WEBVTT 00:00.031 --> 00:04.580 [SPEAKER_01]: I often describe diabetic foot ulcers as many times being the tip of the iceberg. 00:04.620 --> 00:08.387 [SPEAKER_01]: You see this wound on the bottom of the foot and it's like, oh, that doesn't look too bad. 00:08.908 --> 00:18.006 [SPEAKER_01]: One of the things about to remember about diabetic foot infections and diabetic patients is a rule is they've been termed as the great masquerader. 00:18.948 --> 00:22.896 [SPEAKER_05]: Welcome to the Korean Thy Pro's podcast, bringing you high yield evidence based pearls. 00:23.377 --> 00:25.121 [SPEAKER_05]: I'm Dr. Schwarz, everybody, and I'm joined by. 00:25.883 --> 00:26.484 [SPEAKER_02]: Hi, everyone. 00:26.684 --> 00:30.552 [SPEAKER_02]: I'm Koleewa, and I'm an internal medicine resident at BIDMC. 00:31.154 --> 00:35.082 [SPEAKER_02]: Today, we're tackling diabetic foot infections and foot osteomyelitis. 00:35.423 --> 00:38.509 [SPEAKER_02]: The topic that feels routine, but is anything but simple. 00:38.928 --> 01:07.804 [SPEAKER_05]: Yeah, and I think one of the reasons why at least for me, I feel like I haven't clarified a lot of the pain points that come up with this topic is because I think it's just a bunch of different specialties that kind of own it right so it's kind of easy to defer to like whatever podiatry or infectious disease or ortho or wound care is saying and not really solidify why do they recommend is for this one patient versus something else for another patient with maybe a slightly different presentation so let's do some solidification today test yourself by pausing after each of these five pearls. 01:11.969 --> 01:14.434 [SPEAKER_05]: Pearl 1, eDiology of foot ulcers. 01:15.476 --> 01:23.011 [SPEAKER_05]: Why is thinking about the why of foot ulcers so important? 01:23.031 --> 01:25.095 [SPEAKER_05]: Pearl 2, work up and imaging. 01:25.816 --> 01:28.963 [SPEAKER_05]: Which diagnostics are most helpful and which ones can mislead you? 01:29.524 --> 01:31.648 [SPEAKER_05]: Do you always need to get that foot MRI? 01:35.948 --> 01:38.951 [SPEAKER_02]: Pearl 3, surgical department, and source control. 01:39.732 --> 01:41.815 [SPEAKER_05]: What actually does surgical debris mean in tail? 01:42.155 --> 01:43.216 [SPEAKER_05]: Do we always need it? 01:43.717 --> 01:45.819 [SPEAKER_05]: And when do we have to think about bascular flow? 01:50.104 --> 01:52.386 [SPEAKER_05]: Pearl 4, antibiotics. 01:52.407 --> 01:55.370 [SPEAKER_05]: Can we get away with PO antibiotics for osteomyllitis? 01:59.815 --> 02:01.737 [SPEAKER_05]: Pearl 5, wound care. 02:02.324 --> 02:09.297 [SPEAKER_05]: Why is the wound care nurse asking you to order a zero full room and beta-dine for one patient versus Aquacel and Dakeins for another? 02:15.419 --> 02:18.562 [SPEAKER_05]: All right, Colby, we often see these patients with foot infection. 02:18.602 --> 02:21.645 [SPEAKER_05]: And I think it's so easy to jump into management, right? 02:21.805 --> 02:23.006 [SPEAKER_05]: Do I hold antibiotics? 02:23.026 --> 02:25.989 [SPEAKER_05]: Do I start, which ones should I get the surgical team on board? 02:26.469 --> 02:35.037 [SPEAKER_05]: But what I really appreciate is when we spoke to our discussions, they said, hold on, wait a minute, before you jump into management, it is so important to step back and ask, why? 02:35.077 --> 02:37.099 [SPEAKER_02]: Yes, exactly. 02:37.159 --> 02:43.165 [SPEAKER_02]: We talked to Dr. John Greeney, a podiatrist and nationally recognized expert and diabetic foot care. 02:44.140 --> 02:46.464 [SPEAKER_01]: Why did this ulcer develop in the first place? 02:47.185 --> 02:50.951 [SPEAKER_01]: Is there an associated deformity that goes with that ulceration? 02:51.512 --> 02:53.676 [SPEAKER_01]: Like a blanket, like a hammer tub. 02:53.696 --> 02:57.241 [SPEAKER_01]: If it's on the top of the foot, it could be related to shoe gear. 02:57.622 --> 03:03.752 [SPEAKER_01]: So this is some of the investigated work that we do to understand the underlying cause of the ulceration. 03:04.255 --> 03:08.860 [SPEAKER_01]: There was a paper I think was published in 1999 and diabetes care. 03:09.261 --> 03:20.233 [SPEAKER_01]: They found that the combination of neuropathy plus deformities plus minor trauma were the highest risk factors for development of ulcerations. 03:20.473 --> 03:24.878 [SPEAKER_01]: That combination was responsible for 70 to 75% of ulcerations. 03:24.898 --> 03:30.364 [SPEAKER_01]: So when you look at an ulcer, you can pretty much think about, is there a foot to form any? 03:30.344 --> 03:34.269 [SPEAKER_01]: And has there been any micro trauma, including chewy rotation? 03:35.671 --> 03:37.193 [SPEAKER_05]: You know, I get the neuropathy. 03:37.253 --> 03:41.558 [SPEAKER_05]: I get the deformity like bunion or hammer toe being a night is for diabetic foot infection. 03:42.119 --> 03:47.806 [SPEAKER_05]: But I'll admit, I used to think of minor trauma in diabetic foot infections as like blisters a stub toe. 03:48.327 --> 03:56.537 [SPEAKER_05]: But the last point he made surprised me that just repeated shoe irritation without a clear injury can be enough to tip someone over into an ulcer. 03:57.158 --> 04:06.848 [SPEAKER_02]: Yeah, although more reason to ask our patients about their footwear, I mean, it's always nice to get a new pair of shoes, but we really need to be aware of all the issues that they could potentially cause. 04:07.958 --> 04:08.419 [SPEAKER_05]: definitely. 04:08.439 --> 04:14.911 [SPEAKER_05]: And I guess if we dig deeper into the y of the foot ulcer, we classically learn about different types of ulcers, right? 