3/15/18 I have no disclosures Fighting Infection in Diabetes Emily Abdoler, MD Division of Infectious Diseases GomerBlog . http://gomerblog.com/2018/02/nystatin-statin/ Outline Outline • Does DM Increase Risk of Infections? • Does DM Increase Risk of Infections? • Diabetic Foot Ulcers • Diabetic Foot Ulcers • Infections Treated Differently in DM • Infections Treated Differently in DM • Infections Increased in DM • Infections Increased in DM • Other Considerations • Other Considerations 1
3/15/18 Proposed Mechanisms for Does DM Increase Risk of Infection? Increased Infection Risk Decreased Cell-Mediated Immunity Decreased Leukocyte Function (hyperglycemia) Normal BMT Neuropathy Vascular Insufficiency Host Day 2 Ischemia Sensory Autonomic é bacterial ê abx Tissue injury Urinary growth delivery Retention Impaired immune Disrupted Skin response Barrier Rajagoplan S CID 2005;40:990-6. Pozzilli P & Leslie RDG Diab Med 1994;11:935-41. Does DM Increase Risk of Infection? Does DM Increase the Risk of Infection? Surgical Site Infections Adj Odds Diabetes (OR 2.76) Ratio Post-op hyperglycemia (OR 2.02) Lower Respiratory Tract 1.32 - 1.42 Not A1c Infection UTI 1.24 - 1.96 Hospital-Acquired Infections DM is an independent risk factor (RR 1.76) GI 1.4 Bacterial Skin/MM Infection 1.33 – 1.66 Take-Away: Mycotic Skin/MM Infection 1.34 – 1.44 - DM likely increases the risk of some infections - Relationship of hyperglycemia is unclear Rodriguez AL et al Am J Infect Contr 2017;45:e149-56. Latham R et al Infect Contr Hosp Epi 2001;22:607-12. Muller et al CID 2005;41:281-8. Abu-Ashour W et al BMC Infect Dis 2018;18. 2
3/15/18 Outline Diabetic Foot Ulcers • Is it infected? • Does DM increase risk of infections? • How do you evaluate the infection? • Diabetic Foot Ulcers – General evaluation • Infections Treated Differently in DM – Severity – Imaging • Infections Increased in DM – Culture • Other Considerations • How do you manage the infection? – What organisms should you cover? – Surgical management – Treatment duration Question #1 Question #1 When should you suspect MRSA could be playing When should you suspect MRSA could be playing a role in a diabetic foot infection? a role in a diabetic foot infection? A. Positive MRSA nasal carriage within last yr A. Positive MRSA nasal carriage within last yr B. Frequent gym use B. Frequent gym use C. Copious purulence C. Copious purulence D. Extreme erythema D. Extreme erythema 3
3/15/18 Diabetic Foot Ulcer: Is it Infected? Diabetic Foot Ulcer: Is it Infected? Factors Associated with Infection OR ≥2 classic signs of inflammation or purulence Probe to Bone 6.7 Erythema Warmth Tenderness Ulcer >30 Days 4.7 H/o recurrent ulcers 2.4 Swelling/Induration Traumatic foot wound 2.4 Exclude other causes PVD (in affected limb) 1.9 – 5.5 Trauma Gout Acute Charcot Previous amputation 19.9 Fracture Thrombosis Venous Stasis Neuropathy 3.4 ?Renal insufficiency ?H/o walking barefoot IDSA Diabetic Foot Infections Guidelines 2012 IDSA Diabetic Foot Infections Guidelines 2012; Lavery LA Diabetes Care 2006;29:1288-93. Peters EJ et al J Diabetes Complications 2005;19:107-12 Diabetic Foot Infections: Diabetic Foot Infections: Severity? General Evaluation Assess for IDSA Infection Description Severity -Arterial & venous insufficiency Uninfected No s/sx of infection Mild Local infection involving only skin & SQ tissue. -Neuropathy Erythema 0.5-≤2 cm -Biomechanical problems Moderate Local infection with erythema >2cm or involving deeper structures. -Severity of infection Severe Local infection + SIRS IDSA Diabetic Foot Infections Guidelines 2012; Lavery LA et al CID 2007;44:562-5. IDSA Diabetic Foot Infections Guidelines 2007; Lavery LA et al CID 2007;44:562-5. 4
