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Etiology

What is an abscess?

Local bacterial infection

  • polymicrobic in nature
  • Staphylococci (especially S. aureus) and streptococci are the most common pathogens
  • a purulent collection of fluid separated from surrounding tissue by a wall consisting of inflammatory cells and adjacent organs

  • usually contains necrotic debris, bacteria, and

inflammatory cells

  • gram-negative bacilli and/or anaerobes occur in approximately 50% of cases

Dipiro, Pharmacotherapy: A Pathophysiologic Approach

Dipiro, Pharmacotherapy: A Pathophysiologic Approach

Diabetic Foot Abscess

Diabetic foot abscess

Pathophysiology

Treatment

Antimicrobial therapy

Wound

care

(a)peripheral neuropathy

  • diminished sensory perception
  • damaged sympathetic nerve supply

Co-amoxiclav IV intermittent 1.2g, Q8H from Day 1 to Day 5

MOA: inhibit synthesis of the bacterial peptidoglycan cell wall; bactericidal

Change dressing daily and pack with ribbon gauze

Why Co-amoxiclav is given

  • diabetic foot infections are polymicrobial in nature
  • broad-spectrum antibiotic (S.aureus, Strep, gram -ve, anaerobes)

Kept NBM

  • Sodium chloride 0.9% infusion

Surgical

(b) angiopathy and ischemia

  • blood vessels function abnormally
  • undergo structural changes

D3- Incision and drainage of abscess

Tissue culture taken

Continued on IV Augmentin after incision

Augmentin was oralised on discharge on Day 5 x 1/52 til Ortho TCU

Total antibiotics duration: 12 days

Wound inspection:

clean

minimal slough

no surrounding erythema

Alert well

H S1S2

L clear

A soft

(c) immunological defects

  • impaired phagocytosis and intracellular microbicidal function

Pain

DM, HTN, HLD

12 May A&E

SBMY 41 y.o Male Malay

CC: Swelling of left plantar.

A/w pain. Has to limp to walk.

PE: T 35.8 HR 109 RR 20 BP 112/72

Alert well

H S1S2

L Clear

A soft

Left plantar of foot boggy warm abscess, tender

Pain Management

T2DM

Objective: HbA1c 11.4%, high Glucose POCT values

HPI: L foot sole swelling and pain since 30 Apr 14

History of barefoot walk in Mecca.

Started on sole of left foot and progressed.

Seen by KTPH and treated with analgesics with no improvement.

No fever, SOB, palpitations, chest pain.

No URTI or UTI symptoms

Goals: Attain normoglycemia as close as possible

Delay onset & progression of neuropathy, retinopathy, nephropathy complications

Improve quality and quantity of life

Facilitate wound healing on his foot

Subjective: Complained of sharp pain, worse upon movement. Pain score

Post-op (D4): Metformin 500mg BD + Glipizide 5mg BD

Provide subjective pain relief, minimize the risk for adverse effects, allow patient to return to normal daily activities asap

Metformin:

Target goals

Started on 2 agents

Rx from 2010

Aspirin 100mg OM

Dipyridamole 150mg TDS

Famotidine 40mg OM

Metformin 500mg BD

Simvastatin 10mg ON

Atacand 16mg OM

Patients with elevated plasma glucose >16.7 – 19.4mmol/L or HbA1c ≥ 10- 12%, insulin therapy should be strongly considered from the outset

HbA1c <7% FPG 4 -7 mmol/L PPG <10mmol/L

history of non-compliance to medications

Analgesics given: Paracetamol PO 1g QDS PRN Tramadol PO 50mg TDS PRN Pethidine IM 25mg

Monitoring

Antiplatelet Agent: Aspirin 100mg OM

PMH: Obstructive sleep apnea syndrome s/p ENT surgery and weight loss

TIA

DM HTN HLD, non-compliance to treatment

Famotidine 20mg OM

Non- pharmacological

Weight reduction

Alternative analgesic: NSAIDs (+) anti-inflammatory (+)reduce N/V and sedation from opioids

Quit smoking

Physical exercise

(-) increased risk of CV events (history of TIA)

SH: Smoker: 20 cigarettes/day x 20 yrs

Non-drinker

Avoid the use of NSAIDs when possible if an alternative can be employed

Naproxen is the safest choice if NSAIDs is to be used

Post-op (D5): Pethidine IM 25mg

(+)for moderate - severe pain

(-) IM injection (painful)

(-) nausea, vomitting

(-) CNS excitation ( tremors, agitation, muscle twitches, seizures)

Radiology:

