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SIRS Is Valid in Discriminating Between Severe and Moderate Diabetic Foot Infections

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SIRS Is Valid in Discriminating Between Severe and Moderate Diabetic Foot Infections Pathophysiology/Complications ORIGINAL ARTICLE SIRS Is Valid in Discriminating Between Severe and Moderate Diabetic Foot Infections 1 2 DANE K. WUKICH, MD KATHERINE MARIE RASPOVIC, DPM best of our knowledge, the use of SIRS 2 3 KIMBERLEE B. HOBIZAL, DPM BEDDA L. ROSARIO, PHD has not yet been validated as a method of discriminating between moderate and severe DFI. OBJECTIVEdThis retrospective, single-center study was designed to distinguish severe di- The aim of this study was to classify abetic foot infection (DFI) from moderate DFI based on the presence or absence of systemic fl infectionseverityinagroupofhospital- in ammatory response syndrome (SIRS). ized diabetic patients based on the pres- RESEARCH DESIGN AND METHODSdThe database of a single academic foot and ence or absence of SIRS. The reason for ankle program was reviewed and 119 patients were identified. Severe DFI was defined as local hospitalization in this group of patients infection associated with manifestation of two or more objective findings of systemic toxicity was their DFI. Our hypotheses are that using SIRS criteria. patients with DFI who manifest SIRS (i.e., severe infection) will have longer hospital RESULTSdPatients with severe DFI experienced a 2.55-fold higher risk of any amputation – – stays and higher rates of major amputa- (95% CI 1.21 5.36) and a 7.12-fold higher risk of major amputation (1.83 41.05) than patients tion than patients who don’tmanifest with moderate DFI. The risk of minor amputations was not significantly different between the two groups (odds ratio 1.02 [95% CI 0.51–2.28]). The odds of having a severe DFI was 7.82 SIRS (i.e., moderate infection). times higher in patients who presented with gangrene (2.03–44.81) and five times higher in patients who reported symptoms of anorexia, chills, nausea, or vomiting (2.22–11.25). The ; RESEARCH DESIGN AND mean length of stay for patients with severe DFI was 4 days longer than for patients with d moderate DFI, and this difference was statistically significant. METHODS After approval by our local institutional review board, the data- CONCLUSIONSdSIRS is valid in distinguishing severe from moderate DFI in hospitalized base of a single academic foot and ankle patients. Patients with severe DFI, as by manifesting two or more signs of systemic inflammation program was reviewed for patients hos- or toxicity, had higher rates of major amputation and longer hospital stays and required more pitalized with a DFI from 2006 to 2012. surgery and more subsequent admissions than patients who did not manifest SIRS. Inpatient and outpatient electronic med- ical records were reviewed, and 119 patients were identified. We used the IDSA guidelines to classify infection se- n 2004, the Infectious Disease Society chills, tachycardia, hypotension, confu- verity (3). Mild infections were defined as Iof America (IDSA) classified diabetic sion, vomiting, leukocytosis, acidosis, se- having an infection that was limited to the foot infections (DFIs) as mild, moder- vere hyperglycemia, or azotemia). A skin and subcutaneous tissues with ery- ate, and severe based on local and sys- validation study of the IDSA classification thema of ,2 cm (3). Moderate infections temic manifestations of infection (1). demonstrated that as infection severity were defined as local infection with ery- Individuals with mild infections are typi- increased, there was an increased risk of thema .2 cm or involvement of structures cally treated as outpatients but some pa- amputation and hospitalization (2). Nei- deeper than the skin and subcutaneous tients with moderate infections and all ther the initial guideline nor the validation tissues (abscess, osteomyelitis, septic ar- patients with severe infections require study precisely defined what constituted thritis, or fasciitis) who did not manifest hospitalization and potential surgical in- leukocytosis, tachycardia, hypotension, SIRS (3). Severe DFI was defined as local tervention. The International Working severe hyperglycemia, or azotemia (1,2). infection associated with manifestation of Group on the Diabetic Foot devised a sim- Recently, the IDSA updated their guide- two or more objective findings of systemic ilar classification system (1). Severe infec- lines and recommended using systemic toxicity using SIRS criteria (3,4). The find- tions are distinguished from moderate inflammatory response syndrome (SIRS) ings of systemic toxicity include tempera- infections by the presence of systemic tox- as a method for distinguishing between ture (T) .388Cor,368C, heart rate .90 icity or metabolic instability (fevers, moderate and severe DFI (3). To the bpm, respiratory rate .20 breaths/minute or partial pressure of arterial carbon diox- ccccccccccccccccccccccccccccccccccccccccccccccccc ide ,32 mmHg, and a white blood cell From the 1University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center Mercy . , 2 count (WBC) 12,000 cells or 4,000 Center for Healing and Amputation