the role of the id physician in dfi management presen… · the role of the id physician in dfi...

The role of the ID Physician in DFI management

Dr Steve Guy

Western Health

LEAP, 2018

No conflicts of interest or financial disclosures to report. All patient photographs with verbal consent.

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Aims and topics;

1. What is ID / what do we do?

2. (why) Do ID care about DFI?

3. DEFIANZ – Aus/NZ ID diabetic foot research group

4. Where does ID fit in?

a) Diabetes and Infectionsb) Is it OM?c) Microbiology, sampling & antibiotics 101

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What is ID / what do we do?As a specialty;

- Deal with the diagnosis, management and control of infections…. and Antimicrobial stewardship (AMS), and Infection prevention.

In relation to DFI; I would like to think we are active in;

- Inpatient / outpatient management of DFI

- HITH/OPAT - Guideline development wrt antimicrobials

- Research

- Holistic approach to patient

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What do I do where I work?

• Full time ID physician in public hospital setting

• Western Health catchment is >850,000 people

• 55% of whom were born overseas

• Other activities;• Clinical ID; HIV, hepatitis, resistant bacteria, endocarditis, travel.. • Antimicrobial stewardship• Infection Prevention• TB medicine• Teaching & supervision• Research• Committees• Administration

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WH Diabetic Foot Service:Inpatient rounds;Podiatry (x 2-4, senior)

Endo (cons + reg + resident)

Vasc (cons + fellow)ID (cons +/- reg)

Ortho…sometimes!

High risk outpatient;Podiatry, Endocrine, orthotics

Vascular clinic runs concurrently

ID available

Structure / processPodiatry ‘own’ service; co-ordinate, clerical, organisational

24/7 emergency vasc/endo/ID

2 X weekly inpatient rounds2 X weekly outpatients

Always available;

Physio, DM educator, social work, orthotics, wound nurse, pharmacist

Other medical teams prn

Renal, rehab, orthopaedics, gen med, radiology

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Why do I care about Diabetic feet / DFI?

15-25% of people with diabetes will experience foot ulceration-> 15% of these wounds will result in an amputation

Rates of amputation;10 to 20 times those of non-diabetic populations,

1.5 to 3.5 events per 1000 persons per year

These rates can be reduced with good care

(WHO global report on Diabetes 2016, Van Netten, Diabetes/metab research reviews, 2016)

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But why is that relevant?

•Footscray hospital; • Approx 300 beds, average 10 occupied by DFI patients• Average LOS 8 Days

• Diagnosed diabetes present in;

• 8% of our catchment population, • and 30-40% of our inpatients

• Forms a large part of Infectious Diseases work;

• DFI = 20% inpatient ID consults

Bach, MJA, 2014, Commons, J Foot Ankle research, 2018

And more….

Diabetic foot disease causes 33% of Diabetes related clinical costs yet attracts on 0.2% of diabetes related research funding.

And

In Australia, a limb is lost every 2 hours related to diabetes

Lazzarini, MJA, 2018

Can you spot the difference?

Too sexy?? Not sexy enough??

What’s happening in the region??

DEFIANZ (Diabetic Foot Infections Australia New

Zealand)1

1Australasian Society of Infectious Diseases Clinical Research Group

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DIABETIC FOOT INFECTIONS: A SURVEY OF AUSTRALASIAN INFECTIOUS DISEASES CLINICAL PRACTICE

Aims;To identify

1. Quantify ID physician DFI involvement

2. Quantify ID physician inclusion in MDTs

3. To explore current clinical practice (with scenarios)

Methods;Survey monkey

Commons, J Foot Ankle research, 2018

20-30% workload

80% part of an MDT

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Scenario 1 (abbreviated)63 year old lady (hypertension, poorly controlled type 2 diabetes mellitus) has an untreated deep heel ulcer (severity = IDSA moderate / PEDIS 3) present for five weeks. MRI did not demonstrate osteomyelitis. Peripheral pulses present. White blood cell count is normal, ESR is 55. Surgical debridement is undertaken but residual infection remains with non-debrided deep soft tissue samples growing fully sensitive E. coli, fully sensitive P. aeruginosa and methicillin sensitive S. aureus (MSSA).

Outcomes;• 85% chose to give some intravenous therapy

• 91% chose to give some oral therapy afterwards

• 78% treated the pseudomonas

• Total median duration of therapy was 24 days • intravenous median duration 10 days • oral median duration 14 days

Commons, J Foot Ankle research, 2018

Footer Text 11Commons, J Foot Ankle research, 2018

How Does ID fit in To DM Foot disease management?

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Ulceration & wounds.

Secondary infections.

Neuropathy

Ischaemia DeformityApologies to - Monty Python’s Flying Circus

Issue;

DFI is a heterogenous Disease

But; the basic aetiology remains the same

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3 very different problems:

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Where might ID be involved in a Diabetic

patient’s journey?