Medications: Nil current medications

Rx from 2010 - Aspirin 100mg OM

Dipyridamole 150mg TDS

Famotidine 40mg OM

Metformin 500mg BD

Simvastatin 10mg ON

Atacand 16mg OM ( GP Rx from 2012)

Monitor for : Pain relief, respiratory and mental status, excessive sedation, seizures,

respiratory depression, N/V

HTN

Objective: elevated BP (BP chart)

restart his medications

Goals: Reduce risk of CVD

AHA, Treatment of Hypertension in the Prevention and Management of Ischemic Heart Disease 2007

BP < 140/90 JNC8

BP <130/80 JNC7

Post-op: Losartan 25mg BD

Non-pharmacological: Weight reduction

Adopt DASH eating plan

Physical exercise

Quit smoking

Thank You!

Discharge medications and appointment

References

1. ADA, Standards of Medical Care in Diabetes, 2014

2.ADA, Management of Hyperglycemia in Type 2 Diabetes, 2012

3.Stone NJ, et al 2013 ACC/AHA Blood Cholesterol Guideline

4.Dipiro, Pharmacotherapy -A Pathophysiologic Approach

5.Lexi-Comp online, Lexi-Drugs Multinational, Acute Postoperative Pain; accessed May 20, 2014

6. UpToDate

7. AHA, Use of Nonsteroidal Antiinflammatory Drugs, 2007.

HLD

Objective: TC 6.25 mmol/L TG 1.28 mmol/L

LDL 4.12 mmol/L HDL 1.55 mmol/L

Goal: Reduce ASCVD risk

ATPIII LDL <1.8 to 2.6 (DM, CKD, Clinical ASCVD)

TG <1.7

HDL >1.6

TC <5.2

Check fasting lipids panel

LFT (ALT AST)

CK

ALT: 16 (6 -66 U/L)

AST: 18 (12-42 U/L)

CK: 106 ( 56 -336 U/L)

Post-op (D4): Simvastatin 20mg ON

Monitoring

LFTs should be performed before starting statin therapy, and "as clinically indicated thereafter"

Diagnosis

Left plantar diabetic foot abscess

Uncontrolled DM HTN HLD, non compliance to medication

High Intensity Therapy

Hx of ASCVD (TIA)

Non-pharmacological

Weight reduction BMI 29.1

Diet modification

Physical exercise

Quit smoking

ACE/ARB: 1st line agent in patients with DM & CKD

Class I ACC/AHA recommendation

Check renal function, K+

Metformin, if not contraindicated and if tolerated, is the preferred initial agent in T2DM

(ADA, Standards of Medical care in Diabetes 2014)

Lab:

Use aspirin therapy ( 75- 162mg/day) as a secondary prevention strategy in those with diabetes with a history of CVD

(Evidence A, ADA, Standards of Medical Care in Diabetes 2014)

renal function: CrCl 171 ml/min

Check for renal function, platelet count

(CrCl 171ml/min) (Plt 311)

Peri-op: Paracetamol PO 1g QDS PRN Tramadol PO 50mg TDS PRN

AHA , Use of Nonsteroidal Antiflammatory Drugs, 2007

  • cultures should be obtained from wound base,

from the expressed pus

(+) useful for DM with proteinuria

Urine protein/Creatinine ratio 0.2 (normal <0.2 nephrotic range >3.0)

HbA1c Q3 month. If stable, Q6 month or 1yr

Lipid panel Q3 -6 month if unstable, annually if stable

Albuminuria Q6 month or annually

Eye Q6 month if unstable, annually if stable

Blood pressure Q routine visit

Foot every day, annually by podiatrist

Monitor: renal function, K+, dry cough & angioedema

(less likely vs ACE inhibitors)

  • wound swab not clinically useful

– Follow up fasting lipids panel in 4-12 weeks after initiation or dose adjustment

– If therapeutic, follow up 3-12 months thereafter

– If not therapeutic, follow up in 4-12 weeks again for adherence and tolerability as needed

2013 ACC/AHA Blood Cholesterol Guideline

high baseline HbA1c ≥9% have low probability of achieving target with monotherapy

it is justified to start directly with a combination of 2 non-insulin agents or with insulin itself

ADA, Managementof Hyperglycemia in Type 2 Diabetes, 2012

Prevent target organ damage

(stroke, MI, CHF, proteinuira, retinopathy)

Off-loading the pressure on diabetic foot wound

  • rest
  • Darco shoes: to relieve pressure at the foot while walking

Avoid use in renal impairment

(American Pain Society)

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