Infectious Disease with High Mortality and Morbidity in Diabetic Patients 내분비 대사 내과 R3 송 란

Infections in diabetes mellitus More susceptible to particular infections Unique features when they occur in diabetics Foot infections Superficial fungal infections : oral candidiasis, onychomycosis, intertrigo Urinary tract infections : emphysematous pyelonephritis Mucormycosis Malignant external otitis Emphysematous cholecystitis Necrotizing fasciitis Pyomyositis

Why are diabetics more susceptible to infection ? Hyperglycemia Impairment of immune response Vascular insufficiency Sensory peripheral neuropathy Autonomic neuropathy Increased skin and mucosal colonization

Emphysematous Pyelonephritis

Generally regarded as rare renal infection Definition gas-producing, necrotizing infection involving the renal parenchyma and perirenal tissue Generally regarded as rare renal infection US or CT  more recognized recently Diabetic patients or urinary tract obstruction without DM Radiological classification, adequate therapeutic regimen prognostic factors, pathogenesis  Unclear, Controversial

Pathogenesis 4 factors Gas-forming bacteria High blood glucose level Most Enterobacteriaceae High blood glucose level High tissue glucose Impaired tissue perfusion Urinary tract obstruction Infarction or vascular thrombosis ↓ Leukocyte and antibiotics into lesions Defective immune response (such as DM )

Diagnosis Simple abdomen or KUB : 33 % Abdomen US Difficult to detect because of bowel gas Urinary tract obstruction Abdomen CT Confirm of diagnosis Extent of disease Follow up

National Cheng Kung University Hospital, Taiwan - Arch Intern Med. 2000;160:797-805 National Cheng Kung University Hospital, Taiwan 1989.08.01 - 1997.09.30 48 consecutive cases Class 1: gas in the collecting system only Class 2: gas in the renal parenchyma without extension to the extrarenal space Class Class 3A: extension of gas or abscess to the perinephric space Class 3B: extension of gas or abscess to the pararenal space Class 4: bilateral EPN or solitary kidney with EPN

Class 1 Class 2 Class 3A Class 3B Class 4

Radiologic Classification, Management, Outcome Class 1 and 2 EPN Antibiotic treatment combined with PCD Class 3 or 4 with benign manifestation (<2 risk factors) PCD combined with antibiotic treatment High success rate and so preserve their kidney Class 3 or 4 with fulminant course (≥2 risk factors) Nephrectomy Class 4 EPN High risk of emergency nephrectomy in these unstable patients Tried first bilateral PCD Nephrectomy should be done if PCD fails

Antibiotics Seriously ill patients with APN Severe complicated UTI Ceftazidime (3-6 g/day), cefepime (2-4 g/day), ticarcillin- clavulanate (18 g of ticarcillin/day), aztreonam (3-6 g/day), imipenem (2 g/day), meropenem (1.5 -3 g/day) often in combination with Aminoglycoside (GM 3-5 mg/kg/day) or iv fluoroguinolone Severe complicated UTI Imipenem (250-500 mg q 6-8hr), penicillin/cephalosporin + AG F/U urine culture Within 1-2 (2-4) weeks of completion of therapy Pregnant women, children, recurrent symptomatic pyelonephritis, complicated UTI

Prognostic Factors of Mortality and Poor Outcome    - Arch Intern Med. 2000;160:797-805

Necrotizing Fasciitis

Necrotizing fasciitis Deep seated infection of the subcutaneous tissue  Progressive destruction of fascia and fat (spare the skin) Normal Necrotizing fasciitis Pregressive Necrotizing fasciitis

Two clinical types Type I Type II Mixed infection of aerobic & anaerobic bacteria DM, peripheral vascular disease Type II Monomicrobial infection by group A streptococcus (GAS, Streptococcus pyogenes) Methicillin-resistant Staphylococcus aureus (MRSA)

Type I S.aureus, streptococci, enterococci, E.coli, peptostreptococcus species, prevotella,porphyromonas species, Bacteroides fragilis group, Clostridium species Feet  leg (rapid extension along the fascia) Head & neck region and perineum Cervical necrotizing fasciitis dental origin : 78 % pharyngeal origin or occurring after surgery or trauma Fournier's gangrene : perineal area Ant. abdominal wall : gluteal muscles, scrotum & penis (male) + + diabetic patients cellulitis systemic signs of infection

