best practice guidelines: wound management in diabetic foot ulcers

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DFU WOUNDMANAGEMENTTABLE 4: General principles of bacterial management (adapted from 49 ) At initial presentation of infection it is important to assess its severity, take appropriatecultures and consider need for surgical procedures Optimal specimens for culture should be taken after initial cleansing and debridementof necrotic material Patients with severe infection require empiric broad-spectrum antibiotic therapy,pending culture results. Those with mild (and many with moderate) infection can betreated with a more focused and narrow-spectrum antibioticPatients with diabetes have immunological disturbances; therefore even bacteria regardedas skin commensals can cause severe tissue damage and should be regardedas pathogens when isolated from correctly obtained tissue specimens Gram-negative bacteria, especially when isolated from an ulcer swab, are oftencolonising organisms that do not require targeted therapy unless the person is at riskfor infection with those organisms Blood cultures should be sent if fever and systemic toxicity are present Even with appropriate treatment, the wound should be inspected regularly for earlysigns of infection or spreading infection Clinical microbiologists/infectious diseases specialists have a crucial role; laboratoryresults should be used in combination with the clinical presentation and history toguide antibiotic selection Timely surgical intervention is crucial for deep abscesses, necrotic tissue and forsome bone infectionsBOX 4: Guidelines for the useof systemic antibiotic therapyAntibiotics should be prescribedusing local protocolsand, in complex cases, theadvice of a clinical microbiologistor infectious diseasesspecialist. Avoid prescribingantibiotics for uninfectedulcerations. IDSA 46 offersevidence-based suggestions,which can be adapted to localneeds.http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/2012%20Diabetic%20Foot%20Infections%20Guideline.pdfIf there are clinical signs of infection atdressing change, systemic antibiotic therapyshould be started. Topical antimicrobialsare not indicated as the only anti-infectivetreatment for moderate or severe infectionof deep tissue or bone 38,46 .Patients may also require debridement toremove infected material. In addition, infectedwounds should be cleansed at eachdressing change with saline or an appropriateantiseptic wound cleansing agent.Deep tissue infection (moderate to severeinfection)For treating deep tissue infection (cellulitis,lymphangitis, septic arthritis, fasciitis): Start patients quickly on broad-spectrumantibiotics, commensurate with the clinicalhistory and according to local protocolswhere possible 37 Take deep tissue specimens or aspiratesof purulent secretions for cultures at thestart of treatment to identify specificorganisms in the wound, but do not waitfor results before initiating therapy 1,37 Change to an alternate antibiotic if:— indicated by microbiology results 46— the signs of inflammation are notimproving 84 Administer antibiotics parenterally forall severe and some moderate infections,and switch to the oral route when thepatient is systemically well and cultureresults are available 46 Continue antibiotic therapy until the infectionresolves, but not through to completehealing 46 . In most cases 1–3 weeks oftherapy is sufficient for soft tissue infections Consider giving empiric therapy directedagainst MRSA 46 :— in patients with a prior history of MRSAinfection— when the local prevalence of MRSAcolonisation or infection is high— if the infection is clinically severe.Note that the optimal duration of antibiotictreatment is not clearly defined andwill depend on the severity of infection andresponse to treatment 84 .Infection in a neuroischaemic foot is oftenmore serious than in a neuropathic foot(which has a good blood supply), and thisshould influence antibiotic policy 49 . Antibiotictherapy should not be given as a preventivemeasure in the absence of signs of infection(see Box 4). This is likely to cause infectionwith more resistant pathogens.Obtain an urgent consultation with experts(eg foot surgeon) for patients who havea rapidly deteriorating wound that is notresponding to antibiotic therapy. Infectionsaccompanied by a deep abscess, extensivebone or joint involvement, crepitus, substantialnecrosis or gangrene, or necrotisingfasciitis, need prompt surgical interventionalong with appropriate antibiotic therapy, toreduce the risk of major amputation 51,85 .Biofilms and chronic persistent infectionPolymicrobial infections predominate insevere diabetic foot infections and thisdiversity of bacterial populations in chronicwounds, such as DFUs, may be an importantcontributor to chronicity 86,87 . Biofilms arecomplex polymicrobial communities thatdevelop on the surface of chronic wounds,which may lack the overt clinical signs of infection34 . They are not visible to the naked eye andcannot be detected by routine cultures 88 .The microbes produce an extra-polymericsubstance that contributes to the structure ofthe biofilm. This matrix acts as a thick, slimyprotective barrier, making it very difficult for312 BEST PRACTICEBEST PRACTICEGUIDELINESGUIDELINES:FOR SKINWOUNDAND WOUNDMANAGEMENTCARE ININEPIDERMOLYSISDIABETIC FOOTBULLOSAULCERS
