Download Skin and Soft Tissue: Diabetic Foot Infections

 Skin
Skinand
andSoft
SoftTissue:
Tissue:
Diabetic
Foot
Infections
Diabetic
Foot
Infections
SEVERITY OF INFECTION
Mild
• Only skin and
subcutaneous tissue
involvement
AND
• Erythema > 0.5 cm and
≤ 2 cm around ulcer
• Perform incision and
drainage as necessary
Moderate**
• Deeper tissue
involvement
OR
• Erythema > 2.0 cm
around ulcer
AND
• No systemic signs of
infection
• Perform incision and
drainage as necessary
SUSPECTED ORGANISMS
RECOMMENDED EMPIRICAL
TREATMENT
DURATION
MSSA
Streptococcus spp.
Oral
Amoxicillin/clavulanate 875 mg
PO Q12H
OR
Cephalexin 500 mg PO Q6H
OR
Dicloxacillin 250 – 500 mg PO
Q6H
MRSA
Doxycycline 100 mg PO Q12H
OR
SMX/TMP 2 DS tablets PO Q12H
(Does not cover Group A Strep)
Oral OR Initially Parenteral
1–3 weeks
Ampicillin-sulbactam 1.5–3 gm IV
Q6H
OR
Ceftriaxone 1 gm IV Q24H
MSSA
Streptococcus spp.
Enterobacteriaceae
Obligate anaerobes
1–2 weeks
Penicillin Allergy:
MRSA
Pseudomonas
aeruginosa
Ciprofloxacin 500 mg PO Q12H
AND
Clindamycin 300 mg PO Q6H
OR
Ceftriaxone 1 gm IV Q24H
Linezolid 600 mg IV/PO Q12H†
(Requires ID Consult)
OR
Daptomycin 6 mg/kg IV Q24H†
(Requires ID Consult)
OR
Vancomycin 15 mg/kg IV*
Piperacillin-tazobactam
3.375 gm IV Q4H
DS= Double Strength; H= hour(s); IV= intravenous; MRSA= methicillin resistant S. aureus; MSSA= methicillin sensitive S. aureus;
PO= by mouth; Q= every; SMX-TMP= sulfamethoxazole/trimethoprim; spp= species
† Restricted Antibiotic – refer to Table of Contents for Guidelines for Restricted Antimicrobials
* Refer to Table of Contents for section on Vancomycin Dosing and Monitoring in Adult Patients
** Consult Infectious Diseases and Podiatry
NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult
Patients Based on Renal Function
PAGE 24
Skin and Soft Tissue: Diabetic Foot Infections
Skin
Skinand
andSoft
SoftTissue:
Tissue:
Diabetic
Foot
Infections
Diabetic
Foot
Infections
R
E
SEVERITY OF INFECTION
SUSPECTED ORGANISMS
ECOMMENDED MPIRICAL
DURATION
TREATMENT
RECOMMENDED EMPIRICAL
SUSPECTED ORGANISMS Initially Parenteral
DURATION
MSSA/MRSA
TREATMENT
P. aeruginosa
Vancomycin
15
mg/kg
IV*
MSSA/MRSA
Initially Parenteral
Streptococcus spp.
AND**
P.
aeruginosa
2–4 weeks
Enterobacteriaceae
Vancomycin
15 IV
mg/kg
Cefepime 2 gm
Q8HIV*
+
Streptococcus
spp.
Obligate anaerobes
AND**
metronidazole 500 mg IV Q6H 2–4 weeks
Enterobacteriaceae
Cefepime
2 gm IV Q8H +
OR
Obligate anaerobes
metronidazole
500 mg IV Q6H
Piperacillin-tazobactam
OR
3.375 gm IV Q4H
Piperacillin-tazobactam
3.375 gm IV Q4H
Bone OR Joint Involvement‡
SevereS**EVERITY OF INFECTION
• Same
as moderate
**
Severe
AND
•• Same
as moderate
Systemic
signs of infection
AND
present
•
Systemic
signs
of infection
Systemic Inflammatory
presentSyndrome (SIRS)
Response
Systemic
Criteria ≥2Inflammatory
of the following:
Response Syndrome (SIRS)
• Temperature
Criteria
≥2 of the <96.8°F
following:
OR >100.4°F
•• Temperature
P > 90 BPM <96.8°F
SourceOR
removed:
2-5 days ‡
Joint Involvement
Bone
• OR
RR >>100.4°F
20 BPM
•• PPaCO
> 90 BPM
<
32
mmHg
Source
removed
but
2
removed: 2-5 residual
days tissue infection:
•• RR
> 20
BPM cells/mm³
WBC
< 4000
1-3 weeks
• PaCO
Source removed but residual tissue infection:
2 < 32 mmHg
OR >12,000
cells/mm³
Source
removed but residual bone infection:
•• WBC
4000 cells/mm³
1-3
weeks
≥ 10%< immature
(band)
4-6 weeks
>12,000 cells/mm³
OR
forms
Source removed but residual bone infection:
•• ≥Perform
10% immature
(band)
incision and
Source
not removed: ≥3 months
4-6
weeks
forms
drainage as necessary
• Perform incision and
Source not removed: ≥3 months
BPM= beats or breaths per minute; H= hour(s); IV= intravenous; MRSA= methicillin resistant S. aureus; MSSA= methicillin
drainage as necessary
sensitive S. aureus; P= pulse; PaCO2= partial pressure of carbon dioxide; Q= every; RR= respiratory rate; SIRS= Systemic
Inflammatory
Syndrome;
spp=
species;
white blood
cellmethicillin resistant S. aureus; MSSA= methicillin
BPM=
beats orResponse
breaths per
minute; H=
hour(s);
IV=WBC=
intravenous;
MRSA=
sensitive S. aureus; P= pulse; PaCO2= partial pressure of carbon dioxide; Q= every; RR= respiratory rate; SIRS= Systemic
†
Restricted
Antibiotic
–
refer
to
Table
of
Contents
for
Guidelines
for
Restricted Antimicrobials
Inflammatory Response Syndrome; spp= species; WBC= white blood cell
* Refer to Table of Contents for section on Vancomycin Dosing and Monitoring in Adult Patients
Consult Infectious
and
Podiatry
†**Restricted
AntibioticDiseases
– refer to
Table
of Contents for Guidelines for Restricted Antimicrobials
Discuss
Infectious
Podiatry,
and Vascular
*‡ Refer
toplan
Tablewith
of Contents
forDiseases,
section on
Vancomycin
Dosing and Monitoring in Adult Patients
** Consult Infectious Diseases and Podiatry
NOTE:
Dosing
based
on
normal
renal
function.
Refer
to
Table of Contents for section on Antimicrobial Dosing for Adult
‡ Discuss plan with Infectious Diseases, Podiatry, and Vascular
Patients Based on Renal Function
NOTE: Dosing based on normal renal function. Refer to Table of Contents for section on Antimicrobial Dosing for Adult
Patients Based on Renal Function
References:
1. Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the
Diagnosis and Treatment of Diabetic Foot Infections. Clin Infect Dis 2012;54(12):e132-73.
References:
2.
insert].
York,
2015.EJ, et al. Clinical Practice Guidelines by the Infectious Diseases Society of America for the
1. Flagyl
Lipsky[package
BA, Berendt
AR, New
Cornia
PB, NY:
Pile Pfizer;
JC, Peters
Diagnosis and Treatment of Diabetic Foot Infections. Clin Infect Dis 2012;54(12):e132-73.
2. Flagyl [package insert]. New York, NY: Pfizer; 2015.
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