Osteomyelitis in the Diabetic Patient

Management OF OSTEOMYELITIS IN THE DIABETIC PATIENT

Osteomyelitis is an infection of the bone or bone marrow which is typically categorized as acute, subacute or chronic.1 It is characteristically defined according to the basis of the causative organism (pyogenic bacteria or mycobacteria) and the route, duration and physical location of the infection site.2 Infection modes usually take one of three forms: direct bone contamination from an open fracture, puncture wound, bone surgery, total joint replacement, or traumatic injury; extension of a soft tissue infection such as a vascular ulcer; or hematogenous (blood borne) spread from other infected areas of the body such as the tonsils, teeth or the upper respiratory system.2(p807) Bacteria such as Staphylococcus aureus, Pseudomonas, Klebsiella, Salmonella, and Escherichia coli are the most common causative agents of the disease, although viruses, parasites and fungi may also lead to the development of osteomyelitis.3

Patients most at risk are the elderly, obese, and malnourished, as well as those suffering from impaired immune systems or chronic illness such as rheumatoid arthritis.3(p348) Other risk factors include long-term skin infections, arteriosclerosis, high blood pressure, cigarette smoking, and high cholesterol, intravenous drug use, sickle cell anemia and cancer. 4 The disease is very common in diabetic patients.5

This case study examines osteomyelitis in the diabetic patient and includes an in-depth look at a diabetic patient that has obtained a foot wound. Over time, the foot wound stalled, became chronic and resisted healing. Eventually, this led to infection which reached the bone, resulting in osteomyelitis. This hypothetical study illustrates that an effective nursing management plan can help diabetic patients facing this condition avoid complications and painful, expensive and intrusive surgeries.6 In extreme cases, the disease can even lead to amputation. The occurrence of osteomyelitis in diabetics can be avoided with routine medical attention and simple and proper patient education.

Osteomyelitis in the Diabetic Patient

There are roughly 14 million diabetics in the United States.5(p1019) Foot complications are among the most serious and costly complications of diabetes.6(p236) 15-25% of diabetics will have a foot ulcer in their lifetime.7 For 14-24%, this will lead to amputation of all or part of a lower extremity.2(p806)

Diabetic foot lesions frequently result from two or more risk factors occurring together. In the majority of patients, diabetic peripheral neuropathy plays a central role: up to 50% of people with Type 2 diabetes have neuropathy and at-risk feet.2(p810) Neuropathy leads to insensitive and sometimes deformed foot and bony prominences, often resulting in an abnormal walking pattern and foot loading. In people with neuropathy, minor trauma – caused for example by ill-fitting shoes, walking barefoot or an acute injury – can precipitate a chronic foot ulcer.8 Loss of sensation and limited joint mobility can also result in the abnormal biomechanical loading of the foot and the formation of calluses. Calluses further contribute to the patient’s discomfort and increase abnormal weight loading which often results in subcutaneous hemorrhage.7(p17) Whatever the primary causes, should a patient continue walking on an insensitive foot, healing will be impaired. The breakdown of skin often leads to a deep foot infection with osteomyelitis.3(p349)

Symptoms and Complications

The onset of osteomyelitis can be sudden. Clinical manifestations include chills, high fever, rapid pulse, and general malaise.9 Osteomyelitis can be difficult to treat, especially if it is undetected at its onset. Systemic symptoms are often more prevalent than local symptoms. As the infection spreads through the cortex of the bone it involves the periosteum and soft tissue.2(p811) This often results in swelling, pain and tenderness for the patient. Many patients describe a “continuous, throbbing pain” that may intensify with movement due to collecting pus.4(pS20) Once bone has become infected, pus is produced within the bone creating an abscess that deprives the bone of its blood supply.

Infection in a diabetic foot presents a direct threat to the affected limb, and should be treated promptly and actively.4(pS21) Signs and/or symptoms of infection, such as fever, pain or increased white blood counts, are often absent. However, if infection is present, substantial tissue damage and risk of osteomyelitis is likely.

