Management of the five presentations of infection

Treatment is discussed for the five presentations of infection, in neuropathic feet and in neuroischaemic feet, both as initial treatment and follow-up.

Infection in the neuroischaemic foot is often more serious than in the neuropathic foot which has a good arterial blood supply. We regard a positive ulcer swab in a neu roischaemic foot as having serious implications, and this influences antibiotic policy.

Ulcer with local signs of infection

Neuropathic feet

We give amoxicillin 500 mg tds, flucloxacillin 500 mg qds and metronidazole 400 mg tds because streptococci, staphylococci and anaerobes are the most likely organisms. We believe that anaerobes are a common feature of superficial as well as deep infections, but may not always be isolated because of restriction on the length of time of incubation of cultures. We avoid the use of clindamycin in local infections because it has serious side-effects, the most alarming toxic effect being antibiotic-associated colitis which may be fatal. Although this can occur with most antibacterials it is more frequently seen with clindamycin.

When the ulcer extends to fascia or tendon we add either trimethoprim 200 mg bd or ciprofloxacin 500 mg bd to cover Gram negatives. However, strictiy, the infection is now classified as a deep infection (see below). We do not routinely use augmentin as the risk of acute liver toxicity is six times greater with augmentin than with amoxicillin.

If the patient is allergic to penicillin, we substitute erythromycin 500 mg qds for amoxicillin.

We send a deep swab or curettings for culture. It is important to know the organisms that are causing the infection so that antibiotics can be used accurately to target the causative organisms. It is said by some that it is not important to know the organisms as there will usually be a good response to antibiotic therapy. However, if there is not a good response and the patient deteriorates and no swab has been taken, it is then difficult to be accurate in antibiotic therapy. Meanwhile, time has been lost while the patient continues to deteriorate.

Follow-up plan. If no signs of infection and no organisms are isolated, we stop antibiotics.

If no signs of infection are present but organisms are isolated, we focus antibiotics and review the patient in 1 week.

If signs of infection are present but no organisms are isolated, we continue antibiotics as above.

If signs of infection are present and organisms are isolated, we focus antibiotics according to sensitivities.

If MRSA is grown, but there are no signs of infection we use topical mupirocin 2% ointment if sensitive. Patients should undergo an MRSA eradication protocol to remove it from carrier sites (Table 5.4). If MRSA is isolated with signs of infection, oral therapy with two of the following should be given: sodium fusidate 500 mg tds, rifampicin

Table 5.3 Antibiotic dosage in renal failure. (HD, haemodialysis; CAPD, continuous ambulatory peritoneal dialysis; CAVH, continuous arteriovenous haemofiltration; Cr, creatinine.)
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