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Case Discussion Diabetic Foot Infection (1).pptx
- 1. Diabetic Foot Infection (DFI) CASEDISCUSSION INSTRUCTOR: DR. SHAM ZAIN ALABDIN LAMAA AL KHAS 05/02/2024
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- 4. Deep Ulcer Neutrophil dysfunction Chronic renal failure Peripheral vascular disease Neuropathy Poor glycemic control DiseaseOverview Presence of manifestations of an inflammatory process in any tissue below the malleoli in a person with diabetes mellitus. Invasion multiplication of microorganisms inflammatory response tissue destruction. I n f e c t i o n R i s k F a c t o r s Skin ulceration Wound (trauma) IWGDF, 2020. Diabetic foot infection (DFI)
- 5. Redness Heat SwellingPain induratio n Purulent secretion s Disease Overview When to Suspect Infection? 2 classic symptoms or signs of inflammation IDSA, 2012 The cardinal signs of inflammation:
- 6. Disease Overview ome infectedpatients may not manifest WITH INFLAMMATORY MARKERS Peripheral neuropathy (absence of pain or tenderness) Limb ischemia (decreasing erythema, warmth, and possibly induration). S e c o n d a r y f i n d i n g s Nonpurulent secretions Undermining of the wound edges Discoloured granulation tissue Foul odour IDSA, 2012
- 7. Pathogens Most DFIs arepolymicrobial, in some cases monomicrobial Aerobic Gram positive • Staphylococcus aureus • Streptococcus spp. • Enterococcus spp. Aerobic Gram negative • Enterobacteriaceae • Pseudomonas aeruginosa Anaerobes, facultative anaerobes • Bacteroides fragilis. • Clostridium spp. • Peptococcus and Peptostreptococcus Superficial infections Chronic ulcer/previous use of Abx Osteomyelitis and gangrene Auwaerter, P. 2020.
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- 9. Diagnosis Os te omye liti s Soft tissue infection that spreads into the bone, involving the cortex first and then the marrow. Probe to bone (PTB) test Blood test ESR X-ray > 70 mm/hr If still in doubt? Magnetic resonance imaging Positron emission tomography — computed tomography (PET/CT). Leukocyte scintigraphy Diabetic foot osteomyelitis (DFO) IWGDF, 2020. ESR- erythrocyte sedimentation rate
- 10. Collection of Specimens IDSA,2012 DO NOT RECOMMEND collecting specimen for clinically uninfected wound. For infected wound, a culture that is from deep tissue obtained by biopsy or curettage should be obtained.
- 11. Hospitalization Severe infection. Moderate infectionwith complicating features (eg, severe PAD). Patients who fail to improve with outpatient therapy may also need to be hospitalized. Any patient unable to comply with an appropriate outpatient treatment regimen for psychological or social reasons. Patients need hospitalization IDSA, 2012
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- 13. Management Mild and moderateDFI Oral antibiotic therapy. Severe DFI Parenteral route oral therapy (clinically improving) and has no contraindications to oral therapy. Topical antimicrobial agent IDSA, 2012 Do you think we can use topical antibiotics for DFI?
- 14. Management Most patients witha DFI require some surgical treatment Bedside debridement Incision and drainage Resection of infected tissue Revascularization Surgical resection of infected bone is the standard treatment of osteomyelitis. Diabetic foot osteomyelitis (DFO) IWGDF, 2020.
- 15. Management Cleveland Clinic AbuDhabi, Antimicrobial Use Guidelines, 2023-2024.
- 16. Management Cleveland Clinic AbuDhabi, Antimicrobial Use Guidelines, 2023-2024 What are the risk factors of P. aeruginosa?
- 17. Management 1. Temperature >38°C or <36 °C, 90 beats/min, RR > 20 breaths/min or PaCO2 < 32 mm, WBC > 12 x 103 cells/mm3 or < 4 x 103 cells/mm3 . Cleveland Clinic Abu Dhabi, Antimicrobial Use Guidelines, 2023-2024.