Diagnosis

The diagnosis of osteomyelitis is based primarily on clinical findings, with data from personal history, physical examination and laboratory tests also being considered in treatment plans.9(p886) Leukocytosis and elevations in the erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level may be noted. Blood cultures or bone biopsies are also used to inform diagnosis.

Many diabetic patients complain of sensory loss. Healthcare practitioners can assess neuropathy using techniques such as pressure perception (i.e., Semmes-Weinstein monofilaments), vibration perception (i.e., 128 Hz tuning fork), discrimination (i.e., pinprick without skin penetration), tactile sensation (i.e., cotton wisp on the dorsum of foot), and Achilles tendon reflexes.9(p888-890) Sensory exams are generally conducted in relaxed settings, normally with patients in reclined positions with feet elevated for proper inspection. When patients fail to protectively respond to two out of three applications of any method, the patient is considered at high risk of ulceration and perhaps osteomyelitis, particularly if this is in combination with other risk factors.3(p349)

Radiographic evidence often provides the clearest diagnostic evidence of the disease, highlighting bone destruction by osteomyelitis.11(p38) However, indications may not appear until roughly two weeks after the start of infection. The radiographs may reveal osteolysis or periosteal reaction.4(pS21) In severe cases, sequestra can occur — a condition in which segments of necrotic bone separate from living bone creating an opportunistic environment for microorganism growth.10 This can lead to chronic osteomyelitis. A bone abscess uncovered during the subacute or chronic stage of hematogenous osteomyelitis is known as a Brodie’s abscess which can require drainage.7(p18)

Treatment

The primary objective of treatment is to eliminate the infection and prevent escalation and recurrence.9(p901) Prompt treatment prevents further bone deformity and injury and restores comfort to the patient. It can also circumvent the complications of impaired mobility. Treatment of osteomyelitis is dependent upon the severity of the clinical manifestations — how the infection has spread to the bone and how deeply it has penetrated. In less severe cases and with early diagnosis, treatment with oral antibiotic medications in high doses proves quite effective.2(p808) Fine needle aspirations of the area surrounding infected bones may be taken for lab cultures to aid physicians in making an official diagnosis and selecting the appropriate antibiotic. Antiviral and antifungal treatment plans may be needed if the causative agent is determined not to be bacterial. Regardless, timely therapy is essential to recovery. Once the bone’s blood supply has been compromised, re-infection can occur which decreases the likelihood of success with any non-surgical treatment.9(p902)

In dangerous cases, patients may begin initial treatment with intravenous antibiotics and then switch to oral antibiotic pills once the infection has subsided.2(p812) In addition, the buildup of pus may need to be drained by surgery or needle aspiration, and any surrounding soft tissue that has been impacted may require surgical removal. Resulting tissue voids are then filled with healthy bone, muscle, or skin grafts before antibiotics are administered. Infected artificial joints may require surgical removal and replacement. Antibiotics are usually given before and after surgery. When the infection cannot be cured, the infected limb may need to be amputated or the joint fused with surgery. The duration of treatment plans can range from 4 to 6 weeks.6(p227) Exceptions include infections of the spinal vertebrae, which necessitate a 6- to 8-week treatment.

In diabetic patients, foot ulcers can spread to the bones of the feet and result in infections that are difficult to cure with antibiotics alone.5(p1020) Diabetic patients with advanced cases of osteomyelitis may face the surgical removal of the infected extremity. This is the chief reason diabetic patients should engage in proper foot care and follow all diet and treatment plans to control blood sugar levels, stabilizing them within normal ranges.4(pS22) Ulcers and osteomyelitis may not be successfully treated when uncontrolled diabetes is a factor.

Case Study — Patient B

Patient B. is an African-American male from Chicago, Illinois suffering for diabetes. He is 65 years of age. He lives alone and is retired from the Burlington Northern Railroad where he served as a Railroad Safety Inspector for more than 25 years. He has a history of metabolic syndrome including Type 2 diabetes mellitus (T2DM), which he has been living with for over 10 years. He also has hypertension and is overweight. His family history indicates susceptibility to T2DM with the disease occurring in both the maternal and paternal families. A combination high calorie diet and sedentary lifestyle due to a back injury prior to his retirement have contributed to his weight gain in recent years. He also complains of occasional bouts of insomnia and general fatigue. His diabetes is managed with oral medication taken daily, as well as a recommended diet and exercise plan – although the management plan is rarely followed.

