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Inpatient Infection
Control of DM
Patients with Open
Wounds
BETTY CORONA MSN, ARNP,
FNP-BC
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Diabetic Foot
Infections
Infection in a diabetic foot is limb threatening
and if untreated can become
life threatening
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Diabetic Foot
Infections
Surgical debridement is essential in acute deep tissue
infections
Podiatrists are experts at debriding and collecting
samples to diagnose infections.
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Diabetic Foot
Infections Superficial infection-confined to skin superficial to fascia
Usually caused by normal skin bacteria
gram positive cocci
Coag neg Staph, strep, Corynebacterium
Deep tissue infection-invasion of
fascia, muscle, tendon, joint or bone Polymicrobial-Gram positives, gram negatives and anaerobes
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Diabetic Foot
Infections
WHAT DO YOU
DO WITH THE
CULTURE
RESULTS???
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Eradicate the Bugs! 6
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How Do We
Eradicate Bugs?
Antimicrobial
Therapy
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How Do We Choose
Antibiotics? Where is the infection? Soft
tissue/gangrene/bone?
Determine length of therapy
What is the infection?
Determine aggressiveness of infection and tailor antibiotics empirically, then to C&S
Know Antibiotic Penetrations
Which antibiotics penetrate bone, joints, etc…?
Appropriate Renal Dosing
DON’T OVERDOSE A RENAL PATIENT!!
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IDSA Guidelines
for DFIReduce emergence of
resistant organisms
Reduce hospital days
Reduce costs
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IDSA Guidelines
for DFI2011-Implementation
Decreased use of blood cx
Decreased advanced imaging
Decreased consultations
Shorter durations of therapy
Decreased use of anti-pseudomonal antibiotics
Decreased use of broader spectrum antibiotics
Decreased costs
No change in adverse outcomes
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Inpatient Hospitalization
Don’t Miss
Sepsis!Should be considered even
when local signs are less
severe
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Inpatient HospitalizationFoot infection determined: Look for s/s of sepsis or SIRS
Systemic Inflammatory Response (SIRS) criteria:
Need 3 for SIRS and 4 for sepsis
Known or suggested infection
Systemic manifestations of sepsis
temperature >38.3°C or <36°C
heart rate >90 beats/min
respiratory rate >20 breaths/min
acutely altered mental status
white blood cell count >12,000 μL (or 12 K/μL) or <4000 μL (or 4 K/μL)
plasma glucose 120 mg/dL in the absence of diabetes
Birriel, 2013, April 2.
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Inpatient
Hospitalization Sepsis: SIRS criteria + organ dysfunction
Indications of new or worsened organ dysfunction:
SBP <90 mm Hg or decrease >40 mm Hg from
baseline
Mean arterial pressure <65 mm Hg
Bilateral pulmonary infiltrates with increasing
oxygen requirements to maintain SpO2 >90%
Creatinine >2.0 mg/dL
Bilirubin >2 mg/dL
Platelet count <100,000/μL (or 100 K/μL)
Coagulopathy
Lactate >2 mmol/L
Birriel, 2013, April 2.
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Other Signs of
Systemic Illness
CRP elevated
Marked left shift
Elevated creatinine
Low serum bicarbonate
Low sodium
CK 2 x the upper limit of normal
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Inpatient
Hospitalization
Patients with SIRS and
sepsis need emergent
debridement of wound
infection
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Diabetic Foot Ulcers 16
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Diabetic Foot Ulcers
Not all diabetic foot ulcers are infected.
Infection if at least 2 present:
Purulent secretions
Redness
Warmth
Swelling/induration
Pain/tenderness
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IDSA Guidelines for
Diabetic Foot Infections
(Many areas need further evaluation for good recommendations)
Keep in mind when choosing treatment.
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IDSA Guidelines
for DFIRoute of therapy based on
severity
Mild & some moderate
DFIs
PO antibiotics with
good bioavailability
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IDSA Guidelines
for DFIRoute of therapy based on
severity
Severe & some moderate DFIs
IV at least initially (weak, low)
Switch to oral agents when
systemically stable and culture
results available
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IDSA Guidelines
for DFI
Continue antibiotics till
resolution of infection but
not through complete
healing of the wound (weak,
low)
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Definitive Therapy
Based on:
Results of appropriately
obtained C&S
Patient's clinical
response to the empiric
regimen (strong, low)
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Is there clinical
evidence of
infection?
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Do not treat clinically
uninfected wounds with
antibiotics
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For clinically
infected wounds
Is there high risk of MRSA?
