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ID Exam 4 D
Beck DFI (Diabetic foot infection)
| Question | Answer |
|---|---|
| Diabetic foot infections are? | neuropathic damage and compromised blood flow leads to breakdown of skin that allows pathogens to enter |
| Severity of DFI includes: | Clinical classifcation of infections, IWGDF/IDSA classification, and Infection severity |
| For pt w/ no systemic or local symptoms or sings of infection, what is the IWGDF/IDSA classification? infection severity? | 1; Not infected |
| For a pt that has an infection present (defined by >/= 2 of the following) ____(5 points)____ would receive a IWGDF/IDSA classification of 2 and be considered MILD for infection severity | local swelling or induration; Erythema > 0.5 cm but <2 cm around wound; local tenderness or pain; local warmth; purulent discharge **caveat--> and no other cause of inflammatory response of the skin (trauma, gout, acute charcot, neuroarthroplasty, fracture, thrombosis, or venous stasis |
| For a pt with an infection w/ no systemic manifestations and involving: ____(2 points)______ would get a IWGDF/IDSA classification of 3 and be considered MODERATE for infection severity | Erythema extending >/= 2 cm from wound margin AND/OR Tissue deeper than skin and SQ tissues (tendon, muscle, joint, and bone) |
| For a pt with an infection involving the BONE (OSTEOMYELITIS) what is the IWGDF/IDSA classification? What is the level of infection severity? | ADD "O" for osteo (??? perhaps 3 and a MODERATE) |
| For a pt with any foot infection w/ associated systemic manifestations (SIRS- as manifested by >/= 2 of the following ____4 points_____ would get a classification of 4 and a SEVERE for infection severity | -temperature > 38 C or < 36 C; HR > 90 BPM; RR >20 bpm or PaCO2 < 32 mmHg; WBC >12k or <4K or >10% immature (band) form |
| Severity of DFI--> triage to consider hospitalization--> guidelines state ________ (consider hospitalization if they have relevant comorbidities like PAD. For ________ consider hospitalization | moderate; severe |
| ________ does not equal an automatic hospital visit (*unless you meet criteria for emergent surgery) | Osteomyelitis |
| Consider hospital if pt: | Needs IV abx initially; Substantial soft tissue infection; Requires special diagnostic test (i.e. MRI); Requires urgent surgical treatment |
| What are the "DOs" for DFI in terms of diagnostic tools? | Obtain culture from almost all infected wounds; Cleanse and debride wound before obtaining culture; obtain cultures by SCRAPING with sterile tools or biopsy from the base of debrided ulcer; Aspirate any purulent secretions with sterile needles and syringe; consider getting bone culture rather than soft tissue sample for pts w/ suspected osteomyelitis (intraoperatively or percutaneously) |
| What are the "DO NOTs" for DFI in terms of diagnostic tools? | Use foot temperature or quantitative microbial assay; culture uninfected lesion for the purpose of epidemiological purposes; obtain specimen without cleansing or debriding the wound (dont want to culture normal flora); Obtain a specimen by swabbing the wound or wound drainage |
| When determining the probable pathogens, its hard to pin on a mono bacteria, since its usually _____________ | POLYMICROBIAL |
| What are my probable pathogens for those that are aerobic and are gram (+)? | S. aureus (including MRSA); Group A. Strep; S. Epidermis |
| What are my probable pathogens for those that are aerobic and are gram (-)? | E. Coli, Klebsiella pneumonaie, Proteus mirabilis, Enterobacter cloacae; Pseudomonas aeruginosa (??) |
| What are my probable pathogens for those that are anaerobic and are gram (+)? | PEPTOSTREPTOCOCCUS; CLOSTRIDIUM PERFRINGES |
| What are my probable pathogens for those that are anaerobic and are gram (-)? | BACTERIOIDES FRAGILIS |
| OLD guidelines for MILD DFI probable pathogens? (1) OLD guidelines for MODERATE DFI probable pathogens? (2) OLD guidelines for SEVERE DFI probable pathogens? (3) | 1. S. aureus (MSSA v MRSA); Strep species 2. S. aureus, Strep species, Enterobacteriacea (E.coli, Klebs, proteus, Anaerobes??) 3. MRSA, Enterobacteriaceae, Anaerobes |
