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Common Infectious Diseases in Diabetic Patients

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Common Infectious Diseases in Diabetic Patients Dr Wu Tak Chiu Division of Infectious Diseases Department of Medicine Queen Elizabeth Hospital Topics to be covered ... – PowerPoint PPT presentation

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Title: Common Infectious Diseases in Diabetic Patients


1
Common Infectious Diseases in Diabetic Patients
  • Dr Wu Tak Chiu
  • Division of Infectious Diseases
  • Department of Medicine
  • Queen Elizabeth Hospital

2
Topics to be covered
  • Pathogenesis of increased risk of infection in DM
    patients
  • DM associated infection disease Clinical
    Management
  • UTI symptomatic and asymptomatic
  • DM foot
  • Chest infection Influenza A, Pneumococcus, PTB

3
DM and Infections
  • Many infections are more common in diabetic
    patients
  • Increased severity
  • Increased risk of complications

4
Suppressed Immunity in DM Patients
  • PMN functions ? (particular when acidosis is
    present)
  • Lecukocyte adherence ?
  • Chemotaxis ?
  • Phagocytosis ?
  • Antioxidant activities ?
  • But response to vaccines appear to be normal
  • Improving glycemic control might improve immune
    function

5
Hyperglycaemia associated with Increased
infection Mortality
6
Good Glycaemic Control Decreased Wound Infection
Rate
7
UTI
  • Symptomatic UTI
  • vs.
  • Asymptomatic Bacteriuria (ASB)

8
Symptomatic UTI and Diabetes
  • The clinical features, diagnosis and treatment of
    uncomplicated UTIs in diabetics are the same as
    for non-diabetics
  • Rare emphysematous UTI
  • Pyelonephritis, pyelitis and cystitis
  • gt 90 occur in diabetics
  • Gas formation
  • Seen in plan X-ray or CT
  • Antibiotics open drainage /- nephrectomy
  • Overall mortality rate was 18.8

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10
UTI Diabetics
  • Same pathogens as non-diabetics
  • E. coli is commonest pathogen
  • Klebsiella pneumoniae, Gp B streptococci and C.
    albicans are more common in diabetics

11
Distribution of bacterial isolates in urine from
QEH AED from 2004 to May 2006
12
Antimicrobial Therapy
  • Choice of antibiotics in UTI
  • Trimethroprim-sulfamethoprim (TMP-SMZ)
  • Fluroquinolones
  • Nitrofurantoin
  • Beta-lactam

13
Antimicrobial Susceptibility Profile for Urine
Specimens at QEH AED from 2004 to 2006 May
14
E. coli Against Nitrofurantoin
  • 100 E-coli isolates from urine culture at
    different wards at QEH were randomly chosen for
    testing sensitivity against Nitrofurantoin

15
of Antibiotics resistance among the most common
isolates of UTI in GOPC
16
Trimethroprim-sulfamethoprim (TMP-SMZ)
  • Well absorbed orally
  • Excreted primarily in urine
  • Use as standard for comparison of efficacy in
    treatment of UTI
  • Sufficient data to support 3 days treatment in
    uncomplicated cystitis
  • Spectrum of activity
  • Enterobacteriaceae (E coli, Klebseilla, Proteus)
  • Staphylococcus aureus, S saprophyticus
  • Group B streptococcus
  • No activity on Pseudomonas aeruginosa,
    enterococcus

17
  • Concerns
  • Wide spread of resistance
  • gt 30-40 of E coli from community acquired UTI
    are resistant
  • Cannot be used in pregnancy

18
Fluoroquinolones
  • Excellent bioavailability ( ORAL IV)
  • Good tissue penetration including kidney,
    prostate, genital tract
  • Long serum half life
  • Sufficient data to support 3 days treatment for
    uncomplicated UTI
  • Spectrum of activity
  • Enterobacteriaceae ( E coli, Klebseilla, Proteus)
  • Some activity against S. aureus, S saprophyticus
    and Streptococcus, enterococci
  • Pseudomonas aeruginosa

