MEDICAL NUTRITION

THERAPY IN A PATIENT
WITH TYPE II DIABETES
AND DIABETES
ASSOCIATED INFECTIONS

Major Case Study

Mariah Staley
Dietetic Intern
University of Maryland,
College Park

February 2016

TABLE OF CONTENTS
Executive Summary ...................................................... 2
Case Report .................................................................. 3
Hospital Course of Patient ............................................ 5
Case Discussion............................................................. 8
Appendices ................................................................. 10
Glossary...................................................................... 12
References .................................................................. 13

EXECUTIVE SUMMARY
Infections are common in patients with poorly controlled Type 1 and Type 2 Diabetes Mellitus (DM); this increased
susceptibility may be related to diabetes-associated neuropathy and vascular insufficiency. Diabetic-associated foot
infections are the most prevalent type, often leading to hospitalization with possible amputation. Patients present
with cellulitis, deep-skin and soft-tissue infections, acute osteomyelitis, and/or chronic myelitis. Clinical diagnosis
requires the presence of either significant inflammation or purulent discharge. Infections are classified as mild,
moderate or severe, and staging often determines hospital course of action. Pathogens found in these wounds are
frequently Staphylococcus species; Staphylococcus aureus is found in 10-32% of diabetic foot infections. The
presence of this pathogen has been associated with higher failure in treatment of these infections. (3)
Diabetic peripheral neuropathy in the lower extremities can delay detection of foot infection. Many people with
diabetes who have neuropathy in their feet will have numbness and tingling in their feet, as well as sores, cuts and
ulcers that do not heal. Patients with diabetes must be educated on regular foot care, including checking for any
cuts, sores, or swelling, washing, and keeping feel moisturized. Regular visits to a podiatrist should be followed to
insure proper foot care. When a foot does become infected it is harder to treat this infection in diabetic patients.
High blood glucose levels create an environment where microorganisms thrive and propagate; infections will also
cause blood glucose levels to rise. For those patients with poorly controlled diabetes, reaching normal blood
glucose levels becomes harder and increases the amount of antibiotics needed to treat the infection. (4)
Medical management of infections over the past two decades has been faced with the dilemma of rising rates of
resistant bacteria and fewer new antibiotic drugs being released. Lipskys 2016 review article (6 ) suggests the
medical approach for infection should be ABX: Appropriate indication; Be focused in spectrum; X cut treatment
duration to address this dilemma. The article also describes several potential new options including teixobactin, a
potential agent in the treatment of gram-positive bacteria as well as bacteriophages that are being used to treat
infections (in place of antibiotics) in several Eastern European Countries with reasonable results. (6)
Research has defined nutrition management guidelines to prevent wounds from becoming chronic and promote
wound healing. Weight management, by diet and physical activity, work to maintain A1c levels below 7% and has
been proven to improve glycemic control (4). A diet with even distribution of complex carbohydrates throughout
the day was found to provide adequate energy for cells during wound healing, and prevent oxidation of protein for
energy EPUAP (European Pressure Ulcer Advisory Panel) and NPUAP (National Pressure Ulcer Advisory Panel)
recommend 1.25-1.5 g/kg/day of protein, mostly coming from complete protein sources like meat, poultry, eggs,
and soybeans (4). Recommendations also include encouraging whole food, but allow high-calorie/high-protein oral
nutrition supplements to meet protein and energy needs not achieved with fresh foods. Close glucose monitoring
and dietary counseling also aid in blood glucose control and patient knowledge.

CASE REPORT
GENERAL INFORMATION

MB is a 54 year old African American female admitted to MedStar Union Memorial Hospital in Baltimore, MD on
December 8, 2015. The patient reported her grandson noticed a cut on the sole of her left foot and she had been
experiencing some pain when walking. MB complained of decreased appetite and difficulty chewing prior to
admission due to losing some teeth. The patient was diagnosed with a diabetes related infection of the left foot and
hyperglycemia. Her height was 53; her admitting weight was 246 lbs.
After twenty-two days at Union Memorial Hospital, the patient was discharged home with home health care
December 29, 2015.
SOCIAL HISTORY

Patient is single; she lives with her mother and two grandsons. MBs mother has type II diabetes and currently is
receiving dialysis for end stage renal disease. The patient reports having to make meals for her mother following
the guidelines for dialysis patients, as well as preparing meals for her grandsons who want fried or junk foods. The
patient reported she cooks a separate meal for herself. MB denies alcohol abuse, tobacco use, and IV drug use.
Past history of (h/o) cocaine use for 3 months in 1993 intranasal with no recurrence exists.
MEDICAL/SURGICAL DATA

