How long to treat with antibiotics following amputation in patients with diabetic foot infections? Are the 2012 IDSA DFI guidelines reasonable?

WHAT IS KNOWN AND OBJECTIVE: To the best of our knowledge, there has been no published study designed to identify the most appropriate duration of antibiotic therapy in lower extremity skin and skin structure infections in diabetic patients [aka "diabetic foot infections" (DFI)] post-amputation. However, recent guidelines published by the Infectious Diseases Society of America (IDSA) provide recommendations for treatment duration in these patients. Therefore, our objective is to review the literature evaluating antibiotic treatment in DFI to determine if the IDSA guidelines are reasonable. COMMENT: Evidence for the use of antibiotics after amputation comes largely from perioperative surgical prophylaxis studies evaluating the rate of infection after amputation. Three such studies were identified; 2 found a 5-day course of antibiotics post-amputation resulted in a reduction of infection rate, while 1 found no additional benefit. Comparative antibiotic studies in DFI also offers evidence for treatment duration, of which, 10 studies were identified. Five included patients who received amputations; however, only 1 reported treatment outcomes in a subset of diabetics requiring amputation. In this study, the authors concluded that antibiotic treatment is likely necessary after amputation. WHAT IS NEW AND CONCLUSION: Given the general lack of data, we recommend that post-operative treatment duration be individualized, and, until further studies are done, it seems reasonable to adhere to the recommendation provided by the 2012 IDSA DFI guidelines for a 2-5 day course of antibiotic therapy post-operatively when no residual infected tissue remains.

Clinical impact of selective serotonin reuptake inhibitors therapy with bleeding risks.

The selective serotonin reuptake inhibitors (SSRIs) are extensively used for the treatment of multiple psychiatric conditions. In vitro and ex vivo data with these agents indicate they may have varying degrees of antiplatelet activity via multiple receptors. Reports of bleeding in patients receiving SSRIs appeared soon after their introduction. A review of the literature suggests SSRI therapy may increase the risk of bleeding especially with concomitant aspirin or nonsteroidal anti-inflammatory agents. Clinicians should exercise caution when prescribing these agents in high risk patients and maintain awareness of the potential contribution of SSRIs to unexplained bleeding episodes.

Proposed mechanisms and preventative options of Jarisch-Herxheimer reactions.

OBJECTIVE: To review the aetiologies and preventative methods associated with Jarisch-Herxheimer reactions (JHR). DATA SOURCES: Ovid Medline (1966-June Week 1 2004) was utilized to assess biomedical literature; a review of the bibliographies of articles was also performed. DATA SYNTHESIS: JHR often occurs with the treatment of spirochete infections. However, the mechanism by which the reaction takes place is not clearly defined. CONCLUSION: Studies suggest with conflicting evidence that the JHR is caused by release of endotoxin-like material from the spirochete as well as cytokine elevation in the body. It appears the type of drug and the rate of spirochete clearance from the body have little effect on the incidence of the reaction. Many pretreatment options have been explored with limited efficacy with the exception of anti-tumour necrosis factor antibodies.

Treating mammalian bite wounds.

The incidence of dog, cat and human bites has been increasing steadily and represents an important cause of morbidity and mortality in the United States. Approximately half of all Americans will suffer a bite wound during their lifetime, and the annual medical costs of managing these injuries has been estimated to be over $100 million. Possible complications may include disfigurement, dismemberment and infection. Effective management requires rapid medical evaluation and may necessitate surgical intervention and prophylactic antibiotic therapy. As bite wounds are microbiologically diverse and most often polymicrobial in nature, selection of an appropriate antibiotic regimen requires knowledge of common pathogens. Close clinical follow-up is recommended to minimize the risk of late complications.

A prospective, open-label study of single-dose ciprofloxacin absorption after chemotherapy in patients with malignancy.

The absorption of a single oral dose of ciprofloxacin 750 mg in patients with cancer who had chemotherapy-induced Cancer and Leukemia Group B grade I or II mucositis was evaluated. Ciprofloxacin was administered after an overnight fast. Plasma samples were collected before and 0.5, 1, 1.5, 2, 3, 4, 6, 8, and 12 hours after the dose. Drug concentrations were determined by reverse-phase high-performance liquid chromatography with fluorescence detection. Pharmacokinetic values were characterized by noncompartmental methods. The mean +/- SD for area under the curve, mean peak concentration (C(max)), and time to C(max) (T(max)) were 18.7 +/- 5.03 mg/L x hour, 4.41 +/- 1.74 mg/L, and 1.81 +/- 0.843 hours, respectively. The absorption of oral ciprofloxacin in patients with chemotherapy-induced grade I or II mucositis compares with that in healthy volunteers. These findings may call for further pharmacokinetic evaluation of the drug in a similar patient population.

