Treatment of skin and soft tissue infections in the elderly: A review

Protocol for a systematic review and meta-analysis of interventions aimed at delabeling low-risk penicillin allergies with consideration for sex and gender

BACKGROUND

Approximately, 10% of people report a penicillin allergy; however, more than 90% can safely undergo delabeling after a detailed history, oral challenge, or other investigations such as penicillin skin testing (PST). Although PST is the gold standard, the results can be heterogeneous, and awaiting specialist assessment may take an inordinate amount of time. Therefore, oral provocation challenge has become acceptable for individuals with low-risk penicillin allergy histories. There also appears to be an association with increased prevalence of adverse drug reaction reporting in female individuals, which may translate to penicillin allergy prevalence; however, the evidence has not been assessed through a sex and gender lens. This systematic review will identify and synthesize the findings from studies that report measures of effectiveness and safety of interventions aimed at delabeling penicillin allergies in low-risk individuals. Information related to sex and gender will be extracted, where available, to understand potential differences in allergy reporting and patient outcomes.

METHODS

The Cochrane Handbook for Systematic Reviews of Interventions and the Centre for Review and Dissemination's Guidance for Undertaking Reviews in Health Care will be used as frameworks for conducting this systematic review. The literature search will be conducted by a medical librarian (B. M. M.) and will consist of a search strategy to identify and retrieve published studies that meet our inclusion criteria. Studies that require penicillin skin testing (PST) as a step prior to other interventions will be excluded. Integrated knowledge translation involving co-design was carried out for this systematic review protocol creation. Data extraction will be conducted at four levels: (1) study level, (2) patient level, (3) intervention level, and (4) outcome level. A narrative descriptive synthesis of results and risk of bias of all included studies will be provided, and, if relevant, a meta-analysis will be performed.

DISCUSSION

The dissemination of findings from this knowledge synthesis to various stakeholders is intended to inform on options for evidence-based interventions to aid in delabeling penicillin allergies in individuals with a low risk of experiencing a hypersensitivity reaction. Detailed reporting on the characteristics of delabeling interventions as well as the effectiveness of similar interventions will benefit policy makers considering the implementation of a penicillin allergy delabeling protocol. Additionally, findings from this systematic review will report on the current evidence regarding the role of sex and gender in both the prevalence and outcomes associated with the presence of penicillin allergies.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42022336457.

Implementation of a centralized, web-based surveillance for healthcare associated infections among residents of long-term care facilities in Italy

Objective

The Italian National Action Plan to contrast AMR identified among its objectives the development and implementation of a national Healthcare-Associated Infection (HAI) surveillance system based on European Centre for Disease Prevention and Control (ECDC) indications, through point prevalence surveys (PPS) of HAIs and antibiotic use in acute-care hospitals and long-term care facilities (LTCFs). We aimed to assess feasibility and appropriateness of proposed tools for a national surveillance system of HAIs and antibiotic use in LTCFs.

Study design

Point prevalence survey.

Methods

A pilot PPS was conducted between May-June 2022, among 15 LTCFs of 7 Italian regions. Data were collected in a single day in each LTCF, at the LTCF, ward, and resident levels, using a web-based data collection tool developed ad hoc. Data collector teams of each facility were invited to complete a questionnaire investigating opinions on the proposed tools.

Results

Among 1025 included residents, the prevalence of residents with at least one HAI was 2.5% (95% CI 1.7%-3.7%) considering all HAIs and 2.2% (95% CI 1.3%-3%) without considering SARS-CoV-2 infections. The prevalence of antimicrobial use was 3% (95% CI 0.2%-4.3%). Overall, most respondents were satisfied with the web-based software, training and protocol, even though some difficulties were reported.

Conclusions

A national surveillance network was established, which will facilitate future surveillance efforts. Further studies are necessary to evaluate the impact of the pandemic on HAI transmission and antibiotic use in LTCFs.

