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

2. 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

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

4. Emphysematous Pyelonephritis

5. 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

6. 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 )

7. 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

8. National Cheng Kung University Hospital, Taiwan
- Arch Intern Med. 2000;160:
National Cheng Kung University Hospital, Taiwan
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

9. Class 1
Class 2
Class 3A
Class 3B
Class 4

10. 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

11. 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 ( g/day)
often in combination with
Aminoglycoside (GM 3-5 mg/kg/day) or iv fluoroguinolone
Severe complicated UTI
Imipenem ( 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

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

13. Necrotizing Fasciitis

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

15. 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)

16. 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

17. 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 %

18. 대한내과학회지 : 제70권 제6호 2006 국내 세 개 대학 병원에서 괴사성 근막염의 특징 순천향대학교 의과대학 내과학교실
대한내과학회지 : 제70권 제6호 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

19. 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

20. 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

21. 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:

22. 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)

23. 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

24. 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

25. Emphysematous pyelonephritis성별 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