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.
Hello Dr. Joseph,
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.
Thank you for your kind words and thoughtful questions. You are correct that the immune compromise found in patients with diabetes is pretty much taken as gospel without much supporting evidence. I ran Medline searches using lots of combinations of terms. I actually asked around to a few of the “diabetic foot gurus” in our profession looking for some good specific references to pass on to the readership. The response was pretty universal that the data was weak. I would direct you to the following reference as a starting point to look into the subject (thanks to Dr. Frykberg): Delamaire M, et al. Impaired leukocyte functions in diabetic patients. Diabetic Med 1997;14:29-34.
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.