The resistance mechanisms of bacteria against ciprofloxacin and new approaches for enhancing the efficacy of this antibiotic

For around three decades, the fluoroquinolone (FQ) antibiotic ciprofloxacin has been used to treat a range of diseases, including chronic otorrhea, endocarditis, lower respiratory tract, gastrointestinal, skin and soft tissue, and urinary tract infections. Ciprofloxacin's main mode of action is to stop DNA replication by blocking the A subunit of DNA gyrase and having an extra impact on the substances in cell walls. Available in intravenous and oral formulations, ciprofloxacin reaches therapeutic concentrations in the majority of tissues and bodily fluids with a low possibility for side effects. Despite the outstanding qualities of this antibiotic, Salmonella typhi, Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa have all shown an increase in ciprofloxacin resistance over time. The rise of infections that are resistant to ciprofloxacin shows that new pharmacological synergisms and derivatives are required. To this end, ciprofloxacin may be more effective against the biofilm community of microorganisms and multi-drug resistant isolates when combined with a variety of antibacterial agents, such as antibiotics from various classes, nanoparticles, natural products, bacteriophages, and photodynamic therapy. This review focuses on the resistance mechanisms of bacteria against ciprofloxacin and new approaches for enhancing its efficacy.

Paraspinal Necrotizing Fasciitis Associated with Pressure Injury: An Unusual Case Report

ABSTRACT

Necrotizing fasciitis is a type of soft tissue infection that destroys subcutaneous tissue. It is particularly dangerous for patients with chronic diseases and those who are bedridden while recuperating. Although necrotizing fasciitis is often caused by trauma or postoperative infection, in rare cases, it can be attributed to pressure injury (PI). The disease progression is very aggressive and can be lethal for patients who are bedridden or immunocompromised.This case report describes a 47-year-old man with a history of diabetes and hypertension who became bedridden after a sudden status decline caused by nephrotic syndrome. He gradually developed an infection and rare deterioration of a PI on his upper back. After radiologic evaluation with magnetic resonance imaging and computed tomography, surgical intervention was performed and necrotizing fasciitis was confirmed. In this case of necrotizing fasciitis derived from a PI on the upper back, the infected area spread to the periphery at a rapid rate. The infection spread over his back and across the T1-T9 levels.In this report, the authors describe the integrated system of the thoracolumbar fascia and the very aggressive spread of necrotizing fasciitis. Because of the anatomic structure of the back and the characteristics of this infection, only aggressive surgical debridement could prevent the spread of infection and reduce the systemic effects of the infection. Physicians should be aware of the possibility of PIs in bedridden patients and, in cases of exacerbation of the wound, consider rapid surgical intervention after prompt examination and diagnosis to reduce mortality.

Lymphaticovenous Anastomosis for Age-Related Lymphedema

INTRODUCTION

Primary lymphedema is usually caused by intrinsic disruption or genetic damage to the lymphatics but may also be the result of age-related deterioration of the lymphatics. The aims of this study were to determine the characteristics of age-related lymphedema and to assess the effectiveness of lymphaticovenous anastomosis (LVA) in its treatment.

METHODS

Eighty-six patients with primary lymphedema affecting 150 lower limbs were divided into three groups according to whether the age of onset was younger than 35 years, 35-64 years, or 65 years or older. Indocyanine green (ICG) lymphography was performed, followed by LVA surgery. ICG lymphography images were visually classified according to whether the pattern was linear, low enhancement (LE), distal dermal backflow (dDB), or extended dermal backflow (eDB). The lower extremity lymphedema (LEL) index score was calculated before and after LVA. Lymphatic vessel diameter and detection rates were also recorded.

RESULTS

In the ≥65 group, the lymphedema was bilateral in 54 patients and unilateral in 1 patient. There was statistically significant deterioration in the LEL index score with progression from the linear, LE, dDB through to the eDB pattern in the ≥65 group. The lymphatic vessel diameter was significantly greater in the ≥65 group. The rate of improvement was highest in the ≥65 group.

CONCLUSION

Age-related lymphedema was bilateral and deterioration started distally. The lymphatic vessels in patients with age-related lymphedema tended to be ectatic, which is advantageous for LVA and may increase the improvement rate.

Skin and soft tissue infections and current antimicrobial prescribing practices in Australian aged care residents

