Executive summary: 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections.

Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds. Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.

2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections.

Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds. Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.

Peristalsis in an unusual place-The diagnostic utility of point-of-care ultrasound: A case report.

Complications related to inguinal hernias are commonly encountered in medicine. Clinical presentation can vary, and although diagnosis can often be made during physical examination, point-of-care ultrasound (POCUS) can be useful in cases where the diagnosis is unclear. Our case underscores to clinicians the utility of POCUS in diagnosing inguinal hernias.

Rhabdomyolysis after ingestion of "foxy," a hallucinogenic tryptamine derivative.

"Foxy methoxy" (chemical name, 5-methoxy-N,N-diisopropyltryptamine) is a hallucinogenic tryptamine that has been abused with increasing frequency since its appearance in the late 1990s. Like other drugs in this class, foxy frequently produces feelings of euphoria, disinhibition, and auditory as well as visual hallucinations. The drug has been linked to adverse effects, including restlessness, agitation, gastrointestinal distress, and muscle tension. In light of the relatively recent advent of foxy as a drug of abuse and given the inability of commercial toxicologic screening tests to detect the presence of hallucinogenic tryptamines, additional adverse effects seem probable. We report ingestion of foxy by a healthy 23-year-old man that resulted in rhabdomyolysis and transient acute renal failure.

Evaluating postoperative fever: a focused approach.

Postoperative fever should be evaluated with a focused approach rather than in "shotgun" fashion. Most fevers that develop within the first 48 hours after surgery are benign and self-limiting. However, it is critical that physicians who provide postoperative care be able to recognize the minority of fevers that demand immediate attention, based on the patient's history, a targeted physical examination, and further studies if appropriate. Fever that develops after the first 2 days following surgery is more likely to have an infectious cause, but noninfectious causes that require further evaluation and treatment must also be considered. When evaluating postoperative fever, a helpful mnemonic is the "four Ws": wind (pulmonary causes: pneumonia, aspiration, and pulmonary embolism, but not atelectasis), water (urinary tract infection), wound (surgical site infection), "what did we do?" (iatrogenic causes: drug fever, blood product reaction, infections related to intravenous lines).

Hospitalist perspective on the treatment of skin and soft tissue infections.

The prevalence of skin and soft tissue infections (SSTIs) has been increasing in the United States. These infections are associated with an increase in hospital admissions. Hospitalists play an increasingly important role in the management of these infections and need to use hospital resources efficiently and effectively. When available, observation units are useful for treating low-risk patients who do not require hospital admission. Imaging tools may help to exclude abscesses and necrotizing soft tissue infections; however, surgical exploration remains the principal means of diagnosing necrotizing soft tissue infections. The most common pathogens that cause SSTIs are streptococci and Staphylococcus aureus. Methicillin-resistant S aureus (MRSA) is a prevalent pathogen, and concerns are increasing regarding the unclear distinctions between community-acquired and hospital-acquired MRSA. Other less frequent pathogens that cause SSTIs include Enterococcus species, Escherichia coli, Klebsiella species, Enterobacter species, and Pseudomonas aeruginosa. Cephalexin and clindamycin are suitable options for infections caused by streptococcal species and methicillin-susceptible S aureus. The increasing resistance of S aureus and Streptococcus pyogenes to erythromycin limits its use in these infections, and better alternatives are available. Parenteral cefazolin, nafcillin, or oxacillin can be used in hospitalized patients with nonpurulent cellulitis caused by streptococci and methicillin-susceptible S aureus. When oral MRSA therapy is indicated, clindamycin, doxycycline, trimethoprim-sulfamethoxazole, or linezolid is appropriate. Vancomycin, linezolid, daptomycin, tigecycline, telavancin, and ceftaroline fosamil are intravenous options that should be used in MRSA infections that require patient hospitalization. In the treatment of patients with SSTIs, hospitalists are at the forefront of providing proper patient care that reduces hospital costs, duration of therapy, and therapeutic failures. This review updates guidelines on the management of SSTIs with a focus on infections caused by S aureus, particularly MRSA, and outlines the role of the hospitalist in the effective management of SSTIs.

The hospitalist perspective on treatment of community-acquired bacterial pneumonia.

Community-acquired bacterial pneumonia (CABP) is an important health care concern in the United States and worldwide, and is associated with significant morbidity, mortality, and health care expenditure. Streptococcus pneumoniae is the most frequent causative pathogen of CABP. Other common pathogens include Staphylococcus aureus, Haemophilus influenzae, Enterobacteriaceae, Legionella pneumophila, Mycoplasma pneumoniae, and Chlamydophila pneumoniae. However, in clinical practice, the causative pathogen of CABP is most often not identified. Therefore, a common treatment approach for patients hospitalized with CABP is empiric antibiotic therapy with a ß-lactam in combination with a macrolide, respiratory fluoroquinolones, or tetracyclines. An increase in the incidence of S. pneumoniae that is resistant to frequently used antibiotics, including ß-lactams, macrolides, and tetracyclines, provides a challenge for the physician when selecting empiric antimicrobial therapy. When patients with CABP do not respond to initial therapy, they must be adequately reevaluated with further diagnostic testing, change in antimicrobial regimen, and/or transfer of the patient to a higher level of care. The role of hospital medicine physicians is crucial in treating patients who are hospitalized with CABP. An important focus of hospitalists is to provide care improvement in a way that addresses both patient and hospital needs. It is essential that the hospitalist provides best possible patient care, including adherence to quality measures, optimizing the patient's hospital length of stay, and arranging adequate post-discharge care in an effort to prevent readmission and provide appropriate ongoing outpatient care.

