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Infections in Patients with Diabetes Part 3 of 4

Infections in Patients with Diabetes Part 3 of 4. David Joffe, BSPharm , CDE Diabetes In Control Kelsey Schultz PharmD Candidate 2013 Butler University. Bullous Diabeticorum. Non-inflammatory bullae on the subepidermal layer of the skin Commonly occur on feet or lower legs

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Infections in Patients with Diabetes Part 3 of 4

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  1. Infections in Patients with DiabetesPart 3 of 4 David Joffe, BSPharm, CDE Diabetes In Control Kelsey Schultz PharmD Candidate 2013 Butler University

  2. BullousDiabeticorum • Non-inflammatory bullae on the subepidermal layer of the skin • Commonly occur on feet or lower legs • Appearance is similar to blisters Khardori R. Infection in patients with diabetes mellitus. Medscape reference. WebMD 2011. Hull C, Zone JJ. Approach to the patient with cutaneous blisters. ). In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA. 2012. http://www.everydayhealth.com/diabetes-pictures/10-diabetic-skin-problems.aspx

  3. BullousDiabeticorum Treatment • No pharmacological treatment is necessary • This skin infection typically heals on its own after a few weeks (2-6 weeks) Hull C, Zone JJ. Approach to the patient with cutaneous blisters. ). In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA. 2012. http://telemedicine.org/dm/dmupdate.htm Khardori R. Infection in patients with diabetes mellitus. Medscape reference. WebMD 2011.

  4. Diabetic Foot Ulcers • Risk factors: • Neuropathy: decreased sensation and sweat production • Peripheral vascular disease: lack of blood flow • Uncontrolled blood glucose • Extent of foot ulcer: • Local, superficial skin • Deeper, systemic infections of bone, joints Fish DN, Pendland SL, Danziger LH. Skin and Soft-Tissue Infections. Dipiro et al. Pharmacotherapy: A Pathophysiologic Approach, 7th Ed. McGraw-Hill; 2008:1899-1913. Weintrob AC, Sexton DJ. Clinical manifestations, diagnosis, and management of diabetic infections of the lower extremities. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA. 2012. http://www.fitfeetflorida.com/services/diabetic-foot-care/

  5. Diabetic Foot Ulcers: Presentation, Etiology • Presentation: • Erythema, purulent discharge, warmth, pain, fever, chills, tachycardia, hypotension • Etiology: • 5-7 different organisms at one time • S. aureus, Group Streptococci (A, B, C, G), Enterobacteriaceae, and P. aeruginosa. Fish DN, Pendland SL, Danziger LH. Skin and Soft-Tissue Infections. Dipiro et al. Pharmacotherapy: A Pathophysiologic Approach, 7th Ed. McGraw-Hill; 2008:1899-1913. Weintrob AC, Sexton DJ. Clinical manifestations, diagnosis, and management of diabetic infections of the lower extremities. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA. 2012. http://www.tanglewoodfootspecialists.com/faqs/why-can-diabetes-cause-foot-ulcers.cfm

  6. Diabetic Foot Ulcers: Non-Pharmacological Treatment • Wound care: • Debridement of dead/calloused tissue, cleaning the wound, alleviating pressure from the foot • Surgical debridement for severe infections • Maximizing glycemic control Fish DN, Pendland SL, Danziger LH. Skin and Soft-Tissue Infections. Dipiro et al. Pharmacotherapy: A Pathophysiologic Approach, 7th Ed. McGraw-Hill; 2008:1899-1913. Weintrob AC, Sexton DJ. Clinical manifestations, diagnosis, and management of diabetic infections of the lower extremities. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA. 2012. http://www.apligraf.com/patient/wound/diabetic_foot_ulcer_examples.html

  7. Diabetic Foot Ulcers: Mild Treatment • Need to cover Group A streptococci and S. aureus (picture below) • Possible antibiotics include: • dicloxacillin 500mg every 6 hours or • cephalexin 500mg every 6 hours • Treatment with oral antibiotics for 1-2 weeks Fish DN, Pendland SL, Danziger LH. Skin and Soft-Tissue Infections. Dipiro et al. Pharmacotherapy: A Pathophysiologic Approach, 7th Ed. McGraw-Hill; 2008:1899-1913. Weintrob AC, Sexton DJ. Clinical manifestations, diagnosis, and management of diabetic infections of the lower extremities. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA. 2012. http://www.silvermedicine.org/colloidalsilverstudytexas.html

  8. Diabetic Foot Ulcers: Moderate-Severe Treatment • Coverage of Group A streptococci, MRSA, Enterobacteriaceae, P. aeruginosa, and anaerobes • Possible therapy could include: • piperacillin/tazobactam 3.375g-4.5g IVPB every 6 hours • meropenem 1g IVPB every 8 hours • levofloxacin 750mg IV every 24 hours • vancomycin 15-20mg/kg IVPB every 12 hours (for MRSA coverage) • metronidazole 500mg IV every 8 hours (for anaerobe coverage) • Infections requiring hospitalization need IV antibiotics for 2-4 weeks • De-escalate therapy based on culture and sensitivity Fish DN, Pendland SL, Danziger LH. Skin and Soft-Tissue Infections. Dipiro et al. Pharmacotherapy: A Pathophysiologic Approach, 7th Ed. McGraw-Hill; 2008:1899-1913. Weintrob AC, Sexton DJ. Clinical manifestations, diagnosis, and management of diabetic infections of the lower extremities. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA. 2012.

  9. Diabetic Foot Ulcers: Complications • Amputation is a severe and tragic complication • Osteomyelitis if infection spreads to bone Fish DN, Pendland SL, Danziger LH. Skin and Soft-Tissue Infections. Dipiro et al. Pharmacotherapy: A Pathophysiologic Approach, 7th Ed. McGraw-Hill; 2008:1899-1913. Weintrob AC, Sexton DJ. Clinical manifestations, diagnosis, and management of diabetic infections of the lower extremities. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA. 2012. http://hyderabaddiabetes.com/diabetic_foot_clinic.html

  10. Osteomyelitis • Infection of the bone • Common organisms: • S. aureus • coagulase-negative staphylococci • aerobic gram-negative bacilli • Presentation: • Local pain and tenderness, warmth, erythema, swelling, fever Lalani T. Overview of osteomyelitis in adults. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA. 2012. Armstrong EP, Friedman AD. Bone and Joint Infections. Dipiro et al. Pharmacotherapy: A Pathophysiologic Approach, 7th Ed. McGraw-Hill; 2008:1899-1913. http://www.sciencephoto.com/media/260055/enlarge

  11. Osteomyelitis Treatment • Debridement to get rid of necrotic tissue AND antibiotic therapy to eradicate organisms • Want antibiotics that: • Empirically cover S. aureus, penetrate the bone, and are bactericidal • Potential empiric therapy: • Vancomycin PLUS • Ceftazidime 2g IV every 8 hours OR cefepime 2g IV every 12 hours • 6 weeks treatment with antibiotics usually Lalani T. Overview of osteomyelitis in adults. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA. 2012. Armstrong EP, Friedman AD. Bone and Joint Infections. Dipiro et al. Pharmacotherapy: A Pathophysiologic Approach, 7th Ed. McGraw-Hill; 2008:1899-1913.

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