To determine the burden of skin and soft tissue infections (SSTI), the nature of antimicrobial prescribing and factors contributing to inappropriate prescribing for SSTIs in Australian aged care facilities, SSTI and antimicrobial prescribing data were collected via a standardised national survey. The proportion of residents prescribed ⩾1 antimicrobial for presumed SSTI and the proportion whose infections met McGeer et al. surveillance definitions were determined. Antimicrobial choice was compared to national prescribing guidelines and prescription duration analysed using a negative binomial mixed-effects regression model. Of 12 319 surveyed residents, 452 (3.7%) were prescribed an antimicrobial for a SSTI and 29% of these residents had confirmed infection. Topical clotrimazole was most frequently prescribed, often for unspecified indications. Where an indication was documented, antimicrobial choice was generally aligned with recommendations. Duration of prescribing (in days) was associated with use of an agent for prophylaxis (rate ratio (RR) 1.63, 95% confidence interval (CI) 1.08–2.52), PRN orders (RR 2.10, 95% CI 1.42–3.11) and prescription of a topical agent (RR 1.47, 95% CI 1.08–2.02), while documentation of a review or stop date was associated with reduced duration of prescribing (RR 0.33, 95% CI 0.25–0.43). Antimicrobial prescribing for SSTI is frequent in aged care facilities in Australia. Methods to enhance appropriate prescribing, including clinician documentation, are required.

Cellulitis in older people over 75 years - are there differences?

Aim

To examine differences in risk factors, clinical features and outcomes of cellulitis between those 75 + years and those <75 years admitted to a metropolitan hospital.

Methods

A prospective study of patients with limb cellulitis requiring intravenous antibiotics conducted at Bankstown-Lidcombe Hospital, Australia from June 2014 to April 2015.

Results

Thirty one patients were 75 + years and 69 less than 75 years. A greater proportion of older patients resided in nursing home (25.8% vs 2.9% respectively, p = 0.001) and mobilized with walking aid(s) (58.1% vs 11.6% respectively, p < 0.001). Significantly more older patients had documented hypertension (45.2% vs 23.2% respectively p = 0.035), atrial fibrillation (33.5% vs 5.8% respectively, p < 0.001), dementia (22.6% vs 1.4% respectively, p = 0.001) and malignancy (16.1% vs 1.4% respectively, p = 0.010). The clinical presentation of cellulitis and cellulitis severity (Eron classification) did not significantly differ in both groups; however older patients were more likely to have dependent edema (OR 4.0, 95%CI 1.3-12.6, p = 0.018) and less likely to be obese (OR 0.3, 95%CI 0.1-0.8, p = 0.012) or had a past history of cellulitis (OR 0.3, 95%CI 0.1-1.0, p = 0.044) on presentation. Despite the age difference, there were no major differences in intravenous antibiotic choice, hospital length of stay, and hospital readmission rates in both groups. Older patients however, were more likely to experience complications such as falls and/or decreased mobility (38.7% vs 15.9% respectively, p = 0.020) during the cellulitis episode.

Conclusion

There are minor differences in the risk factors and clinical features of cellulitis in older patients as compared to the young. Outcomes are similar except for a higher incidence of hospital related complications.

Influence of chewing on expression level of human beta-defensin 2 and secretory immunoglobulin A in the epithelium

PURPOSE

This study aimed to clarify the influence of chewing on human β-defensin 2 (hBD-2) and secretory immunoglobulin A (SIgA) expression levels.

METHODS

We included 15 healthy males with no missing teeth (mean age, 25.5±2.5years). Subjects were instructed to chew a piece of gum for 30min. Saliva and skin-extraction samples were collected before and after chewing for 15 and 30min. hBD-2 and SIgA concentrations in the samples were determined using enzyme-linked immunosorbent assay (ELISA). hBD-2 and SIgA expression levels before and after chewing were analyzed using the Mann-Whitney U test, following the Friedman test. The significance level was 0.05.

RESULTS

The hBD-2 level in skin-extraction samples was significantly different before (99.4±17.3pg/mL) and after chewing for 30min (142±23.0pg/mL). The SIgA level in skin-extraction samples was also significantly different before (2.39±0.25μg/mL) and after chewing for 30min (3.61±0.33μg/mL). No significant difference was noted in either hBD-2 or SIgA secretion rate in saliva between before and after chewing.

CONCLUSIONS

Chewing gum for 30min increased hBD-2 and SIgA expression levels in skin. Moreover, chewing gum could influence the secretion pattern of these two biomolecules on skin, but not in saliva.

Nasal colonization with methicillin-resistant Staphylococcus aureus among elderly living in nursing homes in Brazil: risk factors and molecular epidemiology

BACKGROUND

Methicillin-resistant Staphylococcus aureus poses a threat to elderly living in nursing homes. Studies focusing on the epidemiology of colonization may help in the design of infection control strategies.

OBJECTIVE

To identify factors associated with MRSA colonization and the dissemination of clones among nursing home residents.

