I’M BAAAACCK

October 20th, 2014 by Warren S. Joseph DPM FIDSA
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Dear Readers,

It’s been awhile. Time really does fly. I realize it has been over a year and a half since my last post. I really don’t have any excuses. Life just seems to happen that way. One day I am posting all sorts of updates on what’s happening in the world of lower extremity infections and then I just stopped. Over these past months, I have had a number of people ask me what ever happened to the blog as they really enjoyed reading it and felt it was valuable. I’ve heard from students, residents, colleagues, my publisher and a surprising number of people I would have never expected to be interested. It made me realize how large my readership and reach really was.

I’ve heard you. I believe that the time is finally right to start things up again. You may have seen the recent ad that DataTrace placed on PM News about the resurrection of the blog. www.podiatrym.com/pmnews.cfm.  There has been quite a bit happening in the world of antibiotics and antifungals for onychomycosis. After having only one FDA approved antibiotic in 5 years, now we have had 3 new drugs released in just a few months. The antifungal situation is even more exciting. It has been 15 years since any new drug has been approved for the treatment of onychomycosis. In just over a month this summer, two new topical agents were approved and are now being marketed. And, that is just the beginning. The literature continues to contain studies on diabetic foot infections, onychomycosis and osteomyelitis at a seemingly increasing rate. I have become a big fan of My NCBI (www.ncbi.nlm.nih.gov/) a free service that allows you to sign up for alerts to newly published literature using any search terms you wish. For example, every Monday morning I receive weekly emails alerting me to papers on the topics of “foot osteomyelitis”, “diabetic foot infections”, and “onychomycosis”.

Over the next few weeks I hope to cover all of these topics and more. I may experiment a bit with format providing some really brief entries to compliment the longer more in-depth posts that really take some time and effort to sit down and write.

I want to thank all of you who have inquired about the blog and asked me to re-start it. Also, thank you to ALL of my readers. The site had quite a nice sized following in the past and I hope to build it back up and surpass that reach in the near future.

Posted in Antibiotics, Diabetic Foot, Osteomyelitis | No Comments »

News Story About Pharma Industry Payments – Response

March 13th, 2013 by Warren S. Joseph DPM FIDSA
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I am sorry that it has been so long since I put up a post.  Things have been slightly hectic. Unfortunately, instead of reporting on new infectious disease information, with this entry I find myself responding to a story about my receiving payments to lecture from the pharmaceutical industry.  The story ran today (3/13/13) in the Philadelphia Inquirer and online at www.philly.com/philly/health/
20130312_Philly_foot_doc_among_highest_paid_by_Big_Pharma.html

When the original print story was run I had not had a chance to respond to the author, reporter Sam Woods.  I give Mr. Woods credit for updating the online story in response to some of my comments, reproduced below, which I emailed to him this morning.

I feel that the Pharma Industry has done an excellent job in disseminating important information that may otherwise not be available to those of us interested in saving limbs of patients with diabetes.  This is done in an unbiased, government approved and monitored way, under strict federal guidance.  My lectures are randomly, and independently audited for compliance with these guidelines and I have never been found to be deficient.

Here is my response to Mr. Wood in its entirety:

Sam

I read your article from today in Philly.com.  Just to respond to a few items:

1.   I did not call you yesterday since my family was at my father’s deathbed.  We lost him last night at 7PM.  You will probably see the obit in the Inquirer in the next day or so.  I had every intention of contacting you this morning (as I am doing now)

2.  As to responding to ProPublica, they phoned me while I was out of the country lecturing at a continuing education (non Pharma sponsored) meeting.

3.  All of my lectures given for the Pharma industry follow strict FDA guidelines and are consistent with the corporate integrity agreements entered into between the companies and the government.  There is full disclosure of this fact at all lectures.

4.  I have not worked at the Coatesville VA in a number of years.  I strictly work out of Roxborough and am a private, self-employed citizen; not an employee of any company, government, hospital, or health care organization.

