Professional Documents
Culture Documents
Kimberly Oman
Poorly characterized defects in host immunity ... make them more susceptible to certain types of infections including bacterial infections of the skin and soft tissue (CID 1997;25:1318) Impaired wound healing in diabetics (ibid) Decreased cell mediated immunity (Mandell 1990 p. 129) Decreased neutrophil chemotaxis and phagocytosis (Mandell p. 145)
system
patients on insulin ? Increased frequency of infection More likely to be severe and protracted
Crepitant soft tissue wounds (p. 809): nonclostridial anaerobic cellulitis, necrotizing fasciitis, synergistic necrotizing cellulitis (Gas gangrene) Forniers gangrene (necrotizing fasciitis of the male genitals) - if the abdominal wall becomes involved in an obese patient with diabetes, the process can spread like wildfire (p. 810)
Candida vaginitis (p. 1946) Chronic or persistent bacterial pneumonia (p. 566) Infectious arthritis (p. 912) Rhinocerebral mucormycosis (DM esp. acidosis, leukemia, renal transplant) : facial pain, headache, involvement of orbit & braintreat with radicaldebridement (p.1964) ? Cryptococcosis (fungal meningitis, pneumonia) p. 1982
Clinical presentation
Unwell Minimal or no localizing signs Often confused +/- fever Often high white count Respond to cloxacillin and gentamicin May do poorly if antibiotics withheld
Ischemia
Arterial insufficiency in 60% with non-healing
Infection
Superficial fungal infections leading to
maceration or broken skin Increased nasal and skin colonization with Staphylococcus aureus
Peripheral neuropathy present in over 80% of diabetics with foot lesions Sensory neuropathy Motor neuropathy:
Gait disturbances, foot deformities (such as claw
Unperceived injury
Autonomic neuropathy
Interference with sweating can lead to dry,
toe)
cracked skin
Regular foot inspection by clinicians Education in foot care and proper footwear
Wash and dry your feet thoroughly every day, especially between the toes Inspect your feet daily for blister, skin breaks and infection Apply cream to the skin Cut your toenails carefully Wear well-fitting shoes that dont rub or hurt your feet or cause blisters Dont go barefoot
Seek medical care if you have an infection or skin breakdown on your feet. Tell patients that preventing foot problems and treating foot problems early can prevent amputations
Most common
Unperceived, excessive and repetitive pressure on
Others
Foot deformities (elevated focal pressure) Small foreign bodies in footwear Pressure necrosis from poorly fitting footwear Puncture wounds Pacific Islands: going barefoot
History Prior ulceration Prior surgery involving the metatarsal bones Physical findings Callus or hemorrhagic callus Blister or macerated skin Limited hallux dorsiflexion (<30 degrees) Prominent metatarsal heads inadequately covered
No apparent infection
(No signs of inflammation or drainage or evidence
Mild infection
Superficial, < 2 cm of cellulitis No serious ischemia No bone or joint involvement Patient reliable, good home support
Limb-threatening infections
Full-thickness ulcer >2 cm of cellulitis with or without lymphangitis Bone or joint involvement Systemic toxicity Serious ischemia Patient unreliable or poor home support
History:
Ulcer present for more than one week Previous osteomyelitis History of other foot complications secondary to
Physical exam:
peripheral neuropathy
Many are not febrile Increased risk if ulcer over bony prominence Larger or deeper ulcer Bone visible or can be touched with a sterile blunt probe
Laboratory tests
ESR
>70 mm/hr: 100% have osteomyelitis >40 mm/hr: 12x risk of osteomyelitis
Radiography
medullary bone bony abnormalities not present on plain films for 10-20 days Overseas: bone scans / gallium scans / indium labeled leukocytes / MRI
Bone culture
Sensitivity 95% / Specificity 99% Surgical approach OR Percutaneous through uninfected tissue Gram stain and culture Histopathology
Laboratory studies
Similar for soft tissue infection and osteomyelitis Soft tissue cultures often grow different organisms from bone cultures in the same patient Most infections are polymicrobial
Average: 2.2 pathogens in osteomyelitis, twice that in
Anaerobes Relatively frequent in serious soft tissue infections Less common in osteomyelitis More frequent in long-standing infections,
? Role of Staph epi and Corynebacterium spp.
Guided by soft tissue or bone cultures Some treat all organisms cultured, others do not Less serious: anti-Staphylococcal cover is often sufficient More serious: Staphylococcal, gram negative and anaerobe cover
Traditional: 4 - 6 weeks IV antibiotics Basis: animal models and anecdotes No reliable data on: Duration of antibiotic therapy When to switch to oral agents Approach (CID 1997;25:1310) Consider bone biopsy for culture and histopathology Remove entire section of infected bone plus 2 weeks of
weeks of antibiotics - at least one week IV (longer for tarsal or calcaneal bone which must be removed piecemeal)
10 - 12 weeks antibiotics without surgical debridement Chronic suppression without cure can be a valid
Probe to bone? - Osteomyelitis Suggestive xray? - Osteomyelitis Unclear? (Too early for xray changes?)
Treat as for soft tissue infection (culture-directed)
Soft tissue infections: beware gas gangrene and necrotizing soft tissue infections
Severe infections
Metronidazole 400mg po 8/24 PLUS Flucloxacillin 500mg po 6/24 metronidazole 400mg po 8/24 PLUS cloxacillin 1-2g IV 6/24 PLUS Gentamicin 80mg IV 8/24 (adjust as needed) metronidazole 400mg po 8/24 PLUS cephalothin 1-2 gm IV 4/24
Alternative
Change to oral therapy when infection is under control Duration of treatment depends on response Adjust therapy based on culture results
Surgical debridement is often necessary Surgical advice should be sought (often not necessary in mild cases) Proper dressings and wound care very important
Fluoroquinolones (Ciprofloxacin)
Staphylococcus aureus & gram negatives Not anaerobes Newer quinolones cover other gram positives (but
not Ciprofloxacin)
B-lactam / B-lactamase combinations po/IV: gram negative, S. aureus, anaerobes Amoxicillin - clavulanate - po Ampicillin - sulbactam - IV Ticarcillin - clavulanate - IV Piperacillin - tazobactam - IV Cefoxitin or cefotetan (2nd generation cephalosporins) IV S. aureus, anaerobes, gram - with holes Carbapenems (imipenem / meropenem) - IV gram negative, S. aureus, anaerobes
Debridement of infected tissue (diabetics do not tolerate undrained suppuration) Remove infected bone if possible (ie. digital or ray amputation) When to amputate? Revascularization procedures if needed (overseas)
High morbidity and mortality Often hard to distinguish soft tissue infection from osteomyelitis Little data on optimal duration of treatment Little data on IV vs. oral antibiotics Many valid approaches Therefore best treatment is still uncertain
Caputo GM, Cavanagh PR, Ulbrecht JS, Gibbons GW, Karchmer AW. Assessment and management of foot disease in patients with diabetes. N Engl J Med 1994;331:854-60. Lipsky BA. Osteomyelitis of the foot in diabetic patients. Clin Infect Dis 1997;25:1318-26. MandellGL, Douglas RG, Bennett JE eds. Principles of Infectious Diseases 3rd Edition. Churchill Livingstone: New York; 1990.