CELLULITIS

• *As clinically indicated; • †Ulcerated lesions should be cleaned and debrided before having wound base swabbed; • ‡Most useful if vesicle/bullae or fluid abscess present; • §Seek out bone trauma and air fluid levels; • ¶Indications –neurological deficits, vision nonassessable, proptosis/deteriorating acuity or colour/bilateral edema/ophthalmoplegia, no improvement

after 24 h and swinging pyrexia not resolving within 36 h (for head only); • **Only if central nervous system involvement suspected

Diagnosis• Clinical diagnosis• Fine Needle Aspiration

– Technique • Leading edge injection and aspiration

with saline – Efficacy

• May assist diagnosis with cellulitis• Not useful in Erysipelas• 30% sensitivity from closed lesions

– Indication • Unusual pathogens suspected• Cellulitis refractory to current

antibiotics

• Blood Culture (25% sensitivity)• only 20% of cases are positive• Skin biopsy (25% sensitivity)

www.fpnotebook.com/DER/Endo/SknInfctnsInDbtsMlts.html and Harrison’s 17 th ed

Diagnosis• Based on appearance of the skin and patient history

– Drainage from an abscess or weeping wound associated with cellulitis should be sent for culture and sensitivities.

– Material from needle aspiration of inflamed skin or skin biopsy can be cultured in cases of cellulitis without purulence, abscess, or a necrotic

– Indications for blood cultures include significant fever and chills, severe immunocompromise, periorbital cellulitis, and cellulitis superimposed on lymphedema.

• A polymorphonuclear leukocytosis is often present with cellulitis; a complete blood cell count and differential may help gauge the severity of infection and the hematologic response.

Goals of therapy

DM1. Eliminate symptoms

related to hyperglycemia2. Reduce or eliminate the

long-term microvascular and macrovascular complications of DM

3. Allow the patient to achieve as normal a lifestyle as possible

Cellulits• treat the affected area and

any underlying conditions that would increase the chance of cellulitis returning

Harrisons 17th ed http://skin.emedtv.com/cellulitis/cellulitis-treatment.html

• oral therapy for mild infections

• intravenous therapy for severe infections – achievement of high

drug levels with rapid delivery.

Therapeutic approach

Non-pharmacologic• Rest affected area, elevate

the area of the body involved (this will help decrease swelling and relieve discomfort)

• Clean wound site

PharmacologicCellulitis in a DM patient• Early or Mild disease

– Augmentin 875 mg PO bid– Second Generation

Cephalosporin (cefoxitin, cefacor, cefuroxime)

– Third Generation Cephalosporin (cefotaxime, ceftazidime,m ceftriaxone, cefixime)

• Severe disease – Imipenem-Cilastatin (Primaxin)– Meropenem– Trovafloxacin IV

www.emedicinehealth.com/cellulitis www.fpnotebook.com/DER/Endo/SknInfctnsInDbtsMlts.htm

Management: Facial Cellulitis

Mild to Moderate Infection – Augmentin 875 mg PO bid – Cefazolin (Ancef) 1 g IV every 8 hours

Severe Infection – Nafcillin 2 g IV every 4 hours – Oxacillin 2 g IV every 4 hours – Vancomycin 1.0-1.5 g IV qd– Linezolid

• In a study by Kohno et al, Linezolid was compared with vancomycin; both had a comparable clinical success rate in the treatment of SSTi.

• In the lab tests done after the end of the treatment and during follow up, Linezolid had a better microbial eradication rate. Also, for the adverse effects (hematologic), linezolid was safer.

• S. Kohno1, K. Yamaguchi2, et al. Linezolid versus vancomycin for the treatment of infections caused by methicillin-resistant. Staphylococcus aureus in Japan. Journal of Antimicrobial Chemotherapy 2007 60(6):1361-1369; doi:10.1093/jac/dkm369

• http://jac.oxfordjournals.org/cgi/content/full/60/6/1361

• Vancomycin is distributed widely to various tissues and body fluids, however in patient with DM, its penetration in soft tissues is greatly impaired

• AUSkhirtladze K; Hutschala D; Fleck T; Thalhammer F; Ehrlich M; Vukovich T; Muller M; Tschernko. Impaired target site penetration of vancomycin in diabetic patients following cardiac surgery. EM SOAntimicrob Agents Chemother. 2006 Apr;50(4):1372-5.

