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"Foot wounds are among the most common and severe complications of diabetes
and are now the most frequent cause for diabetes-associated hospitalization,"
write Lawrence A. Lavery, DPM, MPH, of the Scott and White Hospital, Texas A&M
University Health Science Center College of Medicine in Temple, and colleagues.
"About one-half of these wounds become clinically infected during the course
of therapy.... Ascertaining the severity of infection should help clinicians
determine what treatments are needed, as well as in what environment and how
urgently they must be provided."
In 2004, the IDSA and the International Working Group on the Diabetic Foot
(IWGDF) each published a comprehensive set of guidelines for the management
of diabetic foot infections, including a classification scheme for infection
severity. Both systems first divide wounds by whether they are clinically infected
based on the presence of purulent secretions or local or systemic signs of inflammation
or infection. Infected wounds are further classified as mild, moderate, or severe,
based on the size (especially of any cellulitis) and depth (or level of tissue
involved) of the infection, and on the presence of systemic manifestations of
infection or metabolic instability.
Although these systems were developed by an international consensus of experts
in various fields, no studies to date have validated their ability to predict
clinical outcomes of diabetic foot infection. Using a database developed for
a prospective diabetes-related foot care management program, the investigators
evaluated the ability of the IDSA-IWGDF classification scheme to predict adverse
outcomes.
In this longitudinal study of 1666 persons with diabetes, 27 (18%) of all
infections were severe, and 50 patients required a lower extremity amputation
of some type. Increasing infection severity on the IDSA-IWGDF classification
scheme was associated with an observed trend toward an increased risk for amputation
(?2 test for trend, 108.0; P < .001), higher-level amputation (?2 test for
trend, 113.3; P < .001), and lower-extremity–related hospitalization
(?2 test for trend, 118.6; P < .001).
Increasing severity of infection was also associated with more-frequent lower
extremity comorbidities, such as peripheral neuropathy and arterial vascular
disease, and with deeper infection-related bone and joint disease.
"The Infectious Diseases Society of America's foot infection classification
system may be a useful tool for grading foot infections," the authors write.
"It suggests that persons with mildly infected or noninfected wounds are
highly unlikely to require hospitalization, develop osteomyelitis, or undergo
amputation."
The authors suggest that determining the severity of a foot infection in a
patient with diabetes may help the clinician decide on hospitalization, whether
to use parenteral or oral antibiotics, and how urgently surgery or other treatments
need to be performed.
"We believe that the simplicity of determining the components of this system,
coupled with the strong suggestion of its clinical utility, may make it a useful
instrument in helping clinicians determine which of their patients are at the
highest risk for adverse outcomes from a diabetic foot infection," the
authors conclude. "Perhaps more aggressive medical, surgical, and adjunctive
measures could be directed at these patients, with the hope that this would
improve their foot salvaging outcome. This system should also be useful for
clinical research studies, to allow for comparisons among patients enrolled
in various investigations."
Diabetes is the most common underlying reason for lower extremity amputation
in the developed world, and improved identification and classification of diabetic
foot infections may promote improved care and reduced morbidity. To this end,
the IDSA has presented guidelines for clinicians diagnosing diabetic foot infections.
These guidelines were published in the October 1, 2004, issue of Clinical Infectious
Diseases and infections were graded as follows:
| Clinical Description |
Degree of Infection |
| No purulence or evidence of inflammation |
Uninfected |
| 2 signs of inflammation, such as pain or induration; cellulitis,
2 cm or less around ulcer; infection limited to skin and subcutaneous tissues
|
Mild |
| At least one of the following: cellulitis > 2 cm around
ulcer, lymphangitis, spread beneath fascia, abscess, gangrene, or involvement
of muscle, tendon, or bone |
Moderate |
| Evidence of local infection as well as systemic toxicity,
such as fever, hypotension, leukocytosis, or azotemia |
Severe |
The current prospective study applied these criteria to diabetic patients and
followed them up for outcomes related to foot infections. The results of a study
reported in the February issue of Clinical Infectious Diseases provides validation
for their system.
Clin Infect Dis. 2007;44:562-565.
================================
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