Search Results
Therapeutic Options for Diabetic Foot Infections
A Review with an Emphasis on Tissue Penetration Characteristics
Foot complications are common in diabetic patients; foot ulcers are among the more serious consequences. These ulcers frequently become infected, and if not treated promptly and appropriately, diabetic foot infections can lead to septic gangrene and amputation. Foot infections may be classified as mild, moderate, or severe; this largely determines the approach to therapy. Staphylococcus aureus is the most common pathogen in these infections, and the increasing incidence of methicillin-resistant S aureus during the past two decades has further complicated antibiotic treatment. Chronic infections are often polymicrobial. Physiologic changes, and local and systemic inflammation, can affect the plasma and tissue pharmacokinetics of antimicrobial agents in diabetic patients, leading to impaired target-site penetration. Knowledge of the serum and tissue concentrations of antibiotics in diabetic patients is, therefore, important for choosing the optimal drug and dose. This article reviews the commonly used therapeutic options for treatment, including many newer antibiotics developed to target multidrug-resistant gram-positive bacteria, and includes available data relating specifically to the tissue penetration of these agents. (J Am Podiatr Med Assoc 100(1): 52–63, 2010)
Because of the ubiquitous nature of dermatophytes and a lack of an adaptive immune response in the nail plate, recurrence and relapse rates associated with superficial fungal infections are high (10%–53%). Cured or improved dermatophytosis patients could become reinfected if exposed to fungal reservoirs, such as an infected shoe, sock, or textile. To prevent this, footwear, sock, and textile sanitization methods can be used. To provide insight into effective sanitization options, the focus of this article is to review footwear, sock, and textile sanitization studies conducted throughout history (1920–2016). Thirty-three studies are covered in this review, encompassing techniques ranging from formaldehyde fumigation and foot powder application, to more modern approaches such as UV light and silver-light irradiation technologies. Older sanitization methods (eg, boiling, use of chlorine and salts) are quite limited in their practicality, as they can result in health complications and ruin shoe integrity. Newer approaches to shoe and sock sanitization, such as ozone application and UV irradiation, have shown very promising results. Further research is still needed with these modern techniques, as knowledge gaps and cost prevent the creation of standardized parameters for successful use. By combining sanitization methods with other preventative measures, protection against reinfection may be enhanced.
Antibiotic Stewardship
The Lower-Extremity Physician's Prescription for Effectively Treating Infection
The discovery of antibiotic drugs was one of the most significant medical achievements of the 20th century. The improper use of antibiotic drugs to prevent and treat infections has resulted in the emergence of resistance. Antimicrobic stewardship programs are becoming a mainstay in the fight against multidrug-resistant organisms. Individual clinicians should be encouraged to adopt the principles of antibiotic stewardship when treating lower-extremity infections in their scope of practice. First, a review of the available literature outlining the concept and practice of antibiotic stewardship is offered. Second, a discussion describing how to adopt and apply these principles to the individual clinician's practice as it applies to lower-extremity infections is offered. Finally, specific antimicrobial pharmacologic spectra and antibiogram information are offered.
Onychomycosis is a chronic fungal infection of the nail that is recalcitrant to treatment. It is unclear why normally effective antifungal therapy results in low cure rates. Evidence suggests that there may be a plethora of reasons that include the limited immune presence in the nail, reduced circulation, presence of commensal microbes, and fungal influence on immune signaling. Therefore, treatment should be designed to address these possibilities and work synergistically with both the innate and adaptive immune responses.
