Internal Medicine Potpourri!

Today we heard about a potpourri of Internal Medicine cases. Here are a few highlights:

1) Diabetic foot infections:

• IDSA Classification: Grade 1 = colonisation, no evidence of infx (clean based ulcer with granulation tissue, no purulence or cellulitis); Grade 2 = At least two signs of infection (erythema, purulence, pain, warmth, induration) and less than 2cm of surrounding cellulitis; Grade 3 = 2+ cm surrounding cellulitis, involvement of bone, tendon or deep fascia but no systemic toxicity; Grade 4= systemic toxicity.
• Microbiology: Grade 1-2 : usually gram + organisms (MSSA, Strep group A, B, C, G, enterococcus). Grade 3+ Polymicrobial: MRSA, staph, strep, gram negative bacilli (e. coli, proteus, klebsiella, ESBL, pseudomonas) and anaerobes (peptococcus, peptostreptococcus, bacteroides, fusobacterium). Risks for resistance: chronic wounds, prior hospitalization and previous abx therapy.
• Treatment: 
• Non pharmacologic: decrease pressure on wounds, good wound care.  
• Pharmacologic: (suggested regimens only, check with institution specific resistance profiles) Grade 1-2: Abx with good Gram + coverage (Cloxacillin, Cephalexin, Amoxi-clav), if MRSA possible add Septra or Vancomycin. Grade 3: Add aerobic Gram - coverage and anaerobic coverage (Cipro + Clinda, moxifloxicin, cephalosporin + Clinda). Grade 4: consider Pipericillin/tazobactam or a carbapenem. 
• See the following article for a review on the microbiology and treatment of Diabetic foot infections: Diabetic foot infections

2) NSAIDS and PUD

• The risk of causing GI bleeding is nto equal amongst all NSAIDS. A meta-analysis of controlled trials   of commonly prescribed non-selective NSAIDs found that the risk of highest in indomethacin (RR 2.25), then naproxen (RR1.83), diclofenac (RR1.73), ibuprofen (1.43) and meloxicam (RR 1.24).
• The latest trend is to prescribe an NSAID with a PPI (ie. Vimovo has naphroxen and esomeprazole) However, there is evidence for worsening NSAID induced small bowel injury, due to the changes in small bowel micro-flora with PPI use. So ultimately, NSAID use should still be limited in patients at risk of GI complications.

3) DKA

• While serum K+ may be normal, patients have low total K+. Must treat K+ and maintain greater than 4. Best way is orally (may need to place NG tube)
• Insulin IV to treat the Anion Gap
• Fluids to treat the hyperglycemia
• Patients are usually phosphate deficient, however trials looking at repletion of phosphate in DKA showed no difference in duration of DKA, rate of AG improvement or morbidity/mortality. Hypophosphatemia of less than 0.32mmol/L can cause hemolysis, rhabdomyolysis, myoglobinuria (but is rare). Therefore consider treating only if Phosphate is less than 0.3.