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DIABETIC FOOT WITH NECROTISING FASCIITIS IN A 31 YEAR OLD DIABETIC FEMALE - A CASE REPORT.
Abstract
INTRODUCTION Diabetic foot can be dened as an infection involving the foot due to chronic or acute injury to the soft tissues of the foot with evidence of pre existing sensory neuropathy, micro vasculopathy and immunodeciency. Angiopathy and neuropathy are relatively common complications of diabetes mellitus (DM), causing diabetic foot, which brings enormous social and economic pressure to the patients. Diabetic foot ulcers combined with necrotizing fasciitis has rapid onset, involves a wide range of lesions. Necrotizing fasciitis is a rapidly progressive life-threatening infection. The risk factors for necrotizing fasciitis are diabetes, immunosuppression, hypertension, chronic renal failure. It causes systemic toxemia, septic shock and multiple organ dysfunctions increasing the mortality rate to 15% to 35%.
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Recommendations
Classification/diagnosis
Diabetic foot infection must be diagnosed clinically, based on the presence of local or systemic signs or symptoms of inflammation (strong; low).
Assess the severity of any diabetic foot infection using the Infectious Diseases Society of America/International Working Group on the Diabetic Foot classification scheme (strong; moderate).
Osteomyelitis
For an infected open wound, perform a probe‐to‐bone test; in a patient at low risk for osteomyelitis, a negative test largely rules out the diagnosis, while in a high‐risk patient, a positive test is largely diagnostic (strong; high).
Markedly elevated serum inflammatory markers, especially erythrocyte sedimentation rate, are suggestive of osteomyelitis in suspected cases (weak; moderate).
A definite diagnosis of bone infection usually requires positive results on microbiological (and, optimally, histological) examinations of an aseptically obtained bone sample, but this is usually required only when the diagnosis is in doubt or determining the causative pathogen's antibiotic susceptibility is crucial (strong; moderate).
A probable diagnosis of bone infection is reasonable if there are positive results on a combination of diagnostic tests, such as probe‐to‐bone, serum inflammatory markers, plain X‐ray, magnetic resonance imaging (MRI) or radionuclide scanning (strong; weak).
Avoid using results of soft tissue or sinus tract specimens for selecting antibiotic therapy for osteomyelitis as they do not accurately reflect bone culture results (strong; moderate).
Obtain plain X‐rays of the foot in all cases of non‐superficial diabetic foot infection (strong; low).
Use MRI when an advanced imaging test is needed for diagnosing diabetic foot osteomyelitis (strong; moderate).
When MRI is not available or contraindicated, consider a white blood cell‐labelled radionuclide scan, or possibly single‐photon emission computed tomography (CT) and CT (SPECT/CT) or fluorine‐18‐fluorodeoxyglucose positron emission tomography/CT scans (weak; moderate).
Assessing severity
At initial evaluation of any infected foot, obtain vital signs and appropriate blood tests, debride the wound and probe and assess the depth and extent of the infection to establish its severity (strong; moderate).
At initial evaluation, assess arterial perfusion and decide whether and when further vascular assessment or revascularization is needed (strong; low).
Microbiological considerations
Obtain cultures, preferably of a tissue specimen rather than a swab, of infected wounds to determine the causative microorganisms and their antibiotic sensitivity (strong; high).
Do not obtain repeat cultures unless the patient is not clinically responding to treatment, or occasionally for infection control surveillance of resistant pathogens (strong; low).
Send collected specimens to the microbiology laboratory promptly, in sterile transport containers, accompanied by clinical information on the type of specimen and location of the wound (strong; low).
Surgical treatment
Consult a surgical specialist in selected cases of moderate, and all cases of severe, diabetic foot infection (weak; low).
Perform urgent surgical interventions in cases of deep abscesses, compartment syndrome and virtually all necrotizing soft tissue infections (strong; low).
Consider surgical intervention in cases of osteomyelitis accompanied by spreading soft tissue infection, destroyed soft tissue envelope, progressive bone destruction on X‐ray or bone protruding through the ulcer (strong; low).
Antimicrobial therapy
While virtually all clinically infected diabetic foot wounds require antimicrobial therapy, do not treat clinically uninfected wounds with antimicrobial therapy (Strong; Low)
Select specific antibiotic agents for treatment based on the likely or proven causative pathogens, their antibiotic susceptibilities, the clinical severity of the infection, evidence of efficacy of the agent for diabetic foot infection and costs (strong; moderate).
A course of antibiotic therapy of 1–2 weeks is usually adequate for most mild and moderate infections (strong; high).
Administer parenteral therapy initially for most severe infections and some moderate infections, with a switch to oral therapy when the infection is responding (strong; low).
Do not select a specific type of dressing for a diabetic foot infection with the aim of preventing an infection or improving its outcome (strong; high).
For diabetic foot osteomyelitis, we recommend 6 weeks of antibiotic therapy for patients who do not undergo resection of infected bone and no more than a week of antibiotic treatment if all infected bone is resected (strong; moderate).
We suggest not using any adjunctive treatments for diabetic foot infection (weak; low).
When treating a diabetic foot infection, assess for use of traditional remedies and previous antibiotic use and consider local bacterial pathogens and their susceptibility profile (strong; low).