19
  • Concerns
  • Wide spread of resistance
  • About 20-30 of E. coli in community acquired
    UTI are resistant
  • Induce multiple drug resistance such as ESBL E.
    coli
  • Cannot be used in children and pregnant woman

20
Nitrofurantoin
  • Urinary antiseptics
  • Cannot achieve therapeutic level in blood
  • Low incidence of resistance even with 4 decades
    of use
  • Spectrum of activity
  • E coli, (even some ESBLve strains in vitro)
  • Some activity against gram ve org such as S.
    saprophyticus and E. faecalis
  • Klebsiella spp. Proteus are usually resistant
  • Not active against Pseudomonas species

21
Nitrofurantoin
  • Concerns
  • Mostly for treatment of lower UTI.
  • Should not be used in patients with systemic
    sepsis because of low serum level.
  • Contraindicated in patients with impaired renal
    function because decrease concentration in urine
    and increase serum level causing toxicity
  • Special caution for elderly because of renal
    impairment and high incidence of serious side
    effect
  • Side effects
  • GI upset
  • Pneumonitis, polyneuropathy, hepatitis, bone
    marrow suppression

22
Beta-lactam
  • Choice
  • Amoxicillin/Clavulanate (Augmentin)
  • Oral 2nd generation cephalosporins (Zinnat)
  • Ampicillin generally is not a choice because most
    E-coli are resistant.

23
Oral Augmentin vs. Zinnat
24
  • Most reviews consider that Beta-lactam in general
    is inferior than TMP/SMZ and quinolones in
    eradication of bacteriuria or may associate with
    higher rate of recurrence
  • However,
  • Conclusion drawn from studies using different
    kind of beta-lactam, e.g. ampicillin
  • Difference is significant but not big
  • High resistance rate in HK for TMP/SMZ and
    quinolones

25
Antimicrobial Therapy
  • Choice of antibiotics in UTI
  • Trimethroprim-sulfamethoprim (TMP-SMZ)
  • Fluroquinolones
  • Nitrofurantoin
  • Beta-lactam
  • Therefore, nitrofurantoin (Lower UTI) or
    Amoxicillin/Clavulanate is a good choice for
    empirical treatment for community acquired UTI in
    Hong Kong

26
Asymptomatic Bacteriuria (ASB) in Diabetic Women
27
Asymptomatic Bacteriuria (ASB) in Diabetics
  • Questions
  • Should we screen for asymptomatic bacteriuria in
    diabetics?
  • Should we treat ASB in diabetics?
  • Do the diabetic women
  • have higher incidence rate of ASB?
  • with ASB have higher risk of developing
    symptomatic UTI than those without ASB?
  • with ASB have poor long term prognosis than those
    without ASB?
  • with ASB have higher risk of developing long term
    complications such deterioration of RFT?
  • with ASB benefit from antibiotic therapy by
    reducing the risk of developing symptomatic UTI?

28
ASB in Diabetes
  • Definition
  • Presence of high quantities of a uropathogen in
    the urine of an asymptomatic person
  • Colony count 105cfu.ml x 2 times
  • 3-4 times increase in risk of bacteriuria in
    diabetic women (26 vs. 6)
  • Risk factors
  • Longer diabetes duration (gt10yrs, relative risk
    2.6)
  • Macroabluminuria
  • Non-circumcised partners?
  • But no association with current HBA1c level or
    glucose control
  • Microbiology
  • E. coli and other gram-negative organisms

29
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32
  • Methods
  • Diabetic women gt16 yrs of age
  • Bacteriuria without urinary symptoms
  • 50 received placebo
  • 55 received 14 days antibiotics
  • Screened for bacteriuria every 3 months for up to
    3 years

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Summary of ASB in Diabetics
  • ASB is more common in diabetic women but not men
  • More likely to develop symptomatic UTI in
    asymptomatic bacteriuric patient
  • Does not have increased risk of faster decline in
    long term renal function
  • Antibiotic use
  • Not affect the frequency of or time to
    symptomatic infection, including pyelonephritis,
  • Recurrent asymptomatic bacteriuria in treating
    group is common
  • Antibiotic related adverse effects
  • Associated with resistance development