Type II Necrotizing fasciitis caused by GAS :1990s 50 % : streptococcal toxic shock syndrome Any age & healthy group Community-associated MRSA Risk factors : injection drug use - 43% diabetes - 21% hepatitis C infection – 21 % malignancy – 7 % HIV infection – 7 %

대한내과학회지 : 제70권 제6호 2006 국내 세 개 대학 병원에서 괴사성 근막염의 특징 순천향대학교 의과대학 내과학교실 대한내과학회지 : 제70권 제6호 2006 국내 세 개 대학 병원에서 괴사성 근막염의 특징 순천향대학교 의과대학 내과학교실 - 한남동 순천향대학교 순천향대학교 부천병원 순천향대학교 천안병원 - 2001년5월 ~ 2005년 5월 - 후향적 조사 - 총 환자 : 22명 Table 3. Etiologic organisms of necrotizing fasciitis Gram stain Identified organisms Number Streptococcus pyogenes 4 Staphylococcus aureus Gram (+) ; 13 (54%) Coagulase negative staphylococci 3 Enterococcus faecalis 1 Enterococcus faecium Escherichia coli Vibrio vulnificus 2 Pseudomonas aeruginosa Gram (-) ; 11 (46%) Klebsiella pneumoniae Yersinia enterocolitica Aeromonas hydrophilia Serratia marscens

Clinical manifestations Unexplained pain : first manifestation DM patients : peripheral neuropathy  absence of pain Erythema : diffusely or locally Bullous stage Extensive deep soft tissue destruction Fever, malaise, myalgias, diarrhea, anorexia : first 24 hours erythema 24hrs ~ 48hrs

Diagnosis - decision of prompt surgical exploration History & Clinical features Laboratory findings : nonspecific Imaging studies Soft tissue x-rays CT scan MRI  Gas in the tissue - J. Bone Joint Surg. Am.2003:85

Treatment Prompt Surgical exploration Early & aggressive debridement (involving fascia) Obtaining material for appropriate cultures Reexploration : in 24 hours Singapore Changi General Hospital 89 patients Jan.1997~Aug.2002 retrospectively - J. Bone Joint Surg. Am. 2003;85:1454-1460

Antibiotic therapy Hemodynamic support First choices ampicillin or ampicillin-sulbactam + clindamycin or metronidazole Hospitalization patients gram-negative coverage ticarcillin-clavulanate, piperacillin-tazobactam, 3rd cephalosporin, carbapenem, fluoroquinolone, aminoglycoside Group A streptococcal infection combination of clindamycin and penicillin Risk factor of MRSA, Hemodynamic unstable vancomycin Hemodynamic support massive amounts of intravenous fluids (10 ~ 20 L/day)

Uncontrol Infective Process Mortality rate type I necrotizing fasciitis : 21 % type II necrotizing fasciitis : 30 ~ 34 % cervical necrotizing fasciitis : 22 ~ 22 % Fournier's gangrene : 40 % within 24 hrs after admission Clinical Suspension Intravenous Antibiotics Uncontrol Infective Process Emergent Operative Débridement

Septic Shock, ARF  Expire 경희의료원에서의 necrotizing fasciitis 와 emphysematous pyelonephritis 현황 (1996 년~2006년 현재) Necrotizing fasciitis 성별 나이 발생년도 동반질병 예후 이 0 형 M 70 1999 DM Fasciotomy 후 회복 김 0 례 F 72 2001 Septic Shock  Expire 김 0 재 56 김 0 수 88 2003 최 0 웅 62 Septic Shock, ARF  Expire 허 0 선 40 2004 최 0 렬 2005 이 0 순 71 - 심 0 남 51 2006 antibiotics

Emphysematous pyelonephritis 성별 나이 발생년도 동반질병 예후 강 0 근 M 65 2004 DM PCD & antibiotics 권 0 란 F 50 Nephrectomy 권 0 이 75 2006 Antibiotics