1. CELLULITIS

4. Figure 1
Diagnostic evaluation of skin and soft tissue infections (SSTIs). *As clinically indicated; †Ulcerated lesions should be cleaned and debrided before having wound base swabbed; ‡Most useful if vesicle/bullae or fluid abscess present; §Seek out bone trauma and air fluid levels; ¶Indications –neurological deficits, vision nonassessable, proptosis/deteriorating acuity or colour/bilateral edema/ophthalmoplegia, no improvement after 24 h and swinging pyrexia not resolving within 36 h (for head only); **Only if central nervous system involvement suspected and intracranial pressure excluded. CT Computed tomography; MRI Magnetic resonance imaging
*As clinically indicated;
†Ulcerated lesions should be cleaned and debrided before having wound base swabbed;
‡Most useful if vesicle/bullae or fluid abscess present;
§Seek out bone trauma and air fluid levels;
¶Indications –neurological deficits, vision nonassessable, proptosis/deteriorating acuity or colour/bilateral edema/ophthalmoplegia, no improvement after 24 h and swinging pyrexia not resolving within 36 h (for head only);
**Only if central nervous system involvement suspected

5. Diagnosis Clinical diagnosis Fine Needle Aspiration
Technique
Leading edge injection and aspiration with saline
Efficacy
May assist diagnosis with cellulitis
Not useful in Erysipelas
30% sensitivity from closed lesions
Indication
Unusual pathogens suspected
Cellulitis refractory to current antibiotics
Blood Culture (25% sensitivity)
only 20% of cases are positive
Skin biopsy (25% sensitivity)
and Harrison’s 17th ed 5

6. Diagnosis Based on appearance of the skin and patient history
Drainage from an abscess or weeping wound associated with cellulitis should be sent for culture and sensitivities.
Material from needle aspiration of inflamed skin or skin biopsy can be cultured in cases of cellulitis without purulence, abscess, or a necrotic
Indications for blood cultures include significant fever and chills, severe immunocompromise, periorbital cellulitis, and cellulitis superimposed on lymphedema.
A polymorphonuclear leukocytosis is often present with cellulitis; a complete blood cell count and differential may help gauge the severity of infection and the hematologic response.

7. Goals of therapy DM Cellulits
Eliminate symptoms related to hyperglycemia
Reduce or eliminate the long-term microvascular and macrovascular complications of DM
Allow the patient to achieve as normal a lifestyle as possible
treat the affected area and any underlying conditions that would increase the chance of cellulitis returning
Harrisons 17th ed 7

8. oral therapy for mild infections
intravenous therapy for severe infections
achievement of high drug levels with rapid delivery.

9. http://www. pubmedcentral. nih. gov/articlerender. fcgi

10. Therapeutic approach Non-pharmacologic Pharmacologic
Rest affected area, elevate the area of the body involved (this will help decrease swelling and relieve discomfort)
Clean wound site
Cellulitis in a DM patient
Early or Mild disease
Augmentin 875 mg PO bid
Second Generation Cephalosporin (cefoxitin, cefacor, cefuroxime)
Third Generation Cephalosporin (cefotaxime, ceftazidime,m ceftriaxone, cefixime)
Severe disease
Imipenem-Cilastatin (Primaxin)
Meropenem
Trovafloxacin IV
Augmentin: amoxicillin/potassium clavulanate – b-lactams inihibit bacterial growth by interfering with the transpeptidation reaction of bacterial cell wall synthesis the clavulanate extends the spectrum of amoxycillin to embrace a wider range of organisms, including many resistant to other ß-lactam antibiotics. 
Cephalosporins: similar to penicillin just more stable to many bacterial b-lactamases therefore have broader spectrum of activity.
2nd- more gram – effect
Imipenem-cilastatin: imipenem has wide spectrum with good activity against many gram-negative rods, inc. P.aeruginosa. Resitant to most b-lactamases except metallo-b-lactamases. Imipenem is inactivated by dehydropeptidases in renal tubules, resulting in low urinary conc. So it must be administered with cilastatin(inhibitor of renal dehydropeptidase)
Meropenem: similar to imipenem but slightly greater activity against gram – aerobes and slightly less activity with gram +
rovafloxacin (sold as Trovan by Pfizer and Turvel by Laboratorios Almirall) is a broad spectrum antibiotic that inhibits the uncoiling of supercoiled DNA in various bacteria by blocking the activity of DNA gyrase and topoisomerase IV.[1] It was withdrawn from the market due to the risk of hepatotoxicity. It had better gram-positive bacterial coverage and less gram-negative coverage than the previous fluoroquinolones. 10

