Lipsky Benjamin A, Berendt Anthony R, Cornia Paul B, Pile James C, Peters Edgar J G, Armstrong David G, Deery H Gunner, Embil John M, Joseph Warren S, Karchmer Adolf W, Pinzur Michael S, Senneville Eric
Department of Medicine, University of Washington, Veterans Affairs Puget Sound Health Care System, Seattle.
J Am Podiatr Med Assoc. 2013 Jan-Feb;103(1):2-7. doi: 10.7547/1030002.
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.
足部感染在糖尿病患者中是一个常见且严重的问题。糖尿病足感染（DFIs）通常始于伤口，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项炎症或化脓的典型表现来定义。然后将感染分为轻度（表浅且大小和深度有限）、中度（更深或更广泛）或重度（伴有全身症状或代谢紊乱）。这种分类系统，连同血管评估，有助于确定哪些患者应住院治疗，哪些可能需要特殊的影像学检查或手术干预，以及哪些将需要截肢。大多数DFIs是多微生物感染，需氧革兰氏阳性球菌（GPC），尤其是葡萄球菌，是最常见的致病菌。需氧革兰氏阴性杆菌在慢性感染或抗生素治疗后的感染中常为共病原体，而专性厌氧菌可能是缺血或坏死伤口中的共病原体。无软组织或骨感染证据的伤口不需要抗生素治疗。对于感染伤口，获取清创后标本（最好是组织标本）进行需氧和厌氧培养。在许多急性感染患者中，经验性抗生素治疗可狭义地针对GPC，但有感染耐抗生素 organisms风险或患有慢性、先前治疗过的或严重感染的患者通常需要更广泛的抗菌方案。影像学检查对大多数DFIs有帮助；普通X线平片可能就足够了，但磁共振成像更敏感和特异。骨髓炎发生在许多有足部伤口的糖尿病患者中，可能难以诊断（最佳通过骨培养和组织学定义）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DFIs需要一些手术干预，范围从小手术（清创）到大手术（切除、截肢）。伤口还必须妥善包扎并减轻压力，患者需要定期随访。缺血性足部可能需要血管重建，一些无反应的患者可能从选定的辅助措施中获益。采用多学科足部治疗团队可改善治疗效果。临床医生和医疗机构应尝试监测并从而改善他们在治疗DFIs方面的治疗效果和流程。