Past Medical History

Past medical history includes Type II Diabetes Mellitus (duration unknown), Gout, High Blood Pressure,
Hyperlipidemia, Neuropathy, and history of Depression. The patient has no known food allergies.
Past Surgical History
Patient did not have any history of major surgeries, but underwent surgical irrigation and debridement with
antibiotic bead placement during the current hospital stay.
Admitting Physical Examination
Upon admission, patients blood pressure and temperature were normal.
Laboratory Results
Refer to Appendix A for laboratory results during this hospitalization.
Medications
Refer to Appendix B for complete lists of home and in-patient medications.
Diagnostic Tests with Results
Date
Dec 9

Diagnostic Test
MRI of left foot

Dec 10
Dec 17

MRI of left foot

MRI of left foot

Results
No evidence of fracture, subluxation/dislocation, or any focal
osseous lesion seen. Osteoarthritis of intertarsal joints noted.
Extensive soft tissue edema or inflammation with possible large
effusion versus phlegmon or early abscess surrounding the third
and fourth metatasophangeal joints. Mild bone marrow signal

abnormality involving third through fifth metatarsophalangeal

joint possibly representing septic arthritis and early osteomyelitis.

NUTRITIONAL HISTORY FROM INITIAL ENCOUNTER

Diet History
MB reported difficulty chewing recently due to losing multiple teeth. Patient was scheduled to have a dental
appointment on December 10, 2015, but had to re-schedule due to hospitalization on December 8, 2015. The
patient reported having poor appetite since admission. MB reported weight loss from about 400 pounds to 250
pounds in the past few years. She reported trying to make healthier food choices, but still reported blood sugar
levels of 200 to 300. A diet recall of one day of meals included: corn flakes, toast, eggs, and sausage for breakfast, a
sandwich for lunch, and chicken or turkey with rice or potato salad for dinner. Patient consumed 25-50% of meals.
Weight History
Using the Hamwi equation to calculate ideal body weight (IBW) for women, MBs ideal body weight is 51.2
kilograms. Per patient, MBs usual weight (UBW) is 250 pounds. The patient reports having significant weight loss
from about 400 pounds to 240 pounds in the past few years.
Date
February 12,
2012
December 9,
2015

Weight (in kg)

136.2

Source of Weight
Measured

% UBW
100

% IBW
266

117.7

Measured

86.4

218

Physical Activity Level

No information regarding the patients physical activity prior to admission was obtained. During patients
hospitalization, she was not ambulatory. During the admission, MB began physical therapy putting weight on left
foot.
Estimated Nutrient Needs
Source
Facility Standards

Evidence Analysis Library

(EAL)
Online Nutrition Care Manual
(NCM)

Kcal Requirements
Mifflin St Jeor
With 500 kcal deficit for
weight loss
1440-1592 kcal
MSJ
30-35 kcal/kg
1364-1591 kcal

Protein
Requirements
1-1.2 g/kg
Based on IBW
51-61 g
n/a
1.5-2.5 g/kg
68-114 g

Fluid Requirements
15-20 mL/kg
Based on >160% of
IBW
1676-2234
n/a
n/a

Use of Vitamins/Minerals, Oral Liquid Supplements, and/or Alternative Supplements

No information is provided in regards to patients use of vitamins/minerals. MB reported using oral liquid
supplement of Glucerna Shake strawberry flavor when she did not have an appetite. The patient provided no
information on alternative supplement use.
Cultural Attitudes That Influence Dietary Intake

Patient did not express any cultural or religious food preferences or restrictions during hospitalization.
Past Nutritional Therapy
Patient had no past nutritional therapy.

