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Evidence base for Antibiotic selection in Diabetic foot ulceration

Discussion in 'Diabetic Foot & Wound Management' started by nicpod1, Feb 26, 2006.

  1. nicpod1

    nicpod1 Active Member


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    Does anyone work to any National Guidelines for antibiotic choice in Diabetic foot ulceration/infection?

    I've searched around, but have drawn a blank! A Meta-analysis level study would be ideal!

    Thanks for any info!
     
  2. Craig Payne

    Craig Payne Moderator

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  3. nicpod1

    nicpod1 Active Member

    Thanks Craig,

    Still not a great deal of solid evidence is there!

    I'll grill the Endocrinologists and see what they have as I'm sure there should be something in the Diabetologica Journal. I think it just demonstrates that although Diabetic Foot Complications are the main reason a person with Diabetes will end up in hospital, there's not as much emphasis on getting those treatments right as there is for e.g. blood glucose, cholesterol, blood pressure etc.

    One reason for this in the UK is that the money for the GPs is in getting those other levels down below a certain level, whereas, although it is regularly quoted about how expensive amputations are, there's no money in their prevention!

    Ho hum!
     
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    Last edited by a moderator: Mar 2, 2006
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    The April 2006 issue of Diabetic Medicine has an editorial by Bill Jeffcoate on The evidence base to guide the use of antibiotics in foot ulcers in people with diabetes is thin, but what are we going to do about it? ... unfortunatly its content is only available online to subsricbers :(

    However, there was also this in the same issue:
    Systematic review of antimicrobial treatments for diabetic foot ulcers.
    Diabet Med. 2006 Apr;23(4):348-59
     
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    Diagnosis and Treatment of Diabetic Foot Infections.
    Plast Reconstr Surg. 2006 Jun;117(7S SUPPLEMENT):212S-238S
     
  7. pd6crai

    pd6crai Active Member

    The CREST guidelgines (clinical resource efficiency spport team) have recommendations for practice and page 16 has the antibiotic recommendations and can be found on their website. http://www.crestni.org.uk/publications/diabetic_foot.pdf
    Superficial ulcer:- flucloxacillin 500mg qds or co-amoxiclav 625mg tds for 7-17 days with frequent reassessment.
    Deep ulcer:- flucloxaxillin 500mg ds, ciprofloxacin 500mg bd and metronidazole 400mg. Triple therapy regimen, the duration of therapy usually depends on severity but should be considered for 6 weeks.
    Deep ulcer plus active cellulitis: regiemen as above but i.v. antibiotics essential, usually based on sensitivity testing.

    For patients with a penicillin allergy:- erythromycin 500mg qds or clarithromycin 500mg bd.

    Its all on their web site and is usefull as a guideline.
     
  8. nicpod1

    nicpod1 Active Member

    Thanks for this - better than anything else out there, but it has no evidence to back it up unfortunately - perhaps they published their references elsewhere??

    Prodigy guidance and NICE state that there is a sytematic reveiw underway at present which should help in the future, but NICE stated this in 2004, and still no sign, so let's hope it's here soon!

    Unfortunately, I've already handed-in my non-medical prescribing coursework which I needed it for, but it's good for clinical practice and development of guidelines.

    I've asked our mirobiology dept to analyse most commonly found micro-organisms from swabs of DFU's (I know swabs not v.reliable, but still no access to soft tissue biopsy here at the moment), and I'm going to devise our own guidelines hopefully!

    The next sticking point is guidance on dressing selection - minefield!!!!!

    Thanks for the resources all!
     
  9. Tuckersm

    Tuckersm Well-Known Member

    Antibiotic Guidelines

    Information from the Therapeutic Guidelines Series on Antibiotic Use
    http://etg.hcn.net.au/ available through the Clinician's Health Channel to all Public Sector employees in Victoria
    There is also a reference list attached to the site
     
  10. HJM41

    HJM41 Member

    I Have A Friend Stil Using H2o2 And That Old Purple Stuff Anyone Have Any Reason That He Should Stop
     
  11. robby

    robby Active Member

    Speak to your LOCAL infection control/Pharmacy officers, there will be local guidelines, the bugs involved vary from place to place.

    You should also read the numerous articles published by Lipsky, which is research and EVIDENCE based about the use of antibiotics in ulceration in Diabetes.

    There have been several published in The Diabetic Foot journal.


