Zusammenfassung
Das diabetische Fußsyndrom (DFS) stellt unter den Komplikationen des Diabetes mellitus
die wohl komplexeste Problematik dar. Besorgniserregend hoch ist die Zahl der in Deutschland
deshalb durchgeführten Major-Amputationen, für die in bis zu 40 % der Behandlungsfälle
nicht beherrschbare Infektionen ursächlich sind. Um diesbezüglich Verbesserungen zu
erreichen, ist neben einem abgestuften integrierten interdisziplinären Behandlungskonzept
auf eine stadiengerechte und ausreichend fokussierte antimikrobielle Therapie zu achten.
Neben einer umfassenden Übersicht der pathophysiologischen Zusammenhänge werden die
in der Literatur verfügbaren Daten zur Erregerätiologie und zum Einsatz von Antibiotika
bei diabetischen Fußläsionen dargestellt. Die gängigen Therapieempfehlungen der Fachgesellschaften
werden wiedergegeben und unter Berücksichtigung der beim Diabetiker noch unzureichend
untersuchten pharmakodynamischen und pharmakokinetischen Charakteristika erläutert.
Summary
Diabetic foot lesions are regarded as one of the most complex complications in diabetic
patients. The number of major amputations in Germany caused by diabetes is still alarmingly
high. Up to 40 percent of major amputations in diabetic patients evolve from uncontrollable
foot infections. To achieve clinical improvements apart from integrated interdisciplinary
treatment concepts a main focus should lie on adequate antimicrobial intervention.
Gram-positive cocci, especially staphylococci and also streptococci, are the predominant
pathogens. Chronic or previously treated wounds often yield several microbes on culture,
including gram-negative bacilli and anaerobes. Optimal culture specimens are taken
from deep tissue after debridement. Only infected wounds require antibiotic therapy.
The antimicrobial agents, route and duration have to correspond with the severity
of infection. Mild to moderate infections can usually be treated in the outpatient
setting with oral agents. Severe infections require hospitalization and parenteral
therapy. Empirical therapy must cover gram-positive cocci and should be broad spectrum
for severe infections. Definitive therapy depends on culture results and clinical
response. Bone infection is particularly difficult to treat and often requires surgery.
Several adjuvant agents may be beneficial in some cases.
Literatur
- 1
American Diabetes Association .
Consensus Development Conference on Diabetic Foot Wound Care.
Diabetes Care.
1999;
22
1354-1360
- 2
Apelqvist J, Castenfors J, Larsson J, Stenstrom A, Agardh CD.
Wound classification is more important than site of ulceration in the outcome of diabetic
foot ulcers.
Diabet Med.
1989;
6
526-530
- 3
Armstrong DG, Lavery LA, Sariaya M, Ashry H.
Leukocytosis is a poor indicator of acute osteomyelitis of the foot in diabetes mellitus.
J Foot Ankle Surg.
1996;
35
280-283
- 4
Armstrong DG, Lavery LA, Harkless LB.
Who is at risk for diabetic foot ulceration?.
Clinics in Podiatric Medicine and Surgery.
1998;
15
11-19
- 5
Armstrong DG, Nguyen HC.
Improvement in healing with aggressive edema reduction after debridement of foot infection
in persons with diabetes.
Arch Surg.
2000;
135
1405-1409
- 6
Armstrong DG, Lavery LA, Abu-Rumman P, Espensen EH, Vazquez JR, Nixon BP, Boulton AJ.
Outcomes of subatmospheric pressure dressing therapy on wounds of the diabetic foot.
Ostomy Wound Manage.
2002;
48
64-68
- 7
Barnett SJ, Shield JPH, Potter MJ, Baum JD.
Foot Pathology in Insulin Dependent Diabetes.
Archives of Disease in Childhood.
1995;
73
151-153
- 8
Borssen B, Bergenheim T, Lithner F.
The epidemiology of foot lesions in diabetic patients aged 15-50 years.
Diabet Med.
1990;
7
438-444
- 9
Boulton AJM.
The Pathogenesis of Diabetic Foot Problems: an Overview.
Diabet Med.
1996;
13
12-16
- 10
Boyko EJ, Ahroni JH, Stensel V.
A Prospective Study of Risk Factors for Diabetic Foot Ulcer.
The Seattle Diabetic Foot Study. Diabetes Care.
1999;
22
1036-1042
- 11
Calle-Pascual AL, Redondo MJ, Ballesteros M.
Nontraumatic lower extremity in diabetic and nondiabetic subjects in Madrid, Spain.
Diabet Metab.
1997;
23
519-523
- 12
Cavanagh PR, Ulbrecht JS, Caputo GM.
The Non-Healing Diabetic Foot Wound: Fact or Fiction?.
Ostomy Wound Management.
