the nail plate. This allows you to prevent the transition of pre-ulcer changes in the skin of the floor with a thickened fingernail into the trophic ulcer.

Evaluation of treatment effectiveness

Evaluation of the effectiveness of the treatment of the neuropathic form of the diabetic foot syndrome is based on the rate of contraction of the wound defect within the next 4 weeks from the start of treatment. In 90% of cases, the full healing of neuropathic ulcers is 7-8 weeks. If the reduction of the wound size after 4 weeks is less than 50% of the initial size, if it is observed with all the conditions of therapy (especially limb discharge) and elimination of the decrease in the main blood flow, then it is a slow reparative process. In such cases, it is advisable to use dressings that accelerate the healing process (for example, it is possible to use bekaplemine).

The effectiveness of treatment of the ischemic form of the diabetic foot syndrome depends on the degree of decrease in blood flow. With critical ischemia, the condition of healing of a ulcerative defect is angiosurgical restoration of blood flow. The soft tissue flow is restored within 2-4 weeks after reconstructive angiosurgical interventions. The healing time for wound defects is largely determined by the initial size of the wound defect, its depth and localization, ulcerative defects in the heel area heal less well

Errors and unreasonable appointments

Quite often in patients with diabetic foot syndrome, the excretory function of the kidneys is impaired due to diabetic nephropathy. The use of medications in usual average therapeutic doses can worsen the general condition of the patient, adversely affect the effectiveness of treatment and adversely affect the state of the kidney for a number of reasons:

• a decrease in the excretory function of the kidneys increases the likelihood of toxic effects of drugs and its metabolites on the body;
• in patients with impaired renal function there is a decrease in tolerance to side effects of drugs;
• some antibacterial drugs do not show their full properties in the event of a violation of the excretory function of the kidneys.

In view of the foregoing, corrections should be made when choosing an antibacterial drug and its dose.

[6], [7], [8], [9], [10]

Forecast

The prognosis for ulcerative lesion of the foot depends on the stage of the process. In stages IA and IIA, the prognosis with a timely onset of treatment is favorable. At stage IB, the prognosis depends on the degree of decrease in blood flow. In stages IIB and III, the forecast is unfavorable, since the probability of amputation is high. In stages IV and V, amputation is unavoidable.

The prognosis of neuro-osteoarthropathy largely depends on the degree of destruction that occurred in the acute stage, and on the continuing burden in the chronic. An unfavorable outcome in this case will be a significant deformation of the foot, the formation of unstable false joints, which increases the likelihood of ulceration, attachment of the infectious process.

[11], [12],