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Respiratory tract infections

It has not been proven that DM is an independent risk factor for the development of common upper and lower respiratory tract infections. However, infections from certain micro-organisms are definitely more common in individuals with diabetes. Such micro-organisms are Staphylococcus aureus, Gram ( ) bacteria and mycobacterium tuberculosis.

Pain as the sole manifestation of infection in a neuroischaemic foot

A 77-year-old blind Afro-Caribbean man with type 2 diabetes of 22 years' duration, and peripheral vascular disease complained of pain in his right hallux and was brought to the foot clinic the same day (Fig. 5.7a). There was no swelling or cellulitis but pain was exacerbated by gentle pressure on the nail plate and a small area of nail plate close to the medial sulcus was very gently pared away to expose a small abscess under the nail which was drained (Fig. 5.7b). A deep swab was sent for culture and the abscess cavity was irrigated with normal saline and dressed with Melolin and Tubegauz amoxicillin 500 mg tds and flucloxacillin 500 mg qds were prescribed. The wound swab grew Staphylococcus aureus and Streptococcus group B. The toe healed in 1 month.

When is hospitalization of a patient with foot problems indicated

Small probability for MRSA Gram+ and Gram- and anaerobes High probability for MRSA In cases where a high probability for MRSA exists (methicillin-resistant Staphylococcus aureus) the addition of linezolide or glycopeptide is indicated. Hemisynthetic penicillins oxacillin, dicloxacillin. First generation cephalosporins Cephalexin, cephazolin, cephapirin. Cephalosporins of 2nd 3rd 4th generation cephaclor, cefuroxime, ceforanid, cefoxitin cefotaxime, ceftriaxone, ceftazidime cefipime. B-lactame antimicrobials with inhibitors of b-lactamases amoxycillin clavulanate, ampicillin sulbactam, ticarcillin clavulanate, piperacillin tazobactam. Glycopeptides teicoplanin, vancomycin. Fluoroquinolones ciprofloxacin, levofloxacin. TMP SMX trimethoprim sulfomethoxazole. Aminoglycosides gentamycin, amikacin, tobramycin, netilmicin. Carbapenems imipenem cilastatin, merope-nem, ertapenem. Other medicines active against MRSA are also expected in the market (e.g. pristinamycin).

Stage Foot with Infection Diagnosis

The microbiology of diabetic foot infections is unique and gram positive, gram negative and anaerobes can be responsible. Staphylococci and streptococci are the most common pathogens. However, infection due to gram negative and anaerobic organisms occur in approximately 50 of patients and often infection is polymicrobial. Staphylococcus aureus is the most common organism although MRSA is increasingly found in infected ulcers (68). There is a poor immune response of the diabetic patient to sepsis and even bacteria regarded as skin commensals, may cause severe tissue damage. This includes gram negative organisms such as Citrobacter, Serratia, Pseudomonas and Acinetobacter. It is advisable to send swabs or preferably tissue for culture after initial debridement in all Stage 4 patients (69,70). In osteomyelitis, superficial swab cultures may not reliably identify bone bacteria and percutaneous bone biopsy seems to be safe for patients with diabetic foot osteomyelitis (71).

Microbiological Control

Topical anti-microbials may be used (57). Iodine is effective against a wide spectrum of organisms. At high concentrations it can be toxic to human cells, but bacteria are more sensitive to these effects than human cells such as the fibreblast. Povidone-iodine is effective in anti-bacterial prophylaxis in burn patients. Cadexomer-iodine consists of microspheres, formed from a three dimension lattice of cross linked starch chains and has been used with success in diabetic foot ulcers. Silver compounds are also widely used in anti-bacterial prophylaxis (58). Mupirocin is active against gram positive bacteria, including methicillin resistant staphylococcus aureus (MRSA).

Openloop Systems Csii

Infection at the site of infusion, sometimes with abscess, is more common than with injections the organisms reported include Staphylococcus aureus, S. epidermidis, and Mycobacterium fortuitum (52-54). It is possible that infection may be more common with certain insulin preservatives such as m-cresol (53), but the risk can be substantially reduced by limiting the cannula use to 2 d, no reuse of cannulae, washing hands, cleaning the implantation site, and covering the implanted needle with a sterile dressing.

