4/8/2017 Disclosures • I have no disclosures Infectious Diseases Approach to the Diabetic Foot Cristina Brickman, MD MSCE Assistant Clinical Professor of Medicine UCSF Division of Infectious Diseases April 8, 2017 General Approach to Antibiotics Overview • Will focus on antibiotic selection Gram Negative Gram Positive – General approach to antibiotics – Skin and soft tissue infections (SSTI) – Osteomyelitis • Borrowing from 2012 IDSA Clinical Practice Guideline for the Treatment and Diagnosis of Diabetic Foot Infections 1
4/8/2017 General Approach to Antibiotics General Approach to Antibiotics Pseudomonas MRSA Pseudomonas MRSA Gram Negative Gram Positive Gram Negative Gram Positive • Do I need to cover MRSA? • Do I need to cover Pseudomonas ? • Do I need to cover anaerobes? Skin and Soft Tissue Infections: Mild Skin and Soft Tissue Infections: Mild Pseudomonas MRSA Pseudomonas MRSA Gram Negative Gram Positive Gram Negative Gram Positive • Mild-moderate infection: localized to skin & subcutaneous • Mild-moderate infection: localized to skin & subcutaneous tissue, mild cellulitis tissue, mild cellulitis • Gram positive coverage sufficient • Gram positive coverage sufficient • Pus or open wound = Staphylococcus aureus • Pus or open wound = Staphylococcus aureus – clindamycin, trimethoprim-sulfamethoxazole – clindamycin, trimethoprim-sulfamethoxazole • Non-purulent cellulitis = Group A Streptococcus • Non-purulent cellulitis = Group A Streptococcus – 1 st generation cephalosporin – 1 st generation cephalosporin • “Treat until better” • “Treat until better” 2
4/8/2017 Skin and Soft Tissue Infections: Severe Skin and Soft Tissue Infections: Severe Pseudomonas MRSA Pseudomonas Clostridia MRSA Gram Negative Gram Positive Gram Negative Gram Positive • Severe infection: extensive cellulitis, myositis, • Severe infection: extensive cellulitis, myositis, necrotizing infections, systemic symptoms necrotizing infections, systemic symptoms • Polymicrobial • Polymicrobial – Vancomycin (MRSA) – Vancomycin (MRSA) – Anti-pseudomonal with anaerobic coverage – Anti-pseudomonal with anaerobic coverage Osteomyelitis Osteomyelitis: oral antibiotics • Multidisciplinary approach Pseudomonas Clostridia MRSA • No single recommended antibiotic regimen Gram Negative Gram Positive – IV therapy common but not strictly required – Combination antibiotics often necessary First Line • Culture data extremely useful Fluoroquinolones Trimethoprim-sulfamethoxazole Metronidazole (anaerobes only) Clindamycin – Help determine whether need MRSA or Pseudomonas coverage Second Line • Optimal duration not well defined Doxycycline Linezolid Amoxicillin-clavulanate 3
4/8/2017 Osteomyelitis Case (1) Osteomyelitis Case (2) • 71M with DM and R 2 nd toe infection s/p • 71M with DM and R 2 nd toe infection s/p debridement with residual osteomyelitis debridement with residual osteomyelitis • Cultures: Klebsiella, E. coli • Cultures: MRSA, Klebsiella, E. coli • My interpretation: • My interpretation: – No evidence of MRSA or Pseudomonas – Require broad-spectrum Gram positive and Gram negative coverage – Still want relatively broad-spectrum coverage • Potential antibiotics: • Potential antibiotics: – IV: vancomycin + ceftriaxone or ertapenem – IV: ceftriaxone, ertapenem – Oral: trimethoprim-sulfamethoxazole +/- – Oral: trimethoprim-sulfamethoxazole, moxifloxacin moxifloxacin Osteomyelitis Case (3) Summary • 71M with DM, CKD and R 2 nd toe infection s/p Diabetic foot infection debridement with residual osteomyelitis • Cultures: MRSA, Pseudomonas • My interpretation: Skin and soft tissue Osteomyelitis – Needs broad-spectrum Gram positive and Gram negative coverage including Pseudomonas • Potential antibiotics: Mild-moderate Severe Consider oral therapy! – IV: vancomycin + piperacillin-tazobactam Gram-positive Broad-spectrum Cultures to determine need coverage coverage for MRSA or Pseudomonas – Oral: clindamycin + moxifloxacin coverage 4
4/8/2017 Thank you! • Cristina.brickman@ucsf@edu 5
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