2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections
2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections
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DOI：
10.1093/cid/cis460
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发表时间：
2012-06-15
影响因子：
11.8
通讯作者：
Senneville, Eric
中科院分区：
文献类型：
--
作者：
Lipsky, Benjamin A.;Berendt, Anthony R.;Senneville, Eric
足部感染是糖尿病患者常见且严重的问题。糖尿病足感染（dfi）通常开始于伤口，最常见的是神经性溃疡。虽然所有伤口都有微生物定植，但感染的存在由>= 2定义为炎症或脓性的经典表现。然后将感染分为轻度（表面感染，大小和深度有限）、中度（更深或更广泛）或严重（伴有全身体征或代谢紊乱）。这种分类系统以及血管评估有助于确定哪些患者应该住院，哪些患者可能需要特殊的成像程序或手术干预，哪些患者需要截肢。大多数dfi是多微生物，有需氧革兰氏阳性球菌（GPC），尤其是葡萄球菌，最常见的致病生物。需氧革兰氏阴性杆菌通常是慢性感染或抗生素治疗后感染的病原体，专性厌氧菌可能是缺血性或坏死伤口的病原体。没有软组织或骨骼感染的伤口不需要抗生素治疗。对于感染的伤口，获得清创后标本（最好是组织）进行有氧和无氧培养。经验性抗生素治疗可以狭窄地针对许多急性感染患者的GPC，但那些有抗生素耐药菌感染风险或慢性、既往治疗或严重感染的患者通常需要更广泛的治疗方案。成像在大多数dfi中是有帮助的；x光平片可能就足够了，但磁共振成像更加敏感和特异。骨髓炎发生在许多足部伤口的糖尿病患者中，并且很难诊断（最好通过骨培养和组织学来确定）和治疗（通常需要手术清创或切除，和/或长期抗生素治疗）。大多数dfi需要一些手术干预，从小的（清创）到大的（切除、截肢）。伤口也必须适当包扎和减轻压力，患者需要定期随访。缺血性足部可能需要血运重建，一些无反应的患者可能从选择的辅助措施中受益。采用多学科的足部团队可以改善结果。临床医生和医疗保健组织应该尝试监测，从而改善他们在照顾dfi方面的结果和过程。足部感染是糖尿病患者常见且严重的问题。糖尿病足感染（dfi）通常开始于伤口，最常见的是神经性溃疡。虽然所有伤口都有微生物定植，但感染的存在由>= 2定义为炎症或脓性的经典表现。然后将感染分为轻度（表面感染，大小和深度有限）、中度（更深或更广泛）或严重（伴有全身体征或代谢紊乱）。这种分类系统以及血管评估有助于确定哪些患者应该住院，哪些患者可能需要特殊的成像程序或手术干预，哪些患者需要截肢。大多数dfi是多微生物，有需氧革兰氏阳性球菌（GPC），尤其是葡萄球菌，最常见的致病生物。需氧革兰氏阴性杆菌通常是慢性感染或抗生素治疗后感染的病原体，专性厌氧菌可能是缺血性或坏死伤口的病原体。没有软组织或骨骼感染的伤口不需要抗生素治疗。对于感染的伤口，获得清创后标本（最好是组织）进行有氧和无氧培养。经验性抗生素治疗可以狭窄地针对许多急性感染患者的GPC，但那些有抗生素耐药菌感染风险或慢性、既往治疗或严重感染的患者通常需要更广泛的治疗方案。成像在大多数dfi中是有帮助的；x光平片可能就足够了，但磁共振成像更加敏感和特异。骨髓炎发生在许多足部伤口的糖尿病患者中，并且很难诊断（最好通过骨培养和组织学来确定）和治疗（通常需要手术清创或切除，和/或长期抗生素治疗）。大多数dfi需要一些手术干预，从小的（清创）到大的（切除、截肢）。伤口也必须适当包扎和减轻压力，患者需要定期随访。缺血性足部可能需要血运重建，一些无反应的患者可能从选择的辅助措施中受益。采用多学科的足部团队可以改善结果。临床医生和医疗保健组织应该尝试监测，从而改善他们在照顾dfi方面的结果和过程。
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.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.