5.  Thank you for at least quoting the article from last year.  I stand by what I said there.  Some organizations have an agenda to make interactions between Pharma and doctors somehow seem nefarious.  Let me give you some statistics if you want the REAL story:  There are 28 million people in the US with diabetes.  About 350 million worldwide (and yes, I have lectured around the world on this topic).  It used to be said that someone in the world loses a limb to diabetes every 30 seconds.  That is now down to every 20 seconds.  Diabetes is the cause for about 70-80,000 amputations per year in the US alone.  The single greatest cause. The 5 year mortality of people who present to their doctors for the first time with a diabetic foot ulceration is HIGHER than the 5 year mortality for breast cancer, prostate cancer and Hodgkin’s lymphoma.  If you add peripheral arterial disease to that, the 5 year mortality is even higher than colorectal cancer.  Diabetic foot infection accounts for about 33% of the >$100 BILLION spent on patients with diabetes each year and accounts for the greatest number of hospital days YET the NIH only provides <0.2% of all of their diabetes funding to study foot complications (soon to be presented new data).  The vast majority of research in the treatment of diabetic foot infections has been done by the private sector including the Pharma industry.  Yes, I go out and spread this information to my colleagues and it is often paid for by industry. However, by doing so I know I have saved countless limbs and lives.  Frankly, I don’t see anything nefarious about that…only good.

Kind Regards,

Warren Joseph, DPM, FIDSA

Consultant, Lower Extremity Infectious Diseases

Posted in Diabetic Foot, Infections, Uncategorized | No Comments »

Off Label Drug Promotion…Coming Soon?

December 12th, 2012 by Warren S. Joseph DPM FIDSA
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(I want to thank my friend and colleague Jeff Karr, DPM (www.osteomyelitiscenter.com) for alerting me to this news story.)

Just this past week the U.S. Second Circuit Court of Appeals ruled to prohibit criminal prosecution for truthful off label promotion of drugs as a First Amendment right. An excellent analysis of the case can by the law firm of Morgan, Lewis and Bockius can be found at:  http://www.morganlewis.com/pubs/WhiteCollar_LF_CriminalProsecutionTruthfulOff-LabelPromotion_6dec12.pdf and I direct anyone interested to read this summary.  I will not go into details but, rather, discuss how this may affect antibiotics and lower extremity infections (LEIs). 

The case, United States v. Caronia, was against a drug rep who was taped on two occasions discussing off label use of a drug, Xyrem used for narcolepsy, which is a misdemeanor.  From my interpretation of the referenced information, it appears that the Court decided that since the Food, Drug and Cosmetic Act allows physicians to legally prescribe any licensed drug for any indication, promotion of such use, as long as it was not false or misleading, was a “lawful activity” protected by the First Amendment. 

I will start by saying that I don’t believe that this will open the floodgates for armies of drug reps knocking down doors to speak about unapproved uses.  This will probably have to go higher in the court system with the next step being the Supreme Court.  Furthermore, many of the Big Pharma players are running somewhat scared of the Feds right now having sustained multi- BILLION dollar fines and signing “Corporate Integrity Agreements” with the Government that puts very strict rules in place on what they can, and cannot, do in terms of promotion. 

How does this impact antibiotics and LEIs?  Currently we only have 3 antibiotics FDA approved for the treatment of Diabetic Foot Infection; ertapenem, linezolid and piperacillin/tazobactam.  This may not change in the near future.  Under the current “Acute Bacterial Skin and Skin Structure Infection” (aBSSSI) guidance being followed by the FDA for new antibiotic approval, diabetic foot infection has been SPECIFICALLY EXCLUDED.  Although I am hoping that will change in the near future, without a pathway for approval, I don’t see any antibiotics being tested for this until there is a change in policy at the Agency.  A similar situation exists with osteomyelitis.  Because the FDA does not currently have Guidance for Industry on performing a clinical trial for osteo, no antibiotic has been approved for the indication in close to 20 years.  In the meantime, there have been a number of excellent antibiotics with good clinical data for both DFI and osteo that have not been promoted for lack of indication.  If this current ruling stands I don’t see why a rep couldn’t speak to a doc in a truthful and scientific manner, using published literature, to discuss the possible off-label use of a given drug.  I really feel that all would benefit.  The physician would be getting sound information to which they may not have been aware and the patient would receive evidenced based therapies which may currently be withheld from them over fears of unlabeled use.  To me, this is a no-brainer.  Thoughts?  Comments?

