Thursday, August 16, 2012

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.

3 comments :

Unknown said...

This was a great post. I am not that intelligent about internal medicine and this post has helped me to understand one of its disease. It is very helpful to know about this and the medicine for this as well.

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