Diabetic Foot Infection Update - University of Texas ...cme.uthscsa.edu/Update/Presentations/Friday/Diabetic Foot Infectio… · Diabetic Foot Infection Update Peter A Blume D.P.M.,F.A.C.F.A.S

Diabetic Foot Infection Diabetic Foot Infection UpdateUpdate

Peter A Peter A BlumeBlume D.P.M.,F.A.C.F.A.SD.P.M.,F.A.C.F.A.SAssistant Clinical Professor of Surgery Assistant Clinical Professor of Surgery OrthopaedicsOrthopaedics and Rehabilitation and and Rehabilitation and

AnesthesiaAnesthesiaYale School of MedicineYale School of Medicine

Yale New Haven HospitalYale New Haven HospitalNorth American Center for Limb North American Center for Limb

PreservationPreservation

Wound InfectionsWound InfectionsAcuteAcute–– BitesBites–– BurnsBurns–– CutsCuts–– TraumaTrauma–– Surgical Surgical

incisionsincisions

ChronicChronic–– Leg/foot ulcersLeg/foot ulcers–– Pressure soresPressure sores–– VenousVenous–– ArterialArterial–– DFUDFU–– Spider BitesSpider Bites

Sumpio,B.E.,Blume,P.A., Contemporary Management of Foot Ulcers, Trends in Vascular Surgery, Textbook by William H. Pierce, John S. Matsumura and James S.T.Yao; Chapter 28, 277 -- 290,Precept Press, Chicago Illinois, 12/02

4th Annual International External Fixation Symposium

December 11-14, 2008

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Defining Presence of InfectionDefining Presence of InfectionNonNon--infectedinfected–– Healthy granulation Healthy granulation

tissuetissue–– Absence of Absence of cellulitiscellulitis–– Skin lines presentSkin lines present

Infected: NonresistantInfected: Nonresistant–– Surrounding Surrounding cellulitiscellulitis–– PeriwoundPeriwound erythemaerythema–– EdemaEdema–– DrainageDrainage–– ExudateExudate

Resistant InfectionResistant Infection–– Low Quant countLow Quant count–– Rusty drainageRusty drainage–– Chronic WoundChronic Wound–– True ColonizerTrue Colonizer

IDSA Guidelines: Diabetic Foot InfectionIDSA Guidelines: Diabetic Foot Infection

History and History and physicalphysicalexaminationexamination

Serum chemistry Serum chemistry analyses and analyses and hematological hematological testingtesting

Assessment of Assessment of mental and mental and psychological statuspsychological status

Interviews with Interviews with family, friends, and family, friends, and health care health care professionalsprofessionals

Fever, chills, sweats, Fever, chills, sweats, vomiting, hypotension, vomiting, hypotension, and tachycardiaand tachycardia

Volume depletion, Volume depletion, azotemia, azotemia, hyperglycemia, hyperglycemia, tachypnea, tachypnea, hyperosmolality, acidosishyperosmolality, acidosis

Delirium, dementia, Delirium, dementia, depression, impaired depression, impaired cognition, and stuporcognition, and stupor

Self neglect, potential Self neglect, potential noncompliance, and lack noncompliance, and lack of home supportof home support

PatientPatient

Systemic response to Systemic response to infectioninfection

Metabolic stateMetabolic state

Psychological/cognitive Psychological/cognitive statestate

Social situationSocial situation

InvestigationsInvestigationsRelevant problems Relevant problems and observationsand observations

Level of evaluation, by Level of evaluation, by area(s) to be assessedarea(s) to be assessed

IDSA = Infectious Diseases Society of America. Lipsky BA et al. Clin Infect Dis. 2004;39:885–910.



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Classification of Diabetic Foot InfectionClassification of Diabetic Foot Infection

Wound lacking purulence or any manifestations of Wound lacking purulence or any manifestations of inflammationinflammation

Presence of Presence of ≥≥2 manifestations of inflammation (purulence, 2 manifestations of inflammation (purulence, erythema, pain, tenderness, warmth, or erythema, pain, tenderness, warmth, or indurationinduration), ), cellulitis/erythema extends cellulitis/erythema extends ≤≤2 cm around the ulcer, 2 cm around the ulcer, infection is limited to the skin or superficial subcutaneous infection is limited to the skin or superficial subcutaneous tissues; no other local complications or systemic illnesstissues; no other local complications or systemic illness