39
Recommendations for ASB in Diabetic Women
  • NOT recommended for routine screening for ASB in
    diabetics
  • NOT recommended antibiotic therapy for diabetic
    women who have ASB
  • Except
  • Pregnant woman
  • Before urological intervention
  • Renal transplant patient

40
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41
Diabetic Foot Infections
42
DM Foot Infections
  • Risk Factors
  • Men
  • DM gt10yrs
  • Poor glycaemic control
  • CVS, retinal or renal complications

43
Pathogenesis
  • Neuropathy
  • Sensory neuropathy ? ? awareness of injury to the
    foot
  • Motor neuropathy ? intrinsic muscles of the foot
    ? foot deformity ? maldistribution of weight
  • Autonomous neuropathy ? ? sweating ? dry and
    cracked skin ? breaches in integrity of skin ?
    entry of microorganism
  • Superficial Fungal skin infection
  • Higher rate of nasal and skin colonization with
    Staph. aureus
  • Vasculopathy and Defects in immunity
  • ? impair wound healing

44

45
Diagnosis
  • Difficult to differentiate
  • infectious vs. non-infectious osteopathy
  • soft tissue infections alone vs. soft tissue
    infections with osteomyelitis.
  • Most patients with diabetic foot infection are
    afebrile and have absence of local inflammatory
    sign.

46
Osteomyelitis in DM Foot
  • 1/3 of the diabetic patients with foot infection
    are found to have evidence of osteomyelitis
  • In patients with osteomyelitis, the cumulative
    amputation rate over 1-3 years is 40

47
Diagnostic Clues of Underlying Osteomyelitis
  • Clinical Findings
  • Ulcer area gt 2cm² ( with sensitive of 56
    specificity of 92 )
  • Deeper ulcers gt 3mm (82 vs 33)
  • All exposed bone has underlying osteomyelitis
  • Probe-to-bone test
  • positive predictive value of 89
  • Negative predictive value of 56
  • Some patients condition may appear less serious
    or more superficial at presentation than they are
    found at surgical exploration

48
Diagnostic Clues of Underlying Osteomyelitis
  • ESR
  • ESR of gt 40mm/h associated with a 12-fold
    increased likelihood of osteomyelitis in a
    prospective study (Diabetes 1991)
  • X Ray
  • Bony abnormalities related to osteomyelitis are
    generally not evident on plain films until 10-20
    days after infection
  • Other imaging studies not cost-effective

49
Microbiology
  • Simply swabbing the overlying ulcer often yields
    organism that are colonizer and not actually the
    causative agents
  • Specimens from the deep tissue or bone increase
    the likelihood of isolating true pathogens

50

51
Microbiology
  • Deep diabetic foot infection is a classical
    polymicrobial infection and anaerobic infection
  • The conditions with the chronic ischemic tissue
  • favor the growth of obligate anaerobic bacteria
  • Permitting synergic interactions with facultative
    bacteria
  • Augment the overall microbial virulence of the
    infectious process

52
Antimicrobial Therapy
  • Should receive therapy effective against S.
    aureus and other aerobic gram-positive cocci.
  • Expanding therapy to cover aerobic gram-negative
    bacilli, anaerobic organism in patients with deep
    infection
  • For examples
  • Ampicillin-clavulanic acid (Augmentin)
  • Ticaricillin-clavulanic acid (Timentin)
  • Cefoperazone-sulbactam (Sulperazon)
  • Piperacillin-tazobactam (Tazocin)
  • Carbapenem
  • Clindamycin fluoroquinolone/2nd or 3rd
    cephalosporin
  • Vancomycin for MRSA

53
Surgery
  • If the infected bone can be easily resected
    without compromising the integrity of the foot,
    this is preferable to prolonged antibiotic
    therapy
  • When the infection involves a digit, especially
    other than the great toe, amputation may the most
    cost-effective approach

