Fighting Infection in Diabetes Emily Abdoler, MD Division of - - PDF document

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Fighting Infection in Diabetes Emily Abdoler, MD Division of - - PDF document

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3/15/18 I have no disclosures Fighting Infection in Diabetes Emily Abdoler, MD Division of Infectious Diseases GomerBlog . http://gomerblog.com/2018/02/nystatin-statin/ Outline Outline Does DM Increase Risk of Infections? Does DM

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3/15/18 1

Fighting Infection in Diabetes

Emily Abdoler, MD Division of Infectious Diseases I have no disclosures

  • GomerBlog. http://gomerblog.com/2018/02/nystatin-statin/

Outline

  • Does DM Increase Risk of Infections?
  • Diabetic Foot Ulcers
  • Infections Treated Differently in DM
  • Infections Increased in DM
  • Other Considerations

Outline

  • Does DM Increase Risk of Infections?
  • Diabetic Foot Ulcers
  • Infections Treated Differently in DM
  • Infections Increased in DM
  • Other Considerations
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SLIDE 2

3/15/18 2 Does DM Increase Risk of Infection?

Normal Host BMT Day 2

Proposed Mechanisms for Increased Infection Risk

Rajagoplan S CID 2005;40:990-6. Pozzilli P & Leslie RDG Diab Med 1994;11:935-41.

Decreased Cell-Mediated Immunity Decreased Leukocyte Function (hyperglycemia)

Disrupted Skin Barrier Tissue injury Urinary Retention Sensory Autonomic Neuropathy é bacterial growth ê abx delivery Impaired immune response Ischemia Vascular Insufficiency

Does DM Increase Risk of Infection?

Adj Odds Ratio Lower Respiratory Tract Infection 1.32 - 1.42 UTI 1.24 - 1.96 GI 1.4 Bacterial Skin/MM Infection 1.33 – 1.66 Mycotic Skin/MM Infection 1.34 – 1.44

Muller et al CID 2005;41:281-8. Abu-Ashour W et al BMC Infect Dis 2018;18.

Does DM Increase the Risk of Infection?

Rodriguez AL et al Am J Infect Contr 2017;45:e149-56. Latham R et al Infect Contr Hosp Epi 2001;22:607-12.

Surgical Site Infections Diabetes (OR 2.76) Post-op hyperglycemia (OR 2.02) Not A1c Hospital-Acquired Infections DM is an independent risk factor (RR 1.76)

Take-Away:

  • DM likely increases the risk of some infections
  • Relationship of hyperglycemia is unclear
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3/15/18 3

Outline

  • Does DM increase risk of infections?
  • Diabetic Foot Ulcers
  • Infections Treated Differently in DM
  • Infections Increased in DM
  • Other Considerations

Diabetic Foot Ulcers

  • Is it infected?
  • How do you evaluate the infection?

– General evaluation – Severity – Imaging – Culture

  • How do you manage the infection?

– What organisms should you cover? – Surgical management – Treatment duration

Question #1

When should you suspect MRSA could be playing a role in a diabetic foot infection?

  • A. Positive MRSA nasal carriage within last yr
  • B. Frequent gym use
  • C. Copious purulence
  • D. Extreme erythema

Question #1

When should you suspect MRSA could be playing a role in a diabetic foot infection?

  • A. Positive MRSA nasal carriage within last yr
  • B. Frequent gym use
  • C. Copious purulence
  • D. Extreme erythema
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Diabetic Foot Ulcer: Is it Infected?

≥2 classic signs of inflammation or purulence

Erythema Warmth Tenderness Swelling/Induration

IDSA Diabetic Foot Infections Guidelines 2012

Exclude other causes Trauma Gout Acute Charcot Fracture Thrombosis Venous Stasis

Diabetic Foot Ulcer: Is it Infected?