Septic arteritis and wet necrosis in a neuropathic foot

A 72-year-old man with type 2 diabetes of 11 years' duration and peripheral neuropathy developed a neuropathic plantar ulcer over his 4th metatarsal head. After 3 weeks the foot became swollen with purulent discharge and he was systemically unwell. He was admitted to hospital and given amoxicillin 500 mg tds, flucloxacillin 500 mg qds and metronidazole 500 mg tds intravenously. An ulcer swab grew Staphylococcus aureus and Streptococcus group B and mixed anaerobes.

Extensive deep soft tissue infection with abscess revealed by MRI

A 65-year-old man with type 2 diabetes for 10 years tripped and fell on the pavement. He had no pain at the time but he noticed swelling the next day and was sent for an X-ray by his general practitioner. The X-ray revealed that he had fractured the necks of his left 2nd, 3rd and 4th metatarsals and he was treated with a below-knee walking plaster. He sustained ulceration on the plantar surface of the foot over the 2nd and 3rd metatarsal heads and the cast was removed. He was referred to the diabetic foot clinic. The left foot was swollen and cellulitic and he had rigors. Clinically there was no obvious abscess, but he had a fever. A deep wound swab grew Staphylococcus aureus. He was treated with intravenous amoxicillin 500 mg tds, flucloxacillin 500 mg qds, metronidazole 500 mg tds and ceftazidime 1 g tds. His left foot remained oedematous with pus discharging from the plantar lesion. He became increasingly unwell and went into renal failure. An MRI then showed an inflammatory mass...

Wet Gangrene And Sepsis

Dry Gangrene

Swab cultures revealed Staphylococcus aureus and Pseudomonas aeruginosa and the patient was treated with ciprofloxacin and clin-damycin. Blood cultures were negative. on the second day the patient felt better and became afebrile by the third day of hospitalization. An infected gangrenous area of the foot and particularly on a toe with bounding feet pulses is a condition that is sometimes seen. This is called 'diabetic gangrene' and it is caused by a thrombosis in the toe arteries which is induced by toxins produced by certain bacteria (mainly staphylococci and streptococci). Plantar abscesses may also result in septic arteritis of the plantar arch and eventually gangrene of the middle toe.

Neuropathic ulcer with extensive sloughing of subcutaneous tissue

Neuroischemic Foot Ulcer

A 68-year-old man with type 2 diabetes of 15 years' duration presented with a swollen left foot which was brawny and cellulitic. There was a deep ulcer over the 4th metatarsal head discharging pus (Fig. 5.19a). It had started as a blister 4 weeks previously. Pulses were bounding. Tissue was sent for culture and he was admitted and treated intravenously with amoxicillin 500 mg tds, flucloxacillin 500 mg qds, metronidazole 500 mg tds and ceftazidime 1 g tds. He underwent operative surgical debridement on the same day (Fig. 5.19b). There was extensive subcutaneous sloughing of deep tissue down to bone in the forefoot. Culture of tissue from the diabetic foot clinic and tissue taken at surgery both grew Staphylococcus aureus, Proteus spp. and mixed anaerobes. The initial antibiotic regime was continued to eradicate the above organisms until the cellulitis had settled. He made a good recovery and the wound healed within 10 weeks (Fig. 5.19c).

Clinical Examination And Screening Techniques To Identify The Patient At Risk Of Foot Ulceration

Foot Ulcer Debridement

Treatment of infection involves debridement of all necrotic tissue with aggressive, adequate drainage along with antibiotic therapy. Antibiotic selection should take into account the likely causative organisms, whereas bearing in mind the potential toxicity of the agents. In the diabetic foot, the bacteria most likely responsible for minor, non-limb threatening infections such as a cellulitis are Staphylococcus and Streptococci. Whereas more severe, deeper, and limb-threatening infections are generally the consequence of a polymicrobial infection (90). Empirical antibiotic selection should be based on the suspected bacterial pathogens along with modifications to address anticipated resistant pathogens that might have been present during earlier episodes of infection. Antibiotic selection should minimize toxicity and be cost effective. Broad spectrum antimicrobial therapy should be initiated empirically with reassessment following the results of culture data. The main antibiotic...

