Dermatology Book

Bacterial Infections

  • Skin Infections in Diabetes Mellitus

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Skin Infections in Diabetes MellitusAka: Diabetic Foot Infection, Cellulitis in Diabetes Mellitus

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  1. See Also
    1. Cellulitis
    2. Skin Infection
  2. Pathophysiology
    1. Most common organisms are still Gram Positive Cocci
      1. Staphylococcus aureus is most common cause
    2. Higher risk for Gram Negative infections (30-40%)
      1. More common in chronic wounds or recent antibiotics
      2. Requires broader spectrum antibiotic use
  3. Examination
    1. Evaluate severity of infection
      1. Distribution of infection
      2. Depth of infection
      3. Associated systemic signs and symptoms
    2. Neurovascular examination
      1. Evaluate for limb ischemia
      2. Evaluate for Diabetic Neuropathy
    3. Diabetic control
      1. Metabolic abnormalities
  4. Radiology
    1. XRay extremity (especially in diabetic foot infection)
      1. Baseline study observing for local destruction
    2. MRI
      1. Characterizes deep infection involvement
      2. Detects Osteomyelitis
  5. Management: Cellulitis in comorbid Diabetes Mellitus
    1. Early or Mild disease
      1. Augmentin 875 mg PO bid
      2. Second Generation Cephalosporin
      3. Third Generation Cephalosporin
    2. Severe disease
      1. Imipenem-Cilastatin (Primaxin)
      2. Meropenem
      3. Trovafloxacin IV
  6. Management: Diabetic Foot Ulcer
    1. See Suspected Osteomyelitis in Diabetes Mellitus
    2. Mild to moderate outpatient management
      1. Dicloxacillin
      2. Cephalexin (Keflex)
      3. Amoxicillin-Clavulanate (Augmentin)
      4. Clindamycin
    3. Moderate inpatient management
      1. Ampicillin-Sulbactam (Unasyn)
      2. Piperacillin-Tazobactam
      3. Ticarcillin-Clavulanate
      4. Clindamycin with (second drug added from list)
        1. Ceftriaxone or Cefotaxime
        2. Ciprofloxacin
        3. Levofloxacin
        4. Aztreonam
    4. Severe or limb-threatening infection
      1. Vancomycin with (second drug added from list)
        1. Imipenem
        2. Meropenem
        3. Trovafloxacin
  7. Management: Intensive Management Indications
    1. Hospitalization Indications
      1. Systemic infection with signs of toxicity
      2. Metabolic instability
      3. Rapidly progressive or deep infection
      4. Significant wound necrosis
      5. Gangrene
      6. Limb-critical ischemia
      7. Urgent or emergent intervention required
      8. Home situation not adequate for management
    2. Surgery Indications
      1. Deep abscess
      2. Bone or joint extensively involved
      3. Crepitation
      4. Significant wound necrosis
      5. Gangrene
      6. Necrotizing Fasciitis
  8. Prevention
    1. Careful wound care
    2. Unload extremity of local pressure sources
      1. Examples: non-weight bearing, well-fitting shoes
    3. Optimize glycemic control
  9. References
    1. Hellekson (2005) Am Fam Physician 71:1429

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