04:14.991 --> 04:21.383 [SPEAKER_05]: The classic diabetic neuropathic, foot ulcer, the arterial or vascular ulcer, the venous ulcer, the pressure ulcer. 04:21.423 --> 04:29.157 [SPEAKER_05]: In reality, of course, this is very multifactorial, but I think it's still helpful to remember the classic presentations. 04:30.098 --> 04:36.510 [SPEAKER_01]: The diabetic ulcer is usually can be a combination of vascular and neuropathic in nature. 04:36.771 --> 04:40.958 [SPEAKER_01]: And the other thing about the diabetic ulcer, it's usually in a weight bearing area. 04:41.580 --> 04:44.445 [SPEAKER_01]: So that's pretty easy to differentiate. 04:45.083 --> 04:52.436 [SPEAKER_01]: The arterial ulcer is usually very eschemic, dry-looking ulcer usually in and around the ankle joint. 04:52.756 --> 05:03.414 [SPEAKER_01]: They tend to be very painful, so it's important to know that because if it's arterial ulcer, then you need to get vascular involved to address the vascular issue. 05:03.975 --> 05:10.146 [SPEAKER_01]: If it's a venous ulcer, again, you're going to see these usually around the ankle area, the shin area, 05:10.126 --> 05:12.450 [SPEAKER_01]: Now, I'll have a healthier look to it. 05:12.751 --> 05:15.456 [SPEAKER_01]: There may be some serious changes associated with it. 05:16.218 --> 05:19.604 [SPEAKER_01]: This surrounding tissue is going to be abnormal. 05:19.965 --> 05:25.215 [SPEAKER_01]: There may be a deema in varicocities and broning hyperpigmentation of the shin. 05:25.668 --> 05:32.343 [SPEAKER_01]: and it's important to differentiate because with Venus ulcers, the important thing to do there is elevation and compression. 05:33.004 --> 05:41.263 [SPEAKER_01]: So making those distinctions is important because the treatment plan and regimen will be slightly different for each one of those. 05:42.188 --> 05:54.688 [SPEAKER_02]: Yeah, so I think what I'm taking away from this is that when we see these foot infections that haven't also, we really need to ask ourselves, one, is it a healed pressure injury and needs more focus on offloading and wound care? 05:54.708 --> 06:01.159 [SPEAKER_02]: Two, is this an arterial ulcer that needs vascular input to improve blood flow? 06:01.139 --> 06:07.146 [SPEAKER_02]: Or three is this ulcer more driven by like Satan or apathy, and we need to think about prevention. 06:08.107 --> 06:15.555 [SPEAKER_02]: Lastly, for those venous ulcers around the shin or ankle, do we really need to be thinking about more compression and elevation? 06:16.256 --> 06:16.777 [SPEAKER_02]: Yeah. 06:16.797 --> 06:21.923 [SPEAKER_05]: And we'll link in the show notes a nice graphic for where each of these ulcers classically are in the differences in management. 06:22.323 --> 06:30.032 [SPEAKER_05]: But as you'll see when we talk about diabetic foot ulcers, knowing these will help in terms of the management and how a little 06:30.721 --> 06:44.905 [SPEAKER_02]: Yeah, so to recap, when we say diabetic foot ulcer, we're usually talking about an ulcer that is neuropathic with a pressure-related wound at the bottom of the foot, and that's plus or minus, fast-gular blood flow issues. 06:45.706 --> 06:53.860 [SPEAKER_05]: Right, and the other things we need to be asking ourselves is to think, are there any foot deformities involved or any recent minor trauma like improper footwear? 06:54.717 --> 07:01.769 [SPEAKER_01]: whenever you see a foot ulcer, to really examine it very closely, look at the ulcer itself. 07:01.789 --> 07:03.592 [SPEAKER_01]: So I have that high index of suspicion. 07:04.593 --> 07:09.882 [SPEAKER_02]: Yeah, so these patients may not have a fever, leukocytosis, erythema, or pain. 07:10.463 --> 07:14.250 [SPEAKER_02]: There's often leads to late presentations and potentially even deep infections. 07:15.171 --> 07:18.717 [SPEAKER_05]: Yes, I guess we have to always assume more meets the eye. 07:19.372 --> 07:22.095 [SPEAKER_02]: Yeah, and I think this sets us up really nicely for Pearl 2. 07:22.415 --> 07:32.744 [SPEAKER_02]: And Pearl 2 will focus on how we actually assess and closely examine these ulcers with a special emphasis on how to make sure we're not missing anything like osteomyolitis. 07:39.631 --> 07:47.218 [SPEAKER_02]: You really have to slow down when osteomyolitis is on the table because what looks like a small foot wound can often represent something much deeper. 07:47.468 --> 07:47.809 [SPEAKER_05]: Yeah. 07:47.849 --> 08:06.540 [SPEAKER_05]: So when we are looking closer, this means don't just upload a picture on to Epic, which I've definitely been guilty of doing before, but really assessing, you know, the temperature is a hot cold, is there any swelling, any discharge odor, especially looking at the ulcer itself and particularly how deep is it and does it track? 08:06.976 --> 08:08.739 [SPEAKER_01]: many times being the tip of the iceberg. 08:09.040 --> 08:12.846 [SPEAKER_01]: You see this wound on the bottom of the foot and it's like, oh, that doesn't look too bad. 08:13.387 --> 08:18.817 [SPEAKER_01]: But until you really probe it and manipulate it, you really don't know how severe this might be. 08:20.059 --> 08:27.111 [SPEAKER_02]: Which brings us to one of our most powerful bedside tools we have, probing the ulcer to evaluate for osteomyelitis. 08:27.952 --> 08:32.397 [SPEAKER_01]: Then I'll take my probe, and I'll insert the probe into the ulcer, gently. 08:32.417 --> 08:36.061 [SPEAKER_01]: I don't jam it in there, but I gently probe the base of the ulcer. 08:36.741 --> 08:40.746 [SPEAKER_01]: I probe around the periphery of the ulcer to see if there's any undermining. 