Infected Plantar Ulcer With Osteomyelitis

Minor Infected Toe

On examination, an irregular, soaked, foul-smelling ulcer with sloughy bed, and surrounding cellulitis of 3 cm in diameter was found body temperature was normal. Diabetic neuropathy was diagnosed, while peripheral pulses were normal. Signs of osteomyelitis (osteolysis of the first metatarsal head, and the base of proximal phalanx of the hallux, with periosteal reaction) were noted on the radiograph (Figure 8.24). A post-debridement swab culture from the base of the ulcer revealed methicillin-resistant Staphylococcus aureus and Escherichia coli. The patient was admitted to the hospital. The white blood cell count was 14,700 mm3, anemia (Hb 9.8 g dl) characteristic of chronic disease was found, the erythrocyte sedimentation rate was 90 mm h and the level of C-reactive protein was 70 mg dl. She was treated with 600 mg teicoplanin

Chronic Neuropathic Ulcer With Osteomyelitis

Diabetic Foot Osteomyelitis

On examination, severe diabetic neuropathy was found. The peripheral pulses were palpable and a full-thickness neuropathic ulcer with gross callus formation was observed under his right fifth metatarsal head (Figure 8.34). Sharp debridement was carried out and the underlying bone was probed with a sterile probe. A plain radiograph revealed pseudoarthrosis of a stress fracture of the upper third of his fifth metatarsal, bone resorption in the metatar-sophalangeal joint, and osteolytic lesions in the fifth metatarsal epiphysis (Figures 8.35 and 8.36). Post-debridement cultures from the base of the ulcer revealed Staphylococ-cus aureus, Proteus vulgaris and Entero-coccus spp. The patient was treated with amoxicillin-clavulanic acid 625 mg three times daily for 2 weeks. He was advised to rest and appropriate footwear and insoles were prescribed. A fifth ray amputation was undertaken and antibiotics continued for two more weeks. A bone culture revealed Staphylococcus aureus. The wound...

Necrotizing Fasciitis Meleneys Synergistic Gangrene Acute Dermal Gangrene Necrotizing Erysipelas

Bacteriologically, two types of infection are described. Type I infection is caused by a combination of at least one anaerobe and one or more facultative anaerobes such as streptococci or enterobacteriaceae. Type II infection is caused by group A P-hemolytic streptococci alone or in combination with staphylococci (38). Recently, Howard et al. have described necrotizing fasciitis on exposure of nonintact skin to salt-water-borne halophilic marine vibrios (39). Tissue damage and systemic toxicity are as a result of release of endogenous cytokines and bacterial toxins.

Fibromyositis and Fibromyalgia

Trichinella is the most common cause of these diseases, but sometimes Ascaris larvae or hookworms or strongyle larvae are the main culprits. These wormlets bring hosts of bacteria with them, mainly Streps (Streptococcus varieties) and Staphs (Staphylococcus varieties), but also Clostridiums (Clostridium (Campylobacter varieties). The bacteria are probably the pain causers. By killing all bacteria Staphs, Streps, Clostridiums and Campyls using a zapper, you may get relief for one hour

Fungal Infection With Multimicrobial Colonization

Diabetic Foot Infection

Superficial ulcers of 10 days' duration on the facing sides of the left first and second toe of a 70-year-old type 2 diabetic lady with diabetic neuropathy, before debridement are shown in Figures 8.8 and 8.9. Note soaking of the skin. An X-ray excluded osteomyelitis. Staphylococcus coagulase-negative, Pseudomonas aerugi-nosa and enterobacteriaceae were recovered after swab cultures in addition to Candida albicans. She was treated successfully with itraconazole for 5 weeks. The patient used a clear gauze in order to keep her toes apart, together with local hygiene procedures twice daily. Weekly debridement was carried out and no antimicrobial agent was needed. The patient was admitted to the hospital and treated with intravenous ciprofloxacin and clindamycin. No osteomyelitis was found on repeated radiographs. Extensive surgical debridement was carried out. Deep tissue cultures revealed Staphylococcus aureus, Escherichia coli and anaerobes. The patient was discharged in fair condition...