Posted in Antibiotics, Diabetic Foot, Infections, Osteomyelitis | 2 Comments »

What’s New & Interesting in the Infectious Diseases Literature – Summer 2012

August 13th, 2012 by Warren S. Joseph DPM FIDSA
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I confess…I have been a bit lackadaisical in my scanning through the journals I receive each month.  This point was driven home to me yesterday when I went to find room on my desk to put some work and realized it was totally covered with stacks of journal back issues I had put aside with all good intentions to eventually read through!  It was time to start clearing my desk with the side benefit of realizing I could probably come up with some interesting articles to blog about.  Well, I did.  In fact, I think I have enough for a few upcoming posts.

Those of you who have heard me lecture on MRSA know that I am not a big fan of the use of trimethoprim/sulfamethoxazole for the treatment of even mild outpatient infections.  My main objection has been increased toxicity of this drug vs. other options including; Stevens-Johnson syndrome, renal toxicity, allergies, drug-drug interactions, etc.   However, I have also questioned the evidence supporting its use and have frequently stated that we don’t even know the proper dosing!  Most clinicians use this drug at the “standard” dose of 1 DS tablet bid (160mg/800mg).  However, some authorities have argued that that dose is too low for MRSA and an increased dose of 2 DS tabs bid should be used.  This has always concerned me because of the potential risk for increased adverse events with the higher dose.  A study published in the December 2011 (I told you I was behind on my reading!) Clinical Infectious Diseases by Cadena and colleagues compared the two dosing regimens and found no difference in outcomes with those treated with the higher dose vs. those treated with the lower “standard” dose (http://www.ncbi.nlm.nih.gov/pubmed?term=Cadena%20J%20AND%20trimethoprim). There was no difference in patient and infection characteristics or in clinical response; 73% (n=121) high dose vs. 75% (n=170) low dose P = 0.79.  Although they did not specifically look at the number of adverse events in each group they do comment that none were found with either group “…although one might anticipate a higher rate of adverse events in those who received the higher dose”.   None of this has changed my mind.  I still prefer doxycycline or minocycline to the use of TMP/SMX although I do see situations where this drug would be useful.

Another huge area of debate on which I have commented a number of time both here in the blog and when I speak on the topic, is this concept of increasing vancomycin dosing to keep trough levels between 15-20 mg/ml.  I fall strongly on the side that this is not only unnecessary for all skin and skin structure infections (it may be necessary for blood stream or pneumonia but that is outside my scope) but is also extremely dangerous.  I do not think that it improves outcomes and not only believe, but have seen, increased cases of nephrotoxicity (aka “Acute Kidney Injury or AKI” in current parlance).   For a more thorough discussion on my reasoning, just search this site for the term “vancomycin” and you can see my posts on the matter.  I always like seeing new papers that support my opinion on something!  In the December 2011 issue of Antimicrobial Agents and Chemotherapy (AAC), Bosso and colleagues prospectively assessed nephrotoxicity in relation to trough concentrations in patients with MRSA treated with vancomycin.  (http://www.ncbi.nlm.nih.gov/pubmed/21947388)    They found that “Nephrotoxicity was observed for 42 patients (29.6%) with trough concentrations >15 mg/ml and for 13 (8.9%) with trough concentrations ≤15 mg/ml.” They concluded that the increased trough concentrations were associated with 3-fold increased risk of nephrotoxicity.  I have to ask…when will this nonsense stop?!  The entire concept of increasing doses of vancomycin is based on a pharmacodynamic model known as the AUC/MIC ratio.  There is essentially no evidence to show that it increases efficacy of vancomycin for the infections we treat in the lower extremity but it IS more toxic.  Yet, I frequently hear of clinicians and clinical pharmacists pushing for this higher dosing even in skin and skin structure infections – a dosing, by the way, NOT supported by the IDSA MRSA Guidelines. If you feel you need to push vanco this high, then consider alternative agents such as linezolid, daptomycin or ceftaroline.