Necrotizing fasciitis (NF) is a severe, rare, potentially lethal soft tissue infection that develops in the scrotum and perineum, the abdominal wall, or the extremities. The infection progresses rapidly, and septic shock may ensue; hence, the mortality rate is high (median mortality 32.2%). Prognosis becomes poorer in the presence of co-morbidities, such as diabetes mellitus, immunosuppression, chronic alcohol disease, chronic renal failure, and liver cirrhosis. NF is classified into four types, depending on microbiological findings. Most cases are polymicrobial, classed as type I. The clinical status of the patient varies from erythema, swelling, and tenderness in the early stage to skin ischemia with blisters and bullae in the advanced stage of infection. In its fulminant form, the patient is critically ill with signs and symptoms of severe septic shock and multiple organ dysfunction. The clinical condition is the most important clue for diagnosis. However, in equivocal cases, the diagnosis and severity of the infection can be secured with laboratory-based scoring systems, such as the laboratory risk indicator for necrotizing fasciitis score or Fournier's gangrene severity index score, especially in regard to Fournier's gangrene. Computed tomography or ultrasonography can be helpful, but definitive diagnosis is attained by exploratory surgery at the infected sites. Management of the infection begins with broad-spectrum antibiotics, but early and aggressive drainage and meticulous debridement constitute the mainstay of treatment. Postoperative management of the surgical wound is also important for the patient's survival, along with proper nutrition. The vacuum-assisted closure system has proved to be helpful in wound management, with its combined benefits of continuous cleansing of the wound and the formation of granulation tissue.
Necrotizing fasciitis is a rapidly progressing skin infection characterized by necrosis of the fascia and subcutaneous tissue, accompanied by severe systemic toxicity. The objective of this systematic review was to identify clinical features and investigations that will aid early diagnosis.
A systematic literature search of PubMed was undertaken using the keywords 'necrotising fasciitis', 'necrotising skin infection', 'diagnosis' and 'outcome'. Case series of 50 or more subjects with information on symptoms and signs at initial presentation, investigations and clinical outcome were included.
Nine case series were selected, with a total of 1463 patients. Diabetes mellitus was a co-morbidity in 44·5 per cent of patients. Contact with marine life or ingestion of seafood in patients with liver disease were risk factors in some parts of Asia. The top three early presenting clinical features were: swelling (80·8 per cent), pain (79·0 per cent) and erythema (70·7 per cent). These being non-specific features, initial misdiagnosis was common and occurred in almost three-quarters of patients. Clinical features that helped early diagnosis were: pain out of proportion to the physical findings; failure to improve despite broad-spectrum antibiotics; presence of bullae in the skin; and gas in the soft tissue on plain X-ray (although this occurred in only 24·8 per cent of patients).
A high index of suspicion of necrotizing fasciitis is needed in a patient presenting with cutaneous infection causing swelling, pain and erythema, with co-morbidity of diabetes or liver disease. The presence of bullae, or gas on plain X-ray can be diagnostic. Early surgical exploration is the best approach in the uncertain case.
In the present study, we aimed to identify the comorbidities that would be predictive of requiring lower extremity amputation or reamputation for diabetic foot wounds. We performed a retrospective review of 132 consecutive patients who had undergone lower extremity amputations (110 patients) or reamputations (22 patients) for diabetic wounds from January 2013 to March 2016. We used multivariate logistic regression to calculate the odds ratios (ORs) for amputation and reamputation for various comorbidities. The ORs of undergoing amputation were greatest for adult males (OR 5.12, 95% confidence interval [CI] 1.56 to 13.04; p = .05) and those with longer term diabetes (OR 4.22, 95% CI 2.01 to 12.95; p = .05), wound infection (OR 3.94, 95% CI 1.04 to 9.00; p = .05), diabetic neuropathy (OR 3.53, 95% CI 1.07 to 9.11; p = .05), and a positive history of smoking (OR 3.04, 95% CI 1.55 to 9.89; p = .05). Similarly, the ORs of undergoing reamputation were greatest for adult males (OR 4.06, 95% CI 1.02 to 12.08; p = .05) and those with longer term diabetes (OR 3.67, 95% CI 1.94 to 11.42; p = .05), wound infection (OR 3.12; 95% CI 0.9 to 8.32; p = .05), diabetic neuropathy (OR 3.01, 95% CI 0.92 to 8.54; p = .05), and a positive history of smoking (OR 2.89, 95% CI 1.09 to 9.42; p = .05). The early identification of these comorbidities could help determine which patients are most likely to require amputation or reamputation.
Necrotizing fasciitis (NF) represents a rapidly progressive, life-threatening infection involving skin, soft tissue, and deep fascia. An early diagnosis is crucial to treat NF effectively. The disease is generally due to an external trauma that occurs in predisposed patients: the most important risk factor is represented by diabetes mellitus. NF is classified into 3 different subtypes according to bacterial strains responsible: type 1 associated to polymicrobial infection, type 2 NF, generally associated to Streptococcus species, often associated to Staphylococcus aureus and, eventually, Type 3, due to Gram-negative strains, such as Clostridium difficile or Vibrio. NF is usually characterized by the presence of the classic triad of symptoms: local pain, swelling, and erythema. In daily clinical practice immune-compromised or neuropathic diabetic patients present with atypical symptomatology. This explains the high percentage of misdiagnosed cases in the emergency department and, consequently, the worse outcome presented by these patients. Prompt aggressive surgical debridement and antibiotic systemic therapy are the cornerstone of its treatment. These must be associated with an accurate systemic management, consisting in nutritional support, glycemic compensation, and hemodynamic stabilization. Innovative methods, such as negative pressure therapy, once the acute conditions have resolved, can help fasten the surgical wound closure. Prompt management can improve prognosis of patients affected from NF reducing limb loss and saving lives.
Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds.
Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.