I am a 4th year podiatry student and was wondering if you could email me your stance/view on prophylactic antibiotics and their use in podiatry. When to use them, when not to, why we use them when we aren’t supposed to, and any other comments/concerns you might have. Thank you!

As for the second question as to whether or not we should be using anti-MRSA prophy instead of just cefazolin, unfortunately there is little good literature or even consensus that I have seen published. I think that it is an entirely valid suggestion. IF you have a hospital where there is a high incidence of MRSA surgical site infection, then yes, I think it would be reasonable to consider prophy against this organism as opposed to just using a cephalosporin active against MSSA. If most of the surgical infections in your community are still MSSA, then I would hold off on the vancomycin prophylaxis. If anyone reading this is aware of any recent consensus document or clinical trials addressing this issue specifically, I would welcome your input!

In the treatment of the Pt’s nasal mucosa I am assuming the method of infection transmission to be the aerosolization Staph. It may ,therefore, be prudent to compare the infection rates of treating a Pt’s nares with simply employing the same surgical masks all others in the OR wear. In addition to finding out which method would be superior to controlling infection it could also give insight to the time frame in which a Pt carring Staph. could infect their surgical wound.

You should get involved! I am sure your expertise would be welcome.

Bret Ribotsky
http://www.PodiatricSuccess.com

As for the difference between bacteriostatic and bactericidal drugs, there were two interesting articles published in Clinical Infectious Diseases within a few months of each other in 2004. The first by Pankey and Sabath in March and the second by Finberg and Moellering in November both pretty much concluded that, at least for most skin and skin structure infections, there was no evidence to support the superiority of one over the other. This may not be true in the treatment of endocarditis or nervous system infections. Although the 2nd Edition did talk about the use of cidal agents in patients with immune compromise, it may be more of a theoretical advantage than one proven in trials. My thinking has “adjusted” a bit given the two papers mentioned above by some of the top people in the field.

Finally, as to your question about how diabetic patients contribute to the development of multi-drug resistant bacteria, I really feel that it is an issue of overuse of antibiotics. Many clinicians see a clinically non infected ulceration and automatically write a prescription (or, worse, they bow to the patient’s demand for an antibiotic…”I have diabetes so I know I need an antibiotic!”). Then, the patient is kept on the drug until the wound heals! This puts tremendous selection pressure on the patient’s inherent flora allowing bugs resistant to the prescribed antibiotic to thrive.

I am currently reading the second edition of your book (I purchased the 3rd one but it has not become available yet). Right now I am reading the chapter on the “Diabetic Foot Infections”. I really like how the text is succinct yet very comprehensive. My question is regarding the Clinical significance part of the chapter on page 107. It talks about Immune system dysfunctions associated with uncontrolled diabetes. could you direct me to the reference article/source you used for this section. I would really like to learn more about immunopathy aspect of this disease. Although it sounds like common sense, no one really emphasizes the use of bacteriostatic meds in non-immunocompromised patient. This is a great comment. Also, I would really like to learn more about how diabetic patients potentially contribute to the development muli-drug resistant bacteria. I guess this is more of public health issue. Or is it wrong to think of it this way and the problem lies with the physicians who prescribe inappropriately? Thank you. Sincerely, Marat.