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3151 Therapeutics > DFI and Pressure Ulcers > Flashcards

DFI and Pressure Ulcers Flashcards

1
Q

What is Diabetic Foot Infection?

A

Soft tissue or bone infection below the malleolus

Areas of DFI:
- skin ulceration (peripheral neuropathy)
- wound (trauma)

Complications:
- hospitalization
- osteomyelitis => amputation

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2
Q

What is the pathophysiology of DFI?

A
  1. Neuropathy
    - Peripheral: decrease pain sensation and altered pain response
    - Motor: muscle imbalance
    - Autonomic: increase dryness, cracks, and fissures
  2. Vasculopathy
    - Early atherosclerosis
    - Peripheral vascular disease
    - Worsened by hyperglycemia and hyperlipidemia
  3. Immunopathy
    - Impaired immune response
    - Increase susceptibility to infections
    - Worsened by hyperglycemia

=> Ulcer formation and wounds
=> Bacterial colonization, penetration and proliferation
=> DFI

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3
Q

Definition of DFI (INFECTED)

A

Purulent discharge

OR

> = 2 signs or symptoms of inflammation (PWETI)
- Erythema
- Warmth
- Tenderness
- Pain
- Induration (hardness)

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4
Q

What are the causative organisms of DFI?
*Typically polymicrobial

A

Staphyloccous Aureus

Streptococcus

Gram-negative bacilli - Particularly in chronic wounds or previously treated with antibiotics
- E. coli, Klebsiella, Proteus
- Pseudomonas (less common)

Anaerobes - ischemic or necrotic wounds
- Peptostreptococcus, Veillonella, Bacteroides

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5
Q

When should culture be obtained for DFI?

A

Mild DFI - optional

Moderate-severe DFI - deep tissue cultures after cleansing and before starting antibiotics (if possible), avoid skin swabs

*Do not culture uninfected wounds

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6
Q

DFI treatment is dependent on _____ and ______

A

Severity of infection

  • based on IDSA (mild, moderate, severe definition)
  • account for SIRS criteria (systemic signs)
  • account for extent of tissue involvement

AND

Patient specific factors

  • allergies
  • MRSA risk factors
  • pseudomonal risk factors (water exposure, warm climate)
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7
Q

When should Pseudomonas cover be considered in DFI?

A

*Pseudomonas should be covered when:
- severe infection
- failure of antibiotics not active against pseudomonas

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8
Q

What constitutes a MILD IDSA Infection Severity (DFI)

A

Mild
- Infection of skin and sc tissue +
- If erythema =<2cm around ulcer +
- No signs of systemic infection

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9
Q

What organisms should be covered in MILD DFI?

A

Staph
Strep

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10
Q

What are the empiric antibiotic options for MILD DFI?

A

PO Cephalexin 500mg q6h
PO Cloxacillin 500mg-1g q6h
PO Clindamycin 300-450mg q6h (penicillin allergy)

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11
Q

What are the empiric antibiotic options for MILD DFI?
(If there are MRSA risk factors, use what instead?)

A

If MRSA risk factors
- PO Cotrimoxazole 960mg bid
- PO Clindamycin 300-450mg q6h
- PO Doxycyline 100mg bid

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12
Q

What is the duration of therapy for MILD DFI?

A

1-2 weeks

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13
Q

What constitutes a MODERATE IDSA Infection Severity (DFI)?

A

Moderate
- Infection of deeper tissue (e.g., joints, bones)
or
- If erythema >2cm +
- No signs of systemic infection

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14
Q

What organisms should be covered in MODERATE DFI?

A

Staph
Strep
Gram-negative
Anaerobic

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15
Q

What are the empiric antibiotic options for MODERATE DFI?

A

IV Amoxicillin-Clavulanate 1.2g q6-8h
IV Cefazolin 1-2g q8h + Metronidazole 500mg q8h
IV Ceftriaxone 1-2g q12-24h + Metronidazole 500mg q8h

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16
Q

What are the empiric antibiotic options for MODERATE DFI?
(What to ADD if there are MRSA risk factors)

A

If MRSA risk factors: add
- IV Vancomycin 15mg/kg q8-12h
- IV Daptomycin 4-6mg/kg q24h
- IV Linezolid 600mg q12h

*Reserve Daptomycin and Linezolid for vancomycin resistance, more ex as well

17
Q

What is the duration of therapy for MODERATE DFI (no bone involvement)?