Conservative treatment of osteomyelitis

Staphylococcus Aureus Foot

She was sent for X-ray (unremarkable), and for vascular assessment which showed monophasic pulsatile waveforms and elevated indices due to arterial calcification. A deep swab was sent for culture and grew Staphylococcus aureus. The ulcer was debrided and dressed with a foam dressing. Quadruple antibiotics were prescribed initially oral amoxicillin 500 mg tds, flucloxacillin 500 mg qds, metronidazole 400 mg tds and ciprofloxacin 500 mg bd and then narrowed down to fucidin 500 mg tds and flucloxacillin 500 mg qds. Although repeat X-ray after 2 weeks showed lucency of the terminal phalanx compatible with osteomyelitis, the ulcer healed

Large tissue deficit in a neuroischaemic foot secondary to infection needing distal arterial bypass

Femoral Popliteal Bypass Incision

A 43-year-old male with type 1 diabetes of 27 years' dura tion, with peripheral and autonomic neuropathy, was referred with indolent neuropathic ulceration complicated by local cellulitis over the left 5th metatarsal head His pedal pulses were palpable. He was treated with ora amoxicillin 500 mg tds and fludoxacillin 500 mg qds anc outpatient debridement. His deep wound swab hac grown Staphylococcus aureus and Streptococcus group G. The cellulitis resolved and he was given a total-contact cast. The ulcer healed after 8 weeks and he was given bespoke shoes with cradled insoles. metronidazole 400 mg tds. He had recently had a methi-cillin-resistant Staphylococcus aureus (MRSA) infection on the contralateral foot. Angiography showed occlusions of the right common iliac artery and superficial femoral artery. It was planned to perform an angioplasty of the The patient was followed up in the diabetic foot clinic and the ulcer had almost healed after 4 months. Despite careful education about...

Urinary Tract Infections in Diabetes

The most common microbe in diabetics with UTI is Escherichia coli. However Klebsiella and Proteus sp are more frequently found in diabetic patients than in the control population (220,221). Also, unusual microbes such as fungi, particularly Candida, staphylococci, and Pasteurella multocida may also be responsible for a small fraction of UTIs (225-229). There are, possibly, multiple mechanisms underlying the reported higher frequency and severity of UTI in diabetes. Some of the proposed mechanisms include gluco-suria, which favors bacterial growth, impaired bladder evacuation, increased adherence of pathogens to uroepithelial cells, and defective neutrophil function (229,230). (232-234), and renal papillary necrosis (235,236). Renal papillary necrosis has been one of the oldest documented and most recognized such complication (235). It can present with recurrent UTI, fever, renal colic, hematuria, flank, and or abdominal pain and the diagnosis is usually established by retrograde...

Delayed presentation of infection masked by callus

Deep Extensive Cellulitis

Men of pus grew Staphylococcus aureus. She was admitted to hospital and given intravenously amoxicillin 500 mg tds, flucloxacillin 500 mg qds, metronidazole 500 mg tds and ceftazidime 1 g tds. When the result of the culture was available this was reduced to flucloxacillin only. The foot healed in 1 week. She was followed up by the diabetic foot service and the problem did not recur.

