Download GOALS OF THERAPY

CELLULITIS
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*As clinically indicated;
†Ulcerated lesions should be cleaned and debrided before having wound base swabbed;
‡Most useful if vesicle/bullae or fluid abscess present;
§Seek out bone trauma and air fluid levels;
¶Indications –neurological deficits, vision nonassessable, proptosis/deteriorating acuity or colour/bilateral edema/ophthalmoplegia, no improvement
after 24 h and swinging pyrexia not resolving within 36 h (for head only);
**Only if central nervous system involvement suspected
Diagnosis
• Clinical diagnosis
• Fine Needle Aspiration
– Technique
• Leading edge injection and aspiration
with saline
– Efficacy
• May assist diagnosis with cellulitis
• Not useful in Erysipelas
• 30% sensitivity from closed lesions
– Indication
• Unusual pathogens suspected
• Cellulitis refractory to current
antibiotics
• Blood Culture (25% sensitivity)
• only 20% of cases are positive
• Skin biopsy (25% sensitivity)
www.fpnotebook.com/DER/Endo/SknInfctnsInDbtsMlts.html and Harrison’s 17th ed
Diagnosis
• Based on appearance of the skin and patient history
– Drainage from an abscess or weeping wound associated with cellulitis
should be sent for culture and sensitivities.
– Material from needle aspiration of inflamed skin or skin biopsy can be
cultured in cases of cellulitis without purulence, abscess, or a necrotic
– Indications for blood cultures include significant fever and chills,
severe immunocompromise, periorbital cellulitis, and cellulitis
superimposed on lymphedema.
• A polymorphonuclear leukocytosis is often present with cellulitis; a
complete blood cell count and differential may help gauge the severity of
infection and the hematologic response.
Goals of therapy
DM
1. Eliminate symptoms
related to hyperglycemia
2. Reduce or eliminate the
long-term microvascular
and macrovascular
complications of DM
3. Allow the patient to
achieve as normal a
lifestyle as possible
Harrisons 17th ed
Cellulits
• treat the affected area and
any underlying conditions
that would increase the
chance of cellulitis returning
http://skin.emedtv.com/cellulitis/cellulitistreatment.html
• oral therapy for mild
infections
• intravenous therapy for
severe infections
– achievement of high
drug levels with rapid
delivery.
Therapeutic approach
Non-pharmacologic
• Rest affected area, elevate
the area of the body
involved (this will help
decrease swelling and
relieve discomfort)
• Clean wound site
Pharmacologic
Cellulitis in a DM patient
• Early or Mild disease
– Augmentin 875 mg PO bid
– Second Generation
Cephalosporin (cefoxitin,
cefacor, cefuroxime)
– Third Generation
Cephalosporin (cefotaxime,
ceftazidime,m ceftriaxone,
cefixime)
• Severe disease
– Imipenem-Cilastatin (Primaxin)
– Meropenem
– Trovafloxacin IV
www.emedicinehealth.com/cellulitis
www.fpnotebook.com/DER/Endo/SknInfctnsInDbtsMlts.htm
Management: Facial Cellulitis
Mild to Moderate Infection
– Augmentin 875 mg PO bid
– Cefazolin (Ancef) 1 g IV every 8 hours
Severe Infection
– Nafcillin 2 g IV every 4 hours
– Oxacillin 2 g IV every 4 hours
– Vancomycin 1.0-1.5 g IV qd
– Linezolid
• In a study by Kohno et al, Linezolid was
compared with vancomycin; both had a
comparable clinical success rate in the
treatment of SSTi.
• In the lab tests done after the end of the
treatment and during follow up, Linezolid had
a better microbial eradication rate. Also, for
the adverse effects (hematologic), linezolid
was safer.