- 18. Management Diabetic foot osteomyelitis(DFO) Cleveland Clinic Abu Dhabi, Antimicrobial Use Guidelines, 2023-2024.
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- 20. 2008 Case Overview Age: 44years old Weight: 87 Kg Height: 167 cm Allergies: None BA Foot ulcer, hypertension, emesis. Chief complaint Diabetes mellitus type 2 Past medical History Medication Dosage glimepiride 4 mg tablet 1 tab daily. metformin 850 mg tablet 1 tab after breakfast and after dinner. Home medications
- 21. History of presentingIllness Chronic wound of the great left toe for the past 3 years. Started to turn black, swollen and erythematous. 2 hospitals in Dubai Advised to have surgery (amputation) IV antibiotics (24hrs) Left AMA to CCAD for third opinion. Fever and chills. Nausea and vomiting, some epigastric pain.
- 22. On Admission Vitals Black, swollenand erythematosus toe, malodorous, diminished sensation. BP: 167/87 mmHg RR:19 Temp: 37.5’C Pulse:112 Bpm Physical Examination 10/1/2024
- 23. On Admission Laboratory Results LABRange Result WBC 4,000 - 11,000 (cells/µL) 20.0* HGB 14-17.5 gm/dL 9.1* HCT 0.38 to 0.48 0.28* PLT 150-450(10-3 L) 320 CRP <100(g/L) 390.2* NA 135 to 145 (mEq/L) 133* K 3.5 to 5.0 mEq/L 3.8 CL 98 to 108 mEq/L 93* CO2 23 to 29 mEq/L 21* BUN 7 to 20 (mg/dL) 22.2* CREAT 65.4 to 119.3 mmol/L 584* GLU 4.2 -7.8 mmol/L 11.1* Foot X-Ray: AP, Oblique & Lateral No acute fracture or dislocation. Soft tissue swelling and emphysema around the big toe. No obvious underlying bony lesion seen. Old healed fracture of fourth metatarsal bone. Calcaneal spur noted. Bony outgrowth from heel bone
- 24. After reviewing patient’sLab and assessment, the severity of the infection in this patient is showing in the following: IDSA, 2012
- 25. On Admission MRI +ve osteomyelitis
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- 27. Hospital Course Asse ss m e n t 10/1/2024 Tachycardia, elevated BP, Leucocytosis, Worsening renal function. Osteomyelitis, considering MRI IV Piperacillin-Tazobactam (renal dose) and IV vancomycin initiated. IV fluids were given. Sepsis secondary due to untreated Foot infection Acute kidney injury due to inappropriate drug therapy Estimated Creatinine Clearance: 14.7 mL/min. HOLD Metformin, since its contraindicated in <30 mL/min. Type 2 diabetes mellitus Lispro Low dose sliding scale with meals. Linagliptin. DVT Prophylaxis Heparin. Diagnosis and identified drug-related Problem:
- 28. Treatment Goals Infection Control: -Monitor and manage DFI to prevent further complications by administering AB empirically and appropriate antibiotics based on culture results. Wound Care: - Ensure adequate blood supply to the affected foot to promote healing. - Regular wound assessments and appropriate dressing changes. Diabetes Management: - Optimize blood glucose control through medication adjustments and lifestyle modifications. - Monitor blood glucose levels regularly to prevent further complications. Goal is FBG 130 mg/dL Acute Kidney Injury Management: - Adjust medications, including avoiding nephrotoxic drugs. - Monitor fluid balance and electrolyte levels closely. - Balance fluid intake and output to prevent complications related to acute kidney injury. Pain Management: - Manage pain effectively to improve the patient's overall comfort and well-being. Nutritional Support: - Ensure proper nutrition to support wound healing and overall health.
