Distant metastatic foci of infection in adult patients with diabetic foot - not as rare as we think?: case series and review of the literature.

BACKGROUND: Diabetic foot is one of the common complications of diabetes mellitus. We report clinical and microbiological characteristics and outcomes of cases with distant metastatic foci of infection arising from diabetic foot. METHODS: Retrospective review of adult patients with diabetic foot infection or diabetic foot ulcer who demonstrated distant metastatic foci of infection between August 2017 and December 2019. We performed a literature search of similar cases published until June 2020. RESULTS: Twelve patients with diabetic foot infection or diabetic foot ulcer with distant metastatic foci of infection were identified. The median age of patients was 67.5 years (range 60.5-73.5 years) and 11 males. The most common distant metastatic foci of infection included endocarditis (n = 7) followed by septic arthritis (n = 3) and spine infections (n = 2). Five patients had multiple site and organ involvement. Staphylococcus aureus was the only organism isolated from blood (n = 11), diabetic foot (n = 7), and metastatic foci (n = 8) sources. Three patients died and three had a relapse of distant metastatic foci of infection. Thirty-eight cases were identified in the literature with similar characteristics. CONCLUSIONS: Prevalence of distant metastatic foci of infection in adult patients with diabetic foot and burden of illness, in terms of mortality, morbidity, and length of hospital stay, appears to be underreported in the literature. A large prospective study is needed to assess the true prevalence of complications, associated risk factors, outcomes and prognostic factors.

Review of high dose vancomycin in the treatment of Clostridioides difficile infection.

BACKGROUND: Guidelines recommend oral vancomycin as first-line therapy for Clostridioides difficile infection. Guideline recommendations vary regarding dosing of vancomycin. Our aim was to summarize the current evidence on the efficacy and adverse effects of high dose oral and vancomycin retention enema (>500 mg/day) for the treatment of C. difficile infection. METHODS: We searched clinical studies and major guidelines in the English language using MEDLINE, the Cochrane Library and Embase from 1985 until 15 April 2020. RESULTS: No evidence supports the use of high dose oral vancomycin in the treatment of severe C. difficile infection. Weak evidence from observational studies supports the use of high dose oral vancomycin in addition to intravenous metronidazole and high dose vancomycin retention enema in fulminant C. difficile infection. Vancomycin retention enema can be used in severe C. difficile infection when oral administration is not possible, or in conditions when the oral formulation cannot reach the colon such as Hartman's pouch, ileostomies, or colon diversions. CONCLUSIONS: The dosing schedules for oral vancomycin and vancomycin enemas are not clearly defined due to widely varying results in clinical studies. Large, comparative multicenter trials are urgently needed to define the role of high dose vancomycin in C. difficile infection.

Treatment of urinary tract infections in the era of antimicrobial resistance and new antimicrobial agents.

Urinary tract infections (UTIs) caused by antibiotic-resistant Gram-negative bacteria are a growing concern due to limited treatment options. Knowledge of the common uropathogens in addition to local susceptibility patterns is essential in determining appropriate empiric antibiotic therapy of UTIs. The recommended first-line empiric antibiotic therapy for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females is a 5-day course of nitrofurantoin, a 3-g single dose of fosfomycin tromethamine, or a 5-day course of pivmecillinam. High rates of resistance for trimethoprim-sulfamethoxazole and ciprofloxacin preclude their use as empiric treatment of UTIs in several communities, particularly if patients who were recently exposed to them or in patients who are at risk of infections with extended-spectrum ß-lactamases (ESBLs)-producing Enterobacteriales. Second-line options include oral cephalosporins such as cephalexin or cefixime, fluoroquinolones and ß-lactams, such as amoxicillin-clavulanate. Current treatment options for UTIs due to AmpC- ß -lactamase-producing Enterobacteriales include nitrofurantoin, fosfomycin, pivmecillinam, fluoroquinolones, cefepime, piperacillin-tazobactam and carbapenems. Treatment oral options for UTIs due to ESBLs-E coli include nitrofurantoin, fosfomycin, pivmecillinam, amoxicillin-clavulanate, finafloxacin, and sitafloxacin while pivmecillinam, fosfomycin, finafloxacin, and sitafloxacin are treatment oral options for ESBLs- Klebsiella pneumoniae. Parenteral treatment options for UTIs due to ESBLs-producing Enterobacteriales include piperacillin-tazobactam (for ESBL-E coli only), carbapenems including meropenem/vaborbactam, imipenem/cilastatin-relebactam, and sulopenem, ceftazidime-avibactam, ceftolozane-tazobactam, aminoglycosides including plazomicin, cefiderocol, fosfomycin, sitafloxacin, and finafloxacin. Ceftazidime-avibactam, meropenem/vaborbactam, imipenem/cilastatin-relebactam, colistin, fosfomycin, aztreonam and ceftazidime-avibactam, aztreonam and amoxicillin-clavulanate, aminoglycosides including plazomicin, cefiderocol, tigecycline are treatment options for UTIs caused by carbapenem-resistant Enterobacteriales (CRE). Treatment options for UTIs caused by multidrug resistant (MDR)-Pseudomonas spp. include fluoroquinolones, ceftazidime, cefepime, piperacillin-tazobactam, carbapenems including imipenem-cilastatin/relebactam, meropenem, and fosfomycin, ceftolozane-tazobactam, ceftazidime-avibactam, aminoglycosides including plazomicin, aztreonam and ceftazidime-avibactam, cefiderocol, and colistin. It is important to use the new antimicrobials wisely for treatment of UTIs caused by MDR-organisms to avoid resistance development.