| Changes in 2023 guidelines----> DO NOT EMPIRICALLY TARGET __________ ________ in TEMPERATE climates | Pseudomonas aeruginosa |
| Probable pathogens for Moderate to Severe DFI: It pt has no complicating features, then the usual pathogens are _____ +/- ____ | GPC +/- GNR (Staphylococci and resistant + gram (-) rods) |
| Probable pathogens for Moderate to Severe DFI: If pt had recent abx exposure, then the usual pathogens are _____ +/- ____ | GPC +/- GNR (Staphylococci and resistant + gram (-) rods) |
| Probable pathogens for Moderate to Severe DFI: If pt has macerated ulcer or lives in warm climate, then the usual pathogens are: | GNR, including Pseudomonas species |
| Macerated means? | soggy feet |
| So it pt lives in a tropical climate or macerated ulcer we look for agents that have ______ coverage | PsA (Pseudomonas) |
| Probable pathogens for Moderate to Severe DFI: if a pt has ischemic limb/necrosis/gas forming, then the usual pathogens are? | GPC +/- GNR (Staphylococci and resistant + gram (-) rods) +/- STRICT anaerobes |
| Definitions: Ischemic means? STRICT anaerobes? | Ischemic means no blood flow or lack of O2 so pt prbably has PAD (peripheral artery disease); Examples of Strict anaerobes would be Pepto, Strepto, clostridium, Bacteriodes Fragilis. B/c we know the anaerobes can potentially be there (no blood flow therefore you don't have oxygenated blood, allows for environment for anaerobes to grow) |
| Probable pathogens for Moderate to Severe DFI: If a pt has risk factors for Streptococci. then the usual pathogen would be? | ESBL |
| What questions should a clinician ask prior to starting abx? | Is there evidence of clinical infection? Is there a high risk for MRSA? Has pt received abx in the LAST MONTH? Are there PsA risk factors? What is the severity of the infection? |
| In a MILD case, HIGH RISK for MRSA (DFI) should be considered given if a pt meets risk factors of: | Prior hospitalization of MRSA infection OR colonization in the last year (*would need to cover empirically) |
| What factors are needed to be considered for Empiric MRSA coverage (DFI)? | MODERATE MRSA risk factors: prolonged hospitalization, ICU admission, Recent hospitalization, Invasive procedures, HIV infection, Admission to nursing home, Open wounds, dialysis, Discharged w/ long term central venous access |
| Pt comes in with a mild severity of infection and this pt has no complicating risk factors and usual pathogen is GPC (gram + cocci (staphylococci and streptococci)--> what are the potential tx regimens, Pick 1 unless noted: | Antistaphylococcal PCN; 1st gen cephalosporin |
| Pt comes in with a mild severity of infection and this pt has Beta-lactam allergy or intolerance and the usual pathogen is GPC (gram + cocci (staphylococci and streptococci)--> what are the potential tx regimens, Pick 1 unless noted: | Clindamycin; FQ (Levo, or Moxi); TMP-SMX; Doxycycline |
| Pt comes in with a mild severity of infection and this pt had recent abx exposure and the usual pathogen is GPC + GNR gram + cocci (staphylococci and streptococci) + gram - rod)--> what are the potential tx regimens, Pick 1 unless noted: | Beta-lactam + Beta lactamase inhibitor (amox-clav OR amp-sul); Levo OR MOXI; TMP-SMX |
| Pt comes in with a mild severity of infection and this pt has HIGH RISK FOR MRSA and the usual pathogen is MRSA--> what are the potential tx regimens, Pick 1 unless noted: | Linezolid; TMP-SMX; Clindamycin; doxycycline |
| Pt comes in with MODERATE or SEVERE (severity of infection) and this pt has NO complicating features and the usual pathogens are GPC +/- GNR (Staphylococci and resistant + gram (-) rods)--> what is the potential regimen (Pick 1 unless noted) | Beta-lactam + Beta lactamase inhibitor (amox-clav, or amp-sul); 2nd or 3rd gen cephalosporin (Cefuroxime, cefotaxime, ceftriaxone) |