To change tone completely, I was recently giving some lectures in Florida. I spoke in Miami, Ft. Lauderdale, Hialeah and Lakeland.  Nothing like the heat and humidity of August in the Sunshine State to make me appreciate the heat and relative dryness (I can’t believe I am saying that) of August in Philadelphia! Little did I know that my visit may have put me at risk for exposure to extended spectrum beta-lactamase (ESBLs).  The May 2012 issue of AAC contains an article by Poirel and colleagues “Wild coastline birds as reservoirs of broad spectrum β lactamase producing Enterobacteriaceae in Miami Beach, Florida” (http://www.ncbi.nlm.nih.gov/pubmed/22314536). The investigators collected 53 fecal samples of wild seagulls and 10 specimens from pelicans.  A total of 10 Enterobacteriaceae isolates containing ESBLs were obtained from 8 (14%) specimens.  They go on to discuss the exact phenotypes and the cross-resistance between various antibiotics.   They conclude that “…beaches may play a significant role for dissemination of various resistance determinants and may be a source of (ESBL) community acquired infections.”  I could make some light of this and compare this report to what the movie Jaws did to destroy beach towns back in the 1970s, but I will show restraint.  This is actually a serious issue.  Multi-drug resistant gram negative rods are, in my opinion, the organisms of the future.   Unlike MRSA where we have a number of different viable antibiotic choices, we have precious few resources to use against these organisms.  To see that they can be found in bird droppings at one of the top beach destinations in the World only adds to the urgency that more be done to fight these bugs. 

That is all for now.  As promised, I still have plenty left

Posted in Antibiotics, Diabetic Foot, Infection control, Infections, MRSA, Wounds | No Comments »

Radio Interview About Diabetic Foot Infections and SALSAL

July 17th, 2012 by Warren S. Joseph DPM FIDSA
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This past Sunday, July 15, I had the pleasure of participating in a radio interview on WOKV, Jacksonville, FL, the largest, most listened to talk radio station in Northern Florida. Here is the link to the audiostream:

http://wokv.media.streamtheworld.com/audio/save_leg_save_101730761.mp3

The show was hosted by Desmond Bell, DPM.  Des, a former student “done good”, is the Executive Director of the Save a Leg, Save a Life Foundation  http://savealegsavealife.org/ or SALSAL. From its modest beginnings as a way for Des and his wife De Anna, a nurse practitioner and wound specialist, to get local providers in the Jacksonville area up to speed in the area of wound care, SALSAL has grown into a nationwide organization with at least 30 local chapters spread throughout the US.  As I mention in the interview, the scope of the organization did not really hit me until I was giving a dinner lecture to the local chapter in Seattle a few months back and over 70 health care providers of all specialties attended.  I have seen this organization grow from its first small meeting in Jacksonville, where I don’t think there even were 70 attendees, to a significant national “player” in the area of limb salvage.  Congrats to Des and De Anna.

In the interview, which was part of the weekly hour long show Des now hosts, we discussed; why diabetic feet become infected, what patients should look for when examining their feet, my thoughts on routinely soaking and the problems with MRSA and antibiotic resistance. Although my comments were directed to a “lay” audience, I felt that readers of this site might just be interested in the discussion we had. I really feel that this sort of outreach to the general public can only be helpful in promoting the message of proper foot care in patients with diabetes and driving patients to their health care provider before it becomes too late to save a leg, save a life.

