1. I NFECTIONS IN P ATIENTS WITH D IABETES P ART 3 OF 4 David Joffe, BSPharm, CDE Diabetes In Control Kelsey Schultz PharmD Candidate 2013 Butler University

2. B ULLOUS D IABETICORUM 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. B ULLOUS D IABETICORUM T REATMENT 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. D IABETIC F OOT U LCERS 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, 7 th 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. D IABETIC F OOT U LCERS : P RESENTATION, E TIOLOGY 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, 7 th 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. D IABETIC F OOT U LCERS : N ON - P HARMACOLOGICAL T REATMENT 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, 7 th 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. D IABETIC F OOT U LCERS : M ILD T REATMENT 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, 7 th 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. D IABETIC F OOT U LCERS : M ODERATE -S EVERE T REATMENT 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, 7 th 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. D IABETIC F OOT U LCERS : C OMPLICATIONS 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, 7 th 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. O STEOMYELITIS 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, 7 th Ed. McGraw-Hill; 2008:1899-1913. http://www.sciencephoto.com/media/260055/enlarge

11. O STEOMYELITIS T REATMENT 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, 7 th Ed. McGraw-Hill; 2008:1899-1913.