08:41.346 --> 08:44.049 [SPEAKER_01]: And then I'll try to probe deep to see if it goes. 08:44.750 --> 08:45.591 [SPEAKER_01]: How deep it goes. 08:46.191 --> 08:48.414 [SPEAKER_01]: That will tell me if there's a tendon involvement. 08:48.974 --> 08:51.377 [SPEAKER_01]: If there is bone involvement. 08:52.150 --> 09:08.978 [SPEAKER_01]: and to the point about to sinus track, if I find that this ulcer now tracks approximately or distally, I know there's a sinus track, and there could be a collection of fluid and abscess in that area, they may need to be open and drained. 09:09.650 --> 09:16.945 [SPEAKER_05]: Interestingly, all the things you can do in your work up, the probe to bone was emphasized the most across for no matter who we talked to. 09:16.985 --> 09:26.545 [SPEAKER_05]: We also sat down with Dr. Sandy Nelson and infectious disease doctor at Mass General who locked us through her approach on the work up and where the probe to bone tests sits within that. 09:27.503 --> 09:42.015 [SPEAKER_03]: You should start with a combination of tests that include clinical evaluation, playing films, which are actually probably, in some ways, the best imaging studies that we have, and laboratory studies, including said rate, C-reactive protein and pro-calcitonian. 09:42.516 --> 09:46.845 [SPEAKER_03]: And oftentimes, you can get to the diagnosis of osteomyulitis through those tests. 09:46.825 --> 09:58.162 [SPEAKER_03]: Clinical evaluation, the element that is important for that is the probe to bone test, and the probe to bone test is actually an excellent test with very high sensitivity and specificity, really approaching what you get with MRI. 09:58.863 --> 10:12.583 [SPEAKER_03]: And if you use it appropriately in the right clinical settings in a high pre-test probability, a probe to bone test is going to definitively rule in osteomyelitis and an allow clinical probability setting, that's going to pretty satisfactorily rule out osteomyelitis. 10:12.943 --> 10:14.706 [SPEAKER_03]: And so that's the starting point. 10:15.395 --> 10:20.883 [SPEAKER_02]: OK, so a positive probe to bone test can basically rule in osteomyelitis. 10:21.904 --> 10:25.009 [SPEAKER_05]: Yes, and with that, let's move from the exam to imaging. 10:25.569 --> 10:28.373 [SPEAKER_05]: Of course, people often start with a plane X-ray. 10:28.413 --> 10:32.139 [SPEAKER_05]: And if that shows signs of osteomyelitis, that might be all we need. 10:33.040 --> 10:36.745 [SPEAKER_05]: But if things are unclear, then we might have to reach for an MRI. 10:37.518 --> 10:44.251 [SPEAKER_03]: And then advanced imaging is really reserved for those tests in which the initial round of testing is not conclusive. 10:44.933 --> 10:54.852 [SPEAKER_03]: And that's the time that you might do an MRI that's probably your next best test in terms of both sensitivity and specificity for the diagnosis of osteomyelitis. 10:54.832 --> 11:07.573 [SPEAKER_03]: I should also say that the other reason to do an MRI, or to do advanced imaging, is not only to confirm the diagnosis of osteomyelitis, but also to guide the need for and the extent of surgical management. 11:08.274 --> 11:13.463 [SPEAKER_03]: And so sometimes you may have met the diagnostic criteria for osteomyelitis by other measures. 11:13.523 --> 11:18.932 [SPEAKER_03]: You may have a very high set rate of positive probe to 11:18.912 --> 11:25.542 [SPEAKER_03]: You know, that patient is going to have asked you my latest, but it becomes important still to pursue the testing to then guide next steps. 11:26.824 --> 11:38.642 [SPEAKER_02]: So, surgical teams might want to get the MRI to further guide the interventions they may offer, but that'll be said MRI isn't perfect, and this is a really important nuance to emphasize. 11:39.618 --> 11:50.050 [SPEAKER_03]: When we look at studies around MRI, in terms of how to use MRI, I do have a big caution around this, which is that the specificity of MRI is not as high as we think it is. 11:50.691 --> 11:52.073 [SPEAKER_03]: The sensitivity is pretty good. 11:52.233 --> 11:54.615 [SPEAKER_03]: It's over 80%, maybe approaching 90%. 11:55.597 --> 12:01.423 [SPEAKER_03]: But the specificity is actually maybe 80%, maybe 75% depending on the clinical scenario. 12:01.924 --> 12:07.971 [SPEAKER_03]: And the reason for that is that the earliest finding in osteomyelitis is one of bone marrow edema. 12:07.951 --> 12:30.043 [SPEAKER_03]: And bone marrow edema is very non-specific, and it's seen in a whole variety of different entities, including pressure-related injury, and so if somebody has been walking on an open wound, they're going to have some bone marrow edema underneath it, and so you'll get a common read on an MRI, which is cannot exclude early osteomyelitis, which is very much not the same as there is osteomyelitis. 12:30.023 --> 12:56.723 [SPEAKER_03]: And so we just have to be careful about not overeating or overrelying on MRI because we then will overdiagnose and oftentimes the better thing to do in that setting is to say, okay, we're going to treat for soft tissue infection and then we'll repeat other imaging modalities, perhaps a CT or a plane films and then really make a decision about whether or not osteomyelitis is present before committing somebody to a full kind of treatment course for that. 12:57.952 --> 13:06.667 [SPEAKER_05]: I have definitely had some more ID colleagues to help me from ordering it MRI in cases where there was just concern that we're going to get too much signal to noise ratio, right? 13:06.687 --> 13:16.163 [SPEAKER_05]: Especially if these patients are already at such high risk for pressure being a part of their injury and pressure itself can cause bone marrow deema just as an example. 