2012 infectious diseases society of america clinical practice guideline for the diagnosis and treatment of diabetic foot infections.

Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds. Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.

Inpatient management of diabetic foot disorders: a clinical guide.

The implementation of an inpatient diabetic foot service should be the goal of all institutions that care for patients with diabetes. The objectives of this team are to prevent problems in patients while hospitalized, provide curative measures for patients admitted with diabetic foot disorders, and optimize the transition from inpatient to outpatient care. Essential skills that are required for an inpatient team include the ability to stage a foot wound, assess for peripheral vascular disease, neuropathy, wound infection, and the need for debridement; appropriately culture a wound and select antibiotic therapy; provide, directly or indirectly, for optimal metabolic control; and implement effective discharge planning to prevent a recurrence. Diabetic foot ulcers may be present in patients who are admitted for nonfoot problems, and these ulcers should be evaluated by the diabetic foot team during the hospitalization. Pathways should be in place for urgent or emergent treatment of diabetic foot infections and neuropathic fractures/dislocations. Surgeons involved with these patients should have knowledge and interest in limb preservation techniques. Prevention of iatrogenic foot complications, such as pressure sores of the heel, should be a priority in patients with diabetes who are admitted for any reason: all hospitalized diabetic patients require a clinical foot exam on admission to identify risk factors such as loss of sensation or ischemia. Appropriate posthospitalization monitoring to reduce the risk of reulceration and infection should be available, which should include optimal glycemic control and correction of any fluid and electrolyte disturbances.

Likelihood of ordering physical restraints: influence of physician characteristics.

OBJECTIVES: To determine physician knowledge regarding restraint regulations and effectiveness and effect of physician characteristics on likelihood of ordering restraints. DESIGN: Cross-sectional, factorial research survey. SETTING: Academic medical center. PARTICIPANTS: Interns in all specialties; residents in internal medicine, family practice, emergency medicine, psychiatry, and surgery; and attending faculty at an academic medical center. MEASUREMENTS: Survey of demographic, professional, and restraint knowledge items and for each of five distinct vignettes; physician ratings of probability of patient harm and likelihood of ordering restraints. For each, physicians rated probability of patient harm and likelihood of ordering restraint. RESULTS: One hundred eighty-nine of 246 (77%) surveys were returned. More than half (58%) were men; the median age was 30 (range 25-63), median years experience was 2 (range 0-33), and 60% were U.S. medical school graduates. Mean knowledge score was 68.4% (range 27-100%). Mean likelihood of ordering restraints ranged from 0.6 (not likely) to 9 (absolutely) (overall mean 3.9 +/- 2.2). Exploratory hierarchical regression on mean likelihood of ordering restraint (outcome) with independent variables of physician age and sex (Step 1), years experience and physician level (Step 2), specialization (Step 3), restraint knowledge (Step 4), and judgment of harm (Step 5) explained 31.9% of the variance (F=7.19, degrees of freedom 13,159, P<.001). Higher appraisal of harm (P<.001), less knowledge regarding restraint (P=.03), and male sex (P=.005) were unique indicators for the likelihood of ordering restraints. Psychiatry (P=.03) or internal medicine physicians (P=.05) were less likely to order restraints. CONCLUSION: Physician characteristics and lack of restraint knowledge are associated with likelihood of ordering restraints. Results will guide medical education initiatives to reduce restraint rates.

Clinical indications for newer antifungal agents.

Recent years have seen the release of multiple new systemic antifungal agents, significantly increasing options for the treatment of most serious fungal infections. Newly available drugs include those in the echinocandin class, including caspofungin, micafungin, and anidulafungin, as well as the newer generation triazoles, voriconazole and posaconazole. Ordering of these agents is variably restricted, depending on a given institution's policies, and all are costly. In this review we examine the available evidence and outline the role of newer antifungal medications in several common and/or important situations, including invasive and mucocutaneous Candida infection, febrile neutropenia, invasive aspergillosis, zygomycosis, and endemic mycoses.

Role of hospitalists in an offsite alternate care center (ACC) for pandemic flu.

Recent concerns about an influenza pandemic have highlighted the need to plan for offsite Alternate Care Centers (ACCs). The likelihood of a successful response to patient surges will depend on the local health systems' ability to prepare well in advance of an influenza pandemic. Our health system has worked closely with our state's medical biodefense network to plan the establishment of an ACC for an influenza pandemic. As hospitalists have expanded their roles in their local health systems, they are poised to play a major role in planning for the next influenza pandemic. Hospitalists should work with their health system's administration in developing an ACC plan.

Pandemic influenza and the hospitalist: apocalypse when?

Beginning with a cluster of human cases in Hong Kong in 1997, avian influenza (H5N1) has spread progressively through, and beyond, Asia in poultry and other birds; and has resulted in sporadic cases of human disease associated with high mortality. The potential for H5N1 influenza to cause a pandemic of human disease continues to be the subject of intense scrutiny by both the media and the scientific community. While the likelihood of such a prospect is uncertain, the inevitability of future pandemics of influenza is clear. Planning for the eventuality of a virulent influenza pandemic at the local, national and global level is critical to limiting the mortality and morbidity of such an occurrence. Hospitalists have a key role to play in institutional efforts to prepare for a influenza pandemic, and should be aware of lessons that my be applied from both the response to Hurricane Katrina, as well as the severe acute respiratory syndrome (SARS) epidemic.