A real and growing concern about “superbugs” brought together over eighty medical professionals to hear specialist Dr. Brian Yu discuss diabetic foot infections from an infectious disease perspective.
There has been an uptick in these cases recently, says Yu, an infectious disease physician who treats inpatients at Advocate South Suburban Hospital. About twenty percent of his cases now involve consulting and treating infected foot ulcers in diabetic patients. “While diabetic foot wounds have always been an issue, there is now an increase in cases. There is more peripheral vascular disease and therefore more risk of infection.”
Peripheral vascular disease (PVD) or peripheral artery disease (PAD) is caused by a build up of plaque, fatty deposits, calcium and cholesterol, along the walls of arteries. This narrows the blood vessels and reduces blood flow to organs, arms, legs and feet. Healthy blood flow is vitally necessary for wounds to heal.
LEA-UP, Lower Extremity Amputation and Ulcer Prevention Event was hosted by the Vascular Education Foundation at Palos Heights’ Capri Ristorante Italiano. LEA-UP meetings, CME presentations and discussions, are open to physicians, specialists, nurse practitioners, and other medical professionals, to learn from presenters, share case studies and discuss methods and results. LEA-UP meetings also offer opportunities for representatives of medical products and services to exhibit and network with these professionals.
Eugene Tanquilut, DO, founded Vascular Education Foundation to increase awareness of the dangers and severity of vascular disease through the education of healthcare professionals and the community. “Our goal is to ensure that everyone is aware of both preventative measures and treatment options for vascular disease,” said Tanquilut. He is a fellowship-trained vascular and endovascular surgeon and president of Vascular Specialists, LLC in Olympia Fields, Orland Park and Chicago. His philosophy of educating his patients about their health issues, their treatment options and their recovery process prompted the formation of Vascular Education Foundation and LEA-UP events to facilitate ongoing learning among medical colleagues. The quarterly dinners are free of charge and open to any medical professional interested in preventing life-changing wounds and amputations.
“I couldn’t pass up this opportunity,” said Yu, to educate fellow medical professional from all over the Southland about the role of infectious disease in amputation. “It is always better to preserve limbs, for morbidity, mobility and patient satisfaction.”
That sentiment was echoed in Tanquilut’s welcome to the group and introduction of Dr. Yu. “Quality of life can be different at different stages of one’s life,” he said. “For example, quality of life for a younger person may be the ability to go for a run, swim or even the ability to do their job; however, when one turns 80, quality of life may be as simple as the ability to walk.”
With Vascular Education Foundation and LEA-UP’s collaborative focus, bringing together different specialities from all hospitals throughout the Southland to share information and theories, Tanquilut is working to do just that: give patients quality of life through the ability to walk independently as long as possible by avoiding amputations.
Vascular Education Foundation and the LEA-UP meetings have already made impacts in real time care. Gladys Macagba, MD, a hospitalist with Advocate South Suburban Hospital, attended the November 2017 meeting that focused on calciphylaxis, a rare, incurable disease often mistaken for PVD. “I had never seen it before, but because of the meeting, I knew what it was when I saw it in a patient. I was able to properly diagnosis it and refer the patient for treatment immediately. I see infections in the foot all the time, so this information is good to know. I will keep coming.”
Dr. Yu earned his medical degree at Rush University Medicine and completed a Fellowship in Infectious Disease at Loyola University Medical Center. He is board certified in Internal Medicine and Infectious Disease. He is with Metro Infectious Disease Consultants, with offices in Crestwood. He has worked and consulted with Dr. Tanquilut for four years at Advocate South Suburban Hospital. “Infectious disease, vascular and podiatry work hand in hand to heal wounds,” he said. “Gene is always cordial in interactions with patients and physicians. He is open-minded about best treatments and we are always on the same page in patient approach.”
George Shehata, MD is a geriatric and wound care physician, seeing patients in area nursing homes. He says wound care and vascular care are “two sides of the same coin. Diabetic cases are more than a third of my patients and the blockage of small arteries, PAD, is the greatest challenge to healing. Most diabetics have PAD. I need this updated information all the time – I want to know if there is anything new.”
Samantha Hathaway, MD, an Advocate South Suburban hospitalist, agrees. “I’m always interesting in learning more.” Susan Diaz, an RN with Palos Hospital, said, “Diabetes is very much everywhere right now. Every one (of my patients) seems to have it. I came here because I want to learn more about it, and how I can use this information to help my patients.”