HOSPITAL COURSE OF PATIENT

MEDICAL TREATMENT

Day 1 (12-9-15) Patient admitted overnight complained of (c/o) left lower extremity (LLE) pain. Patient
underwent radiologic imaging of left foot. Diet order: NPO Intake: N/A
Day 2 (12-10-15) Per MRI of left foot, there was no evidence of fracture, subluxation/dislocation, or any focal
osseous lesion seen; Osteoarthritis of intertarsal joints was noted. Patient denied nausea/vomiting/chest pain or
shortness of breath. The patients left lower extremity (LLE) pain improved after receiving morphine. Patient
left foot, planter aspect had a 4-5 cm linear laceration with surrounding minimal erythema and proximal area of
blanching raising concern for local fluid collection. Diet order: Cardiac Consistent Carb Diabetic, Medium.
Intake:25-50%
Day 3 (12-11-15) Another MRI of left foot completed. Pain in LLE tolerable. Orthopedics team recommended
no surgical intervention. Wound care consulted; they recommended wound dressing that was to be changed
every other day with use of blue special care boot and elevation of legs. Relevant labs: Creatinine (Cr) level rising
from baseline; elevation suspected to be multifactorial, pre-renal vs. renal with impact of current medications:
Vancomycin, Gabapentin, and Lisinopril, dehydration, and infection. Medications (Vancomycin, Gabapentin,
and Lisinopril) were held and Zosyn was adjusted to renal dose level. The plan was to consult renal for possible
short-term inpatient hemodialysis (HD) if Cr continued to rise. Diet order: Cardiac, Mech Soft/Chopped
Medium CHO with Glucerna Shale BID. . Intake: N/A.
Day 4 (12-12-15) Follow up tests included of urine analysis (u/a), urine electrolytes and Cr. Cr continued to rise.
Renal re-consulted; they recommended no acute indication for renal replacement therapy, and will consider renal
ultrasound if renal function does not improve. Diet order: Cardiac, Mech Soft/Chopped Medium CHO with
Glucerna Shale BID. Intake: N/A.
Day 5 (12-13-15) No acute medical updates noted in medical chart. Diet: Cardiac, Mech Soft/Chopped Medium
CHO with Glucerna Shale BID. Intake: N/A
Day 6 (12-14-15) Follow up cultures of wound and blood were sent to pathology. Physicians were monitoring
fever and WBC curve. Diet: Cardiac, Mech Soft/Chopped Medium CHO with Glucerna Shale BID. Intake:
N/A
Day 7 (12-15-15) Microbiology of wound revealed light growth of (non-resistant) staphylococcus aureus.
Physicians were avoiding use of Vancomycin due to AKI (acute kidney injury), but continued to use broadspectrum Zosyn while monitoring fever and WBC curve. Diet: Cardiac, Mech Soft/Chopped Medium CHO
with Glucerna Shale BID. Intake: Meals 50-75%, Supplements 75-100%
Day 8 (12-16-15) MB reported worsening pain in left foot that was evaluated with a repeat MRI of foot and left
duplex. Labs: Cr trending down; WBC is trending up. Endocrine recommended 30U Lantus BID, 24U Lispro
w/ meals. Diet order: Cardiac, Mech Soft/Chopped Medium CHO with Glucerna Shale BID. . Intake: N/A.
Day 9(12-17-15) Per MRI Left foot diagnostic test - extensive soft tissue edema or inflammation with possible
large effusion versus phlegmon or early abscess surrounding the third and fourth metatasophangeal joints; mild
bone marrow signal abnormality involving third through fifth metatarsophalangeal joint possibly representing
septic arthritis and early osteomyelitis. Cardiac, Mech Soft/Chopped Medium CHO with Glucerna Shale BID. .
Intake: N/A.
Day 10 (12-18-15) No patient updates noted in medical chart. Cardiac, Mech Soft/Chopped Medium CHO with
Glucerna Shale BID. Intake: N/A
Day 11 (12-19-15) Creatinine improved; physicians continued holding Vancomycin and Lisinopril. Diet order:
Cardiac, Mech Soft/Chopped Medium CHO with Glucerna Shale BID. Intake: N/A.