Patient B. was recently admitted for medical care due to sudden swelling in the left lower leg and complaints of a tingling sensation in the left foot. Six months prior to admission, he stepped on a small piece of broken glass and sustained a small puncture wound on the bottom of his left foot. He ignored the lesion believing it was only a minor injury. No consultation or treatment was carried out. Within three weeks, the leg swelling and a high grade fever raised concerns and prompted him to seek medical attention.

A physical examination confirmed bone tenderness and tissue inflammation. A battery of tests including blood cultures revealed elevated white blood cell counts and an increased ESR. Patient B’s CRP test was positive. Finally, a bone x-ray led to an official diagnosis of osteomyelitis. The patient went on to receive several rounds of antibiotic therapy. A solid nursing management plan was instituted to help alleviate pain and remedy the condition. A fairly early diagnosis and swift implementation of the treatment plan played a vital role in his successful recovery. Subsequent patient education lowered the risk of reoccurrence.

Patient B – Nursing Management Plan

In developing a nursing management plan for diabetic patients with osteomyelitis, it is important to begin with very specific goals that address patient’s needs and also create the best possible scenario for avoiding reoccurrence. Customary goals are to relieve pain, improve physical mobility, control or eradicate infection and develop a treatment regimen to prevent the recurrence of problems.5(p1021) Patient B’s plan includes the following:

TABLE 1-5 — NURSING INTERVENTIONS FOR PATIENT B

Relief of pain

Immobilize the affected part with a temporary splint to decrease pain.

Monitor the neurovascular status of the affected extremity.

Elevate the affected part to reduce swelling and associated discomfort.

Administer analgesics as prescribed.

Improving physical mobility

The bone is weakened by the infective process and must be protected by immobilization devices and by avoidance of stress on the bone.

Gently place the joints above and below the affected part of the foot through their range of motion. Encourage full participation in activities of daily living (ADLs) to promote general well-being.

Eliminate infection

Monitor the patient’s response to antibiotic therapy.

Observe the IV access site for evidence of phlebitis or infection

Monitor the general health and nutrition of the patient. A diet high in protein and vitamin C promotes healing.

With long-term, intensive antibiotic therapy, monitor the patient for signs of superinfection (e.g., oral candidiasis or foul-smelling stools).

Encourage adequate hydration.

Treatment & Prevention Knowledge

Teach the patient and family the importance of strictly adhering to the therapeutic regimen of antibiotics and preventing falls or other injuries that could result in bone fracture.

Teach the patient how to maintain and manage the IV access and IV administration equipment in the home.

Provide information on medication education.

TABLE 2-5 — EXPECTED PATIENT OUTCOMES

Experiences pain relief

Reports decreased pain.

Experiences no tenderness at site of previous infection.

Experiences no discomfort with movement.

Increases physical mobility

Participates in self-care activities.

Maintains full function of unimpaired extremities.

Demonstrates safe use of immobilizing and assistive devices.

Modifies environment to promote safety and to avoid falls.

Shows absence of infection

Takes antibiotic as prescribed.

Reports normal temperature.

Exhibits no swelling.

Reports absence of drainage.

Laboratory results indicate normal white blood cell count.

Complies with therapeutic plan

Takes medications as prescribed.

Protects weakened bones.

Reports no elevation of temperature or recurrence of pain, swelling, or other symptoms at the site.

Demonstrates proper wound care.

Wears appropriate footwear.

Keeps follow-up health appointments.

Reports increased strength.

Eats a diet that is high in protein and vitamin C

Reports signs and symptoms of complications promptly.

