부산대학교 도서관

Diabetic foot ulcers and infections are considered significant health problems worldwide. Turkish Society of Clinical Microbiology and Infectious Diseases Study Group for Diabetic Foot Infections (DAICG) prepared a consensus report in 2015 regarding the diagnosis, treatment, and prevention of diabetic foot (DF) ulcers and diabetic foot infections (DFI) in national circumstances. Subsequently, in 2023, representatives assigned through collaboration with relevant national specialty associations reviewed the literature and international guidelines on the pathogenesis, microbiology, assessment and grading, treatment, prevention and control, offloading, post- amputation rehabilitation; identified questions that needed to be addressed, and updated the Consensus Report with answers to these questions. The information in this report is intended to assist healthcare professionals caring for diabetic patients. Some of the answers in the report are listed as follows: 1) Many factors cause DF ulcers, with the main causes being sensorimotor polyneuropathy and the development of peripheral arterial disease (PAD). 2) In a patient with a DF ulcer, the infection should be considered if other causes are ruled out and there are at least two local inflammatory signs, such as purulent discharge or erythema, edema, warmth, pain, tenderness, and induration at the ulcer site. In these cases, the severity of the infection is described as mild, moderate, or severe depending on the depth of the ulcer, its width, and the presence of systemic signs of infection. 3) The causative agents in DFI vary depending on whether the infection is acute or chronic and the severity of the infection. Superficial DFIs that develop in patients with cellulitis and with no previous antibiotic use are mostly caused by aerobic Gram-positive cocci (staphylococci, streptococci). 4) Deep and chronic infections and/ or infections of patients that have received previous antibiotic treatment are generally polymicrobial (Gram- positive cocci + Gram-negative rods). 5) The classification of the Infectious Diseases Society of America (IDSA)/International Working Group on the Diabetic Foot (IWGDF) can be used to assess the severity of DFI. 6) According to this classification, severe and certain special cases of DFI should be hospitalized for treatment. 7) Inflammatory markers such as C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and procalcitonin can be useful in differentiating infection from colonization. 8) Before starting antibiotics in suspected DFI, a suitable tissue sample should be taken from the ulcer base by curettage or biopsy for culture. 9) A three-view plain X- ray of the foot should be taken initially as an imaging method for diagnosis. This can help detect infection and bone deformities, fractures, radiopaque foreign bodies, and gas formation in soft tissues. 10) Magnetic resonance imaging (MRI) is a sensitive and specific method for patients who do not respond to treatment or where osteomyelitis or deep soft tissue abscess is suspected. 11) Culture and a positive result in histopathological examination of the bone are accepted as the gold standard in diagnosing osteomyelitis. 12) To promote ulcer healing and salvage of the limb, it is necessary to perform urgent and aggressive debridement to remove dead and infected tissues, provide proper ulcer care, relieve the foot from pressure, administer appropriate antibiotic therapy, achieve metabolic control, diagnose and treat PAD, and restore foot function. 13) In cases of DFI and PAD coexistence, consultation with the relevant surgical specialty is essential for the planning and timing of surgical procedures, and it is also advisable to seek the opinion of a vascular surgeon for revascularization. Surgical management of DF ulcers can be analyzed in five sections: (a) Urgent ulcer intervention; abscess drainage and/or debridement, (b) surgical interventions for vascular pathologies, (c) ulcer closure interventions; reconstruction methods; graft and flap surgery, (d) reconstruction of bone and foot pathologies for ulcer prevention and treatment (Charcot foot deformity, Achilles lengthening, tenotomy, and osteotomies, etc.), (e) minor and major amputations when necessary. 