1998;
44
6S-12S
- 13
Chantelau E, Tanudjaja T, Altenhöfer F, Ersanli Z, Lacigova S, Metzger C.
Antibiotic treatment for uncomplicated neuropathic forefoot ulcers in diabetes: a
controlled trial.
Diabet Med.
1996;
13
156-159
- 14
Cunha BA.
Antibiotic selection for diabetic foot infections: a review.
J Foot Ankle Surg.
2000;
39
253-257
- 15
Edelson GW, Armstrong DG, Lavery LA, Caicco G.
The acutely infected diabetic foot is not adequately evaluated in an inpatient setting.
Arch Intern Med.
1996;
156
2373-2378
- 16
Edmonds ME, Blundell MP, Morris ME, Thomas EM, Cotton LT, Watkins PJ.
Improved survival of the diabetic foot: the role of a specialised foot clinic.
QJ Med New Series.
1986;
60
763-771
- 17
Faglia E, Favales F, Aldeghi A, Calia P, Quarantiello A, Oriani G, Michael M, Campagnoli P,
Morabito A.
Adjunctive systemic hyperbaric oxygen therapy in treatment of severe prevalently ischemic
diabetic foot ulcer. A randomized study.
Diabetes Care.
1996;
19
1338-1343
- 18 Graninger W. Die Infektion beim diabetischen Fuß. Antibiotika Monitor 2001: 17
- 19
Grayson ML, Gibbons GW, Habershaw GM.
Use of ampicillin/sulbactam versus imipenem/cilastatin in the treatment of limb-threatening
foot infections in diabetic patients.
Clin Infect Dis.
1994;
18
683-693
- 20
Grayson ML, Gibbons GW, Balogh K.
Probing to bone in infected pedal ulcers. A clinical sign of underlying osteomyelitis
in diabetic patients.
JAMA.
1995;
273
721-723
- 21
Heller G, Günster C, Schellschmidt H.
Wie häufig sind Diabetes-bedingte Amputationen unter Extremitäten in Deutschland?
Eine Analyse auf Basis von Routinedaten.
Dtsch Med Wochenschr.
2004;
129
429-433
- 22
Hirschl M, Hirschl AM.
Bacterial flora in mal perforant and antimicrobial treatment with ceftriaxone.
Chemotherapy.
1992;
38
275-280
- 23 International Consensus Working Group .International consensus on diagnosing and
treating the infected diabetic foot 2003
- 24
Kumar S, Ashe HA, Parnell LN.
The prevalence of foot ulceration and its correlates in type 2 diabetic patients:
a population based study.
Diabet Med.
1994;
11
480-484
- 25
Lavery LA, Armstrong DG, Vela SA, Quebedeaux TL, Fleischli JG.
Practical criteria for screening patients at high risk for diabetic foot ulceration.
Arch Intern Med.
1998;
15
157-162
- 26
Leslie CA, Sapico FL, Ginunas VJ, Adkins RH.
Randomized controlled trial of topical hyperbaric oxygen for treatment of diabetic
foot ulcers.
Diabetes Care.
1988;
11
111-115
- 27
Lipsky BA.
Osteomyelitis of the foot in diabetic patients.
Clin Infect Dis.
1997;
25
1318-1326
- 28
Lipsky BA, Baker PD, Landon GC, Fernau R.
Antibiotic therapy for diabetic foot infections: comparison of two parental-to-oral
regimens.
Clin Infect Dis.
1997;
24
643-648
- 29
Lipsky BA, Pecoraro RE, Larson SA, Ahroni JH.
Outpatient management of uncomplicated lower- extremity infections in diabetic patients.
Arch Intern Med.
1990;
150
790-797
- 30
Litzelman DK, Marriot DJM, Vinicor F.
Independent physiological predictors of foot lesions in patients with NIDDM.
Diabetes Care.
1997;
20
1273-1278
- 31
Madani SF, Stammler C, Muller UA.
The frequency of lower-limb amputations in people with diabetes in the German state
of Thuringia.
Diabetes und Stoffwechsel.
1999;
8
201-206
- 32 Maier A, Legal F, Dittrich P, Schintler M, Tomaselli F, Koch H, Müller M, Smolle-Jüttner FM.
Interstitieller Konzentrationsverlauf von Fosfomycin bei Patienten mit schwerer Weichteilinfektion
- erste Mikrodialyse-Ergebnisse. Antibiotika Monitor 2000: 16
- 33
McCallon SK, Knight CA, Valiulus JP, Cunningham MW, McCulloch JM, Farinas LP.
Vacuum-assisted closure versus saline-moistened gauze in the healing of postoperative
diabetic foot wounds.
Ostomy Wound Manage.
2000;
46
28-32
- 34
MacFarlane RM, Jeffcoate WJ.
Factors contributing to the presentation of diabetic foot ulcers.
Diabetic Med.