11. Management: Facial Cellulitis
Mild to Moderate Infection
Augmentin 875 mg PO bid
Cefazolin (Ancef) 1 g IV every 8 hours
Severe Infection
Nafcillin 2 g IV every 4 hours
Oxacillin 2 g IV every 4 hours
Vancomycin g IV qd
Linezolid

12. In a study by Kohno et al, Linezolid was compared with vancomycin; both had a comparable clinical success rate in the treatment of SSTi.
In the lab tests done after the end of the treatment and during follow up, Linezolid had a better microbial eradication rate. Also, for the adverse effects (hematologic), linezolid was safer.
S. Kohno1, K. Yamaguchi2, et al. Linezolid versus vancomycin for the treatment of infections caused by methicillin-resistant. Staphylococcus aureus in Japan. Journal of Antimicrobial Chemotherapy (6): ; doi: /jac/dkm369

13. Vancomycin is distributed widely to various tissues and body fluids, however in patient with DM, its penetration in soft tissues is greatly impaired
AUSkhirtladze K; Hutschala D; Fleck T; Thalhammer F; Ehrlich M; Vukovich T; Muller M; Tschernko. Impaired target site penetration of vancomycin in diabetic patients following cardiac surgery. EM SOAntimicrob Agents Chemother Apr;50(4):

14. In a study by Stein et al, Linezolid was effective in the treatment of Staphylococcus aureus in diabetic patients
G E. Stein1,* S Schooley1, et al. Linezolid tissue penetration and serum activity against strains of methicillin-resistant Staphylococcus aureus with reduced vancomycin susceptibility in diabetic patients with foot infections. Journal of Antimicrobial Chemotherapy, doi: /jac/dkm271

15. Duration of therapy response to drug therapy
follow-up is of utmost importance
10 to 14 days of antibiotic therapy
Absence of response/worsening after five days of the initiation of therapy prompts a change in the antibiotic regimen or other investigations to verify the diagnosis

16. Preventing a recurrence of cellulitis
Cellulitis tends to recur in people with certain medical conditions that can lead to skin breakdown, such as edema (fluid buildup), fungal or bacterial infections, diabetes, or peripheral arterial disease.
edema, support stockings and good skin hygiene may reduce or eliminate recurrence of cellulitis.
fungal infections, regular use of antifungal medicines may help reduce recurrent cellulitis.
high risk for recurring cellulitis, (when with open wound or cut) taking preventive antibiotics may help

17. Vincent Ki, MD and Coleman Rotstein, MD
Vincent Ki, MD and Coleman Rotstein, MD. Bacterial skin and soft tissue infections in adults: A review of their epidemiology, pathogenesis, diagnosis, treatment and site of care. Can J Infect Dis Med Microbiol March; 19(2):

18. DIABETES MELLITUS

19. DIAGNOSTIC TEST FOR DIABETES MELLITUS19

20. Diabetes mellitus is characterized by recurrent or persistent hyperglycemia, and is diagnosed by demonstrating any one of the following:
Fasting plasma glucose level at or above 126 mg/dL (7.0 mmol/L).
Plasma glucose at or above 200 mg/dL (11.1 mmol/L) two hours after a 75 g oral glucose load as in a glucose tolerance test.
Symptoms of hyperglycemia and plasma glucose at or above 200 mg/dL (11.1 mmol/L). 20

21. Fasting blood glucose test
The most common test for diagnosis of diabetes.
blood glucose levels are checked after fasting for between 12 and 14 hours.
Patients with fasting glucose levels from 100 to 125 mg/dL (6.1 and 7.0 mmol/L) are considered to have impaired fasting glucose
Patients with diabetes may be asked to delay their diabetes medication or insulin dose until the test is completed.
The fasting blood glucose test will confirm that the person has diabetes if it shows that the level of glucose in their blood is higher than normal when they are fasting. 21

