Does anyone work to any National Guidelines for antibiotic choice in Diabetic foot ulceration/infection?
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I've searched around, but have drawn a blank! A Meta-analysis level study would be ideal!
Thanks for any info!
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The closest we have are
Consensus on Diagnosing and Treating the Infected Diabetic Foot from the International Consensus Group
and
The IDSA guidelines are at:
Diagnosis and treatment of diabetic foot infections.
Clin Infect Dis. 2004 Oct 1;39(7):885-910 -
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 -
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
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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. -
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! -
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
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I Have A Friend Stil Using H2o2 And That Old Purple Stuff Anyone Have Any Reason That He Should Stop
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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. -
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'! -
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. -
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
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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.
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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!!!! -
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 .
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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 -
jude
http://etg.hcn.net.au/TGC/abg/8281.htm
This is the specific link. Otherwise use the search function -
Novel antibiotics for the management of diabetic foot infections.
Omar NS, El-Nahas MR, Gray J.
Int J Antimicrob Agents. 2007 Dec 21 [Epub ahead of print]
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Modified vancomycin dosing protocol for treatment of diabetic foot infections.
Niu SC, Deng ST, Lee MH, Ho C, Chang HY, Liu FH.
Am J Health Syst Pharm. 2008 Sep 15;65(18):1740-3.
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Piperacillin/tazobactam versus imipenem/cilastatin for severe diabetic foot infections: a prospective, randomized clinical trial in a university hospital.
Saltoglu N, Dalkiran A, Tetiker T, Bayram H, Tasova Y, Dalay C, Sert M.
Clin Microbiol Infect. 2009 Oct 14. [Epub ahead of print]
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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.
Jansen JP, Kumar R, Carmeli Y.
Pharmacoeconomics. 2009;27(12):1045-56.
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Variation in antibiotic treatment for diabetic patients with serious foot infections: A retrospective observational study
Benjamin G Fincke, Donald R Miller, Cindy L Christiansen, Robin S Turpin
BMC Health Services Research 2010, 10:193 (6 July 2010)
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Microbiology of diabetic foot infections: role of ertapenem
Lima AL, Oliveira PR, Carvalho VC, Peixoto de Miranda EJ.
Drugs Today (Barc). 2013 May;49 Suppl A:1-20. doi: 10.1358/dot.2013.49(Suppl.A).1981340.
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