Fever is an active yet nonspecific response of the body to infections and other insults that cause immune cells to release cytokines, resulting in a brain prostanoid–mediated rise in body temperature. The causes, types, clinical management, and postoperative consequences of fever are reviewed in this article. Physicians use fever as a clinical sign for diagnoses and prognoses, but “fevers of unknown origin” continue to be problematic. Fevers that arise 1 or 2 days after surgery are usually due to stress and trauma, but later postoperative fevers often have more serious causes and consequences, such as wound infection. Fever is commonly encountered by podiatric physicians and surgeons, and certain procedures with the lower extremity are more likely to eventuate in fever. (J Am Podiatr Med Assoc 100(4): 281–290, 2010)
Azole Resistance in Dermatophytes
Prevalence and Mechanism of Action
Azole antifungal agents (eg, fluconazole and itraconazole) have been widely used to treat superficial fungal infections caused by dermatophytes and, unlike the allylamines (such as terbinafine and naftifine), have been associated with resistance development. Although many published manuscripts describe resistance to azoles among yeast and molds, reports describing resistance of dermatophytes are starting to appear. In this review, I discuss the mode of action of azole antifungals and mechanisms underlying their resistance compared with the allylamine class of compounds. Data from published and original studies were compared and summarized, and their clinical implications are discussed. In contrast to the cidal allylamines, static drugs such as azoles permit the occurrence of mutations in enzymes involved in ergosterol biosynthesis, and the ergosterol precursors accumulating as a consequence of azole action are not toxic. Azole antifungals, unlike allylamines, potentiate resistance development in dermatophytes.
Recently, there has been a resurgence of interest in potential phototherapy technologies for the local treatment of bacterial and fungal infection. Currently, onychomycosis is the principle disease that is the target of these phototherapies in podiatric medicine. Some of these technologies are currently undergoing in vitro and in vivo trials approved by institutional review boards. The three light-based technologies are ultraviolet light therapy, near infrared photo-inactivation therapy, and photothermal ablative antisepsis. Each of these technologies have markedly dissimilar mechanisms of action. In this review, each technology will be discussed from the perspectives of history, photobiology, individual mechanism of action, safety, and potential clinical efficacy, with data presented from published material. This review is intended to give podiatric physicians detailed information on state-of-the-art infectious disease phototherapy. (J Am Podiatr Med Assoc 99(4): 348–352, 2009)
This literature review sought to evaluate the current state of knowledge and guidelines surrounding the role of pH in the recovery of chronic nonhealing wounds. A systematic review of PubMed examining the relationship between pH and wound healing was completed. Seven sources were retrieved for review. The development of a highly structured and reproducible system of pH-driven therapy may add to the treatment algorithm for chronic nonhealing wounds.
Clinical podiatric medical practice encompasses a wide spectrum of podiatric medical and surgical problems. Technological advances such as imaging have greatly improved diagnostic acumen; however, physical diagnosis and blood testing remain extremely important factors in reinforcing diagnostic hypotheses as a part of differential diagnosis. There are certain blood tests of importance that the podiatric medical practitioner should be familiar with in everyday medical and surgical practice. The purpose of this article is to identify and highlight which blood tests are truly essential and practical in terms of diagnosis. This article encompasses blood tests pertinent to the clinical areas of hematology, hemostasis, electrolytes, endocrine, cardiac, rheumatology, nephrology, and gastroenterology. Careful selection of these tests and proper interpretation of their results will help reinforce diagnostic hypotheses.
Fungal Lung
The Risk of Fungal Exposure to Nail Care Professionals
Foot and nail care specialists spend a great portion of their day using nail drills to reduce nail thickness and smooth foot calluses. This process generates a large amount of dust, some of which is small enough to breathe in and deposit into the deepest regions of the respiratory tract, potentially causing health problems. Foot and nail dust often contains fungi, from both fungus-infected and healthy-appearing nails. Although the majority of healthy individuals can tolerate inhaled fungi, the immune systems of older, immunocompromised, and allergy-prone individuals often react using the inflammatory T helper cell type 2 pathway, leading to mucus overproduction, bronchoconstriction, and, in severe cases, lung tissue damage. To protect vulnerable podiatry professionals, wearing a surgical mask, using a water spray suppression system on nail drills, installing air filtration systems, and considering drilling technique can help reduce exposure to nail dust.