Posted in Diabetic Foot, Infections, MRSA | No Comments »

New 2012 IDSA Diabetic Foot Infection Guidelines

May 22nd, 2012 by Warren S. Joseph DPM FIDSA
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As promised, I would post a link to the newly revised, updated IDSA DFI Guidelines as soon as they were available.  Well, I am honored, proud and excited to be able to let my readership know that after about 6 years in writing, multiple levels of peer review and well over 60 individual review comments, that the newly revised guidelines have been posted by IDSA on their website. Here is the link:    http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/2012%20Diabetic%20Foot%20Infections%20Guideline.pdf

Those of you familiar with the 2004 document will immediately notice the changes.  All IDSA Guidelines are now standardized to a “question, recommendation, evidence summary” format.  Each committee is assigned to determine which are the most critical questions that need to be answered.  In this case, we came up with 10 questions that cover everything from diagnosis to antibiotics, to osteomyelitis and wound care.  There are 44 evidenced based recommendations that  guide the clinician in the answers to those 10 questions.  The evidence is then summarized and graded by the British Medical Journal “GRADE” system.  This common sense approach matches the strength of the recommendation with the level of the evidence.  This is given in plain English.  For example “Strong, Low” means that there is a strong recommendation but a relatively low level of evidence on which the decision has been based.

I hope that you all find the new Guidelines helpful in your management of these patients.  I look forward to your comments

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Antibiotic Bone Penetration and Osteomyelitis

April 2nd, 2012 by Warren S. Joseph DPM FIDSA
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A reader of this site, Dr. Steven Klein, emailed me to ask the following questions.  I have obtained his permission to use his excellent thoughts as a “jumping off” point for this post and some subsequent ones to follow:

You recently posted about the article:  “Systemic Antibiotic Therapy for Chronic Oysteomyelitiis in Adults.” Spellberg, Brad and Lipsky, BA. Clinc Inf Dis (Advance Access published 12-12-11). p 1-15.  The article begs the question –  How important is antibiotic bone penetration in treatment of chronic osteomyelitis?  I’d like to know if there are good studies of this issue and your opinion. Or, on the other hand, perhaps studies support good outcomes without regard to bone penetration, but instead using an antibiotic based on cultures, senstivites and MICs from bone culture.  

For example, according to Table 1 in this article, “Bone Penetration of Parental Antibiotics: Data from Clinical Studies”, vancomycin has poor penetrations and concentration in bone. And, according to Table 3, “Cure Rates of Non randomized Clinical Trials of Parental Agents for Chronic Osteomyelitis With or Without Infected Prosthesis in Adults”, vancomycin has the lowest cure rate ( 54% ) with debridement or prosthesis removal., of all listed antibiotics. Yet vancomycon is commonly used for MRSA osteomyelitis. Perhaps we need to re think that. 

On another point, you have expressed your dislike of using Trimethoprim/Sulfamethoxazole. However on reading this article TMP/SMX seems to be one of the oral antibiotics of choice. What are your criticisms of this drug? I’d like to know the down side before deciding on whether to use it (probably with rifampin).

I would like to address the first of these questions/issues with this entry to the blog and discuss a few others in the near future.

How important is bone penetration? -  I have a slide I have used for years in my osteomyelitis lectures entitled  “The Myth of Bone Penetration”…I guess that tells you right there what I think!  Actually, that is a bit of an oversimplification.  The fact is I don’t believe anyone really has a good answer to this question.  It makes empirical sense; if an antibiotic can penetrate bone, the antibiotic should be effective.  There are a number of problems to this thinking.  It does not take into account the bacteria in the bone that is causing the osteomyelitis.  This is one of the reasons many docs continue to use ciprofloxacin for osteo.  They were told by some drug rep 20 years ago that “Cipro penetrates bone” therefore it should be first line therapy for osteo.  What they were failed to be told was that the drug had/has relatively poor activity against Staphylococcus, by far the most common pathogen and that resistance develops rapidly.  In fact, the package insert for the drug shows that it is only indicated for “Bone and Joint Infections caused by Enterobacter cloacae, Serratia marcescens, or Pseudomonas aeruginosa”.  None of this stops many docs from still using it for S. aureus osteo because of the ingrained perception of “good penetration”.  