Factors Associated with Infection OR Probe to Bone 6.7 Ulcer >30 Days 4.7 H/o recurrent ulcers 2.4 Traumatic foot wound 2.4 PVD (in affected limb) 1.9 – 5.5 Previous amputation 19.9 Neuropathy 3.4 ?Renal insufficiency ?H/o walking barefoot

IDSA Diabetic Foot Infections Guidelines 2012; Lavery LA Diabetes Care 2006;29:1288-93. Peters EJ et al J Diabetes Complications 2005;19:107-12

Diabetic Foot Infections: General Evaluation

IDSA Diabetic Foot Infections Guidelines 2012; Lavery LA et al CID 2007;44:562-5.

Assess for

  • Arterial & venous insufficiency
  • Neuropathy
  • Biomechanical problems
  • Severity of infection

Diabetic Foot Infections: Severity?

IDSA Infection Severity Description Uninfected No s/sx of infection Mild Local infection involving only skin & SQ tissue. Erythema 0.5-≤2 cm Moderate Local infection with erythema >2cm or involving deeper structures. Severe Local infection + SIRS

IDSA Diabetic Foot Infections Guidelines 2007; Lavery LA et al CID 2007;44:562-5.

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SLIDE 5

3/15/18 5 Diabetic Foot Infections: Severity?

IDSA Infection Severity Predicts risk for: Hospitalization Osteomyelitis Amputation Uninfected 0% N/A 3% Mild 4% 20% 3% Moderate 52% 46% Severe 89% 30-60% 70%

IDSA Diabetic Foot Infections Guidelines 2007. Lavery LA et al CID 2007;44:562-5. Lipsky Diabetes Metab Res Rev 2004;20(Suppl 1):S68-77.

Diabetic Foot Infections: Imaging Evaluation

IDSA Diabetic Foot Infections Guidelines 2012

Imaging XR for new diabetic foot infections (bony abnl, gas, foreign bodies) MRI if c/f abscess, osteomyelitis Radionuclide bone scan + tagged WBC scan (If MRI not possible)

Diabetic Foot Infections: Osteomyelitis Evaluation

Lauri C et al Diabetes Care 2017;40:1111-20. Lipsky Diabetes Metab Res Rev 2004;20(Suppl1):S68-77.

Diagnostic Tool Sensitivity Specificity FDG-PET Scan 89% 92% WBC Scan (111In-Oxine) 92% 75% WBC Scan (99mTc-HMPAO) 91% 92% MRI 93% 75% XR 54% 68% Probe To Bone Gold Standard: Bone biopsy with pathology and culture Consider inflammatory markers (for monitoring)

Diabetic Foot Infections: Culture Evaluation

IDSA Diabetic Foot Infections Guidelines 2012

Culture No infection = No need for culture If debridement, try to obtain culture Deep Tissue Biopsy/Curettage After debridement & cleansing Drain purulence NO wound swabs Prior to abx if possible

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SLIDE 6

3/15/18 6 Diabetic Foot Infections: Management

IDSA Diabetic Foot Infections Guidelines 2012. Lavery LA et al CID 2007;44:562-5.

  • Determine care setting
  • Debride (necrotic tissue, callus, etc)
  • Offload
  • Wound Care
  • Antibiotics

Diabetic Foot Infections: Management

IDSA Diabetic Foot Infections Guidelines 2012

When to hospitalize?

  • Severe infections
  • Moderate infections with complications
  • Social factors
  • Failure of outpatient therapy

Diabetic Foot Infections: What organisms should be covered?

Lipsky BA et al Arch Int Med 1990;150-790. IDSA Diabetic Foot Infections Guidelines 2012.

Mild/Moderate Infections

  • Staph, Strep
  • Not anaerobes or other resistant organism

Diabetic Foot Infections: What organisms should be covered?

Organism(s) Situation GNRs Warm climate Severe infections Pseudomonas Warm climate Water exposure Severe Infections Anaerobes Chronic Previously Tx’d Severe Infections MRSA H/o MRSA infxn or carriage (last 1y) Severe Infections ESBL When prevalent***

Lipsky BA et al. Arch Int Med 1990. IDSA Diabetic Foot Infections Guidelines 2012.