13:16.143 --> 13:23.621 [SPEAKER_02]: And maybe the takeaway is that if we do get an MRI, we should read not just the impression, but go over the details of the report. 13:24.182 --> 13:30.718 [SPEAKER_02]: Like, should I be asking my radiology colleagues how much of a slam dunk diagnosis those imaging findings are for osteomyllitis? 13:31.419 --> 13:34.607 [SPEAKER_02]: Or are they just calling it based on the amount of bone marrow edema? 13:35.498 --> 13:46.492 [SPEAKER_03]: really the only way to confirm it is through bone biopsy and that would be bone biopsy with the use of either histology and or culture and that's debated as to which of those two is the better test. 13:46.512 --> 13:58.367 [SPEAKER_03]: But I will also say that we don't often times go there strictly for the purposes of confirming osteomyelitis because there are risks associated with a bone biopsy, especially if there's not another indication for surgery. 13:58.347 --> 14:01.772 [SPEAKER_03]: And there's oftentimes logistic hurdles to getting it done. 14:01.832 --> 14:04.717 [SPEAKER_03]: This is especially true when you're talking about a toe. 14:04.757 --> 14:11.207 [SPEAKER_03]: It's very hard to sample a toe without at least causing risk of injury. 14:11.667 --> 14:20.401 [SPEAKER_03]: It's a little bit different in the mid-foot, but as a general rule, bone biopsies strictly to make the diagnosis is not commonly done. 14:20.942 --> 14:25.789 [SPEAKER_03]: And commonly, we're using the surrogate tests recognizing that they're imperfect. 14:26.478 --> 14:29.662 [SPEAKER_05]: Oh man, where the ulcer is makes a difference. 14:29.742 --> 14:31.024 [SPEAKER_05]: And I learned that the hard way. 14:31.464 --> 14:37.552 [SPEAKER_05]: I still remember having a patient that was once admitted over the weekend, there was some concern of ulcer you have a third toe. 14:38.032 --> 14:43.079 [SPEAKER_05]: And I, for sure, thought the game plan would be okay, take to OR for bone biopsie or surgical disagreement. 14:43.779 --> 14:47.544 [SPEAKER_05]: But now it makes sense why podiatry actually said no to the OR. 14:48.105 --> 14:49.887 [SPEAKER_05]: It was just not a feasible area. 14:50.272 --> 14:57.225 [SPEAKER_02]: I know I really thought the bone biopsy would be more of a priority, but I guess that might not always be the case. 14:57.666 --> 15:06.542 [SPEAKER_02]: I think what I'm taking away from this is that a bone biopsy is the gold standard, but it might not always be practical and can do more harm than good. 15:06.522 --> 15:21.190 [SPEAKER_05]: So to recap, the next time I see a foot ulcer, I'm going to try to remember small wounds can be really hiding deeper disease and I'm also going to challenge myself the next time I see one of these to go on with podiatry or the wound characters and have them kind of coach me through that probe to bone test. 15:21.980 --> 15:26.286 [SPEAKER_02]: Yeah, I think I'm gonna try to find those podiatry attendings and see what they can show me. 15:26.306 --> 15:39.983 [SPEAKER_02]: And the key thing about MRI is that it's sensitive, but not a specific, especially with bone marrow deema present, which can easily be seen in early osteo, or with just a pressure-related injury, and are not alone in thinking about these things. 15:40.163 --> 15:47.633 [SPEAKER_02]: Diabetic foot infections are often a team sport, with at least ID, podiatry, and or wound care to help think through things with you. 15:54.245 --> 16:06.167 [SPEAKER_02]: All right, Pearl 3 is all about treatment, which, as I found out, the main days of treatment for diabetic foot infections with or without osteo, are source control and antibiotics. 16:06.868 --> 16:10.895 [SPEAKER_05]: Yes, but none of those things will work if we don't have adequate blood flow. 16:11.396 --> 16:15.223 [SPEAKER_05]: All sources won't heal and antibodies won't penetrate without adequate perfusion. 16:16.030 --> 16:22.183 [SPEAKER_01]: The majority are going to be in the empathic, but there can be a vascular component, so it's important to identify that. 16:22.684 --> 16:29.037 [SPEAKER_01]: Because if there's a significant vascular component, it doesn't matter what you do with the ulcer. 16:29.057 --> 16:34.107 [SPEAKER_01]: If you don't address the blood flow, it's not going to heal, so that's important. 16:34.913 --> 16:47.151 [SPEAKER_02]: That's exactly right, from what I learned, there are some vascular guidelines out there that say any diabetic patient older than 55 years old should get angled, brachial index or an ABI. 16:48.012 --> 16:50.776 [SPEAKER_02]: And this makes total sense to me because it's an easy test. 16:51.037 --> 16:54.963 [SPEAKER_02]: It's just a ratio of the blood pressure between the ankles and that of the arms. 16:55.724 --> 17:01.292 [SPEAKER_02]: They are quick, low cost, and really gives us a sense if peripheral artery disease is at play. 17:01.778 --> 17:07.765 [SPEAKER_05]: Yeah, and I'm sure they're different practice thresholds to get ABI's or not, but I think it's not unreasonable. 17:07.786 --> 17:16.096 [SPEAKER_05]: And especially I think from what I learned on the peripheral RGZs episode where people can have bad PAD and still have palpable pulses, right? 17:16.256 --> 17:19.620 [SPEAKER_05]: Whether it's because they develop collateral blood flow or partial occlusions. 17:20.061 --> 17:23.365 [SPEAKER_05]: For me, if my it's not unreasonable to get it for all our patients with diabetes. 17:24.172 --> 17:25.053 [SPEAKER_02]: Yeah, I agree. 