Eric Senneville (http://www.ncbi.nlm.nih.gov/pubmed/18184898 ) has shown that bone culture directed antibiotic therapy was the single factor predictive of success in the treatment of diabetic patients treated medically for osteomyelitis of the foot.  This study has been picked up upon by the International Working Group on the Diabetic Foot (IWGDF) who just updated some of their recommendations on the diagnosis and treatment of osteomyelitis as recently as February 2012 (http://www.ncbi.nlm.nih.gov/pubmed/22271738http://www.ncbi.nlm.nih.gov/pubmed/22271739 ).  I am not aware that any of these reviews promotes bone penetration as an important measure of success.

Furthermore, until recently there was not a really good, standardized approach to determine bone penetration.  Frequently the tested bone came from arthritic femoral heads removed during hip arthroplasty.  This is not the same as looking at osteomyelitic bone.  There were also different techniques used to measure the antibiotic level in the bone.  I have always quoted a paper by my mentor in ID, Jack LeFrock, which to this day I am unfortunately never able to find the reference, in which he searched the literature for bone levels following a one gram dose of cefazolin.  Levels ranged from 4 micrograms to 43 micrograms depending on the technique used.  Fortunately, this may be changing.  Previously on this site I have written about the microdialysis technique being championed by Dr. Dave Nicolau and others.  This technique, in which a small catheter is inserted into bone, lactated ringers in dripped in and then pulled out and the antibiotic level measured, may finally give us some validated, objective measure of antibiotic penetration.

I know it makes empiric sense but I admit to being biased against the concept that bone penetration is a predictor of success in the treatment of osteomyelitis.  I just don’t feel that there is good enough evidence to support it at this time.  We know that some antibiotics DO penetrate bone well.  The tetracyclines are notorious for how they stain bones and teeth, so they obviously get into the bone.  Early work by one of my heroes in the ID world, Dr. Carl Norden, showed in his elegant rabbit studies that clindamycin was one of the most effective antibiotics in the treatment of experimental osteo.  I am just not sold that penetration, in and of itself, is that important of a goal.

 

 

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Antibiotic Prescribing in Podiatric Medicine

January 24th, 2012 by Warren S. Joseph DPM FIDSA
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I recently came across some fascinating data which breaks down the number of outpatient prescriptions written by podiatrists for all different classes of drug in 2010.  Unlike various surveys that have been done over the years by different magazines, this is hard data based on the actual number of scripts.  I would like to comment on some findings I find interesting in the use of antibiotics. 

Antibiotics were the third most commonly prescribed class of drug following narcotic analgesics and NSAIDs with over 1.6 million scripts written.  This is followed closely by antifungals at about 1.4 mil prescriptions. (Perhaps a topic for a future post?).  I don’t think it would come as any surprise that cephalexin is the most prescribed (530,000) and is actually the second most common drug written by DPMs.  The number two most common antibiotic would also probably not come as a big surprise, amoxicillin/clavulanic acid (Augmentin) down the line a bit at number 15 (177K).  Although amox/clav is a good antibiotic with a favorable spectrum for more complicated lower extremity infections, it is probably a bit unnecessarily broad spectrum for everyday use. I have started to limit my use of this drug after I personally had to take it for an endodontic problem.  First, the 875mg is an amazingly large pill which is not easy to swallow.  Also, I always knew that the drug could be a bit hard on the GI tract and I knew to take it with food and a full glass of water.  Despite those precautions, about 20 minutes after I took each dose, I found my stomach wanting to jump out of my abdomen!  It is true what they say about how a physician can change his way of treating folks after he becomes a patient. 