Local signs of infection not noted by patient

Dangers Infected Diabetic Toe

A 53-year-old lady with type 1 diabetes of 25 years' duration, proliferative retinopathy with reduced vision, peripheral neuropathy and hallux rigidus developed a neuropathic ulcer under callus on the plantar surface of her right hallux. She was warned of the usual danger signs of deterioration (redness, warmth, swelling, pain, purulent discharge) but did not return to clinic until her routine appointment. Callus had grown over the ulcer preventing drainage and the toe had become cellulitic (Fig. 5.1a,b). Callus was debrided and pus drained (Fig. 5.1c). A deep wound swab was taken and oral amoxicillin 500 mg tds and flucloxacillin 500 mg qds were prescribed. She was reviewed the next day. The toe had not improved and she was admitted for bed rest and intravenous antibiotics according to our protocol, namely amoxicillin, 500 mg tds, flucloxacillin 500 mg qds, metronidazole 400 mg tds and ceftazidime 1 g tds. The swab taken at her outpatient clinic visit grew Staphylococcus aureus and...

The Infected Foot Ulcer

Bacteria that colonize normal skin are coagulase-negative staphylococci, a-hemo-lytic streptococci and other gram-positive aerobes, and corynebacteria. Staphylococcus aureus or 3 -hemolytic streptococci, pathogens that colonize the skin of diabetic patients, are the causative agents of acute infections in antibiotic-naive patients, and are nearly always the cause of cellulitis in non-ulcerated skin Staphylococcus aureus is the most commonly recovered pathogen in most infections in which a single agent is isolated. Polymicrobial cultures, with an average of five or six organisms, are often obtained from patients with chronic lesions, especially when they have been treated with antibiotics for some time anaerobes, mostly Bacteroides sp. and various anaerobic gram-positive cocci are often isolated from deep necroses Proteus spp. and Escherichia coli predominate among gram-negative bacilli and Pseudomonas is often isolated from indurated, wet wounds. In severe infections, gramnegative...

Multiple Sclerosis Amyotropic Lateral Sclerosis

Brandi Rainey, age 34, of Amish religious culture, was diagnosed with MS four months earlier after an MRI confirmed it although she had symptoms for many years. She was told she had inherited a gene for it and that Amish folk are particularly susceptible to MS for reasons of inbreeding. She had a constant pain running down the side of her neck, and headache. Her legs were getting too heavy to get up stairs. Our tests showed her brain was full of scandium (tooth metal alloy) and fluoride (toothpaste). Her vision was getting worse her eyes were full of wood alcohol. She lost no time in getting dentures there were no teeth that could be saved. She had several bacteria growing in her jaw bone Strep G (sore throat bacteria), Staphylococcus aureus (this was raising her pulse to over 100), Clostridium tetani (causes great stiffness), and Shigella (produces nerve toxins). She killed these with a frequency generator. Five weeks later the pain and stiffness in her neck were gone, her pulse was...

Extensive deep soft tissue infection secondary to interdigital tinea

A 43-year-old man with type 2 diabetes of 2 years' duration was admitted via casualty with an infected neuropathic left foot with cellulitis, oedema and a purple patch on the dorsum of the foot. He was apyrexial. The dorsum of his foot was fluctuant and he was taken to theatre and underwent incision and drainage of an abscess. The pus from the abscess grew Staphylococcus aureus and he was treated with flucloxacillin 500 mg qds. The wound was not sutured but left open to heal by secondary intention. The original portal of entry was thought to be a webspace infected with tinea pedis. The foot healed in 9 weeks. He was issued with two pairs of bespoke trainer-style shoes and remained healed.

Management of the five presentations of infection

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. 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

Relapse of Charcots osteoarthropathy or infection

A 60-year-old type 1 diabetic of 42 years' duration who had bilateral Charcot's osteoarthropathy affecting both feet and 12 years' previous history of ulcers and infections, was referred to the foot clinic with a hot, swollen left ankle and erythema over the medial malleolus. Both her feet were intact. The left foot was very painful on weightbearing. A provisional diagnosis of infection was made although we could not be sure that this was not a relapse of Charcot's osteoarthropathy. She was given intravenous vancomycin 1 g bd, ceftazidime 1 g tds, metronidazole 500 mg tds and oral fucidin 500 mg tds as she had recently had an MRSA infection. The ankle initially appeared to settle, but after 3 days she developed severe pain in the left foot and ankle at rest, with a fever of 39 C and rigors. She went to theatre and an abscess communicating with the subtalar joint was drained. A swab showed pus cells but no growth. She healed in 4 months, but came back to the foot clinic again with a...