• http://www.uptodate.com/patients/content/abstract.do;jsessionid=F7D4E0E035890469420995852E59E973.1102?topicKey=~aa8X1QFoqoQSyT&refNum=8

• http://www.uptodate.com/patients/content/topic.do?topicKey=~aa8X1QFoqoQSyT

• In a study by Stein et al, Linezolid was effective in the treatment of Staphylococcus aureus in diabetic patients

• G E. Stein1,* S Schooley1, et al. Linezolid tissue penetration and serum activity against strains of methicillin-resistant Staphylococcus aureus with reduced vancomycin susceptibility in diabetic patients with foot infections. Journal of Antimicrobial Chemotherapy, doi:10.1093/jac/dkm271

• http://jac.oxfordjournals.org/cgi/content/full/dkm271v1

Duration of therapy

• response to drug therapy• follow-up is of utmost importance• 10 to 14 days of antibiotic therapy

– Absence of response/worsening after five days of the initiation of therapy prompts a change in the antibiotic regimen or other investigations to verify the diagnosis

Preventing a recurrence of cellulitis

• Cellulitis tends to recur in people with certain medical conditions that can lead to skin breakdown, such as edema (fluid buildup), fungal or bacterial infections, diabetes, or peripheral arterial disease. – edema, support stockings and good skin hygiene may

reduce or eliminate recurrence of cellulitis.– fungal infections, regular use of antifungal medicines may

help reduce recurrent cellulitis. – high risk for recurring cellulitis, (when with open wound or

cut) taking preventive antibiotics may help• http://www.everettclinic.com/kbase/topic/mini/tr5105/treatmnt.htm

• Vincent Ki, MD and Coleman Rotstein, MD. Bacterial skin and soft tissue infections in adults: A review of their epidemiology, pathogenesis, diagnosis, treatment and site of care. Can J Infect Dis Med Microbiol. 2008 March; 19(2): 173-184.

DIABETES MELLITUS

DIAGNOSTIC TEST FOR DIABETES MELLITUS

• Diabetes mellitus is characterized by recurrent or persistent hyperglycemia, and is diagnosed by demonstrating any one of the following:– Fasting plasma glucose level at or above

126 mg/dL (7.0 mmol/L).– Plasma glucose at or above 200 mg/dL

(11.1 mmol/L) two hours after a 75 g oral glucose load as in a glucose tolerance test.

– Symptoms of hyperglycemia and plasma glucose at or above 200 mg/dL (11.1 mmol/L).

Fasting blood glucose test • The most common test for diagnosis of diabetes.

• blood glucose levels are checked after fasting for between 12 and 14 hours.

• Patients with fasting glucose levels from 100 to 125 mg/dL (6.1 and 7.0 mmol/L) are considered to have impaired fasting glucose

• Patients with diabetes may be asked to delay their diabetes medication or insulin dose until the test is completed.

http://ovennewyork.com/diabetes-mellitus-laboratory-tests-or-diagnostic-tests.html

Random blood glucose test

• blood glucose levels are checked at various times during the day, and it doesn’t matter when you last ate.

• Blood glucose levels tend to stay constant in a person who doesn’t have diabetes.

http://ovennewyork.com/diabetes-mellitus-laboratory-tests-or-diagnostic-tests.html

Oral glucose tolerance test (OGTT) • FBS is obtained before the ingestion of a 50- to 200-g

glucose load (usual amount is 75 g),

• blood samples are drawn at ½, 1, 2, and 3 hours (may be 4- or 5-hour sampling).

• Blood samples are checked at regular intervals for two hours.