Also among those in attendance were Narcisa Ditan, an RN with Optimum Home Health Care, Edna Leong, MD and Florentino Leong, MD. Ditan said, “Nurses are the ones who see the most diabetic wounds and it’s important for us to gain knowledge on this, to apply to our cases. Most of our patients have diabetes, and because of this presentation, I’ll be able to suggest better treatments.”
Yu covered several points in his presentation including evaluating diabetic foot infections, categorizing their severity, and when, how and for what length of time an infection should be treated with antibiotics. He explained that diabetic foot ulcers account for about twenty-five percent of all hospital stays for diabetic patients, and stresses that medical professionals should urge patients to be compliant with doctor’s instructions and to stop tobacco use. He instructed that infected wounds should be cultured before prescribing antibiotics. A culture, a test that identifies which bacteria are causing the infection, helps determine which antibiotics will be effective in treating the infection and healing the wound.
His emphasis shifted to a serious problem in health care – growing antimicrobial resistance, or superbugs. Superbugs are bacteria that develop a resistant to antibiotics. Containing superbugs is an ongoing challenge, as medical professional weigh the risks against patient recovery. Each year, over 2 million people are infected with antibiotic-resistant bacteria, and about 23,000 of these infections will be fatal.
Yu stressed the importance of antibiotic stewardship. This stewardship can optimize the treatment of infections while reducing adverse affects of antibiotic use. Put simply, Yu says, “it’s having the right drug for the right person over the right time frame.”
Yu guided participants through charts of antibiotic usage; for specific infections, for specific pre-existing conditions and for potential interactions with other medications, always urging the listeners to avoid prescribing antibiotics unless they were conclusively necessary. He repeatedly sounded the alarm that “clinically uninfected wounds should not be treated with antibiotic therapy” and made recommendations for other types of treatment. He stressed that diabetic care requires a multidisciplinary approach, as it affects so many parts of the body.
Discussion at the end of Yu’s formal presentation clearly showed how the participating medical professionals are invested in patient health.
Collectively, these medical professionals agreed that any patient with an ulcer or open wound on their foot should be seen by a vascular surgeon, a podiatrist or a wound care specialist to immediately initiate care to prevent the ulcer from progressing to gangrene.
Mark Gagnon, DPM, reflected Tanquilut’s original statement about quality of life. “Functionality is the key to amputation decisions. We have to ask ourselves – is the foot functional?”
Participants discussed methods of treating persistent infections, how to find answers for the confounding wound that won’t heal, how to approach a patient that will not comply with instructions and treatments, and shoe recommendations. Yu explained that shoes should be well-fitting and comfortable and that shoes with a rubber sole help to prevent the formation of ulcers.
Asked by several physicians about his recommendation to avoid culturing a wound that does not appear to be infected, Yu clarified that culturing a dry eschar, dead tissue cast off from healthy skin, can pick up normal bacteria, causing the physician to administer unneeded antibiotics. This ultimately leads to a resistance to that antibiotic, making subsequent infections more and more difficult to treat. Several physicians held that culturing and identifying harmful bacteria means an infection can be treated more quickly, avoiding a severe infection. Yu stressed the importance of throughly debriding the wound first to ensure an appropriate culture.
Yu explained that while there is no real time line for the length of time a patient should be or can be on antibiotics, it’s vitally important to take into account responsible antibiotic stewardship.
“CDIF (clostridium difficile colitis) is a major concern for us. Doing less harm is always the goal, and prescribing more antibiotics means more toxins in the body, and more chances of an adverse reaction.”
Nancy Rivera, an NP at Silver Cross Hospital, expressed concern that antibiotic stewardship is necessary at all levels of care, including the primary care physician community. Yu responded, “Yes, there is still too much antibiotic prescribing out there and there’s only a finite amount of antibiotics available. New antibiotics are just not coming in.”
Rivera added, “I love the educational component of LEA-UP to help everyone understand that the overprescribing of antibiotics means infections becoming more and more difficult to treat.”
Yu agreed. “What Gene (Tanquilut) has set up here, these meetings, gets everyone together to talk and to learn. It’s important.”
“To these medical professionals, patient care is of the utmost importance, whether that’s in saving limbs or defeating superbugs,” said Tanquilut. “Getting everyone together – whatever speciality, nurses, doctors, caregivers – is vital to patient care and preserving quality of life. We need to share information to meet the all the healthcare needs of our patients.”
LEA-UP meets again on Thursday, September 20. Dr. Avni Vora will discuss optimal glucose control in diabetic patients to prevent complications. The CME event is open to any health care professional. For more information, email email@example.com or call 815-824-4406 and ask for extension 130. Exhibit opportunities for medical products and services are also available.