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Antibiotic choices are limited compared to choices for adults due to the lack of extensive study on safety and effectiveness in pediatric patients. IV antibiotic dose reduction is common for children versus adults. Not all antibiotics have been adequately tested in children. Some examples of differences in recommendations between adults and children include:
Diabetes Care Considerations Infected foot ulcers are a common and costly complication in diabetic patients. Fifteen percent of diabetic patients may experience foot ulceration and are at higher risk for lower-extremity amputation. This is related to peripheral neuropathy and the inability to feel the warning sensations of pressure. Approximately one-fourth of all hospital admissions for diabetics are related to foot ulcerations. Infected soft tissues of the foot may require and account for most of the extended hospital stays in order to deal with diabetic complications. Thus, appropriate prevention and care for diabetic foot infections have the potential to reduce hospitalizations, decrease lengths of stay, and infection-related complications, including amputations. Home care treatment can include infection control, evaluation and improvement of vascular perfusion of the area, pressure relief, and antimicrobial therapy. An emphasis should be placed on patient/caregiver education to learn routine preventative care to reduce the incidence of diabetic foot infections.
Complications of foot ulceration include poor glycemic control, vascular disease, and immunologic disturbances. The most common pathogen is S. aureus. Multiple pathogens are more common in non-healing wounds, especially when there is a recent history of antibiotic use. There may be an increasing prevalence of MRSA infections and more severe cases may include spread of infection to bone tissues, resulting in osteitis and osteomyelitis requiring both surgical and intravenous antibiotic therapies (Rao 2005).
Foot infections in the diabetic patient are categorized by severity, the tissues that are involved, adequacy of blood supply to the localized area, and presence of systemic toxicity or complicating metabolic issues. Skin biopsies that may be deemed unnecessary in non-diabetic patients may be helpful to determine appropriate therapies for cellulitis in this population.
Simplified regimens can help the patients and caregivers administer therapies more successfully. A comparison of ertapenem and piperacillin/tazobactam therapies for foot infections was explored in a randomized, double-blinded study of 586 diabetic adults with moderate to severe foot infection (Lipsky et al. 2005). This study suggested that both therapies had equivalent cure rates and similar adverse reaction rates. The authors suggested that the once-daily regimen of piperacillin/tazobactam could be considered for IV therapy of diabetic foot infections.
Additional considerations should include the potential to exacerbate metabolic or other potential adverse effects in diabetes. For instance, long-term diabetic patients may be at a higher risk of opportunistic infection or carriage of nasal Staphylococcus aureus, particularly if they are on insulin therapy or have recently used antibiotics (Tamer, Karabay, & Ekerbicer 2006).
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