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S. Kohno1, K. Yamaguchi2, et al. Linezolid versus vancomycin for the treatment of
infections caused by methicillin-resistant. Staphylococcus aureus in Japan. Journal
of Antimicrobial Chemotherapy 2007 60(6):1361-1369; doi:10.1093/jac/dkm369
http://jac.oxfordjournals.org/cgi/content/full/60/6/1361
• Vancomycin is distributed widely to various
tissues and body fluids, however in patient
with DM, its penetration in soft tissues is
greatly impaired
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AUSkhirtladze K; Hutschala D; Fleck T; Thalhammer F; Ehrlich M; Vukovich T; Muller M; Tschernko. Impaired target site
penetration of vancomycin in diabetic patients following cardiac surgery. EM SOAntimicrob Agents Chemother. 2006
Apr;50(4):1372-5.
http://www.uptodate.com/patients/content/abstract.do;jsessionid=F7D4E0E035890469420995852E59E973.1102?topicKey
=~aa8X1QFoqoQSyT&refNum=8
http://www.uptodate.com/patients/content/topic.do?topicKey=~aa8X1QFoqoQSyT
• In a study by Stein et al, Linezolid was
effective in the treatment of
Staphylococcus aureus in diabetic
patients
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G E. Stein1,* S Schooley1, et al. Linezolid tissue penetration and serum activity against strains of methicillin-resistant
Staphylococcus aureus with reduced vancomycin susceptibility in diabetic patients with foot infections. Journal of
Antimicrobial Chemotherapy, doi:10.1093/jac/dkm271
http://jac.oxfordjournals.org/cgi/content/full/dkm271v1
Duration of therapy
• response to drug therapy
• follow-up is of utmost importance
• 10 to 14 days of antibiotic therapy
– Absence of response/worsening after five days of
the initiation of therapy prompts a change in the
antibiotic regimen or other investigations to
verify the diagnosis
Preventing a recurrence of cellulitis
• Cellulitis tends to recur in people with certain
medical conditions that can lead to skin breakdown,
such as edema (fluid buildup), fungal or bacterial
infections, diabetes, or peripheral arterial disease.
– edema, support stockings and good skin hygiene may
reduce or eliminate recurrence of cellulitis.
– fungal infections, regular use of antifungal medicines may
help reduce recurrent cellulitis.
– high risk for recurring cellulitis, (when with open wound or
cut) taking preventive antibiotics may help
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http://www.everettclinic.com/kbase/topic/mini/tr5105/treatmnt.htm
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Vincent Ki, MD and Coleman Rotstein, MD. Bacterial skin and soft tissue infections in adults:
A review of their epidemiology, pathogenesis, diagnosis, treatment and site of care. Can J
Infect Dis Med Microbiol. 2008 March; 19(2): 173-184.
DIABETES MELLITUS
DIAGNOSTIC TEST FOR DIABETES
MELLITUS
• Diabetes mellitus is characterized by recurrent
or persistent hyperglycemia, and is diagnosed
by demonstrating any one of the following:
– Fasting plasma glucose level at or above
126 mg/dL (7.0 mmol/L).
– Plasma glucose at or above 200 mg/dL
(11.1 mmol/L) two hours after a 75 g oral glucose
load as in a glucose tolerance test.
– Symptoms of hyperglycemia and plasma glucose
at or above 200 mg/dL (11.1 mmol/L).
Fasting blood glucose test
• The most common test for diagnosis of diabetes.
• blood glucose levels are checked after fasting for between
12 and 14 hours.
• Patients with fasting glucose levels from 100 to 125 mg/dL
(6.1 and 7.0 mmol/L) are considered to have impaired
fasting glucose
• Patients with diabetes may be asked to delay their diabetes
medication or insulin dose until the test is completed.
http://ovennewyork.com/diabetes-mellitus-laboratory-tests-or-diagnostic-tests.html
Random blood glucose test
• blood glucose levels are checked at various
times during the day, and it doesn’t matter
when you last ate.
• Blood glucose levels tend to stay constant in a
person who doesn’t have diabetes.
http://ovennewyork.com/diabetes-mellitus-laboratory-tests-or-diagnostic-tests.html
Oral glucose tolerance test (OGTT)
• FBS is obtained before the ingestion of a 50- to 200-g
glucose load (usual amount is 75 g),
• blood samples are drawn at ½, 1, 2, and 3 hours (may
be 4- or 5-hour sampling).
• Blood samples are checked at regular intervals for two
hours.