 Day 12 (12-20-15) Patient complaining of increased pain in left foot with pressure. Overnight patient was
given .5 mg dose of dilaudid to relieve pain. Leukocytosis worsening with increases pain. Diet order: Cardiac,
Mech Soft/Chopped Medium CHO with Glucerna Shale BID. Intake: N/A.
Day 13 (12-21-15) Leukocytosis improving. MB underwent debridement (incision & drainage) of possible
abscess; physicians stated patient is not ready for discharge. Per ortho, patient was ready for discharge with
follow up with wound clinic post-discharge. Diet: Cardiac, Mech Soft/Chopped Medium CHO with Glucerna
Shale BID. Intake: N/A.
Day 14 (12-22-15) Patient developed new acute hyperkalemia. RD recommended CKD non HD, med carb
chopped diet. Diet: Renal CKD Non Dialysis Chopped Medium CHO with Glucerna Shale BID. Intake: Meals
50-75%, Supplements N/A
Day 15 (12-23-15) Patient continued to have pain when weight bearing with physical therapy. Patient able to
move toes and ankle with moderate pain. Labs: Monitoring Cr and Potassium, with plant to add Kayexalate if
potassium continued to rise. Patient exuded purulent material drainage from left foot wound on plantar side..
Patient underwent for surgical irrigation and debridement with antibiotic bead placement. Diet: Renal CKD
Non Dialysis Chopped Medium CHO with Glucerna Shale BID. Intake: Meals 50-75%, Supplements N/A
Day 16 (12-24-15) Patient reported pain in foot moderately controlled post-op. Continued monitoring Cr and
potassium levels. Diet: NPO. Intake: N/A
Day 17 (12-25-15) Patient reported pain in foot moderately controlled with Dilaudid. Patient left foot plantar
wound stapled with subsequent bloody drainage. Continued monitoring Cr and K. Diet: Renal CKD Non
Dialysis Chopped Medium CHO with Glucerna Shale BID. Intake: Meals 50-75%, Supplements N/A
Day 18 (12-26-15) Patient states left foot pain moderately controlled with Dilaudid. Bloody drainage from left
foot wound decreased. Continued monitoring of Cr and K. Possible repeat of irrigation and debridement. Diet:
Renal CKD Non Dialysis Chopped Medium CHO with Glucerna Shale BID. Intake: Meals 50-75%,
Supplements N/A
Day 19 (12-27-15) No patient updates noted in medical chart. Diet: Diet: Renal CKD Non Dialysis Chopped
Medium CHO with Glucerna Shale BID. Intake: Meals 50-75%, Supplements N/A
Day 20 (12-28-15) Patient pain moderately controlled with Dilaudid. Left foot plantar wound had purulent
drainage. Ortho to follow-up with recommendations for need of repeat irrigation and drainage at bedside vs.
surgery. Continued monitoring of Cr and K. Diet: Renal CKD Non Dialysis Chopped Medium CHO with
Glucerna Shale BID. Intake: Meals 50-75%, Supplements N/A
Day 21 (12-29-15) Patient continues to have purulent drainage from left foot. Continued monitoring of Cr and
K. Pt/OT re-evaluated patient. Patient medically stable to transfer to subacute rehab. Patient transferred home
via ambulance with home healthcare. Cardiac, Mech Soft/Chopped Medium CHO with Glucerna Shale TID.
Intake: Meals 50-75%, Supplements 50-75%
NUTRITIONAL TREATMENT

Nutrition Assessment
Age: 54 years old
Gender: Female
Weight: 111. 7 kg (Converted to: 246 lb 4 oz.)
Height: 159 cm (Converted to: 5 ft. 3 in)
BMI: 44 (morbidly obese)
PMH: Type II Diabetes Mellitus, Gout, High
Blood Pressure, Hyperlipidemia, Neuropathy,
and history of Depression.

Labs (admission):
Medications prior to admission:
Current Diet: Cardiac Medium Consistent
Carb Diabetic Diet, (60 g carbohydrates at
meals)

Symptoms: Poor appetite, difficulty chewing,

pain on sole of left foot
Diet History: Poor appetite prior to
admission; intake of 25-50% of meals since
admission
Nutrition Diagnosis
Overweight/obesity (NC 3.3) related to excess energy intake as evidenced by BMI 44 and 218%
of IBW.
Chewing difficulty (NC1.2) related to acute loss of teeth as evidenced by need for modified
consistency diet and patient comments unable to chew hard and larger pieces of food.
Food and nutrition knowledge deficit (NB 1.1) related to lack of knowledge of foods and
beverages that affect blood sugar as evidence by patient 24 hour recall.
Nutrition Intervention
Nutrition Prescription
1800 kcal cardiac medium consistent carb
diabetic diet, mechanical chopped, with
nutrition supplement of Glucerna Shake
strawberry flavor once per day

Intervention with goals

Commercial beverage (ND-3.1.4) and food
(ND-3.1.3): Initiate nutrition supplement once
per day of Glucerna Shake. GOAL: Patient
consumes >50% of supplement
Nutrition relationship to health/disease (E 1.4):
Provide patient with nutrition education on
foods and beverages that affect blood sugar
levels and result in hyperglycemia. GOAL:
Patient able to plan 1-2 days of meals
Collaboration with other providers (RC-1.4):
Collaborate with medical team to monitor
adequacy of oral intake of patient meals and
supplements. GOALS: Patient consumes
>75% of meals and supplements

Nutrition Monitoring and Evaluation

Indicators
Total energy intake (FH-1.1.1.1)

Criteria
Patient consumes >75% of meals.

Liquid meal replacement or supplement (FH1.2.1.3)

Patient consumes >75% of nutrition

supplements.