| Pt comes in with MODERATE or SEVERE (severity of infection) and this pt had a recent abx exposure and the usual pathogens are GPC +/- GNR (Staphylococci and resistant + gram (-) rods)--> what is the potential regimen (Pick 1 unless noted) | Beta-lactam + Beta lactamase inhibitor (amox-clav, or amp-sul); 2nd or 3rd gen cephalosporin (Cefuroxime, cefotaxime, ceftriaxone); ERTAPENEM but depends on prior therapy and if resistance occurred |
| Pt comes in with MODERATE or SEVERE (severity of infection) and this pt has Macerated ulcer or lives in a tropical/warm climate and the usual pathogens are GNR, including PsA species--> what is the potential regimen (Pick 1 unless noted) | Beta-lactam + Beta lactamase inhibitor (Pip-tazo); antistaph PCN + Ceftazidime (covers PsA) OR Ciprofloxacin; other options are Meropenem or Imipenem |
| Pt comes in with MODERATE or SEVERE (severity of infection) and this pt has Ischemic limb/necrosis/gas forming and the usual pathogens are GPC +/- GNR (Staphylococci and resistant + gram (-) rods) +/- STRICT anaerobes--> what is the potential regimen (Pick 1 unless noted) | Beta-lactam + beta lactamase inhibitor (amox-clav or amp-sul or pip-tazo); Carbapenems; 2nd or 3rd gen cephalosporin + Clinda or Metronidazole |
| Pt comes in with MODERATE or SEVERE (severity of infection) and this pt has MRSA risk factors and the usual pathogen is MRSA--> what is the potential regimen (Pick 1 unless noted) | Consider adding or substituting with glycopeptides, Linezolid, daptomycin; TMP-SMX; Doxycycline |
| Pt comes in with MODERATE or SEVERE (severity of infection) and this pt has risk factors for resistant GNR (Gram-negative rod)--> what is the potential regimen (Pick 1 unless noted) | Carbapenems; Ciprofloxacin; Amikacin; Collistin *remember there are no ORAL carbapenems |
| Stream-lining therapy DFI--> wait for cultures with _________ return; De-escalate appropriately to most narrow but susceptible; If started on IV abx--> use same criteria from CAP of when to determine to consider changing from ____ to ____ abx | susceptibilities; IV to PO |
| Duration of therapy (DFI): skin and soft tissue Class 2 (mild): route of abx? duration? | PO; 1-2 weeks |
| Duration of therapy (DFI): skin and soft tissue Class 3 or 4 (moderate-severe) route of abx? duration? | PO/ initially IV; 2-4 weeks (no bone or joint involvement) |
| Duration of therapy (DFI): bone or joint: Resected (taken bone out): route of abx? duration? | PO/initially IV; 2-5 days |
| Duration of therapy (DFI): bone or joint: Debrided (soft tissue infection): route of abx? duration? | PO/initially IV; 1-2 weeks |
| Duration of therapy (DFI): bone or joint: Positive culture or histology of bone margins after bone resection: route of abx? duration? | PO/initially IV; 3 weeks |
| Duration of therapy (DFI): bone or Joint: NO surgery or DEAD bone: route of abx? duration? | PO/initially IV; 6 weeks |
| In debrided only cuts away _____ ________ that was infected | soft tissue |
| Positive culture or histology of bone margins refers to? | Pathology will look at it and determine if bacteria are growing. Histology shows that were you chopped the bone, if you find "Clean Margins" (meaning you got ahead of the infection) |
| Culturing done and debrided soft tissue is all about _____ ______. if your bone is infected, you need to get rid of the infected bone. | source control |
| Pts can refuse to getting surgery and be left with only the option of? | antibiotics for 6 weeks |
| Summary: Non-purulent SSTI is most likely to be caused by _______ species more than _________ species | Streptococcus; Staphylococcus |
| Purulent SSTI is most likely to be caused by _______ species | Staphylococcus *assess if your pt has risk factors for MRSA before starting empiric tx; get cultures and streamline therapy |
| Diabetic foot infections are usually __________ | POLYMICROBIAL *Make sure your empiric therapy cover the most likely pathogens dependent on other pt features; Streamline your tx after cultures |
Created by:
Xander635
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