Diabetic Foot Ulcers Flashcards
herring
Mild infections are …
local infection w/o involvement of deeper tissues AND no systemic signs of infection
if erythema is present, its < 2 cm
moderate infections are …
local infection w erythema > 2 cm or infection involving deeper structure AND no systemic signs of infection
severe infections are…
local infection w systemic sx of infection, metabolic disturbances (acidosis, severe hyperglycemia, new onset azotemia) or critical ischemia
What bacteria are common in diabetic foot infections
gram positive: staph/strep (skin)
gram negative: e. coli
anaerobes
pseudomonas
what are risk factors of pseudomonas
not responding to non-pseudomonal therapy
macerated ulcers
foot soaking or other significant exposure to water
known pseudomonas colonization within 1 year
what do IDSA guidelines recommend with empiric tx w antipseudomonal agents for DFI
they are AGAINST emperic tx w antipseudomonal agents
empiric Abx therapy (mercy answer)
ceftriaxone 1-2 g q24h OR cefazolin 1-2g q8h
PLUS
vanco 15-20 mg/kg q12h
Trough 10-15 (no osteo worries) before 4th dose or AUC:MIC ratio 400
empiric Abx therapy (UIHC answer)
ceftriaxone 1 g QD PLUS
vanco 15 mg/kg q12h PLUS
metronidazole 500-750 mg q6-8h
what are the 2 methods of monitoring vanco dosing
AUC:MIC ratio
Trough monitoring
which is safer and why:
AUC:MIC ratio vs Trough monitoring
AUC is safer
associated w less nephrotoxicity though AUC target of >600 has been associated w nephrotoxicity
who still uses trough based dosing
peds (<18 yo)
patients on RRT (HD, peritoneal dialysis, CRRT)
home care patients
why is AUC not used in certain populations that need trough based dosing
peds: want to avoid multiple sticks, PK is different in peds than adults
renal patients: cannot accurately predict AUC
home care: more difficult to obtain 2 levels timed appropriately in outpatient setting
what conditions/infections use the AUC standard intensity dosing
target: 400
cellulitis, intra-abdominal, soft tissue, diabetic foot, febrile neutropenia, surgical ppx
what conditions/infections use the AUC critically ill or serious MRSA infection dosing
target: 600
severe sepsis/septic shock, pneumonia, osteomyelitis, endocarditis, meningitis
what conditions/infections monitor vanco dosing with trough
target: 10-15 mcg/ml
SSTI
UTI
intra-abdominal infections
what conditions/infections monitor vanco dosing with AUC
CNS infection
severe infections due to S. Aureus
culture negative infective endocarditis
why is daptomycin not recommended for MRSA tx
reserved for infectious disease only ($$)
CK monitoring
avoid concomitant statin use
what are oral options for MRSA (outpatient tx)
bactrim (weight based dosing)
doxycycline 100mg BID
clindamycin– not too good (high freq, less tolerable)
linezolid ($$, need close monitoring of BP, some neuropathy SE)
counseling point for doxycycline
take w full glass of water
take w food
what agents cause a glycemic lowering of 1.5-3.5%
insulin
mounjaro
high dose ozempic (1-2 mg)
what agents cause a glycemic lowering of 1-1.5%
metformin
GLP-1 agonists
Sulfonylureas
pioglitazone
what agents cause a glycemic lowering of 0.5-1%
DDP4 inhibitors
SGLT2 inhibitors
Injectable therapy is recommended in what for uncontrolled diabetes mellitus
A1c > 10%
what agents are preferred for diabetic peripheral neuropathy
pregabalin 300-600 mg daily in divided doses
amitriptyline 25-100 mg daily
duloxetine 60-120 mg daily
what are other possible options for diabetic peripheral neuropathy
gabapentin 900-3600 mg daily in divided doses
venlafaxine 75-225 mg daily
sodium valproate 500-1200 mg daily in divided doses
capsaicin 0.075 topically QID (not recommended if open wound)
what is recommended for uncontrolled HTN/albuminuria?
Add acei/arb
Monitor K and scr