A

1-3 weeks

18
Q

What constitutes a SEVERE IDSA Infection Severity (DFI)?

A

Moderate
- Infection of deeper tissue (e.g., joints, bones)
or
- If erythema >2cm +
- Signs of systemic infection

19
Q

What organisms should be covered in SEVERE DFI?

A

Staph
Strep
Gram negative
Anaerobe
Pseudomonas

20
Q

What are the empiric antibiotic options for SEVERE DFI?

A

IV Piperacillin-Tazobactam 4.5g q6-8h
IV Cefepime 2g q8h + Metronidazole 500mg q8h
IV Meropenem 1-2g q8h
IV Ciprofloxacin 400mg q8-12h + Clindamycin 600mg q8h
IV Ceftazidime 1-2g q8h + Clindamycin 600mg q8h

21
Q

What are the empiric antibiotic options for SEVERE DFI?
(What to ADD if there are MRSA risk factors)

A

If MRSA risk factors add:
IV Vancomycin 15mg/kg q8-12h
IV Daptomycin 4-6mg/kg q24h
IV Linezolid 600mg q12h

22
Q

What is the duration of therapy for SEVERE DFI (no bone involvement)?

A

2-4 weeks

23
Q

What is the duration of therapy for DFI with bone involvement?

Surgery - all infected bone and tissue removed

A

Surgery - all infected bone and tissue removed (e.g., amputation): 2-5 days

24
Q

What is the duration of therapy for DFI with bone involvement?

Surgery - residual infected soft tissue

A

Surgery - residual infected soft tissue: 1-3 weeks

25
Q

What is the duration of therapy for DFI with bone involvement?

Surgery - residual viable bone

A

Surgery - residual viable bone: 4-6 weeks

26
Q

What is the duration of therapy for DFI with bone involvement?

No surgery or Surgery - residual dead bone

A

No surgery or Surgery - residual dead bone: >= 3months

27
Q

When should antibiotics for DFI be stopped/changed?

A

Do not continue Abx until complete wound healing (bacteria cleared faster than wound heals)

Streamline choice of Abx based on culture and AST (impt as the empiric choices are broad spectrum => selection pressure)

Switch to oral therapy when patient improved

28
Q

What are the adjunctive measures for DFI?

A

Wound care

  • debridement
  • “off-loading” - relieve pressure on ulcer
  • apply dressings that promote a healing environment and control excess exudation

Foot care

  • daily inspection
  • prevent wounds and ulcers

Optimal glycemic control

29
Q

What are Pressure Ulcers?

A

Pressure ulcers = Decubitus ulcers = Bed sores

Synergistic interaction between 4 factors:
Moisture
Pressure (amount of time and duration)
Shearing force
Friction

30
Q

What are the risk factors for Pressure Ulcers?

A

Reduced mobility

Debilitated by severe chronic diseases

Reduced consciousness

Sensory and autonomic impairment
- incontinence (moisture)

Extremes of age - mobility issue

Malnutrition

31
Q

What are the 4 stages of clinical presentation of Pressure Ulcers?

A

Stage 1: abrasion of epidermis, irregular area of tissue swelling, no open wound

Stage 2: extends through dermis, open wound

Stage 3: extends deep into s/c fat, open sore or ulcer

Stage 4: involves muscle and bone, deep sore or ulcer

*Similar criteria for INFECTION applies:

  • Purulent OR
  • > = 2 signs and symptoms of inflammation: erythema, warmth, tenderness, pain, induration
32
Q

What are the causative organisms of Pressure Ulcers?

A

Identical to DFIs, polymicrobial

Staphyloccous Aureus

Streptococcus

Gram-negative bacilli - Particularly in chronic wounds or previously treated with antibiotics
- E. coli, Klebsiella, Proteus
- Pseudomonas (less common)

Anaerobes - ischemic or necrotic wounds
- Peptostreptococcus, Veillonella, Bacteroides

33
Q

Treatment of Pressure Ulcers?

A

same as DFI

34
Q

What are the adjunctive measures for Pressure Ulcers?

A

Wound care
- debridement of infected or necrotic tissue
- local wound care: normal saline, avoid harsh chemicals

Relief of pressure
- turn/reposition every 2h

Barrier creams/dressings

3151 Therapeutics (12 decks)

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