It is worth noting that Patient B. could have been spared from this encounter with osteomyelitis with proper education in foot care and with very simple preventative measures. Several factors contributed to the development and escalation of his condition, including his diabetic status, poor diet, walking barefoot, low personal motivation, and delayed response to the initial foot injury. In addition, as a diabetic, Patient B. should have been maintaining annual foot exams with a qualified healthcare professional for potential foot problems.

Diabetic patients, particularly those with demonstrated risk factor(s), should be undergo a podiatry exam every 1-6 months.5(p1031) The absence of symptoms does not mean that the feet are healthy; a patient might have neuropathy, peripheral vascular disease or even an ulcer without any complaints. Patient B’s left foot injury received no treatment causing the wound to stall, become infected and progress to the bone. Lack of proper diabetes management and improper preventative measures caused this patient pain and suffering that could have had a much more catastrophic end.11(p38) Festered foot wounds and resulting instances of osteomyelitis can and do lead to amputation in extreme cases.

Education and Prevention

Education, presented in a structured and organized manner, plays an important role in the prevention of osteomyelitis in diabetic patients. The aim is to enhance patient motivation and skills. Diabetics must learn how to recognize potential foot problems and be aware of the steps they need to take in response. Educators must demonstrate appropriate skill sets using a mixture of methods. It is essential to evaluate whether the patient has understood the messages, is motivated to act, and has sufficient self-care skills.5(p1032) Furthermore, healthcare professionals should receive periodic education to improve care for high-risk individuals. The following is a list of items which should be covered when instructing the high-risk patient 11(p40-44):

Daily feet inspection, including areas between the toes. This is best carried out by another person, particularly if the patient experiences vision problems.

Daily inspection of the inside of shoes.

Daily change of socks.

Regular washing of feet with careful drying between the toes.

Moderate water temperatures – always below 37° C.

Refraining from using heaters or hot – water bottles to warm feet.

Avoidance of barefoot walking indoors or outdoors.

Avoidance of chemical agents or plasters to remove corns and calluses. A healthcare provider should assist with removal.

Avoidance of tight shoes or shoes/socks with rough edges and uneven seams.

Avoidance of lubricating oils or creams for dry skin.

Cutting nails straight across to avoid injury.

Notifying the healthcare provider at once if a blister, cut, scratch or puncture wound of any kind has developed.

Foot ulcers

Ill-fitting shoes are the most frequent cause of foot ulcers. Therefore, the shoes of all diabetic patients should be examined meticulously. Most ulcers can be classified as neuropathic, ischemic or neuro-ischemic.4(pS19) Neuropathic ulcers frequently occur on the plantar surface of the foot, or in areas overlying a bony deformity 3(p350) Ischemic and neuro-ischemic ulcers are more common on the tips of the toes or the lateral border of the foot.2(p811) If an ulcer does not improve despite optimal treatment, more extensive vascular evaluation should be performed.

The depth of an ulcer can be difficult to determine due to the presence of overlying callus or necrosis. Therefore, neuropathic ulcers with calluses and necrosis should be debrided as soon as possible. This debridement should not be performed in ischemic or neuro-ischemic ulcers without signs of infection.9(p906) In neuropathic ulcers the debridement can usually be performed without general anesthesia. Patients with an ulcer deeper than the subcutaneous tissues should be treated intensively and, depending on local resources and infrastructure, hospitalization must be considered.3(p352)

The cause of the ulceration should be determined in order to reduce the chance of recurrences.5(p1029) Ulcers on contralateral foot should be prevented and heel protection provided during periods of bed rest. Once the episode is over, the diabetic patient should be included in a comprehensive foot-care program with life-long observation.

Proper Footwear

Inappropriate footwear can create major problems and complications for the diabetic patient. Appropriate footwear should be used both indoors and outdoors, and should be adapted for any existing altered biomechanics and deformities.8(p50) This is essential for prevention. Patients who have not lost foot sensation can select off-the-shelf footwear by themselves. In patients with neuropathy and/or ischemia, extra care must be taken when fitting footwear – particularly when foot deformities are also present. In a high-risk patient, callus, nail and/or skin pathology should be treated regularly, preferably by a trained foot care specialist.11(p45) Foot deformities should also be addressed — preferably non-surgically (e.g. with an orthosis).4(pS21)

Shoes should not be too tight or too loose and should be 1-2 cm longer than the foot itself.8(p50) The internal width should be equal to the width of the foot at the site of the metatarsal phalangeal joints, and the height should allow enough room for the toes. The fit must be evaluated with the patient in standing position, preferably at the end of the day. If the fit is too tight due to deformities or if there are signs of abnormal loading of the foot (e.g. callus, ulceration), patients should be referred for special footwear which may include insoles and orthoses.

