Combined therapy of complicated surgical infections caused by multi-drug resistant microflora in patients with diabetic foot
Abstract
One of the most severe complications of diabetes mellitus (DM) is formation of diabetic foot (DF), the treatment of which requires hospitalization are much more often, than other diabetes complications together: among hospitalized patients with diabetes, there are 46% of patients with purulo-necrotic complications of DF (infection, ulcer and/ or feet deep tissue destruction associated with neurological disorders and /or reduction of blood flow in the main lower limb artery).
DF is a costly complication of diabetes, as it requires prolonged hospitalization, patients’ treatment and rehabilitation, care and social services.
The pathogenesis of DF if complex and associated with several primary risk factors, which include: neuropathy, ischemia, infection and immunological disorders, on the background of which severe purulent necrotic processes may develop.
Activation of lipid peroxidation is one of the leading pathological processes. Free radicals disrupt the activity of endothelium, causing endoneurogenic hypoxia and leading to the development of diabetic polyneuropathy (DPN). In accordance with the vascular theory, microangiopathy of vessels supplying blood to peripheral nerves, is the main cause of DNP.
One of the important components of conservative treatment of purulent necrotic complications of DF is antibacterial therapy (ABT). However, ever-increasing antibiotic resistance of pathogens requires search and implementation of various methods for management of pathogens. One such methods is photodynamic therapy (PDT) – light-induced chemotherapy, which implies three obligatory factors: two exogenous (photosensitizer and light), and am endogenous factor – oxygen. Thus, photosensitizer is prevalently accumulated in bacterial cells and cells of damaged tissues. Oxidative stress, developed as a result of PDT, results in damage of the bacterial cell and its death due to apoptosis or necrosis.
The objective of the paper work was to improve the results of treatment of patients with DF through the combined therapy with the inclusion of physical treatment methods to the therapy regimen – VAC-therapy, light therapy and PDT.
Materials and methods. The study included 25 patients of both sexes aged from 48 to 72 years of neuro- ischemic form of DF. Treatment was prescribed as follows: DM compensation (use of divided insulin therapy); metabolic therapy (drugs of alpha-lipoic acid, B vitamins); anticoagulant and angiotropic therapy; ABT; physical methods of treatment; therapy aimed at the treatment of osteoporosis (calcium-based drugs).
Surgical treatment of purulent necrotic feet lesions in patients with DM included: surgical debridement; its debridement by physical methods; local treatment of purulent focus with modern dressings; early recovery operations.
Vascular intervention was conducted in 17 patients, the supposed indications for was ischemia of IIB- IV degree with the possibility to perform reparative surgery on vascular status, as well as the inefficiency of conservative treatment. Percutaneous angioplasty was performed, including 2 patients with stenotic lesions of iliofemoral segment.
For phototherapy A.M. Korobov’s “Barva-Flex” photon matrices with red, green, blue and purple LED light (wavelengths of 660 nm, 525 nm, 470 nm and 405 nm, respectively) were used in all 25 patients. Phototherapy was conducted by contact directly with the wound after removing the bandages and wounds toilet from the first postoperative days.
PDT was applied in 10 patients. The considered indication for phototherapy were the findings of bacteriological tests, identifying microbial and multiresistance and polyresistance to the main classes of antimicrobial drugs.
Conclusions. Thus, in the course of combined treatment of infectious wound complications in patients with DF, wound healing was more efficient and took shorter term.
The proposed method allows improving the treatment efficiency, reduction of hospitalization, and reduction of expenses for treatment of patients with diabetic foot, as well as reduction of the number of amputations.
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References
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