Pre-diabetes Uncomplicated Diabetes Foot complications Amputations DeathDevelopment of;

• Vascular disease

• Neuropathy

• Deformity

90% patients T2DM

• Metabolic syndrome

• CVS risk factors

OPD or Inpatient

management

• Risk of recurrence

Usually CVS

Mehta, Hepatology, 2003

Risk factor and effect size;

BMI/Obesity – BMI > 35 vs < 22 >100 X

Family History / genetics 2-3 X per parent

Others;

Ethnicity, Birth weight, childhood obesity, physical activity, Smoking,

Sleep <6 or >9 hours/day, Diet (Western with sugary drinks),

Coffee consumption, PCOS, GDM, CVS disease, hyperuricemia

Hepatitis C – up to 11X increased risk

Preventability ????Preventability???????

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Where might ID be involved in a Diabetic patient’s journey?

Pre-diabetes Uncomplicated Diabetes Foot complications Amputations Death

Mehta, Hepatology, 2003

At all stages of care;

Aim to provide holistic care across spectrum diabetic disease

Manage other diseases (Infections and Non-infections)

Care consistent with patient wishes, values, directives etc.

Educate, advocate for and inform patients

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Pre-diabetes Uncomplicated Diabetes Foot complications Amputations DeathDevelopment of;• Vascular disease• Neuropathy• Deformity

90% patients T2DM• Metabolic syndrome• CVS risk factors

ID not really involved here…at least with the feet

However, ID may well see patients for other infections:

Diabetes and infections;

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Infections are more common in diabetes•UTI & asymptomatic bacteriuria

• ASB – 3X RR

•Pneumonia (LRTI)• More complicated CAP;

•Skin and soft tissue• Especially foot infections• Necrotising fasciitis• Fournier’s gangrene

•Post-op infection• Related to D1&D2 glycemia

•Sepsis

•Fungal skin / genital

• Complicated UTI • Pyelonephritis (RR 4-5)• Emphysematous pyelonephritis* • Emphysematous cystitis*• Papillary necrosis• Abscess (intra/perinephric)

• Lung / pneumonia• TB (up to 10X risk)• Melioidosis• Staph, GNB infection• RR death with CAP 1.7 – 7.6

• Rhinocerebral mucormycosis*

• Malignant otitis externa*

• Emphysematous cholecystitis

(Grayson; in Jung et al, Infectious Diseases, a clinical approach,2005, Peleg, Diabetes metab research reviews, 2007)

* Almost exclusive to diabetes, surgery usually necessary

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Infections are more common in diabetes

-> Why?

Gallacher, Diabet med 1995, Rajagopalan, CID 2005,Peleg, Diabetes metab research reviews, 2007,Muller, CID, 2005.

• Multiple Proposed mechanisms;• Reduced activity of lymphocytes; both B and T hypo-reactivity• Glycosylation of antibodies and other innate immune proteins• Increased background pro-inflammatory molecules; TNF-a, IL-6, IL-8• Other cytokines reduces• Thicker capillary basement membranes• Neuropathy

• Probably most important (at least acutely with DFI);

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Dysfunctional Polymorphs;

Peleg. Diabetes Metab Res Rev2007

Polymorphs (white blood

cells)

Adhesion to endothelium

Transmigration through vessel wall

(chemotaxis)

Phagocytosis and microbial killing

Increased in diabetes

Reduced chemotaxis, especially BSL >12

Reduced, especially when BSL >12.

Superoxide production reduced α glycemia

Both somewhat restored in with

euglycemia

GCSF restores PMN superoxide production

Diabetic foot disease and infection

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Injury, ulceration

PAD

(30-40% T2DM have this)

Neuropathy (50% T2DM have this)

+/- deformity

Duration / control of DM

Access to good foot care / footwear &

services

Trauma, abnormal loading, callus

Bakker. Diabetes Metab Res Rev 2012

InfectionAmputation &poor healing

Pathogenesis; DFIPsychosocial, Coping &

Adherence

Long term illness

This is really hard for people to cope with

(indefinitely)

‘diabetes distress’

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Pre-diabetes Uncomplicated Diabetes Foot complications Amputations DeathDevelopment of;Vascular diseaseNeuropathyDeformity

Inpt -> OPD management

Risk of recurrence

Mild/moderate severity;

Guideline and locally adapted resources for outpatient management+/- involvement in high risk foot clinics

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Established neuroischemic footInpt -> OPD

managementRisk of recurrence

Moderate/Severe;Members of inpatient foot services. Use this to optimise processes which enable best infection management;

Ø ID opinion requires information, assessment and plans from at least;Ø podiatry, endo, vascular

Ø Ensure sampling is optimised (clinic/ward based, surgical, radiological)Ø Liaise with lab and interpret microbiologyØ Co-ordinate antimicrobial therapy including HITH/OPATØ Ensure global patient goals are elicited and supported

Is Osteomyelitis present?