Alyce Dold, 64, came because she was worried about her blood sugar and chest pain. Indeed, a blood test showed her fasting blood sugar to be 136, just beginning to show insufficient insulin production by her pancreas. She had pancreatic flukes and wood alcohol there. Also mumps virus and HA virus. She had six more solvents accumulated due to eating raisin bran and other cold cereals each day. She was glad to be forced off this routine she switched to 2 eggs every other day with biscuits or bread (not toast) and cooked cereal in between. Her chest pain was due to dog heartworm and Staphylococcus aureus bacteria that originated at teeth 16, 17, 1, 32. The worms and Staph were killed with a frequency generator. She was referred to a dentist for cavitations and started on kidney herbs. Two weeks later, there was still a little residual heart pain due to Staph dental work was not yet done. She was given chromium (600 mcg per day) to help her insulin regulate sugar. Her LDH (See tests) was...


Physical examination revealed swelling, cellulitis and increased skin temperature of the forefoot with an abscess overlying the 5th metatarsophalangeal joint (Fig. 8.2a). Inspection of the plantar aspect of the foot revealed a thick callus, with haemorrhage, beneath the 5th metatarsal head. The 5th toe appeared bluish-black. Laboratory studies revealed an elevated white blood cell count, 17 000 (lL, and elevated fasting serum glucose, 203 mg dL (11.3 mmol L). Radiographic evaluation revealed subluxation of the 5th metatarsophalangeal joint. The patient was admitted to the hospital for surgical management and intravenous antibiotics. At the bedside, the abscess was incised and drained, revealing a purulent-sanguineous discharge (Fig. 8.2b). Using a sterile probe, the dorsal wound was found to communicate with the plantar aspect of the joint, and exited through the bottom of the foot. Wound cultures revealed a single organism, Staphylococcus aureus, sensitive to penicillinase-resistant...

Heart Disease

Staphylococcus aureus is a bacterium hiding out in far away places like pockets left under teeth when they were extracted or along root canals. Make sure extractions heal and don't leave permanent cavitations where bacteria can live. Ask a dentist familiar with cavitations to do a mouth search. Once the mouth source is cleaned up, the bacteria do not come back to the heart (after one last zapping). If they do, go back to the dentist Killing these three invaders (heartworm, Loa loa, Staphylo-coccus aureus) should cure an irregular heart beat immediately (within a day).

The Diabetic Foot

The main causes of foot ulceration are neuropathy, medium and small vessel peripheral vascular disease and abnormal foot biomechanics. These factors are frequently compounded by bacterial infection with organisms such as Staphylococcus aureus and Streptococcus pyogenes, often accompanied by anaerobes such as Bacteroides species. Neuropathy is thought to be the main factor in over one-half of ulcers with trauma occurring as a result of loss of pain sensation. Minimal trauma, such as a foreign body in the shoes, ill-fitting shoes or walking barefoot on a hot surface may lead to devastating effects (see Figures 108 and 109). Excessive pressure loading on the sole, especially over the metatarsal heads and heels, predisposes to the formation of callus which can break down and lead to ulceration. Indeed callus is an important predictor of ulceration. Such excess pressure is generated by motor-nerve damage altering the posture of the foot, limited joint mobility and local deformities...

Heart Health

Many common bacteria, especially Staphylococcus aureus, choose the heart as their favorite location. Their nesting place, though, will be under a missing tooth in the jaw (cavitation). Heartworm and Loa loa are two very common heart parasites. You can have all these killed in a day, without side effects and your heart is once more free to beat regularly. Don't take a chance on over-medicating. As soon as the beat is regular and under 100 per minute, reduce your heart drugs. Stop them when you are regular and under 80. Fatigue will leave and the brain will work better.