- 29. Management - Treatmentoptions with a rationale based on guidelines Cleveland Clinic Abu Dhabi, Antimicrobial Use Guidelines, 2023-2024 The patient have a CrCl of 14.7 ml/min, so what is the correct dose of Piperacillin- Tazobactam in this patient? MRI osteomyelitis +
- 30. Piperacillin/Tazobactam Dosage Adjustmentsin Altered Kidney Function Traditional infusion method (over 30 minutes) Extended infusion method (over 4 hours) CrCl (mL/minute) If the usual recommended dose is 3.375 g every 6 hours If the usual recommended dose is 4.5 g every 6 hours If the usual recommended dose is 3.375 g infused over 4 hours every 8 hours 100 to <130 Extended infusion preferred Extended infusion preferred 3.375 or 4.5 g infused over 4 hours every 6 hours 40 to <100 (usual recommended dose) 3.375 g every 6 hours 4.5 g every 6 hours 3.375 g infused over 4 hours every 8 hours 20 to <40 2.25 g every 6 hours 4.5 g every 8 hours or 3.375 g every 6 hours 3.375 g infused over 4 hours every 8 to 12 hours <20 2.25 g every 8 hours 4.5 g every 12 hours or 2.25 g every 6 hours 3.375 g infused over 4 hours every 12 hours Lexicomp, 2024. Management - Treatment options with a rationale based on guidelines
- 31. 10/1/2024 IV Piperacillin-tazobactam2.25 g every 8 hours. IV Vancomycin 1,500 mg. Swab taken for culture. 11/1/2024 MRI great toe osteomyelitis and soft tissue infection in the forefoot. IV Vancomycin 500 mg. Left Hallux amputation. Trough level 20 mg/L (24 hours post dose). 12/1/2024 Random level 21, so the pharmacist decided to dose 500 mg IV every 48 hours. Empirical therapy Piperacillin-tazobactam + Vancomycin. Management - Treatment options with a rationale based on guidelines
- 32. Management 13/1/2024 Wound Culture Discontinue empiricIV Vancomycin and Piperacillin- tazobactam switch to ampicillin 1 g IV every 12 hours. 14/1/2024 Ostectomy complete excision. 18/1/2024 Wound closure. Stop IV Ampicillin and switch Oral Amoxicillin / Clavulanic acid for 14 days. Discharged
- 33. Other problems End stagerenal disease Placement of non-tunneled hemodialysis catheter. Done four HD sessions in CCAD. Permanent Dialysis catheter placement. Patient accepted at SKMC Ajman for outpatient HD every Tuesday, Thursday and Sunday. During HD catheter placement required Vernakalant. Bisoprolol 5 mg. Paroxysmal atrial fibrillation Rapid conversion of atrial fibrillation to sinus rhythm.
- 34. Discharge Medication Dosage Indication Amlodipine5 mg capsule 1 capsule daily. Hypertension Bisoprolol fumarate 5 mg tablet 1 tablet daily. Hypertension, PAF Amoxicillin - clavulanate 500-125 mg tablet 1 tablet daily for 12 days. Gangrene of toe of left foot Calcium acetate, phosphate binder, 700 mg tablet 3 times daily. Chronic kidney disease ferrous sulf, dried-folic acid 150 mg (45 mg IRON) capsule 1 capsule daily. Anemia Linagliptin 5 mg tablet 1 tablet daily. Type 2 diabetes mellitus Glimepiride 4 mg tablet 1 tablet daily. Type 2 diabetes mellitus Metformin 850 mg tablet WHY?
- 35. Specialist referral(s) or consults 1.Podiatrist: Regular consultations for foot care and assessment of wound healing. 2. Endocrinologist: Manage and optimize diabetes control for better wound healing. 3. Dietitian: Follow up with the dietitian to improve daily diet to manage high sugar intake. Monitoring and follow-up (parameters and frequency). 1. Wound Assessment: Regularly weekly monitor the diabetic foot wound for signs of healing, infection, or deterioration. 2. Laboratory Parameters: Repeat WBC, CRP, and ESR periodically to track the progress of infection. Frequency weekly then upon follow up appointments. 3. Blood Glucose Monitoring: Regularly check and manage blood glucose levels to ensure optimal diabetes control. This includes daily monitoring and adjustments of oral medications as needed.