17:25.073 --> 17:34.667 [SPEAKER_02]: And I think the real key question for these diabetic footloons is, well, this patient's blood flow support healing after debridement or surgery. 17:35.388 --> 17:43.159 [SPEAKER_02]: And to follow that, do we need to restore blood flow with an angioplasty or those other fancy things that vascular surgery might be able to offer? 17:43.527 --> 17:44.209 [SPEAKER_05]: Yeah, great. 17:44.289 --> 17:46.955 [SPEAKER_05]: Yeah, I feel like that's like a do not pass go must think about that. 17:47.316 --> 17:52.909 [SPEAKER_05]: And then if there isn't any blood flow issue, the next thing we want to also think about is source control, right? 17:52.949 --> 17:59.143 [SPEAKER_05]: And that can be in many forms, ranging from draining an abscess if that's present to doing a surgical to breathe meant. 17:59.504 --> 18:01.789 [SPEAKER_05]: And then in some cases, an amputation. 18:02.123 --> 18:06.211 [SPEAKER_02]: In surgical deployment is something I've heard thrown around a lot on words. 18:06.752 --> 18:23.322 [SPEAKER_02]: I didn't really fully appreciate what it entailed or how powerful a tool it was, but basically what I learned is that the surgical team will divide the wound, remove anything around it, including bone, anything that really just looks grossly infected, and they can even do this at the bedside. 18:24.061 --> 18:26.426 [SPEAKER_01]: The treatment for osteomyelitis is a surgical treatment. 18:26.607 --> 18:28.050 [SPEAKER_01]: The primary treatment. 18:28.070 --> 18:30.736 [SPEAKER_01]: IV antibiotic is an ancillary treatment. 18:31.297 --> 18:32.941 [SPEAKER_01]: It's a supported treatment. 18:33.442 --> 18:43.605 [SPEAKER_01]: In those circumstances where maybe you can't guarantee that you got all the infected bone out of there, or you want to suppress it further for a period of time. 18:44.412 --> 18:54.048 [SPEAKER_05]: One thing I've changed in my practice is to really look at that operative of part and see if the surgical team got all the infected bone out or not, aka was their good margins. 18:54.529 --> 19:01.560 [SPEAKER_05]: And I know that's something that the infectious disease team will ask about and it kind of helps determine their duration of antibodies, which we'll get to in Proof for. 19:02.401 --> 19:12.988 [SPEAKER_02]: And beyond surgery and antibiotics, we can't forget the most basic part of treating these diabetic food infections, which is optimizing their blood sugars and ensuring really good bone care. 19:13.429 --> 19:13.810 [SPEAKER_02]: And try it. 19:13.830 --> 19:14.231 [SPEAKER_02]: Don't worry. 19:14.431 --> 19:17.980 [SPEAKER_02]: I learned all about bone care and I can't wait to tell you about it in profile. 19:17.960 --> 19:19.403 [SPEAKER_02]: That's going to be so good. 19:19.563 --> 19:20.625 [SPEAKER_05]: So many knowledge gaps there. 19:21.186 --> 19:26.395 [SPEAKER_05]: Okay, so to summarize, main statement for diabetic infections with or without osteo of the foot. 19:26.876 --> 19:29.500 [SPEAKER_05]: I think the first thing, you know, do not pass go. 19:29.520 --> 19:32.345 [SPEAKER_05]: We need to make sure we have good blood flow to that wound, right? 19:32.445 --> 19:40.980 [SPEAKER_05]: That is so important because that's going to give that wound the best shot for healing and at the same token adequate blood flow is going to make sure that our antibiotics are getting to the wound. 19:40.960 --> 19:43.148 [SPEAKER_02]: And don't forget about source control. 19:43.188 --> 19:48.085 [SPEAKER_02]: This can be anything from draining an abscess, the surgical department, or even amputation. 19:54.781 --> 19:56.805 [SPEAKER_05]: Okay, let's talk about antibiotics. 19:56.945 --> 19:59.690 [SPEAKER_05]: And here's the thing that's always made me pause, right? 20:00.071 --> 20:02.575 [SPEAKER_05]: Patient comes and over the weekend, skeleton crew is on. 20:02.635 --> 20:12.233 [SPEAKER_05]: No one's definitely said yes or no to the OR for bone biopsy or surgical debris and the big question is, do we hold antibiotics to get cultures? 20:13.192 --> 20:15.715 [SPEAKER_02]: And the answer is, it's nuanced. 20:17.698 --> 20:25.508 [SPEAKER_02]: If your patient is unstable, like their septic, toxic, or crashing, definitely give antibiotics immediately, notobate there. 20:26.149 --> 20:31.977 [SPEAKER_02]: But if they're clinically stable and the cultures might meaningfully guide management, that might be your window. 20:31.957 --> 20:40.947 [SPEAKER_05]: Yeah, imagine if they had, you know, mercy on the past should have known us for some resistant bug that required big gun antibiotics and yeah, the culture would be helpful, right? 20:41.007 --> 20:47.255 [SPEAKER_05]: Or otherwise we're just like subjecting them blindly to like weeks of broad spectrum antibiotics based on prior micro. 20:48.316 --> 20:54.403 [SPEAKER_02]: Yeah, but here's the twist. 20:54.738 --> 21:01.408 [SPEAKER_03]: the other piece to consider is that these are often infections that are associated with some degree of vascular insufficiency. 21:02.269 --> 21:07.096 [SPEAKER_03]: And vascular insufficiency leads to limited antibiotic distribution. 21:07.777 --> 21:21.117 [SPEAKER_03]: And so oftentimes, if a patient has deep cultures collected 24, 48, 72 hours after starting antibiotics, those cultures are almost always still going to be positive and still positive in a way that we trust to them. 21:21.097 --> 21:31.374 [SPEAKER_03]: Once you've gotten beyond that, then it becomes a little bit less certain as to whether or not the organisms that are recovered are fully representative of what's in the deep tissues. 