1997;
14
867-870
- 35
McNeely MJ, Boyko EJ, Ahroni JH.
The independent contributions of diabetic neuropathy and vasculopathy in foot ulceration.
Diabetes Care.
1995;
18
216-219
- 36
Morbach S, Müller E, Reike H, Risse A, Spraul M.
Diagnostik, Therapie, Verlaufskontrolle und Prävention des diabetischen Fußsyndroms.
Diabetes und Stoffwechsel.
2004;
13
9-30
- 37
Murray HJ, Young MJ, Hollis S, Boulton AJM.
The Association Between Callus Formation, High Pressure and Neuropathy in Diabetic
Foot Ulceration.
DiabetMed.
1996;
13
979-982
- 38
O'Meara SM, Cullum NA, Majid M, Sheldon TA.
Systematic review of antimicrobial agents used for chronic wounds.
Br J Surg.
2001;
88
4-21
- 39
Pittet D, Wyssa B, Herter-Clavel C, Kursteiner K, Vaucher J, Lew PD.
Outcome of diabetic foot infections treated conservatively. A retrospective cohort
study with long-term follow-up.
Arch Intern Med.
1999;
159
851-856
- 40
Ramsey SC, Newton K, Blough D.
Incidence, Outcomes, and cost of foot ulcers in Patients with Diabetes.
Diabetes Care.
1999;
22
382-387
- 41
Reiber GE, Vileikyte L, Boyko EJ.
Causal Pathways for Incident Lower-Extremity Ulcers in Patients with Diabetes from
two Settings.
Diabetes Care.
1999;
22
157-162
- 42 Scherbaum WA. Online-Interview zur Zahl der Diabetiker in Deutschland. Deutsches
Diabetes-Zentrum 2005
- 43
Senneville E, Yazdanpanah Y, Cazaubiel M.
Rifampicin-ofloxacin oral regimen for the treatment of mild to moderate diabetic foot
osteomyelitis.
J Antimicrob Chemotherap.
2001;
48
927-930
- 44
Spraul M, Schönbach AM, Mühlhauser I, Berger M.
Amputationen und Mortalität bei älteren, insulinpflichtigen Patienten mit Typ 2-Diabetes.
Zentralbl Chir.
1999;
124
25-31
- 45
Stiegler H, Standl E, Frank S, Mendler G.
Failure of reducing lower extremity amputations in diabetic patients: results of two
subsequent population based surveys in 1990 and 1995 in Germany.
Vasa.
1998;
27
10-14
- 46
Tentolouris N, Jude EB, Smirnof I, Knowles EA, Boulton AJM.
Methicillin-resistant Staphylococcus aureus: an increasing problem in a diabetic foot
clinic.
Diabet Med.
1999;
16
767-771
- 47
Tooke JE, Brash PD.
Microvascular Aspects of Diabetic Foot Disease.
Diabet Med.
1996;
13
26-29
- 48
Trautner C, Standl E, Haastert B, Giani G, Berger M.
Geschätzte Anzahl von Amputationen in Deutschland.
Diabetes und Stoffwechsel.
1997;
6
199-202
- 49
Van Houtum WH, Lavery LH, Harkless LB.
The impact of diabetes-related lower extremity amputations in the Netherlands.
J Diabetes Compl.
1996;
10
325-330
- 50
Venkatesan P, Lawn S, Macfarlane RM, Fletcher EM, Finch RG, Jeffcoate WJ.
Conservative management of osteomyelitis in the feet of diabetic patients.
Diabet Med.
1997;
14
487-490
- 51
Vogel F, Bodmann KF. Expertenkommission der Paul-Ehrlich-Gesellschaft .
Empfehlungen zur kalkulierten Initialtherapie bakterieller Erkrankungen bei Erwachsenen.
Chemother J.
2004;
4
46-105
- 52
Wagner AH, Reike H, Angelkort B.
Highly resistant pathogens in patients with diabetic foot syndrome with special reference
to methicillin-resistant Staphylococcus aureus infections.
Dtsch Med Wochenschr.
2001;
126
1353-1356
- 53
Walters DA, Gatling W, Mullee MA.
The distribution and severity of diabetic foot disease: a community based study with
comparison to a non-diabetic group.
Diabetic Med.
1992;
9
354-358
- 54
Wheat LJ, Allen SD, Henry M.
Diabetic foot infections. Bacteriologic analysis.
Arch Intern Med.
1986;
146
1935-1940
Anschrift für die Verfasser
Dr. med. Christoph Lübbert
Klinik und Poliklinik für Innere Medizin I
Klinikum der Martin-Luther-Universität Halle-Wittenberg
Ernst-Grube-Str. 20
06120 Halle (Saale)
Telefon: 0345/557-2661
Fax: 0345/557-2253
eMail: christoph.luebbert@medizin.uni-halle.de