Food and nutrition knowledge (FH-3.1)

Patient is able to describe the importance of

following a consistent carbohydrate diet and its
effect on her blood sugar levels.

Weight (AD-1.1.2)

Weight gain < 5 lbs of admission weight.

PRESENT NUTRITIONAL THERAPY

Date

Diet

Modifications

Dec 10

RN consult received for weight loss greater than 15 pounds. Nutrition met with patient, who
reported weight loss from 400 pounds to 250 pounds in the past few years. Patient reported having a
poor appetite and consuming 25-50% of meals. Patient also reported having difficulty chewing
secondary to missing teeth. Patient had scheduled a dentist appointment for 12/10, but now must reschedule. Patient agreed to mechanically chopped cardiac consistent carb diabetic diet with
supplements of Glucerna Shale strawberry BID. Dietetic intern also gave education on diabetic meal
plan to patient. Will follow up.

Dec 15

Cardiac Consistent
Carb Diabetic, Med
60 g, Chopped

Dec 22

Renal CKD Non

Dialysis Mech
Soft/Chopped
Diabetic Medium
Carb

Dec 23

Dec 24

Average
Intake

Nutrition
Supplements

Average Intake

100%
breakfast
50% lunch &
dinner

Glucerna
Shale BID

100%

Renal CKD non

dialysis

50-75%

Glucerna
Shale BID

Unknown, limited data

Renal CKD Non

Dialysis Mech
Soft/Chopped
Diabetic Medium
Carb

NPO, after midnight

for 12/24

50-75%

Glucerna
Shale
BID

50-75%

NPO

Cardiac Consistent
Carb Diabetic, Med
60 g, Chopped, Low
Potassium

Glucerna
Shale
BID

CASE DISCUSSION
MEDICAL CONSIDERATIONS

MB presented to the medical team with left foot laceration with cellulitis and poorly controlled diabetes. Foot
infections are common among those with diabetes. It is associated with a higher risk of morbidity and possibility of
lower extremity amputation (1). Frequent infections in patients with diabetes are due to regular hyperglycemia that
promotes neuropathy, lower antibacterial function of urine, immune dysfunction, and the need for extensive
medical intervention (3). Clinical diagnosis of infection requires the presence of either significant inflammation or
purulent discharge. Infections are classified as mild, moderate or severe, and staging often determines hospital

course of action (1). Diabetic infections are monomicrobial or polymicrobial, and most commonly consist of
Staphylococcus aureus and Staphylococcus epidermidis. Enterococci, streptococci, and enterobacteria are present
less frequently (3).
Management of diabetic infections involves a multifactorial treatment approach. It includes antibiotic therapy,
surgical debridement and wound care, and correction of metabolic imbalances. Common contributing issues are
hyperglycemia and the presence of arterial insufficiency (1). Multiple types of antibiotics can be used to treat
infections. MB was started on broad-spectrum antibiotics (Zosyn and Vancomycin) following positive wound
cultures for Staphylococcus aureus. Due to clinical failures of vancomycin therapy treatment in patients with
methicillin-resistant Staphylococcus aureus, the Infectious Disease Society of America clinical practice guideline
recommends use of vancomycin concentration at 10-20 g/mL (5).
While aggressive antibiotic treatment is necessary for effective infection treatment, high-dose vancomycin therapy
has been also been associated with acute kidney injury (AKI). This is a clinical concern, but no consistent
diagnostic criteria exists to define the presences of AKI. The AKI Network (AKIN) defines AKI associated with
vancomycin as rapid (within 48 hours) changes in serum creatinine (increase in Scr of 0.3 mg/dl) or urine output
(<0.5 ml/kg/h for >6 h). The use of AKIN criteria could mean earlier detection of AKI and result in rapid and
more effective treatment (7). MB had AKI believed to be 2/2 nephrotoxicity of vancomycin, gabapentin, and
Lisinopril. MB had medications held and antibiotic Zosyn reduced to renal dose.
Nutrition management has been shown to better glycemic control and foster wound healing. Adequate caloric
intake is necessary for tissue regeneration and immune support. While there is no evidence based recommendation
for energy requirements for diabetic wound healing, the European Pressure Ulcer Advisory Panel (EPUAP) and
the National Pressure Ulcer Advisory Panel (NPUAP) recommend a minimum of 3035 kcal/kg/day (5). An
adequate amount of carbohydrates throughout the day is necessary to maintain steaddy blood glucose and prevent
protein oxidation for energy (5). Wound healing will be delayed if inadequate dietary protein. The EPUAP and
NPUAP recommends 1.25-1.5 g/kg/day for repair and growth of cell tissue at wound sites (5). Tight glucose
control and a balanced diet will promote wound healing in patients with diabetic infections (5)
NUTRITIONAL THERAPY

