You may notice that the top menu bar now has a new selection “Preview the Book”.  My idea in doing this was to get some important content from the book up on this blog to a) be a “public service” to readers of this site and b) act as a bit of a teaser to get the reader interested in purchasing the book in its entirety.  We have now posted the first of the planned previews with the opening 18 pages of Chapter 1 covering the basic principles of diagnosis of lower extremity infections.  This material covers the definition of infection, clinical diagnosis, the physical examination, explanation of fever and laboratory testing.  Readers of earlier editions of the Handbook will recognize that this content has not changed significantly from the previous editions.  Good basic principles are universal and do not change frequently so there was little need to update this material.  In upcoming previews I will include a portion of the totally new chapter on MRSA and a newly revised section of the diabetic foot infection chapter that reviews the Infectious Diseases Society of America diabetic foot infection guidelines.  This is all vital information that I felt was necessary to get on line to as large a readership as possible.  I hope that you find this posted material interesting and useful in everyday practice.

This new consensus document on the use of vancomycin in the treatment of MRSA is a MUST READ for anyone treating MRSA (which pretty much means anyone reading this post!).  The document can be found on the Infectious Diseases Society of America (IDSA) website.  The following address should directly access the document:

http://idsociety.org/WorkArea/showcontent.aspx?id=13052

The panel consisted of representatives from the IDSA, the American Society of Health-System Pharmacists and the Society of Infectious Diseases Pharmacists.  They take an evidence based, detailed look at the pharmacokinetics, dosing recommendations and monitoring of vancomycin for the treatment of MRSA infection.  Little of this information is specific for skin and skin structure infection or diabetic foot infection but there are a number of important issues that are addressed and do directly pertain.  Each recommendation is graded for the level of evidence and the grade of recommendation.  There is also an easy reference table summarizing the major points.

Of particular interest to readers of this blog is a statement, rather buried in the document that mentions how the penetration of vancomycin into tissues of patients with diabetes is significantly lower than those without diabetes.  How this may affect the use vanco in our diabetic foot infection population is never explored.  Also of importance is the formalized recognition that vanco peak levels are not contributory and should not be drawn.  Only serum trough levels give important information that can lead to dosing modification.   The trough should be drawn once the drug reaches steady state which is noted to be after the 4^th dose.  This would mean that the trough should be drawn before the 5^th dose is given.

What concerns me the most, however, is the continued recommendation of increasing the target trough levels from <10 mg/L to between 15-20 mg/L.  This would be accomplished by significantly increasing the drug’s dosing to 15-20 mg/kg (actual body weight) particularly if the isolate’s MIC is 1 or greater.  I should note that the authors grade this as a low level IIIB recommendation.  This concept of increasing the dose and the subsequent trough has been around since the recognition of “MIC creep” (read the book for a full explanation).  In my opinion, it is based more on pharmacokinetics of the drug than on actual clinical data, as evidenced by the low level grading.  The studies that I have reviewed, also reviewed by the panel, show that increasing the dose may prevent the development of further resistance BUT does not translate into increased clinical efficacy and probably increase nephrotoxicity!  The panel recognizes this potential but criticizes the toxicity studies as having technical issues rendering the results as less reliable. The idea of increasing the dose, and even giving a significant loading dose (of up to 30 mg/kg), may be important in the treatment of blood stream infections and pneumonia but I am not clear on its utility in the treatment of lower extremity infections.

Follow this literature…it is fascinating stuff.

Welcome to my blog.  Wow, that has been a long time coming!  I have wanted to do this for a long time. Writing a book is great but it can be partially outdated by the time it is published.  There is always at least some lag time from writing to editing to publishing.  (That being said, I must give “props” to Data Trace as they have been incredible to work with and the lag time from when I finished writing and editing to the publication of the 3^rd Edition of the Handbook can be measured in weeks instead of months as in the past).  The flow of new information in the field of lower extremity infectious diseases progresses rapidly and, when strictly dealing with a published book, there is no convenient way to update it nearly quickly enough since years elapse between revisions. I have always wanted a way to communicate new information as efficiently as possible.  Yes, I still lecture all over the country and include the latest data in those talks but only a relatively small number of interested parties actually ever attend a formal lecture.  A website dedicated to lower extremity infectious diseases (LEID) along with an updateable blog seems to be the most convenient way to reach the greatest number with the most up to date information.

When I originally approached Data Trace about updating the book, I was probably more interested in a Web presence as I was an actual published 3^rd Edition.  The decision was made to do both since they are unique and valuable in their own rights.  Of course, I may already be behind the technology 8-ball with something as prosaic as a website and blog.  I guess I could start “tweeting” to really get things out there quickly, but anyone who knows me realizes I have trouble saying “hello” in the 140 characters Twitter gives you so I don’t see how it could help get out scientific information!  Who knows, maybe that is the next step…we’ll see.

Now down to business.  As I envision it, the purpose of this blog is to give me the ability to disseminate new data, information, reviews and thought leader opinions in the area of LEID.  It also gives me the ability to communicate with anyone throughout the world who may have a question or problem dealing with a LE infection.  The whole idea of this blog is to be interactive.  I want to hear others’ thoughts and ideas!  This is what will make it intellectually stimulating and fun for me and, hopefully, valuable to those monitoring the site.

Although purchase of the 3^rd Edition of the Handbook of Lower Extremity Infections is HIGHLY RECOMMENDED and desirable, it was agreed that this blog should be open to all comers and not just those who have purchased the book.  While revising the book I reviewed every word to make sure it was still current.  Changes were made where necessary, some extensive, such as an entirely new chapter on MRSA.  I will give more specifics about the update in a future posting.

Thanks for reading my initial post.  Please become an active participant!

Warren S. Joseph, DPM, FIDSA