Infection (as above) in a patient who is systemically well, Infection (as above) in a patient who is systemically well, metabolically stable, has metabolically stable, has ≥≥1 of the following 1 of the following characteristics: cellulitis extending >2 cm, lymphangitic characteristics: cellulitis extending >2 cm, lymphangitic streaking, spread beneath the superficial fascia, deepstreaking, spread beneath the superficial fascia, deep--tissue abscess, gangrene, and involvement of muscle, tissue abscess, gangrene, and involvement of muscle, tendon, joint, or bone tendon, joint, or bone

Infection in patient with systemic toxicity or metabolic Infection in patient with systemic toxicity or metabolic instability (eg, fever, chills, tachycardia, hypotension, instability (eg, fever, chills, tachycardia, hypotension, confusion, vomiting, leukocytosis, acidosis, confusion, vomiting, leukocytosis, acidosis, hyperglycemia, or azotemia) hyperglycemia, or azotemia)

UninfectedUninfected 11

MildMild 22

ModerateModerate 33

SevereSevere 44

PEDISPEDISClinical manifestations of infectionClinical manifestations of infection SeveritySeverity gradegradeaa

Identification of Infecting Organism in Identification of Infecting Organism in Diabetic Foot Infection using Superficial Diabetic Foot Infection using Superficial vsvs

Deep CulturesDeep Cultures

*In three of these, the swabs also contained additional organism(s) not found in deep tissue.

Slater RA et al. Diabetic Med. 2004;21:705–709. Reprinted with permission from Blackwell Publishing.11 (18)11 (18)Swabs lacked organism(s) found in deep Swabs lacked organism(s) found in deep

tissue*tissue*

12 (20)12 (20)Swabs contained all organisms found in Swabs contained all organisms found in deep tissue plus additional organism(s)deep tissue plus additional organism(s)

37 (62)37 (62)Swabs and deep tissue cultures identicalSwabs and deep tissue cultures identical

36 (90)36 (90)13 (65)13 (65)

Found in deep tissueFound in deep tissueGrade 1 & 2Grade 1 & 2Grade 3Grade 3

49 (82)49 (82)Swabs contained all organismsSwabs contained all organisms

No. of wounds (%)No. of wounds (%)Correlation between swab and deep tissue Correlation between swab and deep tissue culturescultures

Study Design60 infected pedal wounds examined; 2 cultures taken from every wound

1. Superficial cultures prior to debridement2. Deep tissue cultures at the end of debridement



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Lipsky BA et al. Clin Infect Dis. 2004;39:885–910.

Pathogens Associated With Various Pathogens Associated With Various Clinical FootClinical Foot--Infection SyndromesInfection Syndromes

Mixed aerobic gramMixed aerobic gram--positive cocci, including positive cocci, including enterococcienterococci, , EnterobacteriaceaeEnterobacteriaceae, , nonfermentativenonfermentativegramgram--negative rods, and obligate anaerobesnegative rods, and obligate anaerobes

““Fetid footFetid foot””: extensive necrosis or gangrene, : extensive necrosis or gangrene, malodorousmalodorouscc

Aerobic gramAerobic gram--positive cocci (positive cocci (S aureusS aureus, , coagulasecoagulase--negative staphylococci, and negative staphylococci, and enterococcienterococci), ), diphtheroidsdiphtheroids, , EnterobacteriaceaeEnterobacteriaceae, , PseudomonasPseudomonasspecies, species, nonfermentativenonfermentative gramgram--negative rods, negative rods, and, possibly, fungiand, possibly, fungi

Long duration nonhealing wounds with Long duration nonhealing wounds with prolonged, broadprolonged, broad--spectrum antibiotic spectrum antibiotic therapytherapyc,dc,d

Pseudomonas aeruginosaPseudomonas aeruginosa (often in combination (often in combination with other organisms)with other organisms)

Ulcer that is macerated because of Ulcer that is macerated because of soakingsoakingcc

S S aureusaureus, , ßß--hemolytic streptococcushemolytic streptococcus, and , and EnterobacteriaceaeEnterobacteriaceae

Infected ulcer that is chronic or was previously Infected ulcer that is chronic or was previously treated with antibiotic treated with antibiotic therapytherapycc

S S aureusaureus and and ßß--hemolytic hemolytic streptococcusstreptococcusaaInfected ulcer and antibiotic Infected ulcer and antibiotic nanaïïvevebb