METHODS

Nasal swabs were collected from 300 persons from nine nursing homes in the city of Bauru, Brazil. Resistance to methicillin was identified through amplification of the mecA gene. Strain typing (Pulsed-Field Gel Electrophoresis) and characterization of the Staphylococcal Chromosome Cassette (SCC) mec was performed. Univariate and multivariable models were used to identify predictors of overall S. aureus and MRSA carriage.

RESULTS

Rates of S. aureus and MRSA colonization were 17.7 and 3.7%, respectively. Age and recent admission to a hospital were independently associated with colonization with S. aureus. MRSA colonization was associated with living in small (< 15 residents) and medium-sized (15-49 residents) facilities, as well as with recent hospitalization. Most MRSA strains carried SCCmec types II or IV, and there was evidence of clonal spread within and among different facilities.

CONCLUSIONS

MRSA may be introduced in nursing homes form hospitals or arise from the community setting. Screening for asymptomatic colonization may identify persons with greater risk for infection, and is advised for residents discharged from acute care hospitals.

Supplementation with tocotrienols from Bixa orellana improves the in vivo efficacy of daptomycin against methicillin-resistant Staphylococcus aureus in a mouse model of infected wound

BACKGROUND

Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of skin and soft-tissue infection worldwide. An adequate immune response acts as a first line of defence against infections and therefore plays an essential role in the maintenance of health. Tocotrienols (T3s), the lesser known isomers of vitamin E, possess many biological properties and have been recognized as immunomodulators.

PURPOSE

The aim of this study was to investigate whether the in vivo supplementation with a mixture of 87.1% δ- and 12.9% γ-T3s extract from seeds of Bixa orellana, (T3s) could be effective in increasing the effect of daptomycin (DAP) in a mouse model of wound infection due to MRSA.

STUDY DESIGN/METHODS

Bacteria were inoculated onto full-thickness wound on the dorsal side of BALB/c mice at 5 × 10⁶ CFU per mouse. Mice were randomized into five groups: an uninfected group, an infected-untreated group, a T3s-pretreated group with no antibiotics given after challenge, a T3s-pretreated group plus DAP given after challenge, a group only given DAP after challenge. Main outcome measures were: bacterial load on the wounds, analysis of Natural Killer (NK) cytotoxicity, immunological phenotype and markers of tissue repair.

RESULTS

Our results showed that bacterial load in wounds from mice receiving T3s or DAP alone was 1- or 3-log₁₀ lower, respectively, compared with the infected-untreated group. T3s plus daptomycin showed the highest efficacy, achieving a 4-log₁₀ decrease in bacterial load. This higher antimicrobial effect was associated with increased levels of NK cytotoxicity and markers of wound repair.

CONCLUSION

These data suggest that treatment with T3s may be useful for the management of infected wounds as immune adjuvants in combination with DAP.

Gold-nanoparticles coated with the antimicrobial peptide esculentin-1a(1-21)NH2 as a reliable strategy for antipseudomonal drugs

Naturally occurring antimicrobial peptides (AMPs) hold promise as future therapeutics against multidrug resistant microorganisms. Recently, we have discovered that a derivative of the frog skin AMP esculentin-1a, Esc(1-21), is highly potent against both free living and biofilm forms of the bacterial pathogen Pseudomonas aeruginosa. However, bringing AMPs into clinics requires to overcome their low stability, high toxicity and inefficient delivery to the target site at high concentrations. Importantly, peptide conjugation to gold nanoparticles (AuNPs), which are among the most applied inorganic nanocarriers in biomedical sciences, represents a valuable strategy to solve these problems. Here we report that covalent conjugation of Esc(1-21) to soluble AuNPs [AuNPs@Esc(1-21)] via a poly(ethylene glycol) linker increased by ∼15-fold the activity of the free peptide against the motile and sessile forms of P. aeruginosa without being toxic to human keratinocytes. Furthermore, AuNPs@Esc(1-21) resulted to be significantly more resistant to proteolytic digestion and to disintegrate the bacterial membrane at very low concentration (5nM). Finally, we demonstrated for the first time the capability of peptide-coated AuNPs to display a wound healing activity on a keratinocytes monolayer. Overall, these findings suggest that our engineered AuNPs can serve as attractive novel biological-derived material for topical treatment of epithelial infections and healing of the injured tissue.