Sleep Apnea

Chester Fannon, 5Oish, was quite overweight and wore a mask at night with an air blower to assist his breathing. He had been referred to a sleep center for sleep apnea. He had extreme dryness of his throat at night and some hearing loss in one ear. He was toxic with arsenic (roach killer), bismuth (cologne), tin (toothpaste), and thallium (polluted dentalware). He was infested with both species of Ascaris and had a hacky cough. He had four solvents accumulated in his tissues. He was growing nine pathogens Mycoplasma, Haemophilus inf., Streptococcus pneu, A-strep, Nocardia, Staphylococcus aureus, Bacillus cereus and Flu virus, over half of them in his throat. These were killed with a frequency generator and a general cleanup was done. After two teeth were pulled he no longer needed his mask, he no longer had apnea.

Other Risk Factors

There are many reasons for impaired resistance to infection in a diabetic ulcer. Diabetes is associated with impaired neutrophil function, particularly in the presence of a high blood glucose, and macro- and micro-circulatory abnormalities lead to relative hypoxia in the wound (Pecoraro et al 1991). Multiple microbes, often a mixture of aerobic and anaerobic bacteria, are usually found in cultures from foot ulcers. The commonest pathogenic organisms in diabetic foot ulcers are Staphylococcus and Streptococcus. The streptococci are often faecal in origin. The clinical relevance of organisms grown from superficial swabs is variable as other organisms may colonize the wound surface and the quality of the sample and the method of transport and culture markedly influence the reliability of the result (Louie, Gartlett and Tally 1976). The treatment of infections associated with foot ulceration is detailed further in the management of foot ulceration.

Stomach Pain

Our dairy foods are polluted with Salmonella and Shigella bacteria. It is impossible to operate a dairy without getting some cow manure into the milk. Although udder wash contains antiseptic it does not kill all manure bacteria. Later, when milk is pasteurized, many heat sensitive bacteria are killed like the friendly streps and staphs, but not all the harmful Salmonellas and Shigellas. Some survive to colonize the milk, then later infect the consumer. Only milk that is sterilized is safe. A commercial source of sterilized (safe) milk can sometimes be found on the shelf (unrefrigerated). If it had any bacteria, it would not survive shelf life for more than one day If your body has lost its ability to kill Salmonellas and Shigellas, all the antibiotics and herbs and good bowel habits cannot protect you from these ubiquitous bacteria. You could ask how you lost your natural protection from them. There is evidence that common antibiotics that kill Streptococcus and Staphylococcus...


The choice of proper antibiotics for infected diabetic ulcers depends on an understanding of the bacteria likely to be present in the wounds (14). In new wounds with Gram-positive bacteria, the micro-organisms are most commonly staphylococcus or streptococcus. Appropriate antibiotics include cephalexin, amoxicillin clavulanate, or clindamycin. In older wounds with Gram-negative organisms and anaerobic bacteria, broad-spectrum antibiotics may be more appropriate. Milder infections can be treated with a lactam lactamase inhibitor combination such as ampicillin sulbactam, orpiperi-cillin tazobactam, or clindamycin with a fluoroquinolone. Severe infections may require imipenem cilastatin or the combination of vancomycin, azetreonam, and metronidazole. Antibiotic therapy should be adjusted based on culture and sensitivity of the micro-organisms identified.

Mild Infections

Mild infections with limited cellulitis can generally be treated with oral antibiotics on an outpatient basis. Several antibiotics have been shown to be effective in clinical trials including cephalexin, clindamycin, ciprofloxacin. ofloxacin, levofloxacin, clindamycin, pexiganan, and linezolid. However, no single drug or combination of agents appears to be better than others. If MRSA is grown and there are no local or systemic signs of infection, topical mupirocin 2 ointment (if sensitive) may be used. If MRSA is grown and accompanied by local signs of infection, oral therapy with two of the following should be considered sodium fusidate, rifampicin, trimethoprim and doxycycline, according to sensitivities, together with topical mupirocin 2 ointment.

