Diabetic foot treatment

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 hyperkeratosis

The amount of necessary medical care depends on the stage of the disease. Treatment of patients at stage I of diabetic foot syndrome consists of adequate treatment of the wound defect and the affected area of the foot. Patients with stage IA require a more detailed examination to assess the state of blood circulation. At stage II of diabetic foot syndrome, antibacterial therapy, local treatment and unloading of the limb are indicated. Patients with stages IV-V 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 a vascular surgeon and X-ray contrast angiography are indicated to decide on the possibility of performing vascular reconstructive surgery to restore blood flow. This may be either distal bypass or percutaneous balloon angioplasty with stenting. Angiosurgical interventions are usually supported by conservative measures, among which the suppression of infectious inflammation and local control over the wound process are of exceptional importance. Conservative treatment may be supplemented by the introduction of prostaglandins (alprostadil) or heparin-like drugs (sulodexide).

Treatment of acute osteoarthropathy consists of early immobilization using an individual unloading bandage (IUPB).

In the presence of signs of chronic neuroosteoarthropathy, the basis of treatment is therapeutic orthopedic footwear and adherence to foot care rules.

If necessary, treatment of diabetic neuropathy is carried out.

Compensation for diabetes

Correction of hyperglycemia, arterial hypertension and dyslipidemia is the basis for the prevention of all late complications of diabetes mellitus. In this case, it is necessary to be guided not by the advantages and disadvantages of individual drugs, but by achieving and maintaining 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 hyporeactivity of the immune system in diabetes mellitus (especially in elderly patients), these signs 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 pathogens causing the wound infection and their expected sensitivity to antibiotics, as well as the pharmacokinetics of the drugs and the localization of the infectious process. The optimal choice of antibiotic therapy is based on the results of a bacteriological examination of the wound discharge. 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 frequently isolated from patients with diabetic foot syndrome:

• gram-positive flora:
  • Staphylоcoccus aureus;
  • Streptococcus;
  • Enterococcus;
• gram-negative flora:
  • Klebsiella;
  • Escherichia coli;
  • Enterobacter;
  • Pseudomonas;
  • Citrobacter;
  • Morganella mоrganii;
  • Serratia;
  • Acinetobacter;
  • Proteus;
• anaerobes:
  • acteroides;
  • Clostridium;
  • Peptostreptococcus;
  • Peptococcus.

In severe forms of wound infection that threaten life or limb, such as phlegmon, deep abscesses, wet gangrene, sepsis, antibiotic therapy should be carried out only with parenteral drugs in a hospital setting in combination with full surgical drainage of purulent foci, detoxification and correction of carbohydrate metabolism.

In case of mild to moderate wound infection (only local signs of wound infection and shallow purulent foci), antibacterial drugs can be taken orally in an outpatient setting. In case of impaired absorption of drugs in the gastrointestinal tract, which may be a manifestation of autonomic neuropathy, it is necessary to switch to the parenteral route of drug administration.

The duration of antibiotic therapy is determined individually in a specific case based on the clinical picture and bacteriological analysis data. The longest, several months, antibiotic therapy can be used when attempting conservative treatment of osteomyelitis.

Antibacterial therapy

Antibacterial therapy for staphylococcal infections (Staphylococcus aureus):

• Gentamicin intravenously 5 mg/kg once a day until clinical and bacteriological improvement or
• Clindamycin orally 300 mg 3-4 times a day or intravenously 150-600 mg 4 times a day until clinical and bacteriological improvement or
• Rifampicin orally 300 mg 3 times a day, until clinical and bacteriological improvement or
• Flucloxacillin orally or intravenously 500 mg 4 times a day until clinical and bacteriological improvement.

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

• Vancomycin intravenously 1 g 2 times a day until clinical and bacteriological improvement or
• Doxycycline orally 100 mg once a day, until clinical and bacteriological improvement or
• Linezolid orally or intravenously 600 mg 2 times a day until clinical and bacteriological improvement or
• Rifampicin orally 300 mg 3 times a day until clinical and bacteriological improvement or
• Trimethoprim orally 200 mg 2 times a day until clinical and bacteriological improvement.

Antibacterial therapy for streptococcal infections:

• Amoxicillin orally or intravenously 500 mg 3 times a day, until clinical and bacteriological improvement or
• Clindamycin orally 300 3-4 times a day or intravenously 150-600 mg 4 times a day, until clinical and bacteriological improvement or
• Flucloxacillin orally 500 mg 4 times a day, until clinical and bacteriological improvement or
• Erythromycin orally 500 mg 3 times a day until clinical and bacteriological improvement.