The third most commonly used antibiotic is trimethoprim/sulfamethoxazole (Bactrim/Septra) with 117K Rx’s.  Not surprisingly, this drug’s use has increased dramatically over the past few years with as few as 34K scripts only 2 years before, a stunning increase in such a short period of time.  Probably all of this usage is for the presumptive treatment of MRSA even before cultures have been returned.  I have said it before; I will repeat is again here, I do NOT like to routinely use this drug.  There are reasons this drug was rarely used before the MRSA epidemic we find ourselves facing.  Although broad spectrum, generic and inexpensive it is not benign. Toxicities range from life threatening skin reactions, such as Stevens-Johnson syndrome to renal, neurologic, psychiatric and hematologic problems, not to mention sulfa allergy, drug-drug interactions with other sulfa based drugs and the inability to use in patients with a G6PD deficiency (and, YES, you will see this as I recently did in a patient with a multi-drug resistant Enterobacter cloacae where the ONLY drug to which the organism was reported as susceptible was TMP/SMX).  Because of the lack of studies showing clinical efficacy against MRSA there is also some question as to how it should be dosed for MRSA infections.  It has been suggested that the usual 1DS b.i.d. is insufficient and that should be routinely increased to 2DS b.i.d. thus potentially increasing the rate of adverse events even further.  That is not to say I don’t use TMP/SMX, I just don’t routinely give it to every patient empirically to cover MRSA or even with a positive MRSA culture unless there are other reasons to use it, such as a mixed infection where the use of one drug obviates the need for combination therapy. 

I often get asked the question; “if not TMP/SMX, then what oral antibiotic you using for your MRSA cases”.  That depends on severity.  For my more mild infections where most of you are probably using TMP/SMX, I much prefer doxycycline 100mg q12h.  Minocycline can also be used.  I find that there is more data to support their use and they are well tolerated even for longer courses of therapy such as in osteomyelitis.  Interestingly, NEITHER of these antibiotics is found in the top 60 drugs written by podiatrists.  I would like to see that change.

The next most commonly prescribed antibiotics drive me crazy!  They are ciprofloxacin at 101K followed by levofloxacin at 75K.  Those who have heard me lecture know that I have been preaching avoidance of quinolones, particularly ciprofloxacin since it was first released and people were sold a “bill of goods” about how broad spectrum it was and how wonderfully it penetrated bone.  As time has gone on, my feelings have only intensified. If I am going to use a quinolone, it is levofloxacin rather than ciprofloxacin because of its better gram positive activity and the once daily dosing.  The only time I see a use for ciprofloxacin is for a documented Pseudomonas infection, something that is extremely rare in lower extremity infections (see post on “Pseudomonaphobia”).   Even then, there is no data to suggest that levofloxacin would not be equally efficacious.  Another quinolone, moxifloxacin, has the advantage of better anaerobic coverage in the case of a diabetic foot infection.  My quinolone usage is on a significant decline.  As a class, these drugs can potentiate the development of MRSA infections, have significant toxicities and, probably most importantly, have been implicated in the development of multi-drug resistant (MDRO) gram negative infections.  In fact, at Roxborough a recent antibiogram shows only about 50% of our E. coli still susceptible to ciprofloxaxin.  Furthermore, I have been noticing lately that every patient who gets sent out on a quinolone invariably returns to the hospital but now with an organism resistant to the entire class.  PLEASE, use these drugs sparingly and only when appropriate!!

The final drug on the list I would like to discuss is amoxicillin, currently being prescribed 28,000 times per year.  This, I just don’t understand at all.  Frankly, I don’t think I have ever written for straight amoxicillin nor do I see any reason to ever do so.  Perhaps, if the patient presents with an infection solely caused by Enterococcus or a straight Streptococcal infection, then it may be a reasonable choice but these are extremely rare and I seriously doubt they are occurring 28K times.  This leads me to believe that there is some inappropriate use of amoxicillin in the profession.  Please remember that this drug is not beta-lactamase stable and is therefore ineffective against essentially all clinically relevant S. aureus

These data reveals some interesting information about how lower extremity infections are being treated.  Overall, I find the usage pretty reasonable however, when it comes to what I perceive as an overuse of TMP/SMX, quinolones and amoxicillin, we can always do better.