MB was admitted with a poor appetite and difficulty chewing, which may have been due to underlying infection
(appetite) and tooth loss (difficulty chewing). Nutrition was consulted for weight loss greater than 15 pounds pta.
Patient reported that the weight loss of 400 to 250 pounds in the past few years was intentional; she was not able to
state what her goal weight was, but did not seem adverse to further weight loss. MB reported consuming strawberry
Glucerna at home when she had a poor appetite. Available weights included 117.7 kg (this admission) and 136.2 kg
(February 2012 admission). Actual weight loss over one year was not able to be determined. Based on facility
standards, MBs calorie needs were 1440-1592 calories, per actual body weight with a 500 calorie deficit for weight
loss; continued goal of weight loss was based on her current elevated BMI of 44. Based on facility standards,
patient protein needs were 51-61 grams based on 1-1.2 g/kg for idea body weight. Patient reported eating 25-50%
of meals due to continued poor appetite chewing difficulty after admission. Prior dentist appointment on 12/10/15
will be rescheduled after hospital discharge,. Patients limited oral intake can be explained as a combination of
difficulty chewing, poor appetite and possibly foot-associated pain.
Upon admission, MB was placed on a medium cardiac consistent carbohydrate diabetic diet. The patients diet was
changed to mechanically chopped due to difficulty chewing and Glucerna strawberry shake once a day was added
due to poor oral intake. MB consumed 100% of nutrition supplements. She was able to consume 50-100% of
meals once altered to mechanical chopped diet.
A 24 hour recall revealed intake of corn flakes, toast, eggs and sausage for breakfast, a sandwich for lunch, and
chicken or turkey with rice or potato salad for lunch as well as regular consumption of orange juice or other fruit
drinks. MB voiced an understanding that her current food choices were causing high blood sugar levels (300s). She

reported she had difficulty making healthy choices due to cooking meals for her diabetic mother who receives
hemodialysis as well as two grandsons who frequently request foods like chicken nuggets and French fries. MB
received information explaining how current high carbohydrate choices at meals and sugary beverages result in high
blood sugar. It was also explained to MB how elevated blood sugar increases incidence of infections as well as how
high blood sugar reduces healing of existing infections or wounds. MB agreed to eliminate sweetened beverages and
change them for sugar-free drinks or water. She agreed to limit breakfast to toast or cornflakes and half rice or
potato portions and substitute non-starchy vegetables with meals. Patient requested further education material on
meal planning for diabetes.
12/22/15 patient diet order changed to CKD medium cardiac consistent carbohydrate diabetic diet due to
hyperkalemia secondary to acute kidney injury secondary to antibiotics. Patient remained on this diet for remainder
of hospitalization.
IMPLICATIONS OF FINDINGS TO THE PRACTICE OF DIETETICS

While aggressive antibiotic treatment is necessary to prevent delayed wound healing, kidney function should be
closely monitored to prevent adverse reactions like AKI. Because vancomycin is found to cause nephrotoxicity,
patients presenting with elevated creatinine levels or decreased urine output may be at higher risk for AKI when put
on antibiotic treatment including vancomycin. MB presented with elevated creatinine levels (see Appendix A) and
during treatment had AKI 2/2 medication nephrotoxicity. For future patients with elevated levels other antibiotic
therapy should be consider to prevent this outcome.
MB presented with elevated blood glucose levels (see Appendix A). This made it difficult to achieve glucose
control during treatment. Nutrition education on diabetes was necessary to instruct patient on better dietary
choices to achieve better glucose control in the future. Patients also need to be told of how elevated blood glucose
levels delay wound healing and increase length of hospital stays. Although glucose levels are harder to control for
patients with diabetic associated infections, the education of a carbohydrate controlled diet and close glucose
monitoring can aid in reducing future hospital stays and diabetic associated infections.