Antibacterial therapy for enterococcal infections

• Amoxicillin orally or intravenously 500 mg 3 times a day until clinical and bacteriological improvement.

Antibacterial therapy for anaerobic infections

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

Antibacterial therapy for coliform bacteria infections (E. coli, Proteus, Klebsiella, Enterobacter)

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

Antibacterial therapy for pseudomonad infection (P. aeruginosa):

• Gentamicin intravenously 5 mg/kg once a day, until clinical and bacteriological improvement or
• Meropenem intravenously 0.5-1 g 3 times a day, until clinical and bacteriological improvement or
• Ticarcillin/clavulanate intravenously 3.2 g 3 times a day, until clinical and bacteriological improvement or
• Ceftazidime intravenously 1-2 g 3 times a day, until clinical and bacteriological improvement or
• Ciprofloxacin orally 500 mg 2 times a day, until clinical and bacteriological improvement

Foot unloading and local treatment

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

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

Most ulcerative defects in diabetic foot syndrome are localized on the plantar surface or in the area of interdigital spaces. Mechanical pressure on the supporting surface of the foot during walking prevents the normal course of tissue reparation processes. In this regard, an integral condition for the affective treatment of wound defects of the feet is unloading the affected area of the foot. In the acute stage of Charcot's foot, unloading the foot and lower leg is the main method of treatment.

The methods of unloading used depend on the localization of the ulcerative defect (fingers, metatarsal bone projection area, heel, arch area), as well as the form of the lesion (neuroosteoarthropathy, neuropathic ulcer, neuroischemic ulcer). If the wound is not located on the supporting surface (shin, dorsum of the foot), unloading the limb is not required.

Today, three main types of unloading devices are used in clinical practice:

• individual unloading bandage;
• multifunctional individual unloading bandage-shoes (MIRPO);
• therapeutic and unloading footwear.

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

MIRPO is applicable when ulcerative defects are localized in the forefoot (fingers, interdigital spaces, projection area of the metatarsal bone heads). MIRPO is the only unloading device applicable in case of bilateral lesions.

Therapeutic and unloading footwear (TOU) is used for unilateral lesions, when ulcerative defects are localized in the forefoot. Contraindication for the use of TOU is the presence of signs of osteoarthropathy.

IRP and MIRPO are made from Soft-cast and Scotch-cast fixing polymer materials in a clinical setting. LRO is an orthopedic product manufactured in an orthopedic enterprise.

Unloading of the limb can be supplemented by the administration of bisphosphonates, for example pamidronate:

• Pamidronate intravenously 90 mg once every 3 months, long-term.

In the case of ischemic or neuroischemic forms of limb damage, local treatment of the defect must necessarily be accompanied by measures aimed at correcting hemodynamic disturbances in the affected limb and antibacterial therapy.

Local treatment of the ulcer defect is performed in a specially equipped room or purulent dressing room. Surgical treatment of the wound site includes removal of necrotic tissue, blood clots, foreign bodies, as well as complete release of the wound edges from hyperkeratotic foci, the defect is covered with a dense scab or fibrinous plaque, it is possible to use ointments with proteinase and collagenase activity until the surface is completely cleansed. After surgical treatment, the surface of the trophic ulcer should be thoroughly washed. For this purpose, both liquid antiseptics and sterile saline solution can be used.

The general requirements for a modern aseptic dressing are atraumaticity (non-adhesion to the wound) and the ability to create an optimal, moist environment in the wound.

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

In the first phase (synonyms - recovery phase, exudation and cleansing phase) atraumatic dressings with high absorbency are required, allowing to achieve complete cleansing of the wound surface from necrotic masses and exudate as soon as possible. At this stage of treatment, it is possible to combine general antibacterial therapy with local application of antibiotics and proteolytic enzymes. In the case of a deep wound of small diameter, it is advisable to use medicinal preparations in the form of powder, granules or gel, allowing to facilitate and accelerate the process of removal of anesthetized tissues and to avoid violation of the outflow of exudate.

Dressings in the exudation phase should be changed at least once every 24 hours, and with a large volume of discharge - 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, scar organization and epithelialization phase) phases, various atraumatic dressings can be used.

If there are signs of ischemia, it is recommended to apply dressings that accelerate wound healing.