Include anti-MRSA therapy in empiric regimen if the risk is high or the infection is severe
‐ Has patient received antibiotics in the past month?
If so, include agents active against gram-negative bacilli in regimen If not, agents targeted against just aerobic gram-positive cocci may be sufficient
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For clinically
infected wounds
Are there risk factors for Pseudomonas infection?
If so, consider empiric antipseudomonal agent If not, empiric antipseudomonal treatment is rarely needed
What is the infection severity status?
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MRSA Risk Factors Recent hospitalization last 90 days
Residence in long term care facility
Antibiotics last 90 days
Injection drug use
Hemo- or peritoneal dialysis
Incarceration last 90 days
Home infusion therapy
History of MRSA colonization
Immunosupressive state/medications
Wound care in past 30 days
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Pseudomonas
Risk factors
ICU stay in last 90 days
Immunosuppressive
state/medications
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Immunosuppressive states:
HIV
Solid organ transplants
BMT
Immunosuppressive
medications:
Rejection medications
>20mg/d prednisone x2
weeks
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Mild soft tissue infections 29
1-2 weeks
antibiotics Lipinsky, et al., 2012Wate
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IDSA Guidelines
for DFI Mild and many moderate
DFIs
High bioavailable oral antibiotics alone (strong, moderate)
Selected mild superficial infections
Topical therapy (strong, moderate)
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Empiric TherapyBased on severity and the likely etiologic
agent(s)
Mild to moderate infections in patients who have not recently
received antibiotic treatment
Aerobic gram-positive cocci (GPC) is
sufficient (weak, low)
Severe infections
broad-spectrum empiric antibiotic
therapy, pending culture results and
antibiotic susceptibility data (strong,
low)
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Suggested Empiric
Antibiotic Regimens for
DFIs Mild (usually oral agents)
Staphylococcus aureus (MSSA); Streptococcus spp
Dicloxacillin-QID, narrow specrum, inexpensive
Clindamycin-QID, inexpensive, may cover MRSA,
inhibits protein synthesis of some bacterial toxins
Cephalexin-QID, inexpensive
Levofloxacin-daily dosing, suboptimal against
staph aureus
Amoxicillin-clavulanate-Relatively broad spectrum
with anaerobic coverage
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Suggested Empiric
Antibiotic Regimens for
DFIs Mild (usually oral agents)
Methicillin-resistant S. aureus (MRSA)
Doxycycline-MRSA, some gram
negatives, not reliable against strep
Trimethoprim/sulfamethoxazole-MRSA,
some gram-negatives, not reliable
against strep
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Moderate to severe infections34
2-3 weeks
antibioticsLipinsky, et al., 2012W
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Suggested Empiric
Antibiotic Regimens for
DFIs Moderate (oral or IV) or severe (IV)
MSSA, strep, Enterobacter, anaerobes
Levofloxacin-daily, suboptimal against SA
Cefoxitin-2nd gen cephalosporin w/
anaerobic coverage
Ceftriaxone-daily, 3rd generation
Ampicillin-sulbactam-Adequate if low
suspicion for pseudomonas
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Suggested Empiric Antibiotic
Regimens for DFIs
Moderate (oral or IV) or severe (IV)
MSSA, strep, Enterobacter, anaerobes
Moxifloxacin-daily, Relatively broad
spectrum, covers most anaerobes
Ertapenem-daily, Relativelly broad
spectrum w/ anaerobic coverage;
Tigecycline-MRSA, very broad, high
rates of n/v and increased mortality
warning
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Suggested Empiric Antibiotic
Regimens for DFIs Moderate (oral or IV) or severe (IV)
MSSA, strep, Enterobacter,
anaerobes
Levofloxacin or Cipro w/
clindamycin-limited evidence
supporting coverage for severe
MSSA infections
Imipenem-cilastatin-Very broad
spectrum; Only use when
required
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Empiric Therapy• P. aeruginosa is usually unnecessary
except:
Patients with risk factors for true
infection with this organism
(strong, low)
• MRSA
Prior history of MRSA infection
Local prevalence of MRSA is high
Infection is clinically severe (weak,
low)
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Suggested Empiric Antibiotic
Regimens for DFIs
Moderate (oral or IV) or severe (IV)
Pseudomonas aeruginosa
Piperacillin-tazobactam-TID/QID, anaerobic coverage
Cefepime-BID/TID, no anaerobic or enterococcalcoverage
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Risk of
Nephrotoxicity Piperacillin-tazobactam & vancomycin combination
Increased risk of nephrotoxicity
8.1% vancomycin group
16.3% in combination group
Don’t add fuel to the fired unless absolutely necessary, especially in a
renal patient!