APPENDICES
APPENDIX A: LABORATORY RESULTS
Lab
Na
K
Cl
CO2
Creatinine
Glucose
BUN
Ca
Phos

Reference
Range
135-146
mmol/L
3.5-5.3
mmol/L
98-107
mmol/L
22-32
mmol/L
0.6-1.1
mg/dl
<140
mg/dl
7-20
mg/dl
8.1-10.7
mg/dl
2.4-4.7
mg/dl

12/10

12/11
12:40
137

12/12

12/13

12/14

12/15

12/16

12/17

12/18

12/19

136

12/11
7:36
139

138

141

143

141

141

140

141

140

3.8

3.8

3.6

4.2

3.9

4.1

5.1

4.1

4.7

4.7

4.7

102

105

105

107

109

109

106

108

108

108

107

24

22

22

22

22

22

20

22

23

22

21

1.24

3.13

3.44

3.73

3.25

2.79

2.58

2.48

2.24

2.04

1.90

378

202

280

246

72

143

106

145

136

195

219

15

24

27

33

29

26

26

26

26

23

21

8.0

7.5

8.2

8.2

8.0

8.1

8.0

8.6

8.4

8.0

2.8

3.5

4.1

4.4

4.4

5.0

4.8

4.7

4.5

4.8

Mg
AST
ALT
WBC
Triglyceride

Lab

1.7-2.2
mg/dl
15-41
IU/L
17-63
IU/L
4.8-10.8
k/uL
<150
mg/dl

2.0

1.9

1.8

1.6

1.6

1.6

1.5

1.8

1.7

1.5

13

16.7

18.3

15.3

15.8

15.6

19.5

16.1

14.4

14

12.6

234

12/20

12/21

12/22

12/23

12/24

12/25

12/26

12/27

12/28

12/29

Na

Reference
Range
135-146 mmol/L

139

139

138

139

139

139

139

139

135

136

3.5-5.3 mmol/L

5.2

4.9

5.4

4.8

4.7

5.0

4.5

4.6

4.8

5.0

Cl

98-107 mmol/L

105

104

104

106

106

106

107

105

103

102

CO2

22-32 mmol/L

23

25

23

23

23

25

22

24

22

23

Creati
nine
Gluco
se

0.6-1.1 mg/dl

1.82

1.77

1.93

1.71

1.76

1.56

1.36

1.37

1.44

1.58

<140 mg/dl

188

209

190

217

189

214

168

232

222

192

BUN

7-20 mg/dl

22

24

30

28

31

30

22

23

22

28

Ca

8.1-10.7 mg/dl

8.7

8.4

8.8

8.9

8.7

8.9

8.8

8.7

8.8

9.2

Phos

2.4-4.7 mg/dl

4.9

4.4

5.0

4,1

5.2

4.5

3.3

4.4

4.5

5.0

Mg

1.8-2.5 mg/dl

2.0

1.8

1.7

1.5

1.7

1.6

1.3

1.4

1.6

1.9

AST

15-41 IU/L

ALT

17-63 IU/L

WBC

4.8-10.8 k/uL

13.5

11.1

9.6

8.9

11.4

7.4

7.4

7.5

9.0

7.7

Trigly
ceride

<150 mg/dl

APPENDIX B: MEDICATIONS

Home Medications
Medication

Dosage

Insulin lispro

Insulin glargine

Frequency

Function

Nutritional Implications

15 mL,
3x daily
subcutaneous w/ meals

A rapid-acting human insulin

analog that lowers blood glucose.
Onset is within 15 minutes,
peaks in 30-90 minutes and lasts
3-5 hours.

Can cause hypoglycemia if

food is not consumed within
15 minutes of injection.

10 mL,
Every 12
subcutaneous hours

A long-acting insulin that works

throughout the day to maintain
stable glucose levels. Onset is
within 1 hour, there is no peak,
and duration is 20-26 hours.

Too high of a dosage can

result in hypoglycemia.

Nifedipine

60 mg, oral

1x daily

A calcium channel blocker that

works to relax heart muscles and
blood vessels. It is used to treat
hypertension and angina.

For patients who are

galactose intolerant or have
severe lactose intolerance,
this medication can cause
reactions.

Aspirin

81 mg, oral

1x daily

Salicylate that helps reduce fever,

pain, swelling, and blood clots

Nausea, vomiting, stomach

pain, heartburn

In-Patient Medications
Medication

Function

Nutritional Implications

Acetaminophen

Pain reliever and fever reducer.

Nausea, upper stomach pain, loss of

appetite, and clay colored stools. Should
not be taken if history of cirrhosis or
consumption of 3 or more alcoholic
drinks per day.

Aspirin

Salicylate that helps reduce fever, pain,

swelling, and blood clots

Nausea, vomiting, stomach pain,

heartburn

Atorvastatin

HMG-CoA reductase inhibitor that

helps lower cholesterol.

Diarrhea, constipation, gas, nausea, loss of

appetite. Avoid grapefruit juice.

Docusate-senna

Docusate is a stool softener and senna

is a laxative. This combination of
medications treats constipation.

Stomach/abdominal pain, cramping,

nausea, diarrhea, and weakness.