3/15/18 Diabetic Foot Infections: Diabetic Foot Infections: Severity? Imaging Evaluation IDSA Infection Predicts risk for: Imaging Severity Hospitalization Osteomyelitis Amputation XR for new diabetic foot infections Uninfected 0% N/A 3% Mild 4% 3% (bony abnl, gas, foreign bodies) 20% Moderate 52% 46% Severe 89% 30-60% 70% MRI if c/f abscess, osteomyelitis Radionuclide bone scan + tagged WBC scan (If MRI not possible) IDSA Diabetic Foot Infections Guidelines 2007. Lavery LA et al CID 2007;44:562-5. Lipsky Diabetes Metab Res Rev 2004;20(Suppl 1):S68-77. IDSA Diabetic Foot Infections Guidelines 2012 Diabetic Foot Infections: Diabetic Foot Infections: Osteomyelitis Evaluation Culture Evaluation Culture Diagnostic Tool Sensitivity Specificity No infection = No need for culture FDG-PET Scan 89% 92% If debridement, try to obtain culture WBC Scan ( 111 In-Oxine) 92% 75% WBC Scan ( 99m Tc-HMPAO) 91% 92% Deep Tissue Biopsy/Curettage MRI 93% 75% After debridement & cleansing XR 54% 68% Drain purulence Probe To Bone NO wound swabs Gold Standard: Bone biopsy with pathology and culture Prior to abx if possible Consider inflammatory markers (for monitoring) Lauri C et al Diabetes Care 2017;40:1111-20. Lipsky Diabetes Metab Res Rev 2004;20(Suppl1):S68-77. IDSA Diabetic Foot Infections Guidelines 2012 5
3/15/18 Diabetic Foot Infections: Diabetic Foot Infections: Management Management -Determine care setting When to hospitalize? -Debride (necrotic tissue, callus, etc) -Severe infections -Offload -Moderate infections with complications -Wound Care -Social factors -Antibiotics -Failure of outpatient therapy IDSA Diabetic Foot Infections Guidelines 2012. Lavery LA et al CID 2007;44:562-5. IDSA Diabetic Foot Infections Guidelines 2012 Diabetic Foot Infections: Diabetic Foot Infections: What organisms should be covered? What organisms should be covered? Organism(s) Situation Mild/Moderate Infections Warm climate -Staph, Strep GNRs Severe infections -Not anaerobes or other resistant organism Warm climate Pseudomonas Water exposure Severe Infections Chronic Anaerobes Previously Tx’d Severe Infections H/o MRSA infxn or carriage (last 1y) MRSA Severe Infections ESBL When prevalent*** Lipsky BA et al Arch Int Med 1990;150-790. IDSA Diabetic Foot Infections Guidelines 2012. Lipsky BA et al. Arch Int Med 1990. IDSA Diabetic Foot Infections Guidelines 2012. 6
3/15/18 Diabetic Foot Infections: Diabetic Foot Infections: Surgical Management Antibiotic Duration Balancing of risks & benefits SSTI Infection Severity Duration -Pt preference? Mild 1-2 weeks -Surgical target? Moderate 1-3 weeks -Chance for function? -Location? Severe 2-4 weeks -Surgical risk? -Prolonged abx risk? -Sepsis/disseminated infection? Involve vascular surgeon if ischemia IDSA Diabetic Foot Infections Guidelines 2012 IDSA Diabetic Foot Infections Guidelines 2012 Diabetic Foot Infections: Diabetic Foot Ulcers Antibiotic Duration Take-Aways : Osteomyelitis Duration -Not every ulcer is infected No remaining infection 2-5 days* -Infected ulcers need multipronged assessment Residual soft tissue infxn 1-3 weeks* -Obtain deep culture when feasible Residual infected but reliable bone 4-6 weeks** -Mild/moderate are typically 2/2 Staph, Strep No debridement & residual infected bone ≥ 3 months** -Surgery requires risk/benefit evaluation *PO or IV **IV -> consider PO -Abx duration varies based on severity IDSA Diabetic Foot Infections Guidelines 2012 7
3/15/18 Outline Question #2 A 62yo gentleman with T2DM presents with a • Does DM increase risk of infections? 2d history of cough and fevers. He is febrile but • Diabetic Foot Ulcers otherwise stable and is diagnosed with • Infections Treated Differently in DM community-acquired pneumonia. Which is the most appropriate therapy? • Infections Increased in DM A. Azithromycin • Other Considerations B. Levofloxacin C. Doxycycline D. Ceftriaxone + Azithromycin Question #2 Infections Treated Differently A 62yo gentleman with T2DM presents with a CAP 2d history of cough and fevers. He is febrile but Empiric therapy: FQ vs. (B-Lactam + Macrolide) otherwise stable and is diagnosed with community-acquired pneumonia. Which is the most appropriate therapy? Coccidioidomycosis Treat newly-diagnosed, uncomplicated PNA A. Azithromycin B. Levofloxacin C. Doxycycline Latent TB infection D. Ceftriaxone + Azithromycin DM is an indication for treatment IDSA CAP Guidelines 2007; IDSA Cocci Guidelines 2016; SFDPH LTBI Guidelines 8
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