21:31.394 --> 21:36.302 [SPEAKER_03]: When a patient goes to the OR, for example, they're usually going to the OR because there's some degree of tissue necrosis. 21:36.943 --> 21:39.628 [SPEAKER_03]: So when there's tissue necrosis, the antibiotics aren't getting there. 21:39.768 --> 21:40.569 [SPEAKER_03]: It's dead tissue. 21:41.150 --> 21:45.417 [SPEAKER_03]: And so the cultures are very likely to still be active and reliable. 21:46.612 --> 21:55.469 [SPEAKER_05]: Ah, that is helpful to hear you, I didn't appreciate that since antibiotics literally can't get into necrotic or ischemic tissue, cultures might still grow the bug that was causing the issue. 21:56.050 --> 22:08.434 [SPEAKER_05]: So, I guess in a stable patient, we can try to hold the antibiotics if there's a possibility of getting culture data, and at the same time, we might have some leeway knowing that we can start antibiotics and it might not necessarily ruin the culture yield either. 22:08.971 --> 22:10.275 [SPEAKER_02]: Yes, exactly right. 22:11.117 --> 22:13.364 [SPEAKER_02]: Now let's pivot to the next big question. 22:13.384 --> 22:15.229 [SPEAKER_02]: IV versus PO. 22:15.269 --> 22:23.453 [SPEAKER_02]: A lot of us reflexively go to IV for bad infections, especially osteomyelitis, but the data says we might be able to relax a bit. 22:24.209 --> 22:31.661 [SPEAKER_03]: There have never been any clinical studies that suggest that antibiotics that are considered more bone penetrating actually perform better than others. 22:32.322 --> 22:42.319 [SPEAKER_03]: And then on top of that data, we now have, you know, the very large OVVA study, which was published I want to say in 2019, which randomized patients with a bone and joint infection. 22:42.299 --> 22:50.214 [SPEAKER_03]: to either oral therapy or IV therapy, culture-directed therapy for any type of bone in joint infection, including diabetic foot infections. 22:50.695 --> 23:01.135 [SPEAKER_03]: And the take-home of this study, which is a very well-performed, powerful study over a thousand patients, is that there was no difference between the route of antibiotics and clinical outcomes. 23:01.115 --> 23:09.646 [SPEAKER_03]: So we now have very good evidence that as long as we're using antibiotics well, that we can use oral therapy, and that includes for diabetic food infection. 23:10.247 --> 23:14.893 [SPEAKER_03]: This isn't to say that when patients come into the hospital, what steps this we should be using oral antibiotics. 23:14.913 --> 23:17.015 [SPEAKER_03]: This is really to eat more in the definitive stage. 23:17.496 --> 23:18.677 [SPEAKER_03]: You have to eat your judgment. 23:18.918 --> 23:21.821 [SPEAKER_03]: There are other reasons that we select IV therapy in the acute setting. 23:22.182 --> 23:28.590 [SPEAKER_03]: But once we're in a definitive management setting, many patients, 23:29.228 --> 23:35.087 [SPEAKER_05]: Wow, so patients can do just fine and oral antibiotics for bone-injoin infections. 23:35.950 --> 23:38.277 [SPEAKER_05]: Gosh, and then how long would we treat for? 23:38.915 --> 23:56.835 [SPEAKER_02]: Yeah, so if it's a diabetic foot infection without osteomyelitis, but they were, say, septic or had a lot of air theme around the wound like maybe two centimeters out, or even if it was like a deep wound, then we typically would treat for about like two weeks or sometimes a little bit more than that. 23:57.536 --> 24:04.804 [SPEAKER_02]: And in the absence of all of those things, diabetic foot infections are considered mild and antibiotics can be given over one to two weeks. 24:04.953 --> 24:05.414 [SPEAKER_02]: Awesome. 24:05.434 --> 24:07.236 [SPEAKER_05]: And then what about osteomilitis, right? 24:07.376 --> 24:09.639 [SPEAKER_05]: When there's bone involvement, how does that change things? 24:10.740 --> 24:14.825 [SPEAKER_03]: The most recent guidelines, actually, this has been a change. 24:15.265 --> 24:17.668 [SPEAKER_03]: And I think this hasn't made it pervasively. 24:17.708 --> 24:19.530 [SPEAKER_03]: I think that people still don't know about this. 24:20.171 --> 24:27.320 [SPEAKER_03]: But the most recent guidelines, indicated if a patient has had surgical debrisment, even if they're osteomilitis is not completely resected. 24:27.380 --> 24:31.404 [SPEAKER_03]: Three weeks of treatment beyond surgical debrisment is appropriate. 24:32.085 --> 24:32.766 [SPEAKER_03]: And so, 24:32.746 --> 24:49.255 [SPEAKER_03]: I will say that not everyone agrees with that guidance, and it is based on literature that on science that is not high quality, large-scale randomized control trials, but it is the best data that we have that suggests that anything beyond three weeks may not offer benefit. 24:49.816 --> 24:57.589 [SPEAKER_03]: So I think, you know, for many people, if they've had a surgical procedure, three weeks is going to be sufficient, even when there is residual osteomyelitis. 24:58.666 --> 25:08.787 [SPEAKER_02]: Wow, so three weeks, and that's compared to the traditional guidelines of around four to six weeks, and sometimes I've even read the antibiotics can go all the way out to 12 weeks. 25:09.669 --> 25:17.164 [SPEAKER_05]: Yeah, and just to emphasize again, Dr. Nelson did say not have own degrees, and the data isn't perfect, but three weeks is the best evidence we have right now. 25:17.954 --> 25:20.477 [SPEAKER_02]: Okay, and now our final teaching point. 