14) Amputation may be a more appropriate choice when infected tissue cannot be completely cleaned with debridement, when the patient is bedridden or has a non-functional extremity, when it is believed that adequate revascularization cannot be achieved by orthopedic and plastic surgical interventions, in cases where reconstruction is nearly impossible, and in dialysis patients. 15) The goal of post-DFI reconstruction is to allow the ankle to reach a neutral position and to make the plantar surface of the foot have a balanced contact with the ground. 16) Selected ulcer care products can be used based on the characteristics of the ulcer to support and accelerate ulcer healing, reduce the risk of complications, ensure patient comfort during treatment, and improve quality of life. 17) DF ulcers often develop due to improper shoe selection during the structural and biomechanical changes, resulting in fluid accumulation and callus formation around bone surfaces. 18) Orthoses, which distribute pressure over the widest possible area, are the most effective means of reducing plantar pressure in the foot. 19) Hyperbaric oxygen therapy is beneficial in addition to revascularization and antibiotic therapy, which are the primary treatments for pathologies causing tissue hypoxia, such as ischemia, infection, and edema. 20) Negative pressure ulcer therapy is an additional adjunct method to conventional techniques, and it can contribute to the healing process with the correct indications. 21) In cases where the infection is under control, active osteomyelitis is absent, topical epidermal growth factor (EGF) can be used for Meggitt-Wagner ulcer classification grade 1-3, and intralesional EGF applications can be used for grade 3-4 in addition to standard treatments. 22) Preventive medical practices in people with diabetes, collaborative efforts of the patients, their families, and the medical team, and regular patient education are necessary to prevent DF ulcer development. In the event of DF ulcer development, interdisciplinary collaboration in moderate/severe infections is essential for early treatment and infection prevention. Keywords: diabetes mellitus, diabetic foot, diabetic foot infections, diagnosis, treatment, prevention, off- loading. Diyabetik hastalarda gelisen ayak yaralari ve infeksiyonlari tum dunyada onemli saglik problemleri arasinda yer almaktadir. Turk Klinik Mikrobiyoloji ve Infeksiyon Hastaliklari Dernegi Diyabetik Ayak Infeksiyonlari Calisma Grubu (DAICG), ulkemiz kosullarinda diyabetik ayak (DA) yarasinin ve DA infeksiyonu (DAI)'nun tanisi, tedavisi ve onlenmesine yonelik bir Ulusal Uzlasi Raporunu 2015 yilinda hazirlamistir. Soz konusu raporun guncellenmesi icin 2023 yilinda ilgili ulusal uzmanlik derneklerine is birligi cagrisinda bulunulmustur. Gorevlendirilen temsilcilerin katilimiyla ilgili literatur ve uluslararasi kilavuzlar gozden gecirilerek; patogenez, mikrobiyoloji, degerlendirme ve derecelendirme, tedavi, korunma ve kontrol, basidan kurtarma, amputasyon sonrasi rehabilitasyon konularinda yanit verilmesi gereken sorular saptanmis ve bu sorulara yonelik uzlasilan yanitlarla rapor guncellenmistir. Raporun amaci diyabetik hastalarla ilgilenen tum saglik calisanlarina yardimci olmaktir ve sorulara verilen yanitlar su sekilde ozetlenebilir: 1) DA yarasinin gelisiminin pek cok nedeni olmakla birlikte en onemli nedenler sensorimotor polinoropati ve periferik arter hastaligi (PAH) gelisimidir. 2) DA yarasi olan bir hastada diger nedenler dislandiktan sonra yara bolgesinde purulan akinti veya eritem, odem, isi artisi, agri, hassasiyet, endurasyon gibi lokal inflamasyon bulgularindan en az ikisi varsa yara infeksiyonu dusunulmelidir. Bu olgularda; yaranin derinligi, genisligi ve infeksiyonun sistemik bulgularinin olup olmamasina bagli olarak hafif, orta veya siddetli infeksiyon tanimlamasi yapilir. 3) DAIde etkenler, infeksiyonun akut ya da kronik olmasina ve siddetine bagli olarak degisiklik gosterir. Seluliti olan ve daha once antibiyotik kullanmamis hastalarda gelisen yuzeysel DAI'lerden daha cok aerop Gram-pozitif koklar (stafilokok, streptokoklar) sorumludur. 4) Derin ve kronik infeksiyonlar ve/veya daha once antibiyotik tedavisi alan hastalarda gelisen infeksiyonlar genellikle polimikrobiktir (Gram-pozitif kok + Gram-negatif basil). 5) Diyabetik ayak infeksiyonlarinin ciddiyetinin degerlendirilmesinde Uluslarasi Diyabetik Ayak Calisma Grubu / Amerikan Infeksiyon Hastaliklari Dernegi (IWGDF/ IDSA) siniflamasi kullanilabilir. 6) Bu siniflamaya gore agir ve bazi ozellikli DAI olgulari hastaneye yatirilarak tedavi edilmelidir. 