- 36. Patient education, counseling 1.Wound CareInstructions: Educate the patient on proper wound care, dressing changes, and signs of infection. 2. Diabetes Management: Emphasize the importance of maintaining good blood glucose control through medication adherence, diet, and lifestyle modifications. 3. Foot Care: Provide guidance on proper foot hygiene, wearing appropriate footwear, and avoiding activities that could lead to further injury. 4. Medication Adherence: Stress the importance of completing the prescribed course of antibiotics and other medications. 5. Follow-up Appointments: Emphasize the necessity of attending all follow-up appointments with healthcare providers for ongoing assessment and adjustments to the treatment plan.
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- 38. Duration of Antibiotics Postdebridement systemic antibiotic therapy course for DFO of 3 weeks gave similar (and statistically noninferior) incidences of remission and AE to a course of 6 weeks. 26 November 2020 Gariani, K., et al. 2021.
- 39. Management Can Vancomycin andpiperacillin-tazobactam increase the risk of acute kidney injury? March 18, 2021 Blair, M. et al. 2021
- 40. Management Can Vancomycin andpiperacillin-tazobactam increase the risk of acute kidney injury? 15 July 2020 Avedissian, S. N. et al. 2020.
- 41. References Auwaerter, P. (2020).Diabetic Foot Infection. In Johns Hopkins ABX Guide. The Johns Hopkins University. https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_ABX_Guide/540161/3.1/Diabetic_Foot_Infection Avedissian, S. N., Pais, G. M., Liu, J., Rhodes, N. J., & Scheetz, M. H. (2020). Piperacillin-Tazobactam Added to Vancomycin Increases Risk for Acute Kidney Injury: Fact or Fiction?. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 71(2), 426–432. https://doi.org/10.1093/cid/ciz1189 Blair, M., Côté, J. M., Cotter, A., Lynch, B., Redahan, L., & Murray, P. T. (2021). Nephrotoxicity from Vancomycin Combined with Piperacillin- Tazobactam: A Comprehensive Review. American journal of nephrology, 52(2), 85–97. https://doi.org/10.1159/000513742 Cleveland Clinic Abu Dhabi, Antimicrobial Use Guidelines for 2023-2024. Gariani, K., Pham, T. T., Kressmann, B., Jornayvaz, F. R., Gastaldi, G., Stafylakis, D., Philippe, J., Lipsky, B. A., & Uçkay, L. (2021). Three Weeks Versus Six Weeks of Antibiotic Therapy for Diabetic Foot Osteomyelitis: A Prospective, Randomized, Noninferiority Pilot Trial. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 73(7), e1539– e1545. https://doi.org/10.1093/cid/ciaa1758 Lipsky, B. A., Berendt, A. R., Cornia, P. B., et al. Infectious Diseases Society of America (2012). 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America, 54(12), e132–e173. https://doi.org/10.1093/cid/cis346 Lipsky, B. A., Senneville, É., Abbas, Z. G., et al. International Working Group on the Diabetic Foot (IWGDF) (2020). Guidelines on the diagnosis and treatment of foot infection in persons with diabetes (IWGDF 2019 update). Diabetes/metabolism research and reviews, 36 Suppl 1, e3280. https://doi.org/10.1002/dmrr.3280
Editor's Notes
- #4 Important risk factors for development of diabetic foot infections include neuropathy, peripheral vascular disease, and poor glycemic control. Diabetic foot infections (DFIs) usually arise either in a skin ulceration that occurs as a consequence of peripheral (sensory and motor) neuropathy or in a wound caused by some form of trauma Presence of manifestations of an inflammatory process in any tissue below the malleoli in a person with diabetes mellitus. Factors that predispose to foot infection include having an Deep/Recurrent Ulcer Neutrophil dysfunction Chronic renal failure
- #5 When to Suspect Infection. Any foot wound in a patient with diabetes may become infected. Traditional inflammatory signs of infection are redness (erythema or rubor), warmth (calor), swelling or induration (tumor), tenderness and pain (dolor), and purulent secretions. Some infected patients may not manifest these findings, especially those who have peripheral neuropathy (leading to an absence of pain or tenderness) or limb ischemia (decreasing erythema, warmth, and possibly induration).
