The more read a more ignorant you feel, but gains in experience (security, see evolution of various treatments, arise and seeks to answer questions, they test new methodologies, etc etc) .
As you have posted in the comments of previous posts, in which Javier appreciate the information provided, it appears that when you think you know something, it's because you have not read what contradicts or as recent.
I think it's time information that the blog of a leap in quality and that information is published on quality, based on evidence, even if it takes longer to prepare entries.
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In today's post I talk about antibacterial treatment in the diabetic foot.
As we all know, we can prescribe, recognized by law and all liability involves an obligation.
the last 2 decades, there has been a considerable increase in methicillin-resistant Staphylococcus aureus due to misuse of antimicrobials.
Today encourages rational use of these medications, but many times we can see that for good measure, we prescription defensive guns kill flies because if we have questions and truthful security ....... ..
because I speak of Staphylococcus aureus is the microorganism present in the flora of the skin and has been isolated in cultures at a higher rate in infections and foot ulcers.
Moreover we have the diabetes, which is more harmful to health when coupled with obesity, "Diabesity" as Luke said Ciccinelli during Gijón Dermatology.
Hyperglycemia maintained causes damage to motor nerves, sensory and sist. autonomic nervous.
- Damage motoneurons affecting the intrinsic muscles of the foot, which can lead to foot deformities that contribute to increased local pressure in the tissues and bones resulting in repetitive injuries can lead to ulcers .
- When the skin is broken, allowing the passage of colonies into the body. Our defenses are impaired due to involvement in the autonomic nervous system decreases the blood supply to the area. The secretions of sweat are also welcome producing dryness, breakage of the skin which causes increased susceptibility to infections.
- Damage of sensory neurons causes a loss of sensory protection that tells us when we are injured or damaged.
On the other hand we have vascular abnormalities: macroangiopathy and microangiopathy.
A diabetic vascular aggravated his picture when combined with dyslipidemia, smoking, hypertension, etc because it increases the risk of atherosclerosis (most common form of arteriosclerosis. There is a thickening of the vessels and decreased light).
The worse the artery, increased risk of thrombosis, ischemia and consequently amputation.
Other factors that enhance infection in diabetic patients are usually:
- lower limb edema
- Angiopathy
- Hyperglycemia related to the deterioration of the immune system.
The role of leukocytes and cell-mediated immunity is compromised. Correct
hyperglycemia has been shown to improve chemotaxis (movement that made the cells, in this case defensive, according to certain chemicals in the environment, in this case, chemical signals sent by macrophages presenting leukocytes, the leukocytes to receive these signals go to the tissues indicated to combat pathogens).
Several antibacterial agents have been shown to have immunomodulatory effects in addition to their properties to eliminate bacteria.
The microorganisms that cause most big infections are Staphylococcus aureus and to a lesser extent B-hemolytic Streptococcus can also cause other infections such as Streptococcus agalactiae although more in patients with severe immunodeficiency.
When an ulcer is chronic, it creates a polymicrobial flora in which there are several causes infection. Usually gram - as Enterobacteriaceae, Pseudomonas aeruginosa and anaerobes.
anaerobic microorganisms often occur in patients with ischemia or gangrene.
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------------------ Before the use of antibacterials in patients with diabetes should be a quick summary of existing antibacterial more frequent and efficient use of these:
must always start by the narrower spectrum antibiotic possible, it is clear that it will go based on age, type of infection, etc.
First penicillins:
- The Cloxacillin be the first choice in treating mild to moderate bacterial infections. This antibacterial is effective against methicillin-sensitive Staphylococcus aureus and other Gram + and some gram -.
- Amoxicillin is a broader spectrum antibiotic that apart from the above is more effective against some gram -
- Amoxicillin - clavulanate is prescribed as the clavulanic an inhibitor of the b-lactamase, an enzyme that confers resistance to some bacteria.
Following the B-lactam antibiotics have the Cephalosporins. There are several generations, the first generation have a very similar spectrum to cloxacillin.
There
broader spectrum penicillins (spread spectrum) and piperacillin, as well as inhibitors such as tazobactan but are usually suitable for hospital use.
other hand there is another group of quinolones is also according to the present generation more or less spectrum. They are very active against gram - (Pseudomonas, Enterobacteriaceae). Ciprofloxacin is the most common.
A broad-spectrum quinolone would Levofloxacin is active against gram + and -.
The problem of quinolones they can cause rupture of the Achilles tendon, so that eye at the time of giving it to people who play sports or have a history that discouraged.