Key Points

Patient and family foot care education is critical in the prevention of osteomyelitis in diabetic patients. Teaching is the first step to decrease instances of amputation due to severe cases of the disease. Patients should have adequate instruction in proper foot care, identification of warning signs, and appropriate responses to foot injury. Symptoms should be fully explained to equip patients with the knowledge to protect themselves and report red flags — increased pain, chills, tingling sensations, sensory loss, and drainage — to a qualified healthcare professional for early treatment. Treatment plans and antibiotic therapy should be continued to completion.

However, no amount of treatment is more effective than appropriate prevention. An adequate foot care program, healthy diet, fitting footwear and routine physicals and podiatry exams can eliminate osteomyelitis risk and provide the body with the nutritional support it needs to fight infection.

References

1. Stedman’s Medical Dictionary. 27th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2000.

2. Butalia S, Palda V, Sargeant R, Detsky A, Mourad O. Does This Patient With Diabetes Have Osteomyelitis of the Lower Extremity?. JAMA: Journal of The American Medical Association [serial online]. February 20, 2008; 299(7):806-813. Available from: Academic Search Premier, Ipswich, MA. Accessed September 19, 2012.

3. Lavery L, Peters E, Armstrong D, Wendel C, Murdoch D, Lipsky B. Risk factors for developing osteomyelitis in patients with diabetic foot wounds. Diabetes Research & Clinical Practice [serial online]. March 2009; 83(3):347-352. Available from: Academic Search Premier, Ipswich, MA. Accessed September 19, 2012.

4. Turns M. The diabetic foot: an overview of assessment and complications. British Journal of Nursing [serial online]. August 12, 2011;:S19-S25. Available from: Academic Search Premier, Ipswich, MA. Accessed September 19, 2012.

5. Chow I, Lemos E, Einarson T. Management and Prevention of Diabetic Foot Ulcers and Infections. Pharmacoeconomics [serial online]. August 2008; 26(12):1019-1035. Available from: Academic Search Premier, Ipswich, MA. Accessed September 19, 2012.

6. Tennvall G, Apelqvist J, Eneroth M. Costs of Deep Foot Infections in Patients with Diabetes Mellitus. Pharmacoeconomics [serial online]. September 2000; 18(3):225-238. Available from: Academic Search Premier, Ipswich, MA. Accessed September 19, 2012.

7. Game F, Jeffcoate W. MRSA and osteomyelitis of the foot in diabetes. Diabetic Medicine [serial online]. September 2, 2004; 21:16-19. Available from: Academic Search Premier, Ipswich, MA. Accessed September 19, 2012.

8. Weber L. Diabetic footwear steps out: Stylish shoes enhance compliance. Biomechanics [serial online]. December 2008; 15(12):50. Available from: Academic Search Premier, Ipswich, MA. Accessed September 19, 2012.

9. Lipsky B, Berendt A, Tan J, et al. Diagnosis and Treatment of Diabetic Foot Infections. Clinical Infectious Diseases [serial online]. October 2004; 39(7):885-910. Available from: Academic Search Premier, Ipswich, MA. Accessed September 19, 2012.

10. Merriam-Webster’s Collegiate Dictionary. 10th ed. Springfield, MA: Merriam-Webster; 1993.

11. Aliabadi Z, Ezell O. Avoiding the calamitous complications of Diabetic foot ulcers. Cortlandt Forum [serial online]. April 25, 2004; 17(4):37-46. Available from: Academic Search Premier, Ipswich, MA. Accessed September 19, 2012.

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