STATEMENT OF SIGNIFICANCE

Despite conjugation of AMPs to AuNPs represents a worthwhile solution to face some limitations for their development as new therapeutics, only a very limited number of studies is available on peptide-coated AuNPs. Importantly, this is the first report showing that a covalent binding of a linear AMP via a poly(ethylene glycol) linker to AuNPs highly enhances antipseudomonal activity, preserving the same mode of action of the free peptide, without being harmful. Furthermore, AuNPs@Esc(1-21) are expected to accelerate recovery of an injured skin layer. All together, these findings suggest our peptide-coated AuNPs as attractive novel nanoscale formulation to treat bacterial infections and to heal the injured tissue.

A Proposed New Classification of Skin and Soft Tissue Infections Modeled on the Subset of Diabetic Foot Infection

Schemes for classifying skin and soft tissue infections (SSTIs) pose limitations for clinicians and regulatory agencies. Diabetic foot infections (DFIs) are a subset of SSTIs. We developed and are proposing a classification to harmonize current schemes for SSTIs and DFIs. Existing schemes for classifying SSTIs are limited in both their usefulness to clinicians and to regulatory agencies. The guidelines on SSTI from the Infectious Diseases Society of America (IDSA) and the guidance from the US Food and Drug Administration do not adequately address many types of wound infections. However, guidelines developed by the IDSA for DFIs provide a classification scheme that has been validated and widely used. Diabetic foot infections are similar to SSTIs in pathophysiology, microbiology, and treatment and can be seen as a subset of SSTI. Thus, based on the documents noted above, and our review of the literature, we have developed a proposed classification scheme for SSTI that harmonizes well with the DFI classification. We believe this new scheme will assist clinicians in classifying most wound infections and potentially aid regulatory agencies in testing and approving new antimicrobials for these infections.

Antimicrobial peptides and wound healing: biological and therapeutic considerations

Repair of tissue wounds is a fundamental process to re-establish tissue integrity and regular function. Importantly, infection is a major factor that hinders wound healing. Multicellular organisms have evolved an arsenal of host-defense molecules, including antimicrobial peptides (AMPs), aimed at controlling microbial proliferation and at modulating the host's immune response to a variety of biological or physical insults. In this brief review, we provide the evidence for a role of AMPs as endogenous mediators of wound healing and their promising therapeutic potential for the treatment of non-life-threatening skin and other epithelial injuries.

Inguinal skin colonization with multidrug-resistant bacteria among residents of elderly care facilities: frequency, persistence, molecular analysis and clinical impact

Frequency, persistence and molecular characteristics of multidrug resistant bacteria colonizing inhabitants of long term care facilities are topics of current concern. We performed a point-prevalence survey of 402 residents in 7 elderly care facilities in Berlin, Germany. Inguinal swabs were analyzed for the presence of methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococci (VRE), and multidrug-resistant gram-negative bacteria. Three and six months following the initial investigation, all colonized residents were sampled again and the occurrence of intercurrent infections, hospital admissions and use of antimicrobials were registered. Genetic relatedness of the bacteria was investigated using multi-locus sequence typing (MLST), spa-typing and SmaI/XbaI-macrorestriction analysis. 33 (8.2%) residents were skin-colonized with multidrug-resistant bacteria. MRSA were found in 19 (4.7%) and ESBL-producing Enterobacteriaceae in 16 residents (3.98%). Independent risk factors for colonization with multidrug-resistant bacteria were a high level of care and the presence of chronic wounds. A large proportion of the observed bacteria persisted up to six months and showed a high degree of inter-individual diversity. Outcome analysis revealed that infections tend to occur slightly more often in residents colonized by multiresistant pathogens. We assume that a perceptible population of residents in nursing homes is at risk for individual colonization with multidrug-resistant bacteria as well as healthcare associated infections.

Incidence and predictors of hospitalization for bacterial infection in community-based patients with type 2 diabetes: the fremantle diabetes study

Background

The few studies that have examined the relationship between diabetes and bacterial infections have utilized administrative databases and/or have had limited/incomplete data including recognized infection risk factors. The aim of this study was to determine the incidence and associates of bacterial infection severe enough to require hospitalization in well-characterized community-based patients with type 2 diabetes.