25:21.038 --> 25:23.381 [SPEAKER_02]: What do you tell your patients when they ask you? 25:23.441 --> 25:25.623 [SPEAKER_02]: How do I know if the osteo is gone? 25:25.884 --> 25:27.305 [SPEAKER_02]: Should I get a repeat MRI? 25:28.527 --> 25:30.549 [SPEAKER_03]: None of those tests actually help. 25:30.569 --> 25:32.071 [SPEAKER_03]: It's separate takes a long time to come down. 25:32.692 --> 25:37.958 [SPEAKER_03]: The problem with osteomyelitis is when it's controlled, you can't always tell the difference from blood work, whether it's controlled or cured. 25:38.399 --> 25:41.363 [SPEAKER_03]: I think the best test of cure is what I call the test of time. 25:41.963 --> 25:45.648 [SPEAKER_03]: And if you stop antibiotics and their infection doesn't come back, then they're cured. 25:46.209 --> 25:47.370 [SPEAKER_03]: Patients hate that. 25:47.350 --> 25:52.276 [SPEAKER_03]: you know, because they don't want their infection to come back, but we just don't have anything else. 25:53.338 --> 26:02.309 [SPEAKER_02]: Okay, so labs and imaging lag behind ESR and CRP often stay elevated, MRI can still look bad long after the infection is under control. 26:02.810 --> 26:09.038 [SPEAKER_02]: But the big picture is, if they're improving, you're winning, even if the MRI hasn't gotten the memo yet. 26:09.018 --> 26:10.040 [SPEAKER_02]: Exactly. 26:10.080 --> 26:14.367 [SPEAKER_05]: And then December is antibiotics of diabetic foot infections and osteomylitis. 26:14.988 --> 26:27.550 [SPEAKER_05]: The patients in seabull, yes, start antibiotics, but if they are stable and cultures might change management, you can consider holding, but starting antibiotics doesn't necessarily ruin your healed, especially if there's no chronic tissue. 26:28.238 --> 26:36.788 [SPEAKER_02]: And I think the next time I have a patient who is clinically improving, I'll talk to ID about transitioning to oral options early, since oral options work too. 26:37.569 --> 26:45.297 [SPEAKER_05]: Yes, in terms of duration of antibodies, it really depends on severity for soft tissue infections with an ulcer can range anywhere from one to two weeks or so. 26:46.539 --> 26:51.985 [SPEAKER_02]: And for osteomyelitis after-depriidment, newer guidelines suggest three weeks might be enough. 26:58.597 --> 27:02.102 [SPEAKER_05]: Okay, purl five, all about wound care. 27:02.222 --> 27:06.970 [SPEAKER_05]: Again, Colby, I am so excited to learn why am I ordering this versus that. 27:08.071 --> 27:08.732 [SPEAKER_02]: Yeah, me too. 27:08.752 --> 27:17.506 [SPEAKER_02]: I really had a fun time learning about all of this and teaching myself, but let me start us off with the first basic branch of wound care. 27:17.906 --> 27:19.509 [SPEAKER_02]: Is the wound wet or dry? 27:19.549 --> 27:25.718 [SPEAKER_05]: Yeah, I think from what I've seen, most diabetic foot wounds are usually on the dryer dirtier side. 27:26.356 --> 27:33.045 [SPEAKER_02]: Yeah, we sat down with one of our wound care nurses that we have the pleasure of working with at the IDMC, her name's Brittany Nation. 27:33.065 --> 27:39.033 [SPEAKER_02]: And she said, unless there's massive, Dima, or weeping, the main goals are simple. 27:39.473 --> 27:41.296 [SPEAKER_04]: Clean the wound and keep it moist. 27:42.577 --> 27:47.043 [SPEAKER_04]: When you're looking at a wound, the basics really come down to clean your wounds. 27:47.424 --> 27:54.473 [SPEAKER_04]: If your wounds are clean and you put good moist topical therapy on a wound, that's step number one. 27:54.723 --> 28:00.532 [SPEAKER_04]: So putting the old wives tail up, just keep a dry, keep it the air to it, that is no longer. 28:00.832 --> 28:05.839 [SPEAKER_04]: There's so much evidence out there that a moist topical therapy is needed. 28:05.859 --> 28:09.004 [SPEAKER_04]: Our bodies know how to heal. 28:09.044 --> 28:11.488 [SPEAKER_04]: They know what they need to do. 28:11.528 --> 28:12.569 [SPEAKER_04]: We just have to help them out. 28:14.151 --> 28:15.553 [SPEAKER_05]: What a beautiful mantra. 28:15.594 --> 28:18.778 [SPEAKER_05]: Like we are just supporting our bodies healing and to do that. 28:19.259 --> 28:22.063 [SPEAKER_05]: We need to keep these wounds clean and keep them moist. 28:22.634 --> 28:25.304 [SPEAKER_02]: Yes, these wounds are not a rotisserie chicken. 28:25.324 --> 28:28.395 [SPEAKER_02]: I mean, thank you, Makasko. 28:28.415 --> 28:34.517 [SPEAKER_05]: All right, so Colby, tell us what do we have that in our toolkit to keep these dry wounds more moist? 28:35.088 --> 28:45.504 [SPEAKER_02]: There a form, most of us have heard of it, but I really didn't know exactly what it was, but it's that then a yellow mesh that goes directly onto the wound. 28:46.105 --> 28:52.995 [SPEAKER_02]: It contains Petrolata to keep the wound moist, and this will be your go-to dressing for those really dried wounds. 28:52.975 --> 28:55.581 [SPEAKER_05]: Yeah, I mean, I've ordered that so many times and I had no idea what it did. 28:56.062 --> 28:58.508 [SPEAKER_05]: But okay, so use your form to moisten that wound. 28:59.049 --> 29:06.968 [SPEAKER_05]: Okay, but what if Colby on the off chance there was a DMA and we'd be like say this person had really about heart failure and that was complicating wound healing. 29:07.876 --> 29:14.866 [SPEAKER_02]: Yeah, that would be the circumstance where we would start reaching for something like aquasel, which is basically just a super absorbent fiber. 29:14.906 --> 29:19.072 [SPEAKER_02]: Aquasel, it's used for those wet wounds that have really heavy drainage. 29:19.753 --> 29:20.434 [SPEAKER_05]: OK, that makes sense. 29:20.454 --> 29:24.881 [SPEAKER_05]: So aquasel to absorb the wet wound, maybe AA for absorbing. 29:25.522 --> 29:30.930 [SPEAKER_05]: But for most of the time, these wounds are dry, and we want to give it moisture, and that's going to be with sear for them. 29:30.950 --> 29:33.073 [SPEAKER_05]: All right, Colby, where do we go from here? 29:33.796 --> 29:36.560 [SPEAKER_02]: Then we have to think about, how are we going to clean the loons? 