7) Inflamasyon gostergeleri olan C-reaktif protein (CRP), eritrosit sedimantasyon hizi (ESH) ve prokalsitonin gibi biyobelirtecler, infeksiyonla kolonizasyonun ayirt edilmesinde yararli olabilir. 8) DAI suphesinde antibiyotik baslanmadan once kultur icin uygun doku ornegi yara tabanindan kuretaj veya biyopsi yontemi ile alinmalidir. 9) Tanida goruntuleme yontemi olarak oncelikle uc yonlu direkt ayak grafisi cekilmelidir; boylelikle infeksiyonun yani sira kemik deformiteleri-kirik, radyoopak yabanci cisimler ve yumusak dokudaki gaz olusumlari da saptanabilir. 10) Manyetik rezonans goruntulemesi (MRG), tedaviye yanit alinamayan, osteomyelit ya da derin yumusak doku apsesi dusunulen hastalar icin duyarli ve ozgul bir yontemdir. 11) Osteomiyelit tanisinda, kemik kulturunde ureme olmasi ve histopatolojik incelemede pozitif sonuc altin standart olarak kabul edilmektedir. 12)Yara iyilesmesini saglayabilmek ve ayagi kurtarmak icin gerekenler; acil ve agresif debridmanlarla olu ve infekte dokularin uzaklastirilmasi, uygun yara bakimi, ayagin yukten ve basidan kurtarilmasi, uygun antibiyotik tedavisi, metabolik kontrol, PAH tanisi-uygun sekilde tedavisi ve ayagin islevinin kazandirilmasidir. 13) DAI ve PAH birlikteliginde cerrahi uygulamanin planlamasi ve zamanlamasi icin ilgili cerrahi brans ile birlikte revaskularizasyon kapsaminda vaskuler cerrahiden de gorus alinmalidir. DA yaralarinda cerrahi yaklasimi bes ana baslikta incelemek gerekir: (a) Acil yara mudahalesi; apse drenaji ve/ veya debridman. (b) Vaskuler patolojiler icin yapilan cerrahi girisimler. (c) Yara kapatici mudahaleler, rekonstruksiyon yontemleri, greft ve flep cerrahisi. (d) ulseri onleme ve tedavi amacli kemik ve ayak patolojilerinin rekonstruksiyonu (Charcot ayak deformitesi, asil uzatilmasi, tenotomi ve gerektiginde osteotomiler, vb.). (e) Gereginde uygulanan minor ve major amputasyonlar. 14) Debridmanla infekte dokunun tamamen temizlenmesi mumkun olmadiginda ve hastanin kalan infeksiyon yukuyle basa cikamayacagi durumlarda, yatalak veya fonksiyonel olarak islevsiz bir ekstremitesi olan hastalarda, uygulanacak ortopedi ve plastik cerrahi girisimlerinin uygulanmasi icin gerekli revaskularizasyonun saglanamayacagi dusunulen hastalarda, rekonstruksiyonu neredeyse olanaksiz olan olgularda ve diyaliz hastalarinda amputasyon daha dogru bir secim olabilir. 15) Diyabetik ayak infeksiyonu sonrasi rekonstruksiyonun hedefi, ayak bileginin notral pozisyona kadar gelebilmesini ve ayak tabaninin yere dengeli olarak basmasini saglamaktir. 16) Yara iyilesmesini desteklemek ve hizlandirmak, komplikasyon riskini azaltmak, tedavi sirasinda hastanin gunluk yasantisina konforlu olarak devam etmesini saglamak ve yasam kalitesini artirmak amaci ile yaranin ozelliklerine gore secilen yara bakim urunleri kullanilabilir. 17) Diyabetik ayak yarasi; yapisal ve biyomekanik degisimler surecinde siklikla dogru ayakkabi tercih edilmemesi nedeniyle, kemik yuzeyler cevresinde su toplamasi ve nasirlasma sonucunda ortaya cikmaktadir. 18) Ayak plantarindaki basinci azaltmanin en etkili yolu olan ortezler, basinci mumkun olan en genis alana dagitarak gorev yapar. 19) Hiperbarik oksijen tedavisi; iskemi, infeksiyon, odem gibi doku hipoksisine yol acan patolojilerde, bu patolojilerin ana tedavisi olan revaskularizasyon ve antibiyoterapiye ilave olarak kullanildiginda fayda saglar. 20) Negatif basincli yara kapama sistemlerinin kullanimi, klasik yontemlere ilave ve yardimci bir yontemdir ve iyilesme surecinde katki saglanmasi icin dogru indikasyonla kullanilabilir. 21) Infeksiyonun kontrol altina alindigi, aktif osteomyeliti olmayan hastalarda Meggitt-Wagner siniflamasi derece 1-3 arasinda topikal epidermal buyume faktoru (EGF), derece 3-4te de intralezyoner EGF uygulamalari standart tedavilere ek olarak yer alabilir. 22) Diyabetik hastalarda, koruyucu hekimlik uygulamalari ile birlikte ayak yarasi gelisiminin engellenmesi icin hasta, hasta yakini ve tibbi ekibin is birligi icinde olmasi ve duzenli egitimi gereklidir. Ayak yarasinin gelistigi durumlarda erken tedavi ve infeksiyon gelisiminin onlenmesi icin; infeksiyonun gelistigi durumlarda ise orta/siddetli infeksiyonun tedavi basarisini artirmak icin interdisipliner bir yontemle calismak son derece onemlidir. Anahtar Sozcukler: diabetes mellitus, diyabetik ayak, diyabetik ayak infeksiyonu, tani, tedavi, onleme, basidan kurtarma
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