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

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

BULLOUS DIABETICORUM 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.

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/

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

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

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

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.

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

OSTEOMYELITIS

Infection of the bone Common organisms:

S. aureuscoagulase-negative

staphylococciaerobic gram-

negative bacilli Presentation:

Local pain and tenderness, warmth, erythema, swelling, feverLalani 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

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 usuallyLalani 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.