ßß--hemolytic hemolytic streptococcusstreptococcusaa and and Staphylococcus Staphylococcus aureusaureus

Cellulitis without an open skin woundCellulitis without an open skin wound

PathogensPathogensFootFoot--Infection SyndromeInfection Syndrome

PseudomonasPseudomonas** in Diabetic Foot Infectionsin Diabetic Foot InfectionsP aeruginosaP aeruginosa may be an may be an ““environmentalenvironmental”” pathogenpathogen1 1

P aeuruginosaP aeuruginosa has, however, been associated with the has, however, been associated with the following footfollowing foot--infection syndromesinfection syndromes22::–– Ulcer that is macerated because of soakingUlcer that is macerated because of soaking–– Long duration nonhealing wounds with prolonged, broadLong duration nonhealing wounds with prolonged, broad--

spectrum antibiotic therapyspectrum antibiotic therapy

In 2 multicenter clinical trials in patients with diabetic foot In 2 multicenter clinical trials in patients with diabetic foot infections:infections:–– 9% of 473 specimens were 9% of 473 specimens were P aeruginosaP aeruginosa and only 5% of and only 5% of

those were pure culturesthose were pure cultures33

–– In the second studyIn the second study, Pseudomonas , Pseudomonas species were recovered species were recovered from 7% (27/361) of patientsfrom 7% (27/361) of patients44

1. Lipsky BA et al. Lancet. 2005;366:1695–1703.2. Lipsky BA et al. Clin Infect Dis. 2004;39:885–904.3. Citron DM et al. Bacteriology of diabetic foot infections (DFI): 1640 isolates from 473 specimens [abstract]. IDSA; 2005.4. Lipsky BA et al. Clin Infect Dis. 2004;38:17–24.



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Antibiotic Therapy in Diabetic Foot Antibiotic Therapy in Diabetic Foot InfectionsInfections

Factors that may influence antibiotic treatment Factors that may influence antibiotic treatment of diabetic foot infectionsof diabetic foot infections

Lipsky BA. Clin Infect Dis. 2004;39:S104–S114.

– Gastrointestinal absorption impairment

– Drug toxicity potential– Local antibiotic

susceptibility data– Formulary and cost

considerations– Patient preferences– Published efficacy data

– Clinical severity of infection

– Etiologic agent(s) (known or presumed)

– Recent antibiotic therapy– Vascular status at infected

site– Allergies to antibiotics– Renal or hepatic

insufficiency

IDSA GuidelinesIDSA GuidelinesRoute and agent MildRoute and agent Mild Moderate SevereModerate SevereAdvised routeAdvised route Oral Oral Oral/Oral/parenteralparenteral IVIV

DicloxacillinDicloxacillin yesyesClindamycinClindamycin yesyesCephalexinCephalexin yesyesTrimethoprimTrimethoprim--SulfamethoxazoleSulfamethoxazole yesyes yesyesAmoxicillinAmoxicillin--clavulanateclavulanate yesyes yesyesLevofloxacinLevofloxacin yesyes yesyesCefoxitinCefoxitin yesyesCeftriaxoneCeftriaxone yesyesAmpicillin/sulbactamAmpicillin/sulbactam yesyes



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IDSA GuidelinesIDSA GuidelinesRoute and Route and agent(sagent(s) ) ModerateModerate SevereSevereAdvised routeAdvised route Oral/Oral/parenteralparenteral IVIV

LinezolidLinezolidaa ±± aztreonamaztreonam yesyesDaptomycinDaptomycinaa ±± aztreonamaztreonam yesyesErtapenemErtapenem** yesyesCefuroximeCefuroxime ±± metronidazolemetronidazole yesyesTicarcillin/clavulanateTicarcillin/clavulanate yesyesPiperacillin/tazobactamPiperacillin/tazobactam** yesyes yesyesLevofloxacinLevofloxacin or Ciprofloxacin yesor Ciprofloxacin yes yesyes

with with clindamycinclindamycinImipenemImipenem--cilastatincilastatin yesyesVancomycinVancomycinaa and and ceftazidimeceftazidime yesyes

±± metronidazolemetronidazole

Resistant PathogensResistant PathogensMRSAMRSAVREVRESPACESPACE–– SSerratia erratia marcescensmarcescens–– PPseudomonas seudomonas aeruginosaaeruginosa–– AAcinetobactercinetobacter–– CCitrobacter itrobacter –– EEnterobacternterobacter