Postexposure management of infectious diseases.

Anyone exposed to an infectious disease--whether a healthcare provider, patient, or contact of a patient--should be evaluated promptly and the source of the infection identified. A systematic response entails postexposure prophylactic therapy if available and indicated, infection control measures to prevent further transmission, counseling and educating those involved, and assessing those who may require work restriction or modification.

An update on the management of urinary tract infections in the era of antimicrobial resistance.

Urinary tract infections (UTIs) caused by antibiotic-resistant Gram-negative bacteria are a growing concern due to limited therapeutic options. Gram-negative bacteria, specifically Enterobacteriaceae, are common causes of both community-acquired and hospital acquired UTIs. These organisms can acquire genes that encode for multiple antibiotic resistance mechanisms, including extended-spectrum-lactamases (ESBLs), AmpC- ß -lactamase, and carbapenemases. The assessment of suspected UTI includes identification of characteristic symptoms or signs, urinalysis, dipstick or microscopic tests, and urine culture if indicated. UTIs are categorized according to location (upper versus lower urinary tract) and severity (uncomplicated versus complicated). Increasing rates of antibiotic resistance necessitate judicious use of antibiotics through the application of antimicrobial stewardship principles. Knowledge of the common causative pathogens of UTIs including local susceptibility patterns are essential in determining appropriate empiric therapy. The recommended first-line empiric therapies for acute uncomplicated bacterial cystitis in otherwise healthy adult nonpregnant females is a 5-day course of nitrofurantion or a 3-g single dose of fosfomycin tromethamine. Second-line options include fluoroquinolones and ß-lactams, such as amoxicillin-clavulanate. Current treatment options for UTIs due to AmpC- ß -lactamase-producing organisms include fosfomycin, nitrofurantion, fluoroquinolones, cefepime, piperacillin-tazobactam and carbapenems. In addition, treatment options for UTIs due to ESBLs-producing Enterobacteriaceae include nitrofurantion, fosfomycin, fluoroquinolones, cefoxitin, piperacillin-tazobactam, carbapenems, ceftazidime-avibactam, ceftolozane-tazobactam, and aminoglycosides. Based on identification and susceptibility results, alternatives to carbapenems may be used to treat mild-moderate UTIs caused by ESBL-producing Enterobacteriaceae. Ceftazidime-avibactam, colistin, polymixin B, fosfomycin, aztreonam, aminoglycosides, and tigecycline are treatment options for UTIs caused by carbapenem-resistant Enterobacteriaceae (CRE). Treatment options for UTIs caused by multidrug resistant (MDR)-Pseudomonas spp. include fluoroquinolones, ceftazidime, cefepime, piperacillin-tazobactam, carbapenems, aminoglycosides, colistin, ceftazidime-avibactam, and ceftolozane-tazobactam. The use of fluoroquinolones for empiric treatment of UTIs should be restricted due to increased rates of resistance. Aminoglycosides, colistin, and tigecycline are considered alternatives in the setting of MDR Gram-negative infections in patients with limited therapeutic options.

Community-Acquired Pneumonia in Patients With Diabetes Mellitus: Predictors of Complications and Length of Hospital Stay.

