1. I NFECTIONS IN P ATIENTS WITH D IABETES P ART 4 OF 4 Kelsey Schultz PharmD Candidate 2013 Butler University

2. N ECROTIZING I NFECTIONS Group of very lethal infections with a high (20-50%) mortality rate Polymicrobial including S. aureus, anaerobes, and Group A streptococci Presentation: severe and constant pain, skin necrosis and blisters, gas in the soft tissue, systemic toxicity, and rapid spread despite antibiotics 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. http://hardinmd.lib.uiowa.edu/dermatlas/necrotizing.html

3. N ECROTIZING F ASCIITIS T REATMENT Surgical debridement and drainage of all necrotic tissue Empiric broad spectrum antibiotic therapy could include: piperacillin/tazobactam 4.5g IV every 6 hours clindamycin 600-900mg IV every 8 hours vancomycin 15-20mg/kg IV every 12 hours consideration of an anti-pseudomonal fluoroquinolone or aminoglycoside. 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.

4. P REVENTION : M ETHODS TO A VOID I NFECTIONS Tight blood glucose control Glycemic Measurement ADAAACE Average preprandial plasma glucose (mg/dL) 70-130<110 Peak postprandial plasma glucose (mg/dL) <180<140 HbA1C (%)<7<6.5 American Diabetes Association. Standard of Medical Care in Diabetes-2011. Diabetes Care. 2011;34:S11-S61. The American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for the Management of Diabetes Mellitus 2007. Endocr Pract. 2007;13:S3-S76.

5. P REVENTION : M ETHODS TO A VOID I NFECTIONS Meeting cholesterol and blood pressure goals will prevent further microvascular and macrovascular complications: LDL < 100mg/dL or <70mg/dL in patients with cardiovascular disease (MI, stroke) Triglycerides < 150mg/dL HDL > 40mg/dL in men and >50mg/dL in women Blood pressure <130/80 mmHg American Diabetes Association. Standard of Medical Care in Diabetes-2011. Diabetes Care. 2011;34:S11-S61.

6. P REVENTION : M ETHODS TO A VOID I NFECTIONS Proper foot care including: Daily inspection and cleaning of feet Wear comfortable shoes Don’t walk barefoot or try to remove calluses/corns on your own Avoid dry skin by moisturizing feet before bedtime American Diabetes Association. Standard of Medical Care in Diabetes-2011. Diabetes Care. 2011;34:S11-S61. http://www.umm.edu/patiented/articles/diabetic_foot_care_000207.htm

7. P REVENTION : P ROVIDER S CREENING AND T ESTING OF F OOT C ARE Providers should assess the following information when providing foot care for patients with diabetes: Pulse, temperature, color, skin integrity Fungal growth (within web-spaces of feet especially) Monofilament test Tuning fork for sensitivity to vibration Short distance walking observation to determine bone, joint, and muscle problems American Diabetes Association. Standard of Medical Care in Diabetes-2011. Diabetes Care. 2011;34:S11-S61.

8. P REVENTION : N EUROPATHY F OOT E XAMS Monofilament test: Monofilament is placed at right angle to the skin on the plantar side of the foot Pressure is applied until the filament buckles Patient is asked if pressure was felt those with foot ulcers tend to have a higher pressure threshold than those without ulcers McCulloch DK. Evaluation of the diabetic foot. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA. 2012. http://www.aafp.org/afp/1998/0315/p1325.html http://www.aafp.org/afp/1998/0315/p1325.html

9. P REVENTION : P ATIENT E DUCATION UTI prevention in women: Have patients wipe from front to back to prevent bacteria from entering the urethra Postcoital voiding and increased fluid intake may be beneficial Hooton TM, Gupta K. Recurrent urinary tract infection in women. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA. 2012. http://www.umm.edu/imagepages/19094.htm http://www.umm.edu/imagepages/19094.htm

10. O VERVIEW OF T OPICS C OVERED Reasons for increased infections and delayed wound healing Common infections and their incidence Complications from infections Treatment strategies for infections and wounds Methods to avoid and prevent infections

11. I NFECTIONS IN P ATIENTS WITH D IABETES Kelsey Schultz PharmD Candidate 2013 Butler University