For those allergic to penicillin, quinolones besides, we have other families of antibacterials such as macrolides, clindacimina, etc.
Clindamycin and erythromycin are treatment of choice in patients allergic to penicillin with gram + infections. There
large number and variety of antibacterial but for our use podiatry in the day with those we cover the majority.
It is worth mentioning that with a diabetic ulcer should be performed culture and sensitivity testing and in the meantime seek to establish empirical treatment.
(For visually see a comprehensive list of antibacterials can see the link below. see page ) ------------------
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After this summary .........
The problem of diabetes and infection is not only the immunological or predisposing to infection, but also the antibacterial action of the drug used.
In diabetic patients, according to the antibacterial provided (via both oral and IV) have a pharmacodynamics and pharmacokinetics in the case of these patients will be altered.
In studies, a high-dose intravenous administration (600-900 mg) of clindamycin, it was found that the concentration in tissues was minimal.
oral treatment also has been shown that the alteration reduced by 26% the absorption of ampicillin treatment in patients with diabetes compared with non-diabetics.
Therefore, we must know the tissue concentration of each antibiotic that we use for infections in diabetics.
The treatments used in these patients and having strengths are varied:
- Vancomycin in diabetics have a lower concentration in tissues and blood plasma, and in recent years have met with resistance.
- The Linezolid is a treatment of choice in complicated skin infections in both diabetic and nondiabetic patients. Also in osteomyelitis infections.
The Linezolid is active against MRSA and has good tissue penetration.
In patients with poor blood supply to the foot, also gets a more than acceptable concentration in serum and tissues in the area of \u200b\u200binfection, as well as in the perinecrotic ulcer.
B-lactams (penicillins, cephalosporins and carbapenems): useful for the treatment of mild to moderate infections of the foot.
- cephalosporins 1 generation are effective against gram +, active against some gram-
(Cefazolin, cephalexin)
2 nd generation, are more effective than before against gram - and some are covered against some anaerobes.
3 rd and 4 th generation: more effective against gram - than the previous generation, with activity against Pseudomonas aeruginosa.
5th generation: Ceftobiprole: active against MRSA.
- Piperacillin-Tazobactam: B-lactam inhibits the B-lactamase combined with a broad spectrum of antibacterial activity against most gram + and gram-aerobic and anaerobic. MRSA are resistant to this drug is administered intravenously.
Widely used in moderate to severe infections in diabetic patients.
- Carbapenems: Imipenem-Cilastatin, Meropenem, Ertapenem. The latter is approved for use in the treatment of infections of the skin with moderate to severe diabetic foot without osteomyelitis.
are broad spectrum antibacterial activity against gram + and gram-but with little activity against MRSA and enterococci.
Tetracyclines
Tetracycline and Doxycycline are antibacterial bacteriostatic effect against gram + and gram-Doxycycline has been used effectively in the treatment of MRSA infections of skin and soft tissue.
Fluoroquinolones
- Ciprofloxacin, Levofloxacin and Moxifloxacin are drugs belonging to each generation.
The Ciprofloxacin is effective against gram-and has been used as first-line treatment against pseudomonas aeruginosa, but is also used in infections of the diabetic foot caused by various microorganisms, associated with clindamycin (active gram +)
have been reported cases of rupture of the Achilles tendon and tenosynovitis with the use of fluoroquinolones and cause hypoglycemia in some patients.
- Levofloxacin and moxifloxacin have better coverage against gram + than ciprofloxacin and are more suitable for use in complicated skin infections and soft tissue.
- Moxifloxacin also provides coverage against Gram-anaerobic and is considered as effective as extended-spectrum penicillins for treatment skin and soft tissue.
The Levofloxacin has excellent tissue penetration reaching high concentrations in serum and lesions (diabetic patients with ulcers).
There are many more antibacterial but basically these are the most commonly used in diabetic patients to treat infections of the skin and soft tissue from the mildest to the most severe. Also synergistic partnerships are usually made when a moderate to severe polymicrobial infection.
The treatment of diabetic foot infections is not only to the drug but a good cleaning of necrotic tissue, drainage of abscesses, downloads, clearing the area, etc are as important as the choice of drug, on the other hand, we must be aware that it is very useful and necessary in most cases a culture, with subsequent susceptibility to perform a more causative and to use a narrower spectrum antibiotic in order to preserve the broad spectrum or spectrum extended to more serious cases or avoid resistance in the upper echelons of the ladder.
References consulted:
Journal
JAPMA Medimecum
Various pages scientific internet (Medline, Finisterre, etc)
Wikipedia (link to table of antibacterials)
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