Isolation of bacteriophages to multi-drug resistant Enterococci obtained from diabetic foot: a novel antimicrobial agent waiting in the shelf?

INTRODUCTION: While foot infections in persons with diabetes are initially treated empirically, therapy directed at known causative organisms may improve the outcome. Many studies have reported on the bacteriology of diabetic foot infections (DFIs), but the results have varied and have often been contradictory. The purpose of the research work is to call attention to a frightening twist in the antibiotic-resistant Enterococci problem in diabetic foot that has not received adequate attention from the medical fraternity and also the pharmaceutical pipeline for new antibiotics is drying up. MATERIALS AND METHODS: Adult diabetic patients admitted for lower extremity infections from July 2008 to December 2009 in the medical wards and intensive care unit of medical teaching hospitals were included in the study. The extent of the lower extremity infection on admission was assessed based on Wagner's classification from grades I to V. Specimens were collected from the lesions upon admission prior to the initiation of antibiotic therapy or within the first 48 h of admission. RESULTS: During the 18-month prospective study, 32 strains of Enterococcus spp. (26 Enterococcus faecalis and 06 E. faecium) were recovered. Antibiotic sensitivity testing was done by Kirby-Bauer's disk diffusion method. Isolates were screened for high-level aminoglycoside resistance (HLAR). A total of 65.6% of Enterococcus species showed HLAR. Multidrug resistance and concomitant resistance of HLAR strains to other antibiotics were quite high. None of the Enterococcus species was resistant to vancomycin. CONCLUSION: Multidrug-resistant Enterococci are a real problem and continuous surveillance is necessary. Today, resistance has rendered most of the original antibiotics obsolete for many infections, mandating the development of alternative anti-infection modalities. One of such alternatives stemming up from an old idea is the bacteriophage therapy. In the present study, we could able to demonstrate the viable phages against MDR E. faecalis.

Metallo Beta lactamase producing pseudomonas aeruginosa and its association with diabetic foot.

Pseudomonas aeruginosa strains that produce metallo beta lactamases (MBLs) are becoming increasingly prevalent in wound infections. The aim of the present study is to determine the clinical features, incidence, and to find out the antimicrobial susceptibility pattern of Pseudomonas aeruginosa in diabetic foot infections. Pus samples for bacterial culture were collected from 310 patients admitted with diabetic foot infections. Antimicrobial sensitivity testing was performed by the Kirby-Bauer disc diffusion method. Carbapenem resistance screening and confirmation of MBL was done by the modified imipenem-ethylenediaminetetraacetic acid (EDTA) double disc synergy test. A total of 54 Pseudomonas aeruginosa was isolated from 310 diabetic foot cases. Males were affected more than females with an M:F ratio of 1.6:1. Most patients belonged to the fifth decade of life with a mean age of 49 ± 16.8 years. All the patients were previously diagnosed with diabetes mellitus with duration of the disease at 16 ± 10.2 years and 63% were prescribed oral hypoglycaemic agents. Wound characteristics were classified according to Wagner's classification majority of Pseudomonas aeruginosa were isolated from Wagner's II and III grade wound. A number of 26 (89.7%) patients underwent debridement, while 9 (31%) patients underwent toe disarticulation, and 7 (24.1%) patients underwent below-the-knee (BKA) amputation. Antibiotic sensitivity testing revealed 20.3% of Pseudomonas aeruginosa were resistance to carbapenem and 81.8% of these were MBL mediated resistance. Infection with multi drug resistance organisms (MDROs) is common in diabetic foot ulcers and is associated with inadequate glycemic control and increased requirement for surgical treatment. There is a need for continuous surveillance of resistant bacteria to provide the basis for empirical therapy and reduce the risk of complications.

Anesthesia considerations in large-volume lipoplasty.

BACKGROUND: Large-volume lipoplasty is becoming more common and has been proven to be safe and effective. Large-volume lipoplasty is normally performed with the patient under general anesthesia. Techniques of general anesthesia and fluid management are important factors in improving the safety of large-volume lipoplasty. OBJECTIVE: Certain important considerations in anesthesia and perioperative management can improve outcomes in large-volume lipoplasty. Our objective is to present our protocol and technique for general anesthesia in large-volume lipoplasty METHODS: Large-volume lipoplasty (5 to 18.5 L) was performed on 32 patients under general endotracheal anesthesia. Important considerations included proper selection of patients, low flow of anesthesia gases, prevention of hypothermia, deep vein thrombosis prophylaxis, intraoperative fluid ratio of 1, Foley catheter to monitor urine output, and postoperative overnight or longer monitoring in a well-equipped hospital. Maintaining the endotracheal cuff pressure between 20 to 30 mm of water helped to reduce incidence of sore throat. Addition of lidocaine in wetting solution helped to reduce requirement of general anesthetic agents and as a result, postoperative recovery was faster and more pleasant. RESULTS: Major complications did not occur in any patients. Minor complications encountered were nausea, vomiting, and shivering and occurred in about 25% of patients. All patients were able to walk without support 4 hours after surgery. In spite of minor complications, all patients reported the postoperative recovery to be better than expected. CONCLUSIONS: General anesthesia for large-volume lipoplasty is safe. Postoperative recovery can be made faster and more pleasant by following these recommendations.