• Glucose tolerance tests are used when the results of
the fasting blood glucose are borderline.
http://ovennewyork.com/diabetes-mellitus-laboratory-tests-or-diagnostic-tests.html
• They are also used to diagnose diabetes in
pregnancy (gestational diabetes).
• NORMAL: the results of the glucose tolerance test
will show that their blood sugar levels fall within
the normal range
• Patients with plasma glucose at or above
140 mg/dL or 7.8 mmol/L, but not over 200, two
hours after a 75 g oral glucose load are
considered to have impaired glucose tolerance.
Glycated Hemoglobin
(Glycohemoglobin, HbA1c) for
Diabetes Mellitus
• Measures glycemic control over a 60- to 120-day
period by measuring the irreversible reaction of
glucose to hemoglobin through freely permeable
erythrocytes during their 120-day lifecycle.
• While not used for diagnosis, an elevated level of
glucose irreversibly bound to hemoglobin of 6.0%
or higher (the 2003 revised U.S. standard) is
considered abnormal by most labs
http://ovennewyork.com/diabetes-mellitus-laboratory-tests-or-diagnostic-tests.html
C-Peptide Assay (Connecting Peptide
Assay) for Diabetes Mellitus
• Cleaved from the proinsulin molecule during
its conversion to insulin, C-peptide acts as a
marker for endogenous insulin production.
http://ovennewyork.com/diabetes-mellitus-laboratory-tests-or-diagnostic-tests.html
Fructosamine Assay for Diabetes
Mellitus
• Glycated protein with a much shorter half-life
than glycated hemoglobin, reflecting control
over a shorter period, approximately 14 to 21
days.
• May be advantageous in patients with
hemoglobin variants that interfere with the
accuracy of glycated hemoglobin tests.
http://ovennewyork.com/diabetes-mellitus-laboratory-tests-or-diagnostic-tests.html
GOALS OF THERAPY
• Eliminate symptoms related to hyperglycemia
• Reduce or eliminate the long-term
microvascular and macrovascular
complications of DM
• Allow the patient to achieve as normal a
lifestyle as possible
Harrison’s 17th Edition
Patient education about DM, nutrition
and exercise
• Patient with DM should receive education
about:
– Nutrition
– Exercise
– Care of diabetes during illness
– Medications to lower the plasma glucose
• Continuing process with regular visits for
reinforcement
• Diabetes self-management education (DSME)
Harrison’s 17th Edition
Diabetes education
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Self-monitoring of blood glucose
Urine ketone monitoring (type 1)
Insulin administration
Guidelines for diabetes management during
illness
Management of hypoglycemia
Foot and skin care
DM management before, during and after
exercise
Risk-factor-modifying activities
Harrison’s 17th Edition
Nutrition
• Medical Nutrition Therapy (MNT)
– Modest caloric reduction
– Reduced fat intake
– Increased physical activity
– Reduction of hyperlipidemia and hypertension
Harrison’s 17th Edition
Exercise
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CV risk reduction
Reduced BP
Maintenance of muscle mass
Reduction in body fat and weight loss
Lowering plasma glucose
Increasing insulin sensitivity
*ADA recommends 150 min/week (distributed over
at least 3 days)
Harrison’s 17th Edition
Monitoring the level of glyceminc
control
• Plasma glucose measurements by the patient
and assessment of long-term control by the
physician
• Measurement of A1C and review of the
patient’s self-measurement of plasma glucose
Harrison’s 17th Edition
Self-monitoring of Blood Glucose
• Standard of care in diabetes management and
allows the patient to monitor his/her blood
glucose at any time
• Glucose monitors can rapidly and accurately
measure glucose in small amounts of blood (310 µL obtained from the fingertip
*individuals with type 2 DM who are taking insulin
should utilize SMBG more frequently than than
those on oral agents
Harrison’s 17th Edition
Assessment of Long-term Glycemic
Control
• Measurement of glycated hemoglobin
• Plasma glucose is consistently elevated =
increase in nonenzymatic glycation of
hemoglobin
• Reflects the glycemic history over the previous
2-3 months
Harrison’s 17th Edition