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SLIDE 7

3/15/18 7 Diabetic Foot Infections: Surgical Management

Balancing of risks & benefits

  • Pt preference?
  • Surgical target?
  • Chance for function?
  • Location?
  • Surgical risk?
  • Prolonged abx risk?
  • Sepsis/disseminated infection?

Involve vascular surgeon if ischemia

IDSA Diabetic Foot Infections Guidelines 2012

Diabetic Foot Infections: Antibiotic Duration

SSTI Infection Severity Duration Mild 1-2 weeks Moderate 1-3 weeks Severe 2-4 weeks

IDSA Diabetic Foot Infections Guidelines 2012

Diabetic Foot Infections: Antibiotic Duration

Osteomyelitis Duration No remaining infection 2-5 days* Residual soft tissue infxn 1-3 weeks* Residual infected but reliable bone 4-6 weeks** No debridement & residual infected bone ≥ 3 months**

IDSA Diabetic Foot Infections Guidelines 2012

*PO or IV **IV -> consider PO

Diabetic Foot Ulcers

Take-Aways:

  • Not every ulcer is infected
  • Infected ulcers need multipronged assessment
  • Obtain deep culture when feasible
  • Mild/moderate are typically 2/2 Staph, Strep
  • Surgery requires risk/benefit evaluation
  • Abx duration varies based on severity
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SLIDE 8

3/15/18 8

Outline

  • Does DM increase risk of infections?
  • Diabetic Foot Ulcers
  • Infections Treated Differently in DM
  • Infections Increased in DM
  • Other Considerations

Question #2

A 62yo gentleman with T2DM presents with a 2d history of cough and fevers. He is febrile but

  • therwise stable and is diagnosed with

community-acquired pneumonia. Which is the most appropriate therapy?

  • A. Azithromycin
  • B. Levofloxacin
  • C. Doxycycline
  • D. Ceftriaxone + Azithromycin

Question #2

A 62yo gentleman with T2DM presents with a 2d history of cough and fevers. He is febrile but

  • therwise stable and is diagnosed with

community-acquired pneumonia. Which is the most appropriate therapy?

  • A. Azithromycin
  • B. Levofloxacin
  • C. Doxycycline
  • D. Ceftriaxone + Azithromycin

Infections Treated Differently

CAP Empiric therapy: FQ vs. (B-Lactam + Macrolide) Coccidioidomycosis Treat newly-diagnosed, uncomplicated PNA Latent TB infection DM is an indication for treatment

IDSA CAP Guidelines 2007; IDSA Cocci Guidelines 2016; SFDPH LTBI Guidelines

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3/15/18 9

Outline

  • Does DM increase risk of infections?
  • Diabetic Foot Infections
  • Infections Treated Differently in DM
  • Infections Increased in DM
  • Other Considerations

Urinary Tract Infection

ñA1c = ñ risk UTI (1 unit ñ= 21% ñUTI frequency) Asymptomatic Bacteriuria is common

IDSA UTI Guidelines 2011. Nicolle CID 2005. Table courtesy Dr. Brian Schwartz.

Pre-menopausal women 1-5% Pregnant women 2-10% Post-menopausal women, 50-70 yrs 3-9% Pts with DM 9-27% Elderly in LTC facilities (women; men) 15-50% Pts with spinal cord injuries 23-89% Pts undergoing HD 28% Pts with indwelling catheters 25-100%

Urinary Tract Infection

No treatment for asymptomatic bacteriuria RCT:

  • DM women with asx bacteriuria
  • TMP/SMX vs Placebo
  • 40% (placebo) vs 42% (tx) symptomatic UTI

Treatment

  • If DM well-controlled, treat as

uncomplicated?

  • Otherwise: cipro or levo x7-14d
  • If pregnant: nitrofurantoin or cephalexin

Nicolle CID 2005. IDSA UTI Guidelines 2011.