Prevention, Pittsburgh, Pennsylvania; the Center for Healing and cells/mL (3,4). The foot infections were Amputation Prevention, Department of Orthopaedic Surgery, University of Pittsburgh Medical Center fi Mercy Foot and Ankle Program, Pittsburgh, Pennsylvania; and the 3University of Pittsburgh Graduate classi ed as moderate or severe at the School of Public Health, Pittsburgh, Pennsylvania. time of admission, and the extent of peri- Corresponding author: Dane K. Wukich, [email protected]. wound erythema was documented during Received 6 May 2013 and accepted 23 June 2013. the initial assessment. DOI: 10.2337/dc13-1083 © 2013 by the American Diabetes Association. Readers may use this article as long as the work is properly TheUniversityofTexasSanAntonio cited, the use is educational and not for profit, and the work is not altered. See http://creativecommons.org/ (UTSA) wound classification was also licenses/by-nc-nd/3.0/ for details. used to grade the depth of the wound, care.diabetesjournals.org DIABETES CARE 1 Diabetes Care Publish Ahead of Print, published online September 23, 2013 Severe diabetic foot infections and since this represents a study of interest (e.g., major amputation), in terms 0.51–2.28]). The odds of having a severe hospitalized patients, no superficial of OR and significance level P , 0.05, DFI was 7.82 times higher in patients wounds were observed. All of the wounds were selected for model fitting in a sub- who presented with gangrene (2.03– were infected, and the wounds were sequent multiple logistic regression anal- 44.81) and five times higher in patients classified as either 2B, 2D, 3B, or 3D (5). ysis using a stepwise approach. The level who reported symptoms of anorexia, Grade 2 wounds penetrate to tendon or of significance to enter or remain in the chills, nausea, or vomiting (2.22– capsule, and grade 3 wounds involve the model was set to 0.03 to allow only one 11.25). Laboratory and clinical data are joint, capsule, or bone. Nonischemic in- variable in the model (9). OR and 95% CI recorded in Table 2. There was not a sig- fected wounds are labeled as B, and in- were calculated from the b coefficient. nificant difference in the need for vascu- fected ischemic wounds are labeled as Performance of the model was tested by lar surgery between those with moderate D. Deep tissue specimens were obtained means of the Hosmer and Lemeshow (9%) and severe (17%) DFI (P =0.22) after appropriate skin and wound prepa- goodness-of-fit test. All tests were two (Table 2). ration and sharp debridement. Tissue sided, and the significance level was set The mean length of stay for patients specimens (soft tissue and/or bone) to 0.05. All analyses were conducted us- with severe DFI (11.39 6 8.67 days) was were obtained in lieu of swab cultures. ing SAS version 9.3 statistical software ;4 days longer than for patients with For the purposes of this study, we counted (SAS Institute Inc., Cary, NC). moderate DFI (7.82 6 6.65 days), and bacteria based on the number of different this difference was statistically significant bacteria recovered on deep tissue culture. RESULTSdOf the 119 patients who (Table 2). Patients with severe DFI on av- For example, a deep tissue culture that were hospitalized for DFI, 65 patients erage required more subsequent admis- grew Staphylococcus aureus and Escherichia were diagnosed with moderate infection sions to the hospital than those with coli was counted as having two infecting and 54 with severe infection using SIRS. moderate DFI (P = 0.04). The distribution organisms. There were no significant differences be- of severe and moderate infections was not Major amputations were defined as tween the two groups with regard to age, significantly different when using the amputation at the level of the ankle joint sex, BMI, tobacco use, type of diabetes UTSA wound classification with the ex- or more proximal (6). Minor amputations mellitus (DM; type 1 or 2), insulin use, ception of UTSA 2B wounds. Patients were defined as removal of a part of the duration of DM, presence of peripheral with moderate infections were more foot at or distal to the transverse tarsal artery disease, and neuropathy or Charcot likely to have wounds that were less joint (6). By definition, minor amputa- neuroarthropathy (Table 1). We did not deep (UTSA 2B) than patients with severe tions preserved a part of the foot. For identify a significant difference in the infections (P , 0.0001). the purposes of this study, limb salvage prevalence of osteomyelitis between Major amputation was identified in was defined as preservation of a part of the those with severe and moderate infection 17 (14%) of the 119 patients. On univar- foot and equated to having no amputation (Table 2). iate analysis, several variables were signif- or a minor amputation (6–8). Patients with severe DFI experienced icantly associated with major amputation, a 2.55-fold higher risk of any amputa- including younger age, higher Michigan Statistical analysis tion than patients with moderate infec- Neuropathy Screening Index (MNSI), Char- Descriptive statistics were summarized as tion (95% CI 1.21–5.36) and a 7.12-fold cot neuroarthropathy, elevated erythrocyte frequencies or as mean 6 SD.
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