    I have to say though from clinical experience I would have to agree with tthe last post wrt the antibiotics of choice. Fluclox is not the best choice for Diabetes. See Lipsky.....

    The crest guidelines are excellent and are helpful when discussing infection with less experienced practtioners (eg SHOs ect who automatically prescribe Fluclox for every infection).

    You should set a protocol with your local diabetes team (and I mean Team) they all need to work together and then get it out to the local GPs to make sure you all sing from the same hymn book.

    THis can make a massive difference to the infection rates in Diabetes.
     
  12. nicpod1

    nicpod1 Active Member

    Robby,

    Not sure who your comments are directed to, but I don't agree that the CREST guidelines are excellent, as they are not referenced. Also, we do not have local guidelines and I have read all of Lipsky and used his 'evidence', but I was acutally looking for systematic review / meta-analysis level evidence of which I can assure you, as it brought me just this side of insanity, there is none!

    I do work within a 'team' and I am forming local guidance, but local guidance doesn't cut it in acadaemia!

    I could easily set out my own guidance, but it would be based mainly on clinical experience and limited research - if NICE can't commit to guidance and specifically says there is none of a specifically high enough level, I would be inclined to agree with them, wouldn't you?

    Let's just hope I don't have to fail my Non-Medical Prescribing for the sake of 'no evidence'!
     
  13. robby

    robby Active Member

    Nicpod1

    yes I would agree BUT we have to work with whats available.
    The crest Guidelines are good (yes I agree not referenced) Have you tried contacting the secretariat for the refernces as it says full refs are available?

    This MAY help....! ?

    I would guess that there have been systematic reviws because we all work to local protocols. The US would be the only area where this research would be done.


    We can all live in hope though.

    Good Luck with your Prescribing. I got mine without doing exactly what you have done, so you should be ok.
     
  14. HJM41

    HJM41 Member

    sAW A PT TODAY IN HOUSE WITH TWO KNEE IMPLANTS AND A ROD IN HIS LEFT TIBIA HIS LEFT FOOT IS HYPERPIGMENTED X-RAY SHOW POOR BONE STOCK POSSIBLE FRACTURES OF SEVERAL METS. TX WITH TWO COURSES OF Ab WITHOUT X-RAY, oH YES NUMB FOOT GREAT PULSE PINS AND NEEDLES ONLY SWELLS WHEN HE WALKS ON IT . rEQUESTED IS A WBC LABELED TcSCAN AN MR WITH CONTRAST(MAYBE A POOR IDEA )AND ESR WBC ARE WNL pT GETTING IV Ab UNASYN . hOW MANY VOTE OSTEO AND HOW MANY CHARCOT
     
  15. John Spina

    John Spina Active Member

    Sounds like Charcot to me as he has swelling,great pulses and loss of sensation.The multiple fractures appear to be the famous "bag of bones"related to Charcot foot.An Xray sounds like a good idea to me.
     
  16. pd6crai

    pd6crai Active Member

    Robbie, I am glad you agree about the CREST guidelines. I am from N.Ireland and they are evidence based, although now working in Oz and I have found them a great guideline to show the GPs here, as they only ever prescribe fluclox 250mg.

    Evidence based practice is always the best practice, and the CREST guidelines are that. Robbie is right in that if you are looking for references, ask the people who have written antibiotic guidelines. There is no point in re inventing the wheel, when it works perfectly well. Just ask for the blue prints!!!!
     
  17. HJM41

    HJM41 Member

    In the US i have been using the same Ab as in your guide line for the little stuff out side of hospital in house I call My friends in the ID world and let then make the call. If i do admit as a rule of thumb i use unasyn zosyn timentin vanco and rarely ancef something called tigercycline has also poped up as of late .
     
  18. betafeet

    betafeet Active Member

    Tuckersm
    Information from the Therapeutic Guidelines Series on Antibiotic Use
    http://etg.hcn.net.au/ available through the Clinician's Health Channel to all Public Sector employees in Victoria

    sorry need that ref looked at site but could not see the wood for the trees so could you find it for me.

    thankyou
    jude
     
  19. Tuckersm

    Tuckersm Well-Known Member

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    Piperacillin/tazobactam versus imipenem/cilastatin for severe diabetic foot infections: a prospective, randomized clinical trial in a university hospital.
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    Accounting for the Development of Antibacterial Resistance in the Cost Effectiveness of Ertapenem versus Piperacillin/Tazobactam in the Treatment of Diabetic Foot Infections in the UK.
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