BACKGROUND: The primary objective of the study was to determine factors associated with complications and length of hospital stay (LOS) in hospitalized adult patients with diabetes along with community-acquired pneumonia (CAP). CAP is a common infection in patients with diabetes mellitus and is associated with a significant mortality and morbidity. MATERIALS AND METHODS: This is a retrospective cohort study of 215 adult patients with diabetes who were admitted with CAP. A multivariate logistic and Cox regression analysis were used to assess factors associated with complications and LOS of CAP, respectively. RESULTS: During the follow-up period from admission until discharge, 94 patients (43.7%) developed complications. Respiratory failure was the most common complication (43.6%). The average LOS of study cohort was 9.47 days. In the multivariate analysis, complications of CAP were associated with time to first dose of appropriate antibiotic therapy >8 hours since triage at emergency department (ED) (odds ratio = 3.16; 95% CI: 1.58-6.32; P = 0.001) and pneumonia severity index score >90 (odds ratio = 3.52; 95% CI: 1.45-8.53; P = 0.005). In the multivariate Cox regression analysis, time to first dose of appropriate antibiotic therapy >8 hours since triage at ED (hazard ratio [HR] = 0.56, P = 0.01), pneumonia severity index score >90 (HR = 0.62, P = 0.01), presence of complications (HR = 0.53, P = 0.002), duration of antibiotics (HR = 0.90, P ≤ 0.0001) and duration of symptoms prior presentation to ED (HR = 0.96, P = 0.04) were independently determinants of LOS. CONCLUSIONS: Delayed administration of appropriate antibiotic therapy at ED and moderate-to-severe pneumonia were associated with both increased risk of complications and prolonged LOS in hospitalized adult patients with diabetes along with CAP.

Postexposure management of healthcare personnel to infectious diseases.

Healthcare personnel (HCP) are at risk of exposure to various pathogens through their daily tasks and may serve as a reservoir for ongoing disease transmission in the healthcare setting. Management of HCP exposed to infectious agents can be disruptive to patient care, time-consuming, and costly. Exposure of HCP to an infectious source should be considered an urgent medical concern to ensure timely management and administration of postexposure prophylaxis, if available and indicated. Infection control and occupational health departments should be notified for management of exposed HCP, identification of all contacts of the index case, and application of immediate infection control measures for the index case and exposed HCP, if indicated. This article reviews the main principles of postexposure management of HCP to infectious diseases, in general, and to certain common infections, in particular, categorized by their route of transmission, in addition to primary prevention of these infections.

Management of hospitalized patients with diabetic foot infections.

Diabetic foot infections (DFIs), which present with a variety of clinical manifestations, are commonly encountered by clinicians. They are associated with a high morbidity, a high amputation rate, a high mortality, and increased health care costs. An effective management of DFIs requires a multidisciplinary approach with a strong collaboration among all involved health care providers as well as patient involvement. Diagnosing DFIs appropriately requires consideration of the clinical symptoms and signs of infection in addition to supplementary laboratory testing such as inflammatory markers and imaging studies. The comprehensive patient assessment should include the predisposing risk factors for infection; the type, severity, and extent of the infection; and the assessment of neurologic and vascular status, comorbid conditions, and psychosocial factors. The comprehensive management of DFIs include not only effective antibiotic therapy but also surgical debridement, pressure offloading, wound care and moisture, maintaining good vascular perfusion, control of edema and pain, correction of metabolic abnormalities such as hyperglycemia, and addressing psychosocial and nutritional issues. Discharge planning that addresses full medical and social needs along with suitable follow-up, patient education and counseling, and clear communication with outpatient providers are critical for ensuring a safe and successful transition to outpatient management of hospitalized patients with DFIs.

Herpes zoster: diagnostic, therapeutic, and preventive approaches.

Herpes zoster (Hz), which generally presents as a localized, painful cutaneous eruption, is a common clinical problem, particularly among adults ≥ 50 years of age and immunocompromised patients. The diagnosis of Hz is mainly made clinically, except in patients with atypical manifestations or certain complications, such as central nervous system involvement, in which laboratory virologic testing is required. In addition to having a higher mortality rate, immunocompromised individuals have atypical and severe clinical findings and are at greater risk for complications and recurrence of Hz. Treatment of Hz includes the use of antiviral agents, analgesics for control of acute zoster pain, good skin care for healing, and prevention of secondary bacterial infection. Antiviral agents, preferably valacyclovir or famciclovir, should be started within 72 hours of onset to reduce the severity of the infection, the duration of the eruptive phase, and the intensity of acute pain. Herpes zoster has been associated with several complications, of which post-herpetic neuralgia (PHN) is the most common and debilitating. Varicella-zoster virus vaccine and early treatment with either famciclovir or valacyclovir are the only measures proven to prevent PHN. The options for treating PHN include topical agents, such as lidocaine patches, and systemic agents, such as the anticonvulsants gabapentin and pregabalin. Measures for preventing Hz include infection control through routine hand hygiene and appropriate use of isolation precautions and personal protective equipment; immunoglobulins, such as the varicella-zoster virus immunoglobulin and vaccine; and antiviral agents. The zoster vaccine has been shown to be effective in reducing the incidence of Hz and PHN. The vaccine is recommended for all individuals aged ≥ 60 years who have no contraindications, including individuals who report a previous episode of Hz.