Limb salvaging
Known pseudomonas or enterococcus infection
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Suggested Empiric Antibiotic
Regimens for DFIs Moderate (oral or IV) or severe (IV)
MRSA
Linezolid-Expensive, Increased
rate of toxicities when used > 2
weeks
Daptomycin-Daily, Serial CKs for
potential rhabdomyolysis, Rare
eosinophilic pneumonia
Vancomycin-MICs for MRSA are
gradually rising
Need new options
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Suggested Empiric Antibiotic
Regimens for DFIs
Moderate (oral or IV) or severe (IV)
MRSA, Enterobacter,
pseudomonas & anaerobes
Vancomycin AND ceftazidime,
cefepime, pip/tazo, aztreonam OR a
carbapenem-Very broad spectrum,
usually for empiric therapy for severe
DFIs
Will need metronidazole if using
ceftazidime, cefepime, aztreonam
for anaerobic coverage
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Gangrene
Necrotizing soft tissue infections
of the diabetic foot, including
gas gangrene, are uncommon
and are usually caused by mixed
aerobic (and sometimes
anaerobic) bacteria rather than
Clostridium species.
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Strep Anginosus
Strain of Viridans Strep (Strep milleri)
Multidrug resistant; spreads quickly; abscesses
Ensure susceptibilities are obtained!
Generally susc to ampicillin; tetracycline, erythromycin; Resistance found intermittently to clindamycin, meropenems, some cephalosporins, quinolones, aminoglycosides
Arinto-Garcia, et al., 2015; Stelzmueller, et al., 2007; Gray, 2005;
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Normal Skin Flora
Infections coagulase-negative staphylococci
(CNS), corynebacteria, or Bacillus
spp, and low-virulence organisms
such as enterococci, can usually
be ignored unless cultured from
deep, aseptically collected tissue
or infections involving
osteosynthetic material or
hardware
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IDSA Guidelines
for DFIRadical resection without no
remaining infected tissue
2–5 days (weak, low)
Persistent infected or
necrotic bone
≥4 weeks antibiotic treatment
(weak, low)
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Renally Dosing
Antibiotics Vancomycin
Zosyn
Cephalosporins
Fluoroquinolones
Calculate CrCl every day!
www.globalrph.com CrCl calculator
CrCl < 50 ml/min may need renally dosed
Don’t rely on an EMR to calculate dose
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GlobalRPh.com 48
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GlobalRPh.com 49
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GlobalRPh.com 50
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GlobalRPh.com 51
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Systemic Antimicrobial
Prescribing
to reduce the spectrum and duration of
antibiotherapy to try to slow the tide of
antibiotic resistance
based on the assessment of infection
severity
knowledge of the local microbial
epidemiology
DFIs can develop rapidly, making early
follow-up after starting therapy
imperative
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Peripheral Artery Disease
(PAD)
Most DFIs occur in the setting of PAD, various antibiotic agents may not penetrate the infected site well, especially bone.
Previous practice was to Rx weeks of antibiotics
Evidence no supports the efficacy of current highly bioavailable oral antibiotics, thus not requiring as long of therapy
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Peripheral Artery Disease
(PAD)
Beta-lactam antibiotics-achieve relatively low (albeit therapeutic) tissue levels,
time-dependent (not concentration-dependent) drugs
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No Strong Oral
Antibiotic
RecommendationsSeveral systematic reviews of antimicrobial treatments for DFI have concluded that there is insufficient evidence to
recommend any particular antimicrobial agent or route of administration.
USE ANTIBIOGRAMS FOR
INSTITUTION OR LOCAL REGION
Nelson, et al., 2006; Peters, et al., 2015; Selva Olid, et al., 2015
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Oral Antibiotics
Clindamycin, fluoroquinolones,
linezolid, rifampicin, and to some
degree, tetracyclines and co-
trimoxazole
Good oral bioavailability
Good penetration in bone, synovia,
biofilm, and necrotic tissue.
Uçkay, 2014.
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Antibiotic misuse Excessive and inappropriate uses of
antibiotics have profound negative effect
For the patient by developing resistance
Health care system due to cost
Society as a whole due to resistance.9
Highly recommend not treating clinically
uninfected ulcers with antibiotic therapy.