And

What is the best antibiotic treatment?

Common questionsID gets asked:

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Is Osteomyelitis present?

Markanday, Open Forum Infectious Diseases 2014

Radiology tests Pos LR Neg LRBone scan 1.4 0.4Labelled WBC scan 4.7 0.12MRI 3.8 0.14SpECT/CT 3.0 0.18FDG-PET 5.6 0.4

**

*

*

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Example – OM?Prior TMA

Ulcer present ‘a while’

Size > 2cm sq

Treated with oral antibiotics

Probe to bone positive

IWGDF 4 (systemic upset)

ESR 106

Xray difficult to interpet

In this case Om very likely present. Microbiology could be anything.Best test to guide infection management is deep bone / tissue biopsy, not imagingAntibiotics are only part of the management!!!

Prior TMA

Ulcer present ‘a while’

Size > 2cm sq

Treated with oral antibiotics

Probe to bone positive

IWGDF 4 (systemic upset)

ESR 106

Xray difficult to interpet

Clinical Gestault +

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IWGDF 2 = Superficial local infection < 2cm

IGWDF 3 = More invasive local infection (ie >2cm from wound) or deeper structure involvement

IWGDF 4 = Local infection as well as systemic sepsis / upset

Wound and infection classification systems

Microbiology & antibiotics 101

The only antibiotic to which I haven’t seen resistance develop is….

Stainless steel

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Sampling and interpretation

Superficial swabs correlate poorly with deep tissue samples

49% sensitive for deeper tissue organism

62% specific ‘’ ‘’ ‘’ ‘’

Chakraborti C. J Hosp Med. 2010Wolcott. J wound care. 2010Lipsky. Clin Infect Dis. 2012

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Diabetic foot infections - organisms

Staph and strep (GPC)

Mixed – Staph/strep, enterics, pseudomonas, anaerobes.

+/- resistant organisms (MRSA etc)

As above, with dead tissue

Above + pseudomonas

Staph and strep, some enterics (GPC/GNB)

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Antibiotics; Simples, right Sergei?Issues;

1. Swab of what??

2. What’s happening with a. Offloadingb. Vascular supplyc. BSL / DM Mxd. Sociallye. Finances to afford thisf. Etc

3. If an antibiotic is used, what are the tissue drug levels / PK predictors of success?

Time for the Keflex reflex?!?

Over the 8 years on the DFS Team, the biggest lesson I haveLearnt?

Importance of vascular supply

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Example: partial foot amputation

Day 5 post 1st digit TMA No foot pulses present ->

Angioplasty femoral stenosisDistal disease unable to be corrected

Clean bone chips – no growth->initial healthy wound (day 2)On tazocin throughout

BKA day 6

Day 5 post 1st digit TMA

Both foot pulses intact, TPs 80/90

Clean bone chips from prox MT-> MSSA. 4 weeks fluclox

VAC wound therapy

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Blood supply is key!

Bakker. Diabetes Metab Res Rev 2012

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Risk of recurrence Usually CVS

After an episode of infection / ulceration;

People at much higher risk of recurrence;

BUT: To have recurrence, one must;

A) Be alive, andB) Still have a limb.

Mortality post minor/major amputations:

Similar to malignancy!

3 year mortality after any amputation 35-50%

Hoffman, Diabetes and Vascular disease research, 2015

Footer Text 38Hoffman, Diabetes and Vascular disease research, 2015

10 year survival curves post Amputation for Diabetic foot Disease:

- Minor amputation(s) only- Major amputation- Minor amputation(s)

then Major amputation

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Where might ID be involved in a Diabetic patient’s journey; the upshot….


Optimist view;• (find and treat Hep C!)• Take the time to ensure diabetes is managed

properly when seeing patients for related/unrelated non-DFU issues

• Lobby public health to support good diabetes care• Manage CVS risk profiles

Nihilist view:

Once mod/severe DFI, especially with amputation, its basically palliative care!

Footer Text 40Pre-diabetes Uncomplicated Diabetes Foot complications Amputations Death

SUMMARY;When might ID be

needed, what do we need, & how else

might we contribute

Systems;Research, EducationAdvocate for resourcingInvolvement in QA

Structures / processes:Locally adapted guidelines Local protocolsSpecimen collection

Direct involvement:Participation in Inpatient roundsAvailable for outpatient / high risk clinicsFacilitate HITH/OPATHolistic & CVS disease care

What we need:Knowledge of plans from Pod, Endo, VascEnsure appropriate samples takenEnsure appropriate interventions occurGood information and record keeping

Thanks!

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