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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. In the neuroischemic or ischemic form of diabetic foot syndrome, damage also often becomes a factor provoking the development of skin necrosis.

A set of preventive measures that can sufficiently reduce the risk of damage to the lower extremities can be presented in the form of “prohibitory” and “permissive” rules.

“Prohibitory” rules are aimed at eliminating factors that can damage the tissues of the feet:

• When caring for the skin of your feet, it is strictly forbidden to use sharp cutting objects;
• If the patient has reduced sensitivity of the feet, poor eyesight or has had skin damage when treating nails, he should not trim them with scissors on his own. Nails can be treated with a file or help from relatives. In the absence of these "risk factors", using scissors is possible, but nails should not be cut too short or corners should not be trimmed.
• If your feet are cold, you should not warm them with heating pads, electric heaters or steam heating batteries. If the patient's temperature sensitivity is reduced, he will not feel the burn;
• for the same reason, you cannot take hot foot baths (the water temperature should not be higher than 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), because this significantly increases plantar pressure, and there is also a risk of injury or infection of the already affected area. On the beach, you need to wear bathing slippers, and also protect your feet from sunburn;
• You should avoid uncomfortable, tight shoes and avoid wearing high-heeled shoes, as this creates areas of increased pressure on your feet. You should be careful with new shoes: wear them for no more than an hour the first time and never wear them with wet socks. Open shoes, especially those with a strap between the toes, create additional opportunities for injury.
• If you have calluses on your feet, you should not try to get rid of them using callus plasters or keratolytic ointments and liquids, as these products contain substances that damage the skin;
• You should pay attention to the elastic bands of your socks: elastic bands that are too tight will squeeze the skin of your shins, which will impede blood circulation.

The “permissive” recommendations contain a description of the correct implementation of hygiene measures:

• In case of diabetes, it is necessary to regularly examine the feet - this allows detecting damage to the feet at early stages even in patients with impaired sensitivity;
• Nails should be treated in a safe way (preferably with a file). The edge of the nail should be filed in a straight line, leaving the corners untouched;
• the most suitable means for removing calluses and hyperkeratotic areas is pumice. It should be used while washing your feet and do not try to remove calluses in one go;
• Dry areas of the coyote should be lubricated with a water-based cream containing urea. This will prevent the formation of cracks - possible entry points for infection;
• After washing, dry your feet thoroughly, do not rub, but blot the skin, especially between the toes. Increased humidity in these areas contributes to the development of diaper rash and fungal diseases. For the same reason, when using foot cream, do not apply it to the skin between the toes;
• if your feet are cold, you should warm them up with warm socks of the appropriate size, without tight elastic bands. You should make sure that the socks do not get tangled in your shoes;
• you need to make it a rule to feel the inside of your shoes with your hand every time before putting them on, to make sure there are no foreign objects inside that could injure your foot, that the insole is curled up, or that there are no sharp nails sticking out;
• Every day, a diabetic patient should carefully examine their feet, especially the plantar surface and the spaces between the toes. Elderly people and overweight people may experience certain difficulties with this. They can be advised to use a mirror installed on the floor or ask relatives for help. This procedure allows for the timely detection of wounds, cracks, and abrasions. The patient should show even minor injuries to a doctor, but he should be able to provide first aid to himself;
• the wound or crack found during examination of the foot must be washed with a disinfectant solution. For this, you can use a 1% solution of dioxidine, solutions of miramistin, chlorhexidine, acerbin. The washed wound must be covered with a sterile bandage or bactericidal adhesive plaster. You cannot use a regular adhesive plaster, apply alcohol solutions or a concentrated solution of potassium permanganate. It is undesirable to use oil dressings or fat-based creams, which create a good nutrient medium for the development of infection and hinder the outflow of discharge from the wound. If there is no positive effect within 1-2 days, you should consult a doctor in the "Diabetic Foot" office.

It is recommended to include all necessary supplies (sterile wipes, bactericidal plasters, antiseptic solutions) in the patient's first aid kit.

If signs of inflammation appear (redness, local swelling, purulent discharge), urgent medical attention is needed. Surgical cleaning of the wound and prescription of antibacterial agents may be required. In such a situation, it is important to provide the leg with complete rest. The patient is prescribed bed rest; if necessary, it is necessary to use a wheelchair and special unloading devices.

If patients follow these simple rules, the risk of developing gangrene and subsequent amputation can be greatly reduced.

