Benjamin Lipsky , USA ( - PowerPoint Presentation

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Benjamin Lipsky, USA (chair)Éric Senneville, France (secretary)Zulfiqarali Abbas, TanzaniaJavier Aragón-Sánchez, SpainMathew Diggle, UK/CanadaJohn Embil, CanadaShigeo Kono, JapanLarry Lavery, USAMatthew Malone, AustraliaSuzanne van Asten, the NetherlandsVilma Urbančič-Rovan, SloveniaEdgar Peters, the Netherlands (secretary)

www.iwgdfguidelines.org

IWGDF Infection Working Group 2019SennevilleVan Asten

Peters

Lipsky

Aragón-

Sánchez

Lavery

Abbas

Embil

Diggle

Malone

Kono

Urbančič-

Rovan

Slides

courtesy

IWGDF;

available

at:

www.iwgdfguidelines.org

History of IWGDF Foot Infection GuidelinesDiagnosing and treating diabetic foot infections. Lipsky BA, Berendt AR, Embil J, De Lalla F. Diabetes Metab Res Rev. 2004;20 Suppl 1:S56-64Specific guidelines for treatment of diabetic foot osteomyelitis. Berendt AR, Peters EJ, Bakker K, Embil JM, Eneroth M, Hinchliffe RJ, Jeffcoate WJ, Lipsky BA, Senneville E, Teh J, Valk GD. Diabetes Metab Res Rev. 2008;24 Suppl 1:S190-1Expert opinion on the management of infections in the diabetic foot. Lipsky BA, Peters EJ, Senneville E, Berendt AR, Embil JM, Lavery LA, Urbančič-Rovan V, Jeffcoate WJ; IWGDF. Diabetes Metab Res Rev. 2012;28 Suppl 1:163-78

IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes. Lipsky BA, Aragón-Sánchez J, Diggle M, Embil J, Kono S, Lavery L, Senneville É, Urbančič-Rovan V, Van Asten S, Peters EJ; International Working Group on the Diabetic Foot.

Diabetes Metab Res Rev. 2016;32 Suppl 1:45-74

Slides

courtesy

IWGDF;

available

at:

www.iwgdfguidelines.org

What’s New in the 2019 Infection Guidelines?Committee members: 2 new (diabetologist; podiatrist), 10 returning; now representatives from 8 countries, 5 continentsSystematic reviews: first review of diagnosis of infection; update of previous review of interventions for infectionInfection severity classification: first change; osteomyelitis removed from “moderate” and has separate designation

“O”Format: Changed from largely category

style to using “PICOs”Updates: 4 tables (

infection

classification

scheme

;

characteristics

of

serious infection ; features of osteomyelitis on plain X-

rays; empiric antibiotic regimens); 1 algorithm (overview of management)

Slides

courtesy IWGDF; available at:

www.iwgdfguidelines.org

Recommendations: total of 27Topic - Treatment: 17 11 on antimicrobials 2 on surgery 3 on osteomyelitis 2 on adjunctive treatments - Diagnosis: 9 (3 specifically regarding osteomyelitis) - Management: 1 (hospitalization)

Strength: 16 strong; 11 weakQuality: 17 low; 9 moderate; 1 high

Slides

courtesy

IWGDF;

available

at:

www.iwgdfguidelines.org

Key Recommendations: DiagnosisAssess all diabetic foot ulcers (wounds) using the IDSA/IWGDF classificationHospitalize patient if serious infection; outpatient treament adequate for many moderate & most mild infectionsHelpful clinical diagnostic tests: probe-to-bone test; serum inflammatory markers (especially CRP & ESR, ± PCT)

Culture tissue (not swab) specimens of infected (

not uninfected) wounds using standard (rather than molecular) methods

Sample

bone

if

needed

for

definitive diagnosis of osteomyelitis or to determine causative

pathogen(s) & susceptibiltiy resultsPlain X-rays often

sufficient for imaging; if advanced imaging needed MRI usually best, or consider WBC scintigraphy or PET/CT

Slides

courtesy IWGDF; available

at: www.iwgdfguidelines.org

Key Recommendations: Treatment 1Treat infections with antibiotics shown to be effective in clinical trialsSelect agent(s) based on: likely pathogen(s) & susceptibilites; clinical severity of infection; published evidence of efficacy; risk of adverse events or drug interactions; bone involvement; availability; costTreat parenterally

for severe infections initially; switch to oral agents

(if appropriate one available) when patient stable.

Treat

with

oral

agents

for mild and most moderate infections

Using available topical antimicrobials is not supported by published

dataTherapy duration: 1-2 weeks usually adequate for soft tissue; ≤6 weeks for bone

infection (5-7 days if all osteomyelitis resected)

Slides courtesy

IWGDF; available at:

www.iwgdfguidelines.org

Key Recommendations: Treatment 2In temperate climates for patients with no recent antibiotic therapy, target only aerobic GPCs (S. aureus, β-streptococcus)In tropical/subtropical climates, or if recent antibiotic therapy, add coverage for aerobic GNRs (possibly including Pseudomonas), and possibly for obligate anaerobics (especially

if limb ischemia)Do not treat

clinically uninfected wounds with antimicrobialsA surgeon should

urgently

evaluate

all

severe,

and

many moderate infections, especially if ? gangrene

, abscess, compartment syndromeMany cases of forefoot osteomyelitis can be

treated medically, but surgical resection (preferably conservative) may be best

for others

Slides courtesy IWGDF;

available at: www.iwgdfguidelines.org

Key Recommendations: Treatment 3During surgery to resect infected bone, it is likely useful to obtain a “marginal” sample to ensure residual bone uninfected; if not, treatAdjunctive therapies have not (yet) been shown to be effective for treating

the infectious aspects of diabetic foot wounds,

including: hyperbaric oxygen; G-CSF; topical antiseptics; negative pressure

wound

therapy

;

bacteriophages

For

complicated

cases

seek input from infectious diseases/

clinical microbiology clinicians and multidisciplinary teamsMost appropriately treated

infections can be sucessfully treated, but relapses and reinfections are common

Slides

courtesy IWGDF; available

at: www.iwgdfguidelines.org

Key ControversiesWhat is the best approach to imaging bone & soft tissue infectionsIs obtaining marginal bone after resection helpful for selecting best treatmentIs “wound bioburden” a definable or useful conceptWhen might molecular (genotypic) microbiology techniques be usefulHow to monitor treatment & limit antibiotic duration (soft tissue & bone infxn)How

to adapt approaches to DFI management in low-income countriesWhen

might topical/local antimicrobial therapy be useful

How

to

determine

the

presence

and treatment of biofilm infection

Slides courtesy

IWGDF; available at:

www.iwgdfguidelines.org

Thank youSlides courtesy IWGDF; available at: www.iwgdfguidelines.org

www.iwgdfguidelines.orgBenjamin A. Lipsky, USA (chair) Shigeo Kono, JapanÉric Senneville, France

(secretary) Lawrence A. Lavery,

USAZulfiqarali G. Abbas,

Tanzania

Matthew Malone,

Australia

Javier Aragón-Sánchez,

Spain

Suzanne A. van

Asten

,

Netherlands

Mathew Diggle,

UK

/

Canada Vilma Urbančič-Rovan

, SloveniaJohn M. Embil,

Canada Edgar J.G. Peters,

Netherlands (secretary)IWGDF Guideline on the Diagnosis and Treatment of Foot Infection in People with Diabetes

Slides

courtesy

IWGDF;

available

at:

www.iwgdfguidelines.org