Inpatient Infection Control of DM Patients with Open Wounds BETTY CORONA MSN, ARNP, FNP-BC. Watermark

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1 Inpatient Infection Control of DM Patients with Open Wounds BETTY CORONA MSN, ARNP, FNP-BC 1

2 Diabetic Foot Infections Infection in a diabetic foot is limb threatening and if untreated can become life threatening 2

3 Diabetic Foot Infections Surgical debridement is essential in acute deep tissue infections Podiatrists are experts at debriding and collecting samples to diagnose infections. 3

4 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 4

5 Diabetic Foot Infections WHAT DO YOU DO WITH THE CULTURE RESULTS??? 5

6 Eradicate the Bugs! 6

7 How Do We Eradicate Bugs? Antimicrobial Therapy 7

8 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!! 8

9 IDSA Guidelines for DFI Reduce emergence of resistant organisms Reduce hospital days Reduce costs 9

10 IDSA Guidelines for DFI 2011-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 10

11 Inpatient Hospitalization Don t Miss Sepsis! Should be considered even when local signs are less severe 11

12 Inpatient Hospitalization Foot 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 12 Birriel, 2013, April 2.

13 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 13

14 Other Signs of Systemic Illness CRP elevated Marked left shift Elevated creatinine Low serum bicarbonate Low sodium 14 CK 2 x the upper limit of normal

15 Inpatient Hospitalization Patients with SIRS and sepsis need emergent debridement of wound infection 15

16 Diabetic Foot Ulcers 16

17 Diabetic Foot Ulcers Not all diabetic foot ulcers are infected. Infection if at least 2 present: Purulent secretions Redness Warmth Swelling/induration Pain/tenderness 17

18 IDSA Guidelines for Diabetic Foot Infections (Many areas need further evaluation for good recommendations) Keep in mind when choosing treatment. 18

19 IDSA Guidelines for DFI Route of therapy based on severity Mild & some moderate DFIs PO antibiotics with good bioavailability 19

20 IDSA Guidelines for DFI Route 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 20

21 IDSA Guidelines for DFI Continue antibiotics till resolution of infection but not through complete healing of the wound (weak, low) 21

22 Definitive Therapy Based on: Results of appropriately obtained C&S Patient's clinical response to the empiric regimen (strong, low) 22

23 Is there clinical evidence of infection? Do not treat clinically uninfected wounds with antibiotics 23

24 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 24

25 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? 25

26 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 26

27 Pseudomonas Risk factors ICU stay in last 90 days Immunosuppressive state/medications 27

28 Immunosuppressive states: HIV Solid organ transplants BMT Immunosuppressive medications: Rejection medications >20mg/d prednisone x2 weeks 28

29 Mild soft tissue infections weeks antibiotics Lipinsky, et al., 2012

30 IDSA Guidelines for DFI Mild and many moderate DFIs High bioavailable oral antibiotics alone (strong, moderate) Selected mild superficial infections Topical therapy (strong, moderate) 30

31 Empiric Therapy Based 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) 31

32 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 32 Amoxicillin-clavulanate-Relatively broad spectrum with anaerobic coverage

33 Suggested Empiric Antibiotic Regimens for DFIs Mild (usually oral agents) Methicillin-resistant S. aureus (MRSA) Doxycycline-MRSA, some gram negatives, not reliable against strep 33 Trimethoprim/sulfamethoxazole-MRSA, some gram-negatives, not reliable against strep

34 Moderate to severe infections weeks antibiotics Lipinsky, et al., 2012

35 Suggested Empiric Antibiotic Regimens for DFIs Moderate (oral or IV) or severe (IV) MSSA, strep, Enterobacter, anaerobes Levofloxacin-daily, suboptimal against SA Cefoxitin-2 nd gen cephalosporin w/ anaerobic coverage Ceftriaxone-daily, 3 rd generation Ampicillin-sulbactam-Adequate if low suspicion for pseudomonas 35

36 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 36

37 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 37

38 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) 38

39 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 enterococcal coverage 39

40 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 40

41 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 41

42 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 42 Will need metronidazole if using ceftazidime, cefepime, aztreonam for anaerobic coverage

43 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. 43

44 Arinto-Garcia, et al., 2015; Stelzmueller, et al., 2007; Gray, 2005; Strep Anginosus Strain of Viridans Strep (Strep milleri) Multidrug resistant; spreads quickly; abscesses 44 Ensure susceptibilities are obtained! Generally susc to ampicillin; tetracycline, erythromycin; Resistance found intermittently to clindamycin, meropenems, some cephalosporins, quinolones, aminoglycosides

45 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 45

46 IDSA Guidelines for DFI Radical resection without no remaining infected tissue 2 5 days (weak, low) Persistent infected or necrotic bone 4 weeks antibiotic treatment (weak, low) 46

47 Renally Dosing Antibiotics Vancomycin Zosyn Cephalosporins Fluoroquinolones Calculate CrCl every day! CrCl calculator CrCl < 50 ml/min may need renally dosed Don t rely on an EMR to calculate dose 47

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53 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 53

54 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 54

55 Peripheral Artery Disease (PAD) Beta-lactam antibioticsachieve relatively low (albeit therapeutic) tissue levels, time-dependent (not concentrationdependent) drugs 55

56 No Strong Oral Antibiotic Recommendations Several 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.,

57 Oral Antibiotics Clindamycin, fluoroquinolones, linezolid, rifampicin, and to some degree, tetracyclines and cotrimoxazole Good oral bioavailability Good penetration in bone, synovia, biofilm, and necrotic tissue. Uçkay,

58 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. 58 Abbas, Uçkay & Lipsky, (2015).

59 Take Home Choose 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. 59

60 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 60

61 Take Home Avoid piperacillin/tazobactam combination 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. 61

62 References Abbas, 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, 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), Epub 2015 Sep 9. doi: /jcm Birriel, B. (2013, April 2). Rapid Identification of Sepsis - The Value of Screening Tools. Society of Critical Care Medicine, Retrieved from Connections/Archives/Pages/Rapid-Identification-of-Sepsis--- The-Value-of-Screening-Tools.aspx 62

63 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), doi: /phar GlobalRph: The clinicians ultimate reference. (2015.). Multiple creatinine clearance methods. Retrieved from Gray, T. (2005). Streptococcus anginosus group: Clinical significance of an important group of pathogens, Clinical Microbiology Newsletter, 27(20),

64 References Lipinsky, B. A., Berendt, A. R., Cornia, P. B., Pile, J. C., Peters, E. J. G., Armstrong, D. G., et al. (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, 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 64

65 References 65 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. CD Retrieved from Stelzmueller, I., Berger, N., Wiesmayr, S., Eller, M., Tabarelli, W., Fille, M., Margreiter, R., & Bonatti, H. (2007). Transplant International, 20(1), 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, doi: /j.ijid

66 References Uçkay, I., Gariani, K., Pataky, Z., & Lipsky, B.A. (2014). Diabetic foot infections: State-of-the-art. Diabetes Obesity and Metabolism, 16,