DFU WOUNDMANAGEMENTantimicrobial agents to penetrate it 89 . Theimpact of biofilms may depend on which speciesare present rather than the bioburden 34 .Treatment should aim to 88 : Disrupt the biofilm burden through regular,repeated debridement and vigorous woundcleansing Prevent reformation and attachment of thebiofilm by using antimicrobial dressings.Appropriate wound bed preparation remainsthe gold standard for biofilm removal 90 .Moisture balance: optimal dressingselectionMost dressings are designed to create a moistwound environment and support progressiontowards wound healing. They are not asubstitute for sharp debridement, managingsystemic infection, offloading devices anddiabetic control.Moist wound healing has the potential toaddress multiple factors that affect woundhealing. It involves maintaining a balancedwound environment that is not too moist ortoo dry. Dressings that can help to managewound exudate optimally and promote abalanced environment are key to improvingoutcomes 91 . However, a dressing that may beideal for wounds of other aetiologies may beentirely inappropriate for certain DFUs. Thedressing selected may have a considerableeffect on outcome and, due to the varyingcomplexities of DFUs, there is no singledressing to suit all scenarios.Many practitioners are confused by the greatrange of dressings available. Impressiveclaims are rarely supported by scientificstudies and there is often a lack of highqualityevidence to support decision making.One inherent problem is whether thecharacteristics of each wound randomised toa specific dressing in a trial correspond to thecharacteristics that the dressing was designedto manage 92 . Many dressings are designedfor non-foot areas of the body and may bedifficult to apply between or over the toes orplantar surface. In addition, most practitionershave historically had little specific, practicalguidance on selecting dressings.In the absence of strong evidence of clinicalor cost effectiveness, healthcare professionalsshould use wound dressings that best matchthe clinical appearance and site of the wound,as well as patient preferences 1 . Dressingchoice must begin with a thorough patientand wound assessment. Factors to considerinclude: Location of the wound Extent (size/depth) of the wound Amount and type of exudate The predominant tissue type on the woundsurface Condition of the periwound skin Compatibility with other therapies (egcontact casts) Wound bioburden and risk of infection Avoidance of pain and trauma at dressingchanges Quality of life and patient wellbeing.The status of the diabetic foot can changevery quickly, especially if infection has notbeen appropriately addressed. The need forregular inspection and assessment meansthat dressings designed to be left in situ formore than five days are not usually appropriatefor DFU management.Practitioners should also consider the followingquestions 93 .Does the dressing: Stay intact and remain in place throughoutwear time? Prevent leakage between dressingchanges? Cause maceration/allergy or sensitivity? Reduce pain? Reduce odour? Retain fluid? Trap exudate components?Is the dressing: Comfortable, conformable, flexible and of abulk/weight that can be accommodated inan offloading device/footwear? Suitable for leaving in place for the requiredduration? Easy to remove (does not traumatise thesurrounding skin or wound bed)? Easy to apply? Cost effective? Likely to cause iatrogenic lesions?Tables 5 and 6 (pages 14-15) provide adviceon type of dressing and how to select accordingto tissue type (see also Figures 11–14).FIGURE 11: Dry necrotic wound.Select dressing to rehydrateand soften the escharFIGURE 12: Sloughy wound bedwith areas of necrosis. Selectdressing to control moistureand promote debridement ofdevitalised tissueFIGURE 13: Infected woundwith evidence of swelling andexudate. Start empiric antibiotictherapy and take cultures.Consider selecting an antimicrobialdressing to reducewound bioburden and manageexudateFIGURE 14: A newly epithelialisingDFU. It is important toprotect new tissue growthBEST PRACTICE GUIDELINES: WOUND MANAGEMENT IN DIABETIC FOOT ULCERS 13
Page 1 and 2: INTERNATIONAL BEST PRACTICEBEST PRA
Page 3 and 4: INTRODUCTIONIntroductionDFUs are co
Page 5 and 6: AETIOLOGY OFDFUsAetiology of DFUsTh
Page 7 and 8: ASSESSING DFUsFIGURE 5: Procedure f
Page 9 and 10: ASSESSING DFUsBOX 1: Signs of sprea
Page 11 and 12: DFU WOUNDMANAGEMENTDFU wound manage
Page 13: DFU WOUNDMANAGEMENTHydrosurgical de
Page 17 and 18: DFU WOUNDMANAGEMENTTABLE 6: Wound m
Page 19 and 20: DFU WOUNDMANAGEMENTexclusion of inf
Page 21 and 22: Integrated care approachINTEGRATEDC
Page 23 and 24: REFERENCES1. National Institute for
Page 25 and 26: REFERENCES94. International Consens

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