Postexposure prophylaxis for common infectious diseases.

Postexposure prophylaxis (PEP) is effective in preventing illness after potential or documented exposure to a variety of microbial pathogens and in reducing the risk of secondary spread of infection. Guidelines have been published by the Centers for Disease Control and Prevention and the Advisory Committee on Immunization Practices for proper use of PEP for bloodborne pathogens, for microorganisms transmitted by either airborne or droplet spread or through direct contact, and for infections acquired after traumatic injuries. Depending on the type of exposure, different forms of PEP are available, including vaccines, immune globulins, antibiotics, and antiviral medications. Physicians should assess a patient's potential need for PEP based on several factors, including the type of exposure, the timing and severity of illness in the source patient, the exposed person's susceptibility to infectious diseases of concern, and the relative risks and benefits of the PEP regimen in an individual situation. Immunity to certain infectious diseases can be ensured with prior infection or vaccination, and by serologic testing in patients with a negative or uncertain history. PEP should be given to persons exposed to index cases of pertussis and invasive meningococcal infection regardless of immunization history, and should be given following rabies and tetanus exposure regardless of the length of delay. In general, PEP should be given as soon as possible following a high-risk exposure. Persons exposed to bloodborne pathogens should have baseline testing for human immunodeficiency virus, hepatitis B virus, and hepatitis C virus antibodies, and follow-up testing at six weeks, three months, and six months postexposure.

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.

Risk factors of cellulitis treatment failure with once-daily intravenous cefazolin plus oral probenecid.

OBJECTIVES: Once-daily intravenous cefazolin with probenecid is used commonly to treat cellulitis. The primary objective of this study was to determine the risk factors of treatment failure with this regimen. METHODS: This was a retrospective cohort study of adult outpatients with cellulitis who were initially treated with once-daily intravenous cefazolin plus probenecid. Treatment failure is defined as inadequate improvement that necessitates either hospital admission or a change in antibiotic therapy to a different intravenous regimen. A stepwise logistic regression analysis was performed to determine the risk factors for regimen failure. RESULTS: From January 2003 to December 2008, 159 patients with cellulitis were initially treated with once daily intravenous cefazolin plus probenecid. Thirty-five (22%) patients had treatment failure. The treatment for 53% (9/17) of the patients with a history of chronic venous disease (CVD) failed, whereas the treatment for 18% (26/142) of patients without CVD failed (P = 0.001). Multivariate analysis identified the presence of CVD as the only risk factor associated with treatment failure (odds ratio 4.4, 95% confidence interval 1.5-13; P = .007). CONCLUSIONS: Patients with cellulitis and CVD who are being treated with once-daily intravenous cefazolin plus probenecid should be monitored closely for treatment failure.

Management of complicated urinary tract infections in the era of antimicrobial resistance.

Complicated urinary tract infections (cUTIs) are a major cause of hospital admissions and are associated with significant morbidity and health care costs. Patients presenting with a suspected UTI should be screened for the presence of complicating factors, such as anatomic and functional abnormalities of the genitourinary tract. In the setting of cUTIs, the etiology and susceptibility of the causative organism is not predictable; therefore, when infection is suspected, patients should undergo a urinalysis in addition to culture and sensitivity testing. Although not warranted in all cases of complicated pyelonephritis, blood cultures are appropriate in some clinical settings. With the increased prevalence of antimicrobial resistance, and the lack of well-designed clinical trials, treatment of cUTIs can be challenging for clinicians. Although resistant organisms are not always implicated as the causative agent, all patients with cUTIs should be assessed for predisposing risk factors. Consideration of an optimal antimicrobial agent should be based on local resistance patterns, patient-specific factors, including anatomic site of infection and severity of disease, pharmacokinetic and pharmacodynamic principles, and cost. Resistance to first-line antimicrobial agents, including fluoroquinolones, has become increasingly common in Escherichia coli. Fluoroquinolones should not be used as a first-line option for empiric treatment of serious cUTIs, especially when patients exhibit risk factors for harboring a resistant organism, such as previous or recent use of fluoroquinolones. Fluoroquinolones, trimethoprim-sulfamethoxazole, and nitrofurantoin are still appropriate empiric options for mild lower cUTIs. However, empiric treatment for serious cUTIs, where risk factors for resistant organisms exist, should include broad-spectrum antibiotics such as carbapenems or piperacillin-tazobactam. Once organisms and susceptibilities are identified, treatment should be targeted accordingly. Nitrofurantoin and fosfomycin have limited utility in the setting of cUTIs and should be reserved as alternative treatment options for lower cUTIs following confirmation of the causative organism. Aminoglycosides, tigecycline, and polymyxins can be used for the treatment of serious cUTIs when first-line options are deemed to be inappropriate or patients fail therapy. The duration of treatment for cUTIs has not been well established; however, treatment durations can range from 1 to 4 weeks based on the clinical situation.