Possible interaction involving phenytoin, dexamethasone, and antineoplastic agents: a case report and review.

OBJECTIVE: To describe a patient with subtherapeutic phenytoin concentrations and to review the literature regarding a possible interaction between phenytoin and chemotherapeutic agents as well as dexamethasone. CASE SUMMARY: A 29-year-old white man with brain metastases secondary to malignant melanoma consistently had suboptimal phenytoin concentrations while receiving chemotherapy consisting of cisplatin, carmustine, dacarbazine, and tamoxifen. In addition, this patient received dexamethasone, which may have influenced his phenytoin concentrations. DATA SOURCES AND STUDY SELECTION: Case reports were identified through a MEDLINE search and by cross referencing the articles identified. DISCUSSION: The available literature addressing suboptimal phenytoin concentrations in the setting of chemotherapy is reviewed. Aggressive dosing of phenytoin may be required to achieve therapeutic concentrations in patients who are concurrently receiving chemotherapy and/or dexamethasone, especially in patients who fall outside the predictive pharmacokinetic model for phenytoin. CONCLUSIONS: Subtherapeutic phenytoin concentrations may be decreased secondary to several proposed mechanisms: (1) the patient falls outside the predicted pharmacokinetic population parameters for phenytoin, (2) phenytoin absorption is decreased secondary to chemotherapy-induced gastrointestinal toxicity, and (3) metabolism of phenytoin is increased secondary to chemotherapy agents.

Effect of simultaneous didanosine administration on itraconazole absorption in healthy volunteers.

STUDY OBJECTIVE: To investigate the effect of simultaneously administered didanosine (ddI) on the absorption of a single dose of itraconazole. DESIGN: Randomized, crossover, unblinded single-dose pharmacokinetic study in healthy volunteers. Comparisons of itraconazole alone and itraconazole with simultaneous ddI were performed on days 1 and 15. SETTING: A university medical center. PATIENTS: Seven healthy men and women. Six subjects (86%) completed the study; one was removed due to the development of a rash. INTERVENTIONS: Volunteers received a single 200-mg oral dose of itraconazole or itraconazole with concomitant oral ddI 300 mg (two 150-mg tablets) dispersed in 240 ml water. Each regimen was separated by a 2-week washout period. Serum samples were obtained frequently for 12 hours after the dose. MEASUREMENTS AND MAIN RESULTS: Concentrations of itraconazole were determined using a microbiologic assay. Individual concentrations in serum versus time data were evaluated by linear regression analysis. Peak serum concentration and time to peak were determined by visual inspection of each individual's serum concentration-time curve. A mean +/- SD peak serum itraconazole concentration of 0.90 +/- 0.30 micrograms/ml was observed at 3.0 +/- 0.7 hours when itraconazole was administered alone, compared with undetectable levels in all patients during therapy with ddI. CONCLUSIONS: Simultaneous oral administration of ddI significantly decreases absorption of itraconazole. These drugs should not be administered concurrently.

A hybrid approach for managing a medical record facility information system.

The concept of totally computerizing an organization is appealing; however, this may not always be a practical solution. A medium size medical group, housing 64,000 medical records, located in a mid-eastern state was the basis of this study. The immediate problem was the development of a comprehensive medical records control system. The proposed hybrid solution provides automation with respect to controls while relying on manual methods for execution of process.

Physiologic effects of chest percussion and postural drainage in patients with stable chronic bronchitis.

The effects of a 30-minute period of chest percussion and postural drainage were compared to a sham treatment (infrared lamp) in 35 patients with stable chronic bronchitis and to a period of directed coughing in 11 of these same patients. There were no differences in subjective responses or arterial blood gas levels following therapy. Spirometric studies showed small improvements over baseline values following either treatment but no difference between active and sham treatments. The volume of sputum expectorated during percussion and drainage was significantly greater than during the infrared warming (5.5 vs 1.4 ml) or during the directed coughing (9.0 vs 3.5 ml). Although chest percussion and postural drainage are effective in augmenting the volume of expectorated sputum, no significant alternations in air flow or gas exchange after two hours were demonstrated.