Posted in Antibiotics, Diabetic Foot, Infections, MRSA | 3 Comments »

Bacteria and Social Networking

January 9th, 2012 by Warren S. Joseph DPM FIDSA
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A few weeks ago my old Podiatric College roommate sent me a link to a fascinating YouTube video.  I then sent it to a few friends who, in turn, posted it on a few other blogs so it has become a minor viral (or should I say “bacterial”) success.  This lecture, by Professor Eshal Ben-Jacob of Tel Aviv University, covers aspects of bacterial communication and their “social interactions” as regulated by various stimuli.  It is an utterly fascinating subject presented in a clear, understandable manner with incredible videos and photographs.  This work has major implications in the way bacteria become pathogenic, are currently treated and some future directions that could be considered.  Just as a “heads-up” it will take a commitment of time from you, the viewer, as the lecture is an hour long but please don’t let that keep you from viewing it in its entirety.  It is absolutely worth it.  http://www.youtube.com/watch?v=yJpi8SnFXHs

Posted in Infection control, Infections, Wounds | No Comments »

A New Review of Antibiotic Therapy for Osteomyelitis

January 4th, 2012 by Warren S. Joseph DPM FIDSA
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I wish all of my readers a healthy, happy and prosperous 2012.  With this post I am trying something a bit different.  In the past I usually waited to put up a post until I come up with an “ah ha” moment on something I have seen, heard or read about which I then pontificate on this site.  These could occur only days apart, but usually it was a much longer time period leading to relatively infrequent additions to the blog.  My “resolution” for 2012 is to try to put up more frequent, quick hits where I don’t have as much to write and you don’t have as much to read.  That’s not to say that I won’t still post the occasional tome on a particular topic.  Sometimes, I just have to vent!  I have one coming up shortly on antibiotic usage in podiatric medicine…just a heads up.

A recent paper has been published in Clinical Infectious Diseases by Brad Spellberg at UCLA and Ben Lipsky at the Puget Sound VA titled Systemic Antibiotic Therapy for Chronic Osteomyelitis in Adults (http://www.ncbi.nlm.nih.gov/pubmed?term=Spellberg%20B%20AND%20Lipsky%20BA).  I consider it a MUST READ for followers of this site.  This excellent review covers topics including the pharmacology of osteo therapy (i.e. parenteral vs. oral, bone penetration), animal models of osteo, human non-randomized clinical trials and randomized clinical trials.  It is THOROUGH yet quite readable at only 11 pages (there are, however, 172 references!) with 5 tables outlining all of the studies discussed. 

The authors arrive at 4 conclusions which I quote directly from the paper:

1.  “Oral antibiotic therapy with highly bioavailable agents is an acceptable alternative to parenteral therapy.”

2.   “Adding rifampin to a variety of antibiotic regimens has been shown to improve cure rates”

3.   “Clinicians must individualize the duration of antibiotic therapy based on the patient’s clinical and radiographic response…”

4.   “Surgical resection of necrotic and infected bone, in conjunction with antibiotic therapy, appears to increase the cure rate of chronic osteomyelitis. However, not all cases of chronic osteomyelitis require surgical debridement for cure, and we need studies to clarify which may and which may not.”

None of these conclusions should come as a surprise to regular readers of this blog or those who have heard me lecture on the topic, as I have discussed these very points in the past.  Dr. Lipsky and I collaborate frequently and I find it almost frightening how often we agree.  In this one paper he and Dr. Spellberg have eloquently laid out all of the evidence supporting these positions.  If I have said it once, I have said it a thousand times…We MUST rethink the universally pervasive dogma of 4-6 weeks of IV antibiotic therapy for osteomyelitis based on the best available evidence!

Posted in Antibiotics, Diabetic Foot, Infections, Osteomyelitis | No Comments »

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