BukholderiaBukholderia



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Poor Wound HealingPoor Wound Healing

Host ResistanceHost Resistance–– ImmunocompromisedImmunocompromised–– NeutropenicNeutropenic–– HIVHIV–– MalnourishedMalnourishedSystemic FactorsSystemic Factors–– PVD/PADPVD/PAD–– Venous Venous InsuffiencyInsuffiency–– Poorly controlled DMPoorly controlled DM–– EtohEtoh

Where is Wound Management & Where is Wound Management & Infection Infection controlcontrol Best Served ?Best Served ?

HospitalsHospitals–– MultidrugMultidrug--resistant gram negative resistant gram negative

bacteriabacteria–– MRSAMRSA–– VRSAVRSA

Hospitals are breeding grounds Hospitals are breeding grounds Home is the best place for wound Home is the best place for wound managementmanagement



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Bacterial Affect on Wound CareBacterial Affect on Wound Care

BacterialBacterial–– QuantityQuantity–– QualityQuality–– VirulenceVirulence

Gram Positive Bacteria Gram Positive Bacteria produce virulence factorsproduce virulence factors

–– BiofilmsBiofilms–– AdhesinsAdhesins–– Polysaccharide capsulesPolysaccharide capsules

Bacteria become indestructibleBacteria become indestructible

Local Factors : Affect Wound HealingLocal Factors : Affect Wound Healing

Size of woundSize of woundDepth of woundDepth of woundChronicityChronicityLocationLocationForeign BodyForeign BodyAmount of necrosisAmount of necrosis



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Bacterial ContaminationBacterial Contamination

Bacterial colony counts are low but Bacterial colony counts are low but negatively impact wound healingnegatively impact wound healing–– Virulence factorsVirulence factors

ExotoxinsExotoxinsEndotoxinsEndotoxinsMetalloproteinasesMetalloproteinases

MRSA in low quantities will prevent MRSA in low quantities will prevent granulation tissue formationgranulation tissue formationColonized but not infected: May not healColonized but not infected: May not healTissue bacteria levels of 10(5)=Impaired Tissue bacteria levels of 10(5)=Impaired Wound Wound Healing,PoorHealing,Poor STSG TakeSTSG Take

Wound Infection from ContaminationWound Infection from ContaminationDeeper woundsDeeper wounds–– Rate of Rate of BacteremiaBacteremia is 10is 10--20% of 20% of severlyseverly

infected woundsinfected woundsObjective evaluation; Problematic because Objective evaluation; Problematic because wounds may or wounds may or maynotmaynot appear infectedappear infectedConcordance rates with swab Concordance rates with swab culutresculutres and and true pathogens is less than 60%true pathogens is less than 60%Needle Aspirate: 69% sensitiveNeedle Aspirate: 69% sensitiveDeep tissue curettage: 75% sensitiveDeep tissue curettage: 75% sensitiveAntibitioticsAntibitiotics used incorrectly 25used incorrectly 25--40% 40% hypotheticallyhypothetically



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SCOPE Study: SCOPE Study: NoscomialNoscomial bloodstream infections bloodstream infections in US hospitals: Analysis of 24,179 cases from a in US hospitals: Analysis of 24,179 cases from a

prospective nationwide surveillance studyprospective nationwide surveillance study

Wisplinghoff et al: CID: 2004;39(3):309Wisplinghoff et al: CID: 2004;39(3):309--31731760% gram + 60% gram + –– 31% 31% CoagCoag negneg staphstaph–– 20% 20% StaphStaph AureusAureus–– 9.5% Enterococcus9.5% Enterococcus

CandidaCandidaGram Negative rodsGram Negative rods–– EcoliEcoli–– Pseudomonas Pseudomonas aeruginosaaeruginosa–– KlebsiellaKlebsiella pneumoniapneumonia–– EnterobacterEnterobacter

Antimicrobial Resistance DevelopmentAntimicrobial Resistance Development

Overuse/Abuse of systemic antibioticsOveruse/Abuse of systemic antibiotics–– MutationMutation–– BiofilmBiofilm productionproduction

Secondary resistanceSecondary resistanceTransfer of genetic materialTransfer of genetic material–– VRSA VRSA aquiredaquired vanAvanA gene from VREgene from VRE