- #7 Most diabetic foot infections (DFIs) are polymicrobial; however, if the patient hasn’t recently received abx therapy, often monomicrobial and due to either staphylococcal or streptococcal infection. Initially, wounds usually with Gram-positive flora from the skin; as it becomes more chronic, tilts toward Gram negatives. Following broad-spectrum abx, flora may evolve to MRSA, VRE and more resistant Gram negatives. Aerobic Gram positive: Staphylococcus aureus Streptococcal spp. Enterococcus spp. Aerobic Gram negative Enterobacteriaceae Pseudomonas aeruginosa Anaerobes, facultative anaerobes: usually when ulcers are deep, chronic and/or necrotic tissue is present. B. fragilis Clostridia spp. Peptococcus and Peptostreptococcus Superficial, early infections (cellulitis, cellulitis involving blisters and shallow ulcers) are typically caused by S. aureus or beta-hemolytic streptococci. Infections of ulcers that are chronic or previously treated with antibiotics may be caused by aerobic Gram-negative bacilli, S. aureus or Streptococci. Deep soft tissue infections, osteomyelitis, and gangrene are more often polymicrobial, including aerobic Gram-negative bacilli and anaerobes (anaerobic streptococci, Bacteroides fragilis group, Clostridium species), but Staphyloccocus aureus is also common as single pathogen. Multi-drug resistant Gram-negative organisms described in DFI especially ESBL, but most resistant organisms w/ reports from India and warmer climates.
- #10 16. For clinically uninfected wounds, we recommend not collecting a specimen for culture (strong, low). 17. For infected wounds, we recommend that clinicians send appropriately obtained specimens for culture prior to starting empiric antibiotic therapy, if possible. Cultures may be unnecessary for a mild infection in a patient who has not recently received antibiotic therapy (strong, low). 18. We recommend sending a specimen for culture that is from deep tissue, obtained by biopsy or curettage and after the wound has been cleansed and debrided. We suggest avoiding swab specimens, especially of inadequately debrided wounds, as they provide less accurate results (strong, moderate).
- #11 Severe infection Moderate infection with complicating features (eg, severe PAD) Any patient unable to comply with an appropriate outpatient treatment regimen for psychological or social reasons. Patients who fail to improve with outpatient therapy may also need to be hospitalized
- #13 reconsider the need for collecting a bone specimen for culture, undertaking surgical resection, or selecting an alternative antibiotic regime While antibiotic therapy is necessary for DFIs, it is often not sufficient. Most patients with a DFI require some surgical treatment, ranging from minor bedside debridement or incision and drainage to major operative procedures, including resection of deep infected tissue, drainage of abscesses or infected compartments, resection of necrotic or infected bone, or revascularization. Surgical resection of infected bone has long been the standard treatment of osteomyelitis, but over the past two decades, evidence from several retrospective case series,146-149 one retrospective cohort study,150 and one prospective controlled study151 has demonstrated that in properly selected patients, antibiotic therapy alone is effective. Select an antibiotic agent: Likely/proven causative pathogen(s) and their antibiotic susceptibilities Clinical severity of the infection Published evidence of efficacy of the agent for DFIs Risk of adverse events, including collateral damage to the commensal flora Drug interaction Agent availability Financial costs Severe DFI Administer antibiotic therapy initially by the parenteral route to Switch to oral therapy if the patient is clinically improving and has no contraindications to oral therapy and if there is an appropriate oral agent available Duration? Treat patients with a mild DFI and most with a moderate DFI, with oral antibiotic therapy, either at presentation or when clearly improving with initial intravenous therapy 1 to 2 weeks. Consider continuing treatment, perhaps for up to 3 to 4 weeks, if the infection is improving but is extensive and is resolving slower than expected or if the patient has severe peripheral artery disease. (Weak; low) c) If evidence of infection has not resolved after 4 weeks of apparently appropriate therapy, re-evaluate the patient, and reconsider the need for further diagnostic studies or alternative treatments. (Strong; low)
