Das diabetische Fußsyndrom aus infektiologischer Sicht

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.

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