I NFECTIONS IN P ATIENTS WITH D IABETES David Joffe, BSPharm, CDE Diabetes In Control Kelsey Schultz PharmD Candidate 2013 Butler University

R HINOCEREBRAL M UCORMYCOSIS Fungal infection caused mainly by Rhizopus oryzae High risk of infection in those with DKA Presents as fever, nasal pain, ulceration, and necrosis with black nasal discharge Can spread quickly to the brain Cox GM. Mucormycosis (zygomycosis). In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA Grandis JR, Yu VL. Malignant (necrotizing) external otitis. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA

R HINOCEREBRAL M UCORMYCOSIS T REATMENT Surgical debridement of tissues IV lipid formulation of amphotericin B is the drug of choice Amphotericin 5mg/kg daily is the usual starting dose. Some doctors increase the dose to amphotericin 10mg/kg daily Control of contributing factors: hyperglycemia, metabolic acidosis Cox GM. Mucormycosis (zygomycosis). In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA Grandis JR, Yu VL. Malignant (necrotizing) external otitis. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA

U RINARY T RACT I NFECTIONS /

U RINARY T RACT I NFECTIONS

U RINARY T RACT I NFECTIONS Urinary infections diabetics are at increased risk for include: Urinary tract infections Pyelonephritis Asymptomatic bacteriuria Khardori R. Infection in patients with diabetes mellitus. Medscape reference. WebMD 2011.

U RINARY T RACT I NFECTIONS Presence of bacteria in the urinary tract bladder, urethra, prostate, kidneys Caused by Escherichia coli about 85% of the time Bacteria often comes from normal flora found around the rectal area Patient education point: wipe from front to back Coyle EA, Prince RA. “Urinary Tract Infections and Prostatitis.” Dipiro et al. Pharmacotherapy: A Pathophysiologic Approach, 7 th Ed. McGraw-Hill; 2008: Khardori R. Infection in patients with diabetes mellitus. Medscape reference. WebMD 2011.

U RINARY T RACT I NFECTIONS More common in women due to shorter urethra length and close proximity of urethra to rectum Signs and symptoms include: Dysuria, urgency, nocturia, flank pain Elderly present a little differently: Altered mental status, change in eating habits, gastrointestinal symptoms Coyle EA, Prince RA. “Urinary Tract Infections and Prostatitis.” Dipiro et al. Pharmacotherapy: A Pathophysiologic Approach, 7 th Ed. McGraw-Hill; 2008: Khardori R. Infection in patients with diabetes mellitus. Medscape reference. WebMD 2011.

U RINARY T RACT I NFECTIONS T REATMENT Generally the same as those without diabetes, except 7 days of treatment is preferred Nitrofurantoin 100mg orally twice daily for 7 days Trimethoprim/sulfamethoxazole DS 160mg/800mg orally twice daily for 7 days NOT if sulfa allergy! Coyle EA, Prince RA. “Urinary Tract Infections and Prostatitis.” Dipiro et al. Pharmacotherapy: A Pathophysiologic Approach, 7 th Ed. McGraw-Hill; 2008: Khardori R. Infection in patients with diabetes mellitus. Medscape reference. WebMD 2011.

P YELONEPHRITIS Upper UTI affecting kidneys Mainly caused by E. coli Presents as fever and severe flank pain Treatment doesn’t differ for diabetics, but hospitalization threshold may be lower Coyle EA, Prince RA. “Urinary Tract Infections and Prostatitis.” Dipiro et al. Pharmacotherapy: A Pathophysiologic Approach, 7 th Ed. McGraw-Hill; 2008: Khardori R. Infection in patients with diabetes mellitus. Medscape reference. WebMD

P YELONEPHRITIS O UTPATIENT T REATMENT Oral antibiotics are preferred in outpatients Fluoroquinolones or trimethoprim/sulfamethoxazole are the drugs of choice Treat for at least 2 weeks Cipro XR 1000mg orally daily or trimethoprim/sulfamethoxazole DS 160mg/800mg orally twice daily for 14 days Coyle EA, Prince RA. “Urinary Tract Infections and Prostatitis.” Dipiro et al. Pharmacotherapy: A Pathophysiologic Approach, 7 th Ed. McGraw-Hill; 2008: Khardori R. Infection in patients with diabetes mellitus. Medscape reference. WebMD

P YELONEPHRITIS I NPATIENT T REATMENT For seriously ill patients hospital admission and IV therapy are appropriate Broad coverage is warranted empirically Possible therapy includes: IV fluoroquinolone Aminoglycoside +/- ampicillin Extended spectrum cephalosporin Generally stop IV therapy and switch to oral after patient is afebrile for 24 hours Total therapy duration should be 2 weeks Coyle EA, Prince RA. “Urinary Tract Infections and Prostatitis.” Dipiro et al. Pharmacotherapy: A Pathophysiologic Approach, 7 th Ed. McGraw-Hill; 2008: Khardori R. Infection in patients with diabetes mellitus. Medscape reference. WebMD

P YELONEPHRITIS C OMPLICATIONS Diabetes patients are at an increased risk for complications from pyelonephritis: Renal abscess Emphysematous pyelonephritis Renal papillary necrosis (see white spots on picture) Gram-negative sepsis Insulin resistance makes controlling blood sugars more difficult Khardori R. Infection in patients with diabetes mellitus. Medscape reference. WebMD