- #14 antibiotic therapy is necessary for DFIs, it is often not sufficient reconsider the need for collecting a bone specimen for culture, undertaking surgical resection, or selecting an alternative antibiotic regime While antibiotic therapy is necessary for DFIs, it is often not sufficient. Most patients with a DFI require some surgical treatment, ranging from minor bedside debridement or incision and drainage to major operative procedures, including resection of deep infected tissue, drainage of abscesses or infected compartments, resection of necrotic or infected bone, or revascularization. treatment for just 1 to 2 weeks (or less) should be sufficient for patients in whom all infected bone has been resected.1 Surgical resection of infected bone has long been the standard treatment of osteomyelitis, but over the past two decades, evidence from several retrospective case series,146-149 one retrospective cohort study,150 and one prospective controlled study151 has demonstrated that in properly selected patients, antibiotic therapy alone is effective. Select an antibiotic agent: Likely/proven causative pathogen(s) and their antibiotic susceptibilities Clinical severity of the infection Published evidence of efficacy of the agent for DFIs Risk of adverse events, including collateral damage to the commensal flora Drug interaction Agent availability Financial costs Severe DFI Administer antibiotic therapy initially by the parenteral route to Switch to oral therapy if the patient is clinically improving and has no contraindications to oral therapy and if there is an appropriate oral agent available Duration? Treat patients with a mild DFI and most with a moderate DFI, with oral antibiotic therapy, either at presentation or when clearly improving with initial intravenous therapy 1 to 2 weeks. Consider continuing treatment, perhaps for up to 3 to 4 weeks, if the infection is improving but is extensive and is resolving slower than expected or if the patient has severe peripheral artery disease. (Weak; low) c) If evidence of infection has not resolved after 4 weeks of apparently appropriate therapy, re-evaluate the patient, and reconsider the need for further diagnostic studies or alternative treatments. (Strong; low)
- #15 Goal: cover the likely pathogens without prescribing an unnecessarily broad-spectrum regimen. For decades, studies (temperate climates in North America and Europe) demonstrated that the most common pathogens in DFIs are aerobic gram-positive cocci, especially S aureus, and to a lesser extent streptococci and coagulase-negative staphylococci. Patients in tropical/subtropical climates (mainly Asia and northern Africa) have shown that aerobic gram-negative bacilli are often isolated, either alone or in combination with gram-positive cocci. Empiric treatment aimed at P aeruginosa, which usually requires either an additional or broader-spectrum agent, is generally unnecessary in temperate climates. It should, however, be considered in tropical/subtropical climates or if P aeruginosa has been isolated from previous cultures of the affected patient. Obligate anaerobes can play a role in a DFI, especially in ischemic limbs and in case of abscesses. Treated with an imidazole (metronidazole), or beta-lactam with beta-lactamase inhibitor, should be considered for a DFI associated with ischemia or a foul-smelling discharge.
- #16 Goal: cover the likely pathogens without prescribing an unnecessarily broad-spectrum regimen. For decades, studies (temperate climates in North America and Europe) demonstrated that the most common pathogens in DFIs are aerobic gram-positive cocci, especially S aureus, and to a lesser extent streptococci and coagulase-negative staphylococci. Patients in tropical/subtropical climates (mainly Asia and northern Africa) have shown that aerobic gram-negative bacilli are often isolated, either alone or in combination with gram-positive cocci. Empiric treatment aimed at P aeruginosa, which usually requires either an additional or broader-spectrum agent, is generally unnecessary in temperate climates. It should, however, be considered in tropical/subtropical climates or if P aeruginosa has been isolated from previous cultures of the affected patient. Obligate anaerobes can play a role in a DFI, especially in ischemic limbs and in case of abscesses. Treated with an imidazole (metronidazole), or beta-lactam with beta-lactamase inhibitor, should be considered for a DFI associated with ischemia or a foul-smelling discharge.