29:37.000 --> 29:39.344 [SPEAKER_02]: AKA what antimicrobial cleanser will we use? 29:40.225 --> 29:50.680 [SPEAKER_02]: This honestly depends on what your hospital or unicaries, but the foremost common antimicrobials out there are beta-dine, hypercleras acid, acetic acid, and diluted bleach. 29:51.200 --> 29:52.362 [SPEAKER_05]: Deluted bleach? 29:52.696 --> 29:53.657 [SPEAKER_02]: Yes, crazy. 29:53.777 --> 30:08.334 [SPEAKER_02]: I know diluted bleach is, or the wise known as daykins under floor is used for those wounds that have very active or angry infections, but we don't typically use it for very long or very often just because it's super irritating to the skin. 30:08.374 --> 30:16.022 [SPEAKER_02]: And then on the other hand, I just wanted to mention the other cleanser that I thought was very interesting, which is CDic acid. 30:16.683 --> 30:20.948 [SPEAKER_02]: And 30:21.637 --> 30:22.338 [SPEAKER_05]: Hmm. 30:22.398 --> 30:22.559 [SPEAKER_05]: Okay. 30:23.080 --> 30:28.109 [SPEAKER_05]: So it sounds like most of the time we're going to be reaching for beta died or hypoclorist acid. 30:28.129 --> 30:30.914 [SPEAKER_05]: These are like just first-line wound cleansers. 30:30.994 --> 30:37.366 [SPEAKER_05]: And then there's like the two other ones to know which is diluted bleach or daykins for the angry looking infections. 30:37.526 --> 30:42.295 [SPEAKER_05]: And then if we're worried about pseudomonas, we might be reaching for acidic acid. 30:42.275 --> 30:44.617 [SPEAKER_05]: Oh, Colby, I feel like I'm being the hang of wound care. 30:44.637 --> 31:04.158 [SPEAKER_02]: I know, it's not that bad, but putting this all together, practically what this looks like is, clean first with either beta-dine, hypacloric acid, diluted bleach, or cetic acid, then choose addressing based on if the wound is wet, with something like aquasel, or if it's dry, with xero form. 31:05.239 --> 31:07.962 [SPEAKER_04]: If you're questioning something and you just need to get through the night, 31:08.600 --> 31:12.726 [SPEAKER_04]: put on beta-dine, put on a zero-formed dressing, you can't go wrong with that. 31:13.427 --> 31:19.456 [SPEAKER_04]: And then problem-one consult-in, trouble, podiatry, consult-in, and then they can be more formally evaluated. 31:20.498 --> 31:23.002 [SPEAKER_05]: Okay, beta-dine and zero-form it is. 31:23.763 --> 31:27.368 [SPEAKER_05]: My takeaway is beta-dine and zero-form is basically like the peanut-perjellia food care. 31:28.478 --> 31:37.475 [SPEAKER_02]: I love her food analogies, but yes, I would emphasize that wound care isn't just what you put on the wound, but it's also what you take off of it. 31:37.976 --> 31:44.749 [SPEAKER_02]: I eat pressure offloading as much pressure off the wound as possible is super important for wound healing. 31:45.556 --> 31:54.196 [SPEAKER_01]: studies have shown that as little as two hours of constant pressure is enough to clear the local blood flow and lead to eschemic changes. 31:54.817 --> 32:02.755 [SPEAKER_01]: So it's important in those patients to elevate, keep the pressure off the mattress, put them in protective boots, things like that. 32:03.680 --> 32:07.003 [SPEAKER_05]: two hours of pressure, that's like a Netflix season finale. 32:07.784 --> 32:11.207 [SPEAKER_05]: Gosh, so much good teaching here, call me, let's summarize Rooncare. 32:11.227 --> 32:23.059 [SPEAKER_05]: I want him to take away his first wing to clean the wound, and that could be either with hyperplors acid, beta-dine, and if it's a very active infection, diluted bleach, or acidic acid, if we're concerned about pseudomonas. 32:23.539 --> 32:27.683 [SPEAKER_05]: And since most wounds are on the dry side, we want to keep it moist with something like zero-four. 32:28.404 --> 32:32.708 [SPEAKER_02]: Yes, clean first, then choose addressing based on wet versus dry. 32:32.924 --> 32:38.176 [SPEAKER_05]: And then one end out, most dry diabetic foot wounds we can get away with beta-dine and zero form. 32:38.256 --> 32:41.644 [SPEAKER_05]: And that'll get us through the weekend or the night too. 32:41.664 --> 32:42.606 [SPEAKER_05]: And that is all for today. 32:42.646 --> 32:43.789 [SPEAKER_05]: Thank you so much for listening. 32:43.849 --> 32:50.865 [SPEAKER_05]: If you got some value from this episode, our ask is to please share it with Elise just one other college who might also get a good offer on this episode. 32:50.885 --> 32:51.827 [SPEAKER_05]: I know I did. 32:52.195 --> 32:56.386 [SPEAKER_02]: Thank you to our reviewers, Dr. Noah Rosenberg and Dr. Barry Rosenblom. 32:57.008 --> 33:00.698 [SPEAKER_02]: And thank you to Dr. Kathy Shashan for the accompanying graphics. 33:00.959 --> 33:04.990 [SPEAKER_02]: The episode was made as part of the Digital Education Track at the idea of C. 33:06.488 --> 33:07.990 [SPEAKER_05]: two hours of pressure. 33:08.050 --> 33:10.053 [SPEAKER_05]: That's like one Netflix episode, right? 33:10.794 --> 33:12.377 [SPEAKER_05]: And it's an episode or a movie. 33:13.238 --> 33:14.400 [SPEAKER_05]: I guess we can do episodes. 33:15.461 --> 33:19.267 [SPEAKER_05]: I watch too many YouTube shorts, which is the opposite. 33:19.607 --> 33:22.872 [SPEAKER_02]: It could be like a season finale episode on Netflix. 33:23.313 --> 33:25.376 [SPEAKER_05]: I trust your cultural reference. 33:25.756 --> 33:28.100 [SPEAKER_05]: I started over a whole lot of it's hard to transition. 33:28.220 --> 33:30.403 [SPEAKER_05]: I'm thinking about all the Netflix.