• Glucose tolerance tests are used when the results of the fasting blood glucose are borderline.

http://ovennewyork.com/diabetes-mellitus-laboratory-tests-or-diagnostic-tests.html

• They are also used to diagnose diabetes in pregnancy (gestational diabetes).

• NORMAL: the results of the glucose tolerance test will show that their blood sugar levels fall within the normal range

• Patients with plasma glucose at or above 140 mg/dL or 7.8 mmol/L, but not over 200, two hours after a 75 g oral glucose load are considered to have impaired glucose tolerance.

Glycated Hemoglobin (Glycohemoglobin, HbA1c) for

Diabetes Mellitus

• Measures glycemic control over a 60- to 120-day period by measuring the irreversible reaction of glucose to hemoglobin through freely permeable erythrocytes during their 120-day lifecycle.

• While not used for diagnosis, an elevated level of glucose irreversibly bound to hemoglobin of 6.0% or higher (the 2003 revised U.S. standard) is considered abnormal by most labs

http://ovennewyork.com/diabetes-mellitus-laboratory-tests-or-diagnostic-tests.html

C-Peptide Assay (Connecting Peptide Assay) for Diabetes Mellitus

• Cleaved from the proinsulin molecule during its conversion to insulin, C-peptide acts as a marker for endogenous insulin production.

http://ovennewyork.com/diabetes-mellitus-laboratory-tests-or-diagnostic-tests.html

Fructosamine Assay for Diabetes Mellitus

• Glycated protein with a much shorter half-life than glycated hemoglobin, reflecting control over a shorter period, approximately 14 to 21 days.

• May be advantageous in patients with hemoglobin variants that interfere with the accuracy of glycated hemoglobin tests.

http://ovennewyork.com/diabetes-mellitus-laboratory-tests-or-diagnostic-tests.html

GOALS OF THERAPY

• Eliminate symptoms related to hyperglycemia• Reduce or eliminate the long-term

microvascular and macrovascular complications of DM

• Allow the patient to achieve as normal a lifestyle as possible

Harrison’s 17th Edition

Patient education about DM, nutrition and exercise

• Patient with DM should receive education about:– Nutrition– Exercise– Care of diabetes during illness– Medications to lower the plasma glucose

• Continuing process with regular visits for reinforcement

• Diabetes self-management education (DSME) Harrison’s 17th Edition

Diabetes education• Self-monitoring of blood glucose• Urine ketone monitoring (type 1)• Insulin administration• Guidelines for diabetes management during

illness• Management of hypoglycemia• Foot and skin care• DM management before, during and after

exercise• Risk-factor-modifying activities

Harrison’s 17th Edition

Nutrition

• Medical Nutrition Therapy (MNT)– Modest caloric reduction– Reduced fat intake– Increased physical activity– Reduction of hyperlipidemia and hypertension

Harrison’s 17th Edition

Exercise• CV risk reduction• Reduced BP• Maintenance of muscle mass• Reduction in body fat and weight loss• Lowering plasma glucose• Increasing insulin sensitivity

*ADA recommends 150 min/week (distributed over at least 3 days)

Harrison’s 17th Edition

Monitoring the level of glyceminc control

• Plasma glucose measurements by the patient and assessment of long-term control by the physician

• Measurement of A1C and review of the patient’s self-measurement of plasma glucose

Harrison’s 17th Edition

Self-monitoring of Blood Glucose

• Standard of care in diabetes management and allows the patient to monitor his/her blood glucose at any time

• Glucose monitors can rapidly and accurately measure glucose in small amounts of blood (3-10 µL obtained from the fingertip*individuals with type 2 DM who are taking insulin

should utilize SMBG more frequently than than those on oral agents

Harrison’s 17th Edition

Assessment of Long-term Glycemic Control

• Measurement of glycated hemoglobin• Plasma glucose is consistently elevated =

increase in nonenzymatic glycation of hemoglobin

• Reflects the glycemic history over the previous 2-3 months

Harrison’s 17th Edition