- #19 Goal: cover the likely pathogens without prescribing an unnecessarily broad-spectrum regimen. For decades, studies (temperate climates in North America and Europe) demonstrated that the most common pathogens in DFIs are aerobic gram-positive cocci, especially S aureus, and to a lesser extent streptococci and coagulase-negative staphylococci. Patients in tropical/subtropical climates (mainly Asia and northern Africa) have shown that aerobic gram-negative bacilli are often isolated, either alone or in combination with gram-positive cocci. Empiric treatment aimed at P aeruginosa, which usually requires either an additional or broader-spectrum agent, is generally unnecessary in temperate climates. It should, however, be considered in tropical/subtropical climates or if P aeruginosa has been isolated from previous cultures of the affected patient. Obligate anaerobes can play a role in a DFI, especially in ischemic limbs and in case of abscesses. Treated with an imidazole (metronidazole), or beta-lactam with beta-lactamase inhibitor, should be considered for a DFI associated with ischemia or a foul-smelling discharge.
- #20 Select an antibiotic agent: Likely/proven causative pathogen(s) and their antibiotic susceptibilities Clinical severity of the infection Published evidence of efficacy of the agent for DFIs Risk of adverse events, including collateral damage to the commensal flora Drug interaction Agent availability Financial costs Severe DFI Administer antibiotic therapy initially by the parenteral route to Switch to oral therapy if the patient is clinically improving and has no contraindications to oral therapy and if there is an appropriate oral agent available Duration? Treat patients with a mild DFI and most with a moderate DFI, with oral antibiotic therapy, either at presentation or when clearly improving with initial intravenous therapy 1 to 2 weeks. Consider continuing treatment, perhaps for up to 3 to 4 weeks, if the infection is improving but is extensive and is resolving slower than expected or if the patient has severe peripheral artery disease. (Weak; low) c) If evidence of infection has not resolved after 4 weeks of apparently appropriate therapy, re-evaluate the patient, and reconsider the need for further diagnostic studies or alternative treatments. (Strong; low)
- #23 The patient states that he has had a chronic wound of the toe for the past 3 years but it had been stable until when he noticed that it was turning black and becoming swollen and erythematous. The patient has been to 2 hospitals in Dubai where he was advised to have surgery with likely amputation of the toe. He left AGAINST MEDICAL ADVICE to come to CCAD for third opinion.
- #25 AP, X-ray: An X-ray picture in which the beams pass from front-to-back (anteroposterior) They did for the patient basic labs which reveled high WBC indicating an infection low hemoglobin, high crp inflammation high create and bun indicating the kidney is not working well and high glucose which means the pt is having hyperglycemia. They have also font foot x ray which showed soft tissue swelling around the big toe and Calcaneal spur noted.
- #27 Evaluation reveals patient with gangrene of the left great toe who has elevated white blood cell count and CRP and has been having fevers earlier in the week. The patient is not acutely septic but was tachycardic. He was given IV fluids. Blood cultures were drawn, and the patient was started on Piperacillin / Tazobactam. Patient has been advised that amputation is likely to be advised. The patient has evidence of kidney disease. Unclear if this is acute or chronic. He has been given medications to help his acid reflux and nausea and is feeling better at this time.