22. Random blood glucose test
blood glucose levels are checked at various times during the day, and it doesn’t matter when you last ate.
Blood glucose levels tend to stay constant in a person who doesn’t have diabetes. 22

23. Oral glucose tolerance test (OGTT)
FBS is obtained before the ingestion of a 50- to 200-g glucose load (usual amount is 75 g),
blood samples are drawn at ½, 1, 2, and 3 hours (may be 4- or 5-hour sampling).
Blood samples are checked at regular intervals for two hours.
Glucose tolerance tests are used when the results of the fasting blood glucose are borderline.
This test will confirm diabetes if the person’s blood sugar levels stay high for a long time after the tests. . 23

24. They are also used to diagnose diabetes in pregnancy (gestational diabetes).
NORMAL: the results of the glucose tolerance test will show that their blood sugar levels fall within the normal range
Patients with plasma glucose at or above 140 mg/dL or 7.8 mmol/L, but not over 200, two hours after a 75 g oral glucose load are considered to have impaired glucose tolerance. 24

25. Glycated Hemoglobin (Glycohemoglobin, HbA1c) for Diabetes Mellitus
Measures glycemic control over a 60- to 120-day period by measuring the irreversible reaction of glucose to hemoglobin through freely permeable erythrocytes during their 120-day lifecycle.
While not used for diagnosis, an elevated level of glucose irreversibly bound to hemoglobin of 6.0% or higher (the 2003 revised U.S. standard) is considered abnormal by most labs 25

26. C-Peptide Assay (Connecting Peptide Assay) for Diabetes Mellitus
Cleaved from the proinsulin molecule during its conversion to insulin, C-peptide acts as a marker for endogenous insulin production. 26

27. Fructosamine Assay for Diabetes Mellitus
Glycated protein with a much shorter half-life than glycated hemoglobin, reflecting control over a shorter period, approximately 14 to 21 days.
May be advantageous in patients with hemoglobin variants that interfere with the accuracy of glycated hemoglobin tests. 27

28. GOALS OF THERAPY Eliminate symptoms related to hyperglycemia
Reduce or eliminate the long-term microvascular and macrovascular complications of DM
Allow the patient to achieve as normal a lifestyle as possible
Harrison’s 17th Edition

29. Patient education about DM, nutrition and exercise
Patient with DM should receive education about:
Nutrition
Exercise
Care of diabetes during illness
Medications to lower the plasma glucose
Continuing process with regular visits for reinforcement
Diabetes self-management education (DSME)
Harrison’s 17th Edition

30. Diabetes education Self-monitoring of blood glucose
Urine ketone monitoring (type 1)
Insulin administration
Guidelines for diabetes management during illness
Management of hypoglycemia
Foot and skin care
DM management before, during and after exercise
Risk-factor-modifying activities
Harrison’s 17th Edition

31. Nutrition Medical Nutrition Therapy (MNT) Modest caloric reduction
Reduced fat intake
Increased physical activity
Reduction of hyperlipidemia and hypertension
Increased consumption of soluble dietary fiber may improve glycemic control
Weight loss and exercise improve insulin resistance
Harrison’s 17th Edition

32. Exercise CV risk reduction Reduced BP Maintenance of muscle mass
Reduction in body fat and weight loss
Lowering plasma glucose
Increasing insulin sensitivity
*ADA recommends 150 min/week (distributed over at least 3 days)
Harrison’s 17th Edition

33. Monitoring the level of glyceminc control
Plasma glucose measurements by the patient and assessment of long-term control by the physician
Measurement of A1C and review of the patient’s self-measurement of plasma glucose
These are complementary: A1C-average glycemic control over the previous 2-3 months
patient’s measurement- short term glycemic control
Harrison’s 17th Edition

34. Self-monitoring of Blood Glucose
Standard of care in diabetes management and allows the patient to monitor his/her blood glucose at any time
Glucose monitors can rapidly and accurately measure glucose in small amounts of blood (3-10 µL obtained from the fingertip
*individuals with type 2 DM who are taking insulin should utilize SMBG more frequently than than those on oral agents
Harrison’s 17th Edition

35. Assessment of Long-term Glycemic Control
Measurement of glycated hemoglobin
Plasma glucose is consistently elevated = increase in nonenzymatic glycation of hemoglobin
Reflects the glycemic history over the previous 2-3 months
Harrison’s 17th Edition