Recent Developments

1 Multiresistant strains of bacteria, particularly MRSA, are of increasing concern. Resistance to vancomycin as well as isolated resistance to the oxazolidinone, linezolid, to the streptogramins, quinupristin and dalfopristin, and to the cyclic lipopeptide, daptomycin, has been identified. Spread by cross-contamination has the potential to establish resistant clones, causing endemic, untreatable infections. Rigorous attention to infection control and rapid MRSA testing are increasingly on the agenda of healthcare providers and are needed to facilitate patient isolation and reduce cross-infection rates in healthcare institutions.

Severe Infections

If cellulitis is increasing, then the patient should be admitted for intravenous antibiotics. Quadruple therapy may be used including amoxycillin, flucloxacillin, metronidazole and ceftazidime. REF If patient is allergic to penicillin, amoxycillin and flucloxacillin should be replaced with erythromycin or vancomycin (with doses adjusted according to serum levels). On admission the foot should be urgently assessed as to the need for surgical debridement. On follow-up, the infected foot should inspected daily to gauge the initial response to antibiotic therapy. Appropriate antibiotics should be selected when sensitivities are available. If MRSA is isolated, then vancomycin (dosage to be adjusted according to serum levels) or teicoplanin should be given. These antibiotics may need to be accompanied by a further appropriate oral antibiotic such as sodium fusidate or rifampicin. When the signs of cellulitis have resolved. intravenous antibiotic therapy can be changed to the appropriate...

Skin Infections

People with poorly controlled diabetes are prone to skin infections because elevated blood sugar reduces the effectiveness of bacteria-fighting cells. Carbuncles, boils, and other skin infections may be hazardous if not properly treated. Even a small cut may progress to a deep, open sore, called an ulcer, if not treated promptly. In most cases, good hygiene (clean skin) and good diabetic control will improve your body's ability to resist infection. Sometimes, however, antibiotics are necessary.


2nd Toe Sloughy Ulcer

The sausage-like appearance of a toe usually denotes osteomyelitis. Bone infection was confirmed on X-ray, showing osteolysis of the first and second phalanges. Staphylococcus aureus and Kleb-siella pneumoniae were cultured from the base of the ulcer. The patient was treated with cotrimoxazole and clindamycin for 2 months. She was also referred to the Vascular Surgery Department for a percutaneous transluminal angioplasty of her right popliteal artery. After 2 months the ulcer was still active and the patient had local extension of osteomyelitis despite the restoration of the circulation in the periphery. She eventually had her second ray amputated. A bone culture revealed the presence of Staphylococcus aureus. She continued with cotrimoxazole for two more weeks.


MIDD Maternally inherited diabetes and deafness MO Macular oedema MODY Maturity-onset diabetes of youth MRA Magnetic resonance angiography MRFIT Multiple Risk Factor Intervention Trial MRI Magnetic resonance imaging MRSA Methicillin-resistant Staphylococcus aureus NAOIN Non-arteritic optic ischaemic neuropathy NASCET North American Symptomatic Carotid

Evelina Rojas, age 12, was having extreme fatigue with mood problems and sudden fevers. She killed Ascaris and sheep liver flukes with the parasite program but promptly got them back due to a benzene buildup I believe due to using products containing an herbal oil. Her high levels of Streptococcus pneumoniae (cause of fevers), Staphylococcus aureus and Nocardia could not be eliminated until her three baby teeth (with root canals) were pulled. After that, she was well.

Heel Pain

Another reason not to drink water from bottles, however convenient, is that it is stagnant and is soon contaminated with our own bacteria from contact with mouth or hands. Staphylo-coccus (Staph) and E. coli are commonly seen. The solution is not to add still more chemical disinfectants, the solution is to drink from a flowing source, such as our faucets. If you must carry water, use glass containers plastic is porous and much

Eye Pain

By killing all the large parasites plus a few bacteria (Staphylococci, Chlamydias, Neisserias) the eye can become pain free in a few days. If pain returns, you missed something or reinfected yourself. Everyone in the family including pets needs to be treated for all the parasites. No indoor pets should be kept by a person of low immunity, since infecting yourself daily and then killing parasites daily is not a solution.