Diagnosis and management of common chronic metabolic complications in HIV-infected patients.

Human immunodeficiency virus (HIV) infection has become a chronic illness that requires continuing medical care and patient self-management education to prevent acute complications and to reduce the risk of long-term complications. Metabolic complications such as dyslipidemia, insulin resistance, diabetes mellitus, obesity, and fat distribution abnormalities are associated with increased risk of cardiovascular disease. Cardiovascular disease is now a leading cause of death among HIV-infected patients. Lipid abnormalities, now often characteristically seen with HIV infection, include elevated triglycerides and low elevated total cholesterol (TC), and low high-density lipoprotein (HDL) levels of total and HDL cholesterol. Many antiretroviral drugs are associated with lipid abnormalities, which commonly include hypertriglyceridemia and increased total and low-density lipoprotein cholesterol levels. The management of dyslipidemia includes lifestyle modifications, lipid-lowering therapy, and switching antiretroviral therapy (ART). The increased prevalence of insulin resistance, impaired glucose tolerance, and diabetes is multifactorial in etiology. Management and goals of diabetes should follow the same practice guidelines in non-HIV-infected patients. Drug interactions and switching ART are additional management measures in diabetic HIV-infected patients. Since the treatment of lipodystrophy is a challenge, its prevention by selecting appropriate ART is the key.

Diabetic foot infection.

Foot infections are common in patients with diabetes and are associated with high morbidity and risk of lower extremity amputation. Diabetic foot infections are classified as mild, moderate, or severe. Gram-positive bacteria, such as Staphylococcus aureus and beta-hemolytic streptococci, are the most common pathogens in previously untreated mild and moderate infection. Severe, chronic, or previously treated infections are often polymicrobial. The diagnosis of diabetic foot infection is based on the clinical signs and symptoms of local inflammation. Infected wounds should be cultured after debridement. Tissue specimens obtained by scraping the base of the ulcer with a scalpel or by wound or bone biopsy are strongly preferred to wound swabs. Imaging studies are indicated for suspected deep soft tissue purulent collections or osteomyelitis. Optimal management requires aggressive surgical debridement and wound management, effective antibiotic therapy, and correction of metabolic abnormalities (mainly hyperglycemia and arterial insufficiency). Treatment with antibiotics is not required for noninfected ulcers. Mild soft tissue infection can be treated effectively with oral antibiotics, including dicloxacillin, cephalexin, and clindamycin. Severe soft tissue infection can be initially treated intravenously with ciprofloxacin plus clindamycin; piperacillin/tazobactam; or imipenem/cilastatin. The risk of methicillin-resistant S. aureus infection should be considered when choosing a regimen. Antibiotic treatment should last from one to four weeks for soft tissue infection and six to 12 weeks for osteomyelitis and should be followed by culture-guided definitive therapy.

Immunization for the elderly.

The morbidity and mortality of vaccine-preventable diseases among older adults are high. Despite the benefits of elderly vaccination, vaccination rates remain low and especially among some minority groups. Specific strategies for improving the rate of vaccination have been developed for medical offices and clinics, hospitals, and other health care institutions. There are vaccines that are recommended routinely for the elderly while other vaccines are recommended in certain circumstances. Knowing the indications, contraindications, and adverse reactions to the recommended vaccines for the elderly is very important to the primary care physicians.

A fatal case of Staphylococcus aureus: associated toxic shock syndrome following nipple piercing.

We describe a case of a healthy adolescent with a fatal toxic shock syndrome due to Staphylococcus aureus. This infection developed 2 weeks after the patient underwent a nipple piercing by a friend. This case should serve as a strong reminder of the potentially fatal consequences of piercing that is becoming increasingly popular worldwide.