Methods and Findings

We studied a cohort of 1,294 patients (mean±SD age 64.1±11.3 years) from the longitudinal observational Fremantle Diabetes Study Phase I (FDS1) and 5,156 age-, gender- and zip-code-matched non-diabetic controls. The main outcome measure was incident hospitalization for bacterial infection as principal diagnosis between 1993 and 2010. We also examined differences in statin use in 52 FDS1 pairs hospitalized with pneumonia (cases) or a contemporaneous non-infection-related cause (controls). During 12.0±5.4 years of follow-up, 251 (19.4%) patients were hospitalized on 368 occasions for infection (23.7/1,000 patient-years). This was more than double the rate in matched controls (incident rate ratio (IRR) (95% CI), 2.13 (1.88–2.42), P<0.001). IRRs for pneumonia, cellulitis, and septicemia/bacteremia were 1.86 (1.55–2.21), 2.45 (1.92–3.12), and 2.08 (1.41–3.04), respectively (P<0.001). Among the diabetic patients, older age, male sex, prior recent infection-related hospitalization, obesity, albuminuria, retinopathy and Aboriginal ethnicity were baseline variables independently associated with risk of first hospitalization with any infection (P≤0.005). After adjustment for these variables, baseline statin treatment was not significant (hazard ratio (95% CI), 0.70 (0.39–1.25), P = 0.22). Statin use at hospitalization for pneumonia among the case-control pairs was similar (23.1% vs. 13.5%, P = 0.27).

Conclusions

The risk of severe infection is increased among type 2 diabetic patients and is not reduced by statin therapy. There are a number of other easily-accessible sociodemographic and clinical variables that could be used to optimize infection-related education, prevention and management in type 2 diabetes.

Application of orange essential oil as an antistaphylococcal agent in a dressing model

Background

Staphylococcus aureus is the pathogen most often and prevalently involved in skin and soft tissue infections. In recent decades outbreaks of methicillin-resistant S. aureus (MRSA) have created major problems for skin therapy, and burn and wound care units. Topical antimicrobials are most important component of wound infection therapy. Alternative therapies are being sought for treatment of MRSA and one area of interest is the use of essential oils. With the increasing interest in the use and application of natural products, we screened the potential application of terpeneless cold pressed Valencia orange oil (CPV) for topical therapy against MRSA using an in vitro dressing model and skin keratinocyte cell culture model.

Methods

The inhibitory effect of CPV was determined by disc diffusion vapor assay for MRSA and vancomycin intermediate-resistant S. aureus (VISA) strains. Antistaphylococcal effect of CPV in an in vitro dressing model was tested on S. aureus inoculated tryptic soya agar plate. Bactericidal effect of CPV on MRSA and VISA infected keratinocyte cells was examined by enumeration of extra- and intra-cellular bacterial cells at different treatment time points. Cytotoxic effects on human skin cells was tested by adding CPV to the keratinocyte (HEK001) cells grown in serum free KSFM media, and observed by phase-contrast microscope.

Results

CPV vapour effectively inhibited the MRSA and VISA strains in both disc diffusion vapour assay and in vitro dressing model. Compared to untreated control addition of 0.1% CPV to MRSA infected keratinocyte decreased the viable MRSA cells by 2 log CFU/mL in 1 h and in VISA strain 3 log CFU/mL reduction was observed in 1 h. After 3 h viable S. aureus cells were not detected in the 0.2% CPV treatment. Bactericidal concentration of CPV did not show any cytotoxic effect on the human skin keratinocyte cells in vitro.

Conclusions

At lower concentration addition of CPV to keratinocytes infected with MRSA and VISA rapidly killed the bacterial cells without causing any toxic effect to the keratinocytes. Therefore, the results of this study warrant further in vivo study to evaluate the potential of CPV as a topical antistaphylococcal agent.

Medical management of diabetic foot infections

Diabetic foot infections (DFIs) are a commonly encountered medical problem. They are associated with an increased frequency and length of hospitalization and risk for lower-extremity amputation. Furthermore, they have substantial economic consequences. Patients with diabetes mellitus are particularly susceptible to foot infections because of neuropathy, vascular insufficiency, and diminished neutrophil function. The approach to managing DFIs starts with determining if an infection exists. If an infection exists, then the type, severity, extent of infection, and risk factors for resistant organisms should be determined through history, physical examination, and additional laboratory and radiological testing. Optimal management requires surgical debridement, pressure offloading, effective antibiotic therapy, wound care and moisture, maintaining good vascular supply, and correction of metabolic abnormalities, such as hyperglycemia, through a multidisciplinary team. Empiric antibiotics for DFIs vary based on the severity of the infection, but must include anti-staphylococcal coverage.