54
Aggressive Surgical Approach Gibbons Curr Clin
Top Infect Dis 1994
  • 110 patients with histopathologically confirmed
    pedal osteomyelitis
  • 76 of 86 patients (88) with infection involving
    the phalanges or metatarsal heads were cured by a
    combined limited surgery (i.e., resection of a
    toe or ray or a transmetatarsal amputation) and
    antibiotic therapy
  • Left a weight-bearing surface in all patients
  • Allowed antibiotic therapy to be limited to an
    average of only 2 weeks

55
Early Surgical Intervention Tan JS CID 1996
  • Patients who had early local limited surgical
    intervention vs. those who did not had a
    significantly lower rate of subsequent
    above-ankle amputation (13 vs. 28) and a
    shorter duration of hospitalization (9.6 days vs.
    18.8 days)

56
Six Principles of Prevention of Foot Ulcers
  • Podiatric care
  • Pulse examination
  • Protective shoes
  • Pressure reduction
  • Prophylactic surgery
  • Patient Education

57

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Respiratory Tract Infections
  • DM is not a significant independent risk factor
    for death in elderly with pneumonia
  • BUT
  • ? frequency with infections caused by S. aureus,
    GNB and PTB
  • ? Bacteremia and mortality in patients with
    pneumonococcal pneumonia
  • ? mortality and incidence of bacterial pneumonia
    during epidemics of influenza
  • Influenza and pneumococcal vaccines should be
    considered for diabetics

60
PTB and DM
  • PTB DM patients had increased frequency of lung
    lesions confined to lower lung compared with PTB
    but w/o DM (23.5 vs. 2.4)
  • PTB DM patients had significant frequency of
    cavitary lung lesions compared with PTB but w/o
    DM (50.8 vs. 39)

Does diabetes alter the radiological presentation
of pulmonary tuberculosis Shaikh MA, et al Saudi
Med J 2003
61
Thank You.

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63
Dipstick leukocyte esterase test
  • Rapid bedside screening test to detect pyuria
  • Sensitive and specific in detecting gt 10 WBC per
    mm3 of urine
  • 75 to 96 sensitivity
  • 94 to 98 specificity
  • Better when combine with nitrate ( positive only
    in nitrate reducing bacteria e.g. E-coli, not in
    Staphylococcus saprophyticus/enetercocci)
  • Still have to take urine for microscopy if
    dipstick negative but patient symptomatic
  • Microscopic haematuria in acute dysuric woman is
    a marker for acute cystitis because it is
    uncommon in vaginitis or urethritis

64
Urine culture
  • Urine culture is advisable in symptomatic UTI if
  • Suspected upper urinary tract infection
  • Complicated UTI
  • Recurrent UTI ( except those that are clearly
    associated sexual activity)
  • UTI in childrenlt5
  • Urine culture is generally not needed for 1st
    episode of uncomplicated UTI in young woman.

65
  • Indication of screening of asymptomatic
    bacteriuria
  • Pregnant women
  • Patient undergoing urological examination
  • Renal transplant patient

66
Recurrent infection in young women
  • Common in women
  • 20 developed 2nd infection during FU period of 6
    months
  • Management
  • Continuous prophylaxis
  • Post-coital prophylaxis
  • Intermittent self-treatment

67
Continuous prophylaxis
  • Indication
  • 2 or more symptomatic infections during 6 months
  • 3 or more symptomatic infections during 12 months
  • Agents
  • Nitrofurantoin 50 /100 mg every night
  • TMP/SMZ half a tablet every night
  • Trimethoprim 100 mg every night
  • the last 2 agents cannot be used in pregnant
    women!
  • Trial basis for 6 months
  • Can be used safely and effectively up to 2 -5
    years without emergence of resistance
  • Start prophylaxis until urine culture is negative

68
Post-coital regimen
  • For those who describe a clear relation between
    sexual intercourse and subsequent cystitis
  • Same dosage as the long term prophylaxis
  • Other methods
  • Avoid use of diaphragm /spermicide
  • Post-coital voiding is not shown to be useful

69
Intermittent self treatment
  • To begin a 3 days course of antibiotics agent at
    the onset of symptoms
  • Use standard dose in UTI
  • Instruct patient to seek medical attention if
    symptoms do not resolve within 48 to 72 hrs
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