Gabapentin

An anti-epileptic used to treat nerve

pain and prevent/control seizures.

No known drug/nutrient interactions

Heparin

Anticoagulant that prevents blood clots

Maintain consistent levels of vitamin K in

diet. Take caution with vitamin E and
alcohol intake.

Insulin glargine

A rapid-acting human insulin analog

that lowers blood glucose. Onset is
within 15 minutes, peaks in 30-90
minutes and lasts 3-5 hours.

Can cause hypoglycemia if food is not

consumed within 15 minutes of injection.

Insulin lispro

A long-acting insulin that works

throughout the day to maintain stable
glucose levels. Onset is within 1 hour,
there is no peak, and duration is 20-26
hours.

Too high of a dosage can result in

hypoglycemia.

Lactobacillus acidophilus
and bulgaricus

Aids in digestion, preventing diarrhea

and alleviating symptoms of IBS.

Patients that are sensitive to milk or soy

products should not use.

Oxycodone

Opiod medication used to treat

moderate to severe pain.

No known drug/nutrient interactions.

Albuterol-ipratropium

GLOSSARY
Cellulitis: a spreading bacterial infection of the skin and tissues beneath the skin. Usually this occurs where the skin ahs
broken open, such as ulcers, surgical wounds, or lesions.
Osteomyelitis: inflammation of the bone caused by and infecting organism. When acute, the infection has been present
for less than 6 weeks. Chronic is when the infection has been present for more than 6 weeks.

Purulence: the state of being purulent; pus containing or discharging.

REFERENCES
1. BADER, MAZEN S., MD, MPH. "Diabetic Foot Infection." American Family Physician. N.p., 1 July 2008. Web. 09 Apr.
2016.URL: http://www.aafp.org/afp/2008/0701/p71.html. Accessed: April 4, 2016.
2. Bertoni, Alain G., MD, MPH, Sharon Saydah, MHS, and Frederick L. Brancati, MD, MHS. "Diabetes and the Risk of InfectionRelated Mortality in the U.S." Diabetes Care. American Diabetes Association, June 2001. Web. 09 Apr. 2016.URL:

http://care.diabetesjournals.org/content/24/6/1044.full. Accessed: April 4, 2016.

3. Casqueiro, Juliana, Janine Casqueiro, and Cresio Alves. "Infections in Patients with Diabetes Mellitus: A Review of
Pathogenesis." Indian Journal of Endocrinology and Metabolism. Medknow Publications & Media Pvt Ltd, 16 Mar. 2012. Web.
09 Apr. 2016.URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3354930/. Accessed: April 4, 2016.
4. Collins, Nancy, PhD, RD, LD/N, and Collen Sloan, RD, LD/N. "Diabetic Wound Healing Through Nutrition and Glycemic
Control." Today's Wound Clinic 7.2 (2013): n. pag. Web. 9 Apr. 2016.URL:

http://www.todayswoundclinic.com/articles/diabetic-wound-healing-through-nutrition-and-glycemic-control.
Accessed: April 4, 2016.
5. Elyasi, S., H. Khalili, S. Dashti-Khavidaki, and A. Mohammadpour. "Vancomycin-induced Nephrotoxicity: Mechanism,
Incidence, Risk Factors and Special Populations. A Literature Review." National Center for Biotechnology Information. U.S.
National Library of Medicine, 13 Mar. 2012. Web. 09 Apr. 2016.
URL: http://www.ncbi.nlm.nih.gov/pubmed/22411630. Accessed: April 4, 2016.
6. Lipsky, BA. Diabetic Foot Infections: Current treatment and delaying the post-antibiotic era. Diabetes

Metab Res Rev 2016; 32 (suppl. 1): 246-254. Online publication. Accessed: April 4, 2016.
7. Minejima, Emi, Joyce Choi, Paul Beringer, Mimi Lou, Edmund Tse, and Annie Wong-Beringer. "Applying New Diagnostic
Criteria for Acute Kidney Injury To Facilitate Early Identification of Nephrotoxicity in Vancomycin-Treated
Patients." Antimicrobial Agents and Chemotherapy. American Society for Microbiology, July 2011. Web. 09 Apr. 2016.URL:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3122454/. Accessed: April 4, 2016.
8. "NCM Nutrition Care Manual Eat Right." - Nutrition Care Manual. N.p., n.d. Web. 23 May 2016.

9. "Welcome to the Evidence Analysis Library. Your Food and Nutrition Research Resource." EAL. N.p., n.d. Web. 23 May
2016.