Selective pressure: closed system Selective pressure: closed system overuse(hospitalsoveruse(hospitals))–– FluoroquinolonesFluoroquinolones=MRSA=MRSA–– CephalosporinsCephalosporins==EnterococciEnterococci



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MRSAMRSAVersatile and VirulentVersatile and VirulentMischief to the hostMischief to the hostTriggers inflammatory cascade in the hostTriggers inflammatory cascade in the hostGenotypicallyGenotypically different CAMRSA different CAMRSA vsvs HAMRSAHAMRSAIncreased morbidity/Cost of treatmentIncreased morbidity/Cost of treatmentUSA 100/200: HAUSA 100/200: HA--MRSA I,II,IIIMRSA I,II,IIIUSA 300: CAUSA 300: CA--MRSA IVMRSA IV--PVL+PVL+MRSA Resistance; MRSA Resistance; MecMec--A GeneA GenePVLPVL-- 2 proteins: Increased morbidity2 proteins: Increased morbidity

MRSAMRSA--SubtypesSubtypesI I HA(HealthcareHA(Healthcare Associated)Skin/RespAssociated)Skin/RespII II HA(HealthcareHA(HealthcareAssociated)Skin/RespAssociated)Skin/RespIIIHA(HealthcareIIIHA(HealthcareAssociated)Skin/RespAssociated)Skin/RespIV IV CA(CommunityCA(Community Acquired)SkinAcquired)Skin/Soft/SoftV V CA(CommunityCA(Community Acquired)SkinAcquired)Skin/Soft/Soft



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Mechanism of Antimicrobial Mechanism of Antimicrobial ResistanceResistance

Pathogen Fitness; Ability of Pathogen Fitness; Ability of bacteria to bacteria to survive,growsurvive,grow, and , and thrivethriveVirulence; Ability of bacteria to Virulence; Ability of bacteria to cause damage to the hostcause damage to the hostBacterial resistance increases Bacterial resistance increases the fitness of a pathogenthe fitness of a pathogenCompensatory mechanisms Compensatory mechanisms restore fitness to the restore fitness to the pathogens and make them pathogens and make them more virulentmore virulent

Resistance VirulenceResistance Virulence

Activity of efflux pumps & Activity of efflux pumps & therefore therefore extracellularextracellularconcentration of enzymes and concentration of enzymes and virulence toxinsvirulence toxinsMRSA: Genetically distinct pathogenMRSA: Genetically distinct pathogenCAMRSA: CAMRSA: PantonPanton--Valentine Valentine leukocidinleukocidin locuslocusHAMRSA: HAMRSA: ExotoxinExotoxin--DD



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Six Risk Factors Six Risk Factors IndependentlyIndependently Associated Associated With MRSA InfectionWith MRSA Infection11

Previous Previous hospitalizationhospitalization–– Within the last 12 monthsWithin the last 12 months

Longer LOS before Longer LOS before infectioninfectionSurgerySurgeryEnteralEnteral feedingsfeedingsLevofloxacinLevofloxacin useuseMacrolideMacrolide use use

1. Graffunder EM et al. J Antimicrob Chemother, 2002; 49:999-1005.

The Negative Impact of Resistant The Negative Impact of Resistant Bacterial Strains on Limb PreservationBacterial Strains on Limb Preservation



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MRSA infection spreads by sexMRSA infection spreads by sexStudy discovers Study discovers new new means of means of

transmissiontransmission

By Anita Manning USATODAYBy Anita Manning USATODAYA virulent, drugA virulent, drug--resistant form of resistant form of staphstaph bacteria that has bacteria that has spread across the USA since it was identispread across the USA since it was identi--fied in 2000 fied in 2000 can be spread by sexual activity, a mode of transmission can be spread by sexual activity, a mode of transmission that is "important and previthat is "important and previ--ously unrecognized," a study ously unrecognized," a study shows.shows.Scientists at Columbia University Medical Center, Scientists at Columbia University Medical Center, reporting in the Feb. 1 issue of Clinical reporting in the Feb. 1 issue of Clinical Infectious Infectious Diseases, Diseases, identified three cases in which the bacteidentified three cases in which the bacte--ria ria known as communityknown as community--associated MRSA passed between associated MRSA passed between sexual partners.sexual partners.