- #29 When the patient was admitted The plan and assessment was divided into four problem list 1 - Sepsis : possible secondary to Foot infection Tachycardia, elevated BP, Leucocytosis, Worsening renal function They wanted to confirm if the patient is having osteo or not so they considered MRI IV Piperacillin-Tazobactam (renal dose) and IV vancomycin initiated. Acute kidney injury: Likely secondary to infection vs Diabetic Nephropathy. Estimated Creatinine Clearance: 14.7 mL/min HOLD Metformin since its contraindicated in <30 Type 2 diabetes mellitus with hyperglycaemia - Current regimen : Lispro Low dose sliding scale with meals. Linagliptin DVT Prophylaxis: -Heparin -encourage ambulation if possible
- #31 Goal: cover the likely pathogens without prescribing an unnecessarily broad-spectrum regimen. For decades, studies demonstrated that the most common pathogens in DFIs are aerobic gram-positive cocci, especially S aureus, and to a lesser extent streptococci and coagulase-negative staphylococci. Patients in tropical/subtropical climates (mainly Asia and northern Africa) have shown that aerobic gram-negative bacilli are often isolated, either alone or in combination with gram-positive cocci. Empiric treatment aimed at P aeruginosa, which usually requires either an additional or broader-spectrum agent, is generally unnecessary in temperate climates. It should, however, be considered in tropical/subtropical climates or if P aeruginosa has been isolated from previous cultures of the affected patient. Obligate anaerobes can play a role in a DFI, especially in ischemic limbs and in case of abscesses. Treated with an imidazole (metronidazole), or beta-lactam with beta-lactamase inhibitor, should be considered for a DFI associated with ischemia or a foul-smelling discharge.
- #32 1,500 mg (rounded from 1,460 mg = 20 mg/kg/dose × 73 kg Adjusted weight), Intravenous, Administer over 2 Hours For 1 dose, at 125 mL/hr
- #33 Vancomycin dosing (rounded from 1,460 mg = 20 mg/kg/dose × 73 kg Adjusted weight), Intravenous, Administer over 2 Hours, Once, For 1 dose, at rate 125 mL/hr Patient received vancomycin 1500 mg x 1 (20 mg/kg) today am level was 20 mg/L (24 hours post dose), will supplement with 500 mg x 1 today and recheck level in am (eGFR around 15 mL/min/m2) Trough Vancomycin level Between 10-20 mg/L Left hallux amputation is a surgical procedure that involves removing all or part of the big toe
- #35 The patient done four HD in CCAD due to his detolrizting kidney function and it was considered end stage renal disease and he developed atrial fib during HD catheter placement but he is stable now with bisoprolol.
- #37 He had multiple follow-up appointments with the podiatrist after discharge where they cleaned his wound, and gave him a prescription for diabetic foot inserts and shoes.
- #40 In this randomized controlled pilot trial, a Post debridement systemic antibiotic therapy course for DFO of 3 weeks gave similar (and statistically noninferior) incidences of remission and AE to a course of 6 weeks. In patients with diabetic foot osteomyelitis (DFO) who underwent surgical debridement, we investigated whether a short (3 weeks) duration compared with a long (6 weeks) duration of systemic antibiotic treatment is associated with noninferior results for clinical remission and adverse events (AEs). Among 93 enrolled patients (18% females; median age 65 years), 44 were randomized to the 3-week arm and 49 to the 6-week arm Co amoxciclav.
- #41 β-Lactam antibiotics (penicillins, cephalosporins, and carbapenems) penetrate bone at levels ranging from ∼5% to 20% of those in serum (Table 1). Nevertheless, because serum levels of parenterally delivered β-lactam antibiotics are so high, absolute bone levels likely exceed target minimum inhibitory concentrations (MICs) of etiologic bacteria in most cases. In contrast, because serum levels of oral β-lactam agents are <10% of those of parenteral agents, oral dosing is unlikely to achieve adequate bone levels.
- #42 β-Lactam antibiotics (penicillins, cephalosporins, and carbapenems) penetrate bone at levels ranging from ∼5% to 20% of those in serum (Table 1). Nevertheless, because serum levels of parenterally delivered β-lactam antibiotics are so high, absolute bone levels likely exceed target minimum inhibitory concentrations (MICs) of etiologic bacteria in most cases. In contrast, because serum levels of oral β-lactam agents are <10% of those of parenteral agents, oral dosing is unlikely to achieve adequate bone levels.