Common Infections in the Traveling Diabetic

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