Skin & Soft Tissue Infections

Most commonly due to Staph and Strep

– <10% of cases due to GNRs (same as non-Diabetics)

Higher complication rate in DM

– Predisposing factor for necrotizing fasciitis, Fournier’s

Higher hospitalization rate in DM Tx: Consider abx after I&D of MRSA abscesses

IDSA SSTI Guidelines 2014; Jenkins TC et al J Hosp Med 2014;9:788-94. Suaya JA et al PLoS ONE 2013;8:e60057.

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3/15/18 10

Vulvovaginal Candidiasis

Likely associated with:

  • Glycosuria
  • ñ HgbA1c
  • Blood glucose & glycosuria (even w/o DM)

Donders GGG Current ID Reports 2002;4:536-9.

Less Common Infections

Mucor

  • 36% due to DM
  • 66% of pts with DM had sinus dz
  • ê since 1990s, potentially 2/2 statin

Malignant Otitis Externa

~90% pts have DM

  • Associated with poor DM control
  • Typically Pseudomonas

Roden MM et al CID 2005;14:634-53. Kontoyiannis DP CID 2007;44:1089. Rubin GJ et al Lancet ID 2004;4:34.

Infections Increased in DM

Take-Aways:

  • Asymptomatic bacteriuria is common
  • Don’t treat it!
  • SSTIs are likely due to Staph, Strep
  • Consider I&D plus abx with all abscesses
  • Vulvovaginal candidiasis a/w poor DM control
  • Malignant OE a/w poor DM control

Outline

  • Does DM increase risk of infections?
  • Diabetic Foot Infections
  • Infections Treated Differently in DM
  • Infections Increased in DM
  • Other Considerations

– Vaccinations – Fluoroquinolone therapy

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SLIDE 11

3/15/18 11

Question #3

How do the vaccination recommendations differ for a 55yo woman with DM compared to a 55yo woman without DM?

  • A. Menactra vaccination recommended
  • B. Hepatitis B vaccination recommended
  • C. Hep B and Pneumovax recommended
  • D. Pneumovax recommended

Question #3

How do the vaccination recommendations differ for a 55yo woman with DM compared to a 55yo woman without DM?

  • A. Menactra vaccination recommended
  • B. Hepatitis B vaccination recommended
  • C. Hep B and Pneumovax recommended
  • D. Pneumovax recommended

Vaccinations in DM

Age 19-64y

  • 1 dose PPSV23, then:
  • 1 dose PCV13 at 65y (if none previously)
  • 2nd dose PPSV23

(1y post-PCV13 & 5y after PPSV23)

  • Hepatitis B series (esp if <60y)

CDC Immunization Schedule https://www.cdc.gov/vaccines/schedules/hcp/imz/adult-conditions.html#f7

Fluoroquinolones

FQs have been associated with dysglycemia Cohort Study: Macrolides vs FQs

Chou H-W CID 2013;57:971-80.

FQ Hyperglycemia Adj Odds Ratio Hypoglycemia Adj Odds Ratio Levofloxacin 1.75 1.79 Ciprofloxacin 1.87 1.46 Moxifloxacin 2.48 2.13

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SLIDE 12

3/15/18 12

Outline

  • Does DM Increase Risk of Infections?
  • Diabetic Foot Ulcers
  • Infections Treated Differently in DM
  • Infections Increased in DM
  • Other Considerations

Summary

  • DM likely increases the risk of some infections
  • Relationship of hyperglycemia is unclear
  • Diabetic Ulcers
  • Not every ulcer is infected
  • Infected ulcers need multipronged assessment
  • Obtain deep culture when feasible
  • Mild/moderate are typically 2/2 Staph, Strep
  • Surgery requires risk/benefit evaluation
  • Abx duration varies based on severity

Summary

  • Treat differently: CAP, Cocci, LTBI, ?UTIs
  • Asymptomatic bacteriuria is common
  • SSTIs are likely due to Staph, Strep
  • Consider I&D plus abx with all abscesses
  • Association with poor DM control
  • UTIs
  • Vulvovaginal candidiasis
  • Malignant OM a/w poor DM control

Questions?

GomerBlog http://gomerblog.com/2016/07/epic-consult-once-upon-a-time/