MRSA infection spreads by sexMRSA infection spreads by sexStudy discovers Study discovers new new means of transmissionmeans of transmission

The report is the first to document the spread of MRSA The report is the first to document the spread of MRSA through heterosexual activity, says Rachel through heterosexual activity, says Rachel GorwitzGorwitz of the of the Centers for Disease Control and PreCenters for Disease Control and Pre--vention.vention."MRSA is transmit"MRSA is transmit--ted by direct skinted by direct skin--toto--MRSA MRSA infectionsinfectionsTheThe exact number of infections caused exact number of infections caused by MRSA, or by MRSA, or methidlmethidl--. . linlin--resistant resistant StaphyStaphy--lococcuslococcusaureusaureus, is unknown, but a CDC study estimated in 1999, is unknown, but a CDC study estimated in 1999--2000, nearly 126,000 people were hospitalized each year 2000, nearly 126,000 people were hospitalized each year for MRSA for MRSA infections.Sourceinfections.Source: USA TODAY : USA TODAY researchskinresearchskincontact," she says, "so it's not surprising it could be contact," she says, "so it's not surprising it could be transmitted during sex."transmitted during sex."



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MRSA: 3 Different StrainsMRSA: 3 Different Strains

VISA/GISAVISA/GISA–– VancomycinVancomycin--intermediate S intermediate S aureusaureus–– GlycopeptideGlycopeptide intermediate S intermediate S aureusaureus

VRSAVRSA–– VancomycinVancomycin--resistant S resistant S aureusaureus

HRHR--VISAVISA–– HeteroresistanceHeteroresistance

Vancomycin LimitationsVancomycin LimitationsSlow bactericidal activitySlow bactericidal activityPoor tissue penetrationPoor tissue penetrationRising Rising MICsMICs against MRSAagainst MRSA–– MRSA/MRSA/VancoVanco creepcreep

Insufficient dosingInsufficient dosing–– Normal Normal vancovanco MIC .25MIC .25--1ug/ml1ug/ml

Can be Can be nephrotoxic(combonephrotoxic(combo drugs)drugs)VISA/GISA VISA/GISA strains(MICsstrains(MICs 4ug/ml4ug/ml--8ug/ml)8ug/ml)–– VancoVanco or or glycopeptideglycopeptide

VRSA VRSA strains(MICsstrains(MICs > 32ug/ml) > 32ug/ml) vanAvanA genegeneHeteroresistanceHeteroresistance in MRSA(VISA disguised as MRSA)in MRSA(VISA disguised as MRSA)



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Enterococcus: Super BugEnterococcus: Super Bug

Multiple forms of Multiple forms of resistanceresistanceCause of VRSACause of VRSA30% Mortality rates30% Mortality rates

Drugs for SSSI Due to MRSADrugs for SSSI Due to MRSAZyvox;Linezolid(PfizerZyvox;Linezolid(Pfizer--Pharmacia)Pharmacia)Cubicin;Daptomycin(CubistCubicin;Daptomycin(Cubist))Synercid;Quinupristin/DalfopristinSynercid;Quinupristin/Dalfopristin (Monarch)(Monarch)VancomycinVancomycinTygacil:TigecyclineTygacil:TigecyclineDalbavancin: Dalbavancin: ZevenZevenIclaprimIclaprim: : ArvideArvide PharmPharm: Similar to : Similar to TrimethoprimTrimethoprimTelavancinTelavancin: : TheravanceTheravance: : AstellasAstellas PharmPharmCeftobiproleCeftobiprole: : BasilealBasileal

Eliopoulos GM. Clin Infect Dis. 2003;36:473-481. Rybak MJ. J Hosp Infect. 2001;49 (suppl A):S25-S32.Eisenstein BI. Expert Opin. Investig. Drugs. 2004;13:1159-69



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Recurrent MRSA Recurrent MRSA InfectionsInfections



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SUMMARYSUMMARYPrompt DiagnosisPrompt DiagnosisAppropriate HistoryAppropriate HistoryDeescalationDeescalationTherapyTherapyDeep CulturesDeep CulturesCarrier StateCarrier StateBacterial Reduction Bacterial Reduction –– Latent wound Latent wound

closureclosureChoicesChoices



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Diabetic Foot Infection Update - University of Texas ...cme.uthscsa.edu/Update/Presentations/Friday/Diabetic Foot Infectio… · Diabetic Foot Infection Update Peter A Blume D.P.M.,F.A.C.F.A.S