Abbas, Uçkay & Lipsky, (2015).
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Take HomeChoose antibiotics based on
severity, location and then C&S
Renally dose all antibiotics
Calculate CrCl daily according
to IBW.
Don’t miss sepsis!
Sepsis and SIRS need
emergent debridement.
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Take Home IDSA Guidelines are helpful but not
very specific. Must use clinical
judgement.
MRSA/Pseudomonas risks
IV antibiotics for moderate-severe
infections
Choose oral antibiotics with good
bioavailability
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Take Home
Avoid piperacillin/tazobactamcombination if at all possible to avoid increasing risk of nephrotoxicity.
Use your local antibiogram.
Need good antibiotic stewardship to avoid worsening of resistance. Avoid antibiotics if not infected.
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ReferencesAbbas, M., Uçkay, I., & Lipsky, B. A. (2015). In diabetic foot
infections antibiotics are to treat infection, not to heal wounds.
Expert Opinion on Pharmacotherapy, 16, 821–832.
Arinto-Garcia, R, Pinho, M. D., Carriço, J. A., Melo-Cristino, J., &
Ramirez, M. (2015). Comparing matrix-assisted laser
desorption ionization-time of flight mass spectrometry and
phenotypic and molecular methods for identification of species
within the streptococcus anginosus group. Journal of Clinical Microbiololgy, 53(11), 3580-3588. Epub 2015 Sep 9.
doi:10.1128/JCM.01892-15.
Birriel, B. (2013, April 2). Rapid Identification of Sepsis - The Value
of Screening Tools. Society of Critical Care Medicine,
Retrieved from http://www.sccm.org/Communications/Critical-
Connections/Archives/Pages/Rapid-Identification-of-Sepsis---
The-Value-of-Screening-Tools.aspx
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References
Burgess, L. D., & Drew, R. H. (2014). Comparison of the incidence of vancomycin-induced nephrotoxicity in hospitalized patients with and without concomitant piperacillin-tazobactam. Pharmacotherapy, 34(7), 670-676. doi:10.1002/phar.1442.
GlobalRph: The clinicians ultimate reference. (2015.). Multiple creatinine clearance methods. Retrieved from http://globalrph.com/multiple_crcl.htm
Gray, T. (2005). Streptococcus anginosus group: Clinical significance of an important group of pathogens, Clinical Microbiology Newsletter, 27(20), 155–159.
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ReferencesLipinsky, B. A., Berendt, A. R., Cornia, P. B., Pile, J. C., Peters, E. J. G.,
Armstrong, D. G., et al. (2012). 2012 Infectious Diseases Society
of America clinical practice guidelines for the diagnosis and
treatment of diabetic foot infections, Clinical Infectious Diseases,
54, e132-e173.
Nelson, E. A., O’Meara, S., Golder, S., Dalton, J., Craig, D., & Iglesias,
C. (2006). Systematic review of antimicrobial treatments for
diabetic foot ulcers. Diabetic Medicine, 23, 348–359.
Peters, E. J. B., Aragón-Sánchez, J., Bakker, K., Boyko, E. J., Diggle,
M., Embil, J. M., et al. (2015). A systematic review of interventions
in the management of infection in the diabetic foot. Diabetes Metabolism Research & Reviews, [Epub ahead of print] ,
Retrieved from http://dx.doi.org/10.1002/dmrr.2706
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References
Selva Olid, A.,Barajas-Nava, L. A., Gianneo, O.D., Solà, I., Bonfill
Cosp, X., & Lipsky, B.A. (2015). Systemic antibiotics for
treating diabetic foot infections. Cochrane Database Systematic Review, 9, p. CD009061. Retrieved from
http://dx.doi.org/10.1002/14651858.CD009061.pub2
Stelzmueller, I., Berger, N., Wiesmayr, S., Eller, M., Tabarelli, W.,
Fille, M., Margreiter, R., & Bonatti, H. (2007). Transplant International, 20(1), 51-56.
Uçkaya, I., Aragón-Sánchezc, J., Lewa, D., & Lipskya, B. (2015).
Diabetic foot infections: What have we learned in the last 30
years? International Journal of Infectious Diseases, 40, 81-
91. doi:10.1016/j.ijid.2015.09.023
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References
Uçkay, I., Gariani, K., Pataky, Z., & Lipsky, B.A. (2014).
Diabetic foot infections: State-of-the-art. Diabetes Obesity and Metabolism, 16, 305–316.
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