All "do's" and "do's" should be discussed in detail during the foot care class as part of the patient self-management training program.

Wearing orthopedic shoes

In half of the patients, examination of the feet allows predicting the location of ulcer development (risk zone) long before it occurs. The causes of pre-ulcer skin damage and subsequent development of trophic ulcers are foot deformities (beak-shaped and hammer-shaped toes, Hallux valgus, flat feet, amputations within the foot, etc.), as well as thickening of the nail plates, tight shoes, etc.

Each deformation leads to the formation of a "risk zone" in its typical places. If such a zone experiences increased pressure during walking, pre-ulcerative changes in the skin occur in it: hyperkeratosis and subcutaneous hemorrhage. In the absence of timely intervention - removal of hyperkeratosis areas with a scalpel - trophic ulcers form in these zones.

The main preventive measure that allows to reduce the probability of ulcerative defect formation by 2-3 times is orthopedic footwear. The main requirements for such footwear are the absence of a toe cap, which makes the upper surface of the shoe soft and pliable; a rigid sole, which significantly reduces the pressure in the area of the front plantar surface of the foot, a seamless inner space of the shoe, which eliminates the possibility of abrasions.

Removal of hyperkeratotic areas

Another direction of prevention of diabetic foot syndrome, as already mentioned above, is timely removal of hyperkeratosis areas with special instruments (scalpel and scaler) in the "Diabetic foot" office. Since pathological hyperkeratosis creates additional pressure on the skin, this measure is not cosmetic, but therapeutic and preventive. But until the causes of hyperkeratosis are eliminated, this measure gives a temporary effect - the callus quickly forms again. Orthopedic shoes eliminate the formation of hyperkeratosis completely. Thus, mechanical removal of hyperkeratosis areas should be regular.

A similar situation occurs when the nail plates thicken, which creates pressure on the soft tissues of the subungual space of the finger. If the nail thickening is caused by mycosis, it is advisable to prescribe local therapy with antifungal varnish in combination with mechanical treatment of the nail plate. This helps prevent the transition of pre-ulcer changes in the skin under the thickened nail into a trophic ulcer.

Evaluation of treatment effectiveness

The effectiveness of treatment of the neuropathic form of diabetic foot syndrome is assessed based on the rate of wound defect reduction within the next 4 weeks from the start of treatment. In 90% of cases, the time for complete healing of neuropathic ulcerative defects is 7-8 weeks. If, with all the conditions of therapy (especially unloading the limb) and excluding a decrease in the main blood flow, the reduction in the wound size after 4 weeks is less than 50% of the original size, then we are talking about a sluggish reparative process. In such cases, it is advisable to use dressings that accelerate the healing process (for example, becaplermin can be used).

The effectiveness of the treatment of the ischemic form of diabetic foot syndrome depends on the degree of blood flow reduction. In critical ischemia, the condition for healing the ulcer defect is angiosurgical restoration of blood flow. Blood flow of soft tissues is restored within 2-4 weeks after reconstructive angiosurgical interventions. The healing time of wound defects is largely determined by the initial size of the wound defect, its depth and localization; ulcer defects in the heel area heal worse

Errors and unjustified appointments

Quite often, patients with diabetic foot syndrome have impaired renal excretory function due to diabetic nephropathy. The use of drugs in normal average therapeutic doses can worsen the general condition of the patient, negatively affect the effectiveness of treatment and adversely affect the condition of the kidneys for a number of reasons:

• a decrease in the excretory function of the kidneys increases the likelihood of toxic effects of drugs and their metabolites on the body;
• in patients with impaired renal function, decreased tolerance to the side effects of drugs is observed;
• Some antibacterial drugs do not fully exhibit their properties when the excretory function of the kidneys is impaired.

Taking into account the above, adjustments should be made when choosing an antibacterial drug and its dosage.

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Forecast

The prognosis for ulcerative lesions of the foot depends on the stage of the process. At stages IA and IIA, the prognosis is favorable if treatment is started in a timely manner. At stage IB, the prognosis depends on the degree of blood flow reduction. At stages IIB and III, the prognosis is unfavorable, since there is a high probability of amputation. At stages IV and V, amputation is inevitable.

The prognosis of neuroosteoarthropathy largely depends on the degree of destruction that occurred in the acute stage and on the ongoing load in the chronic stage. An unfavorable outcome in this case will be significant deformation of the foot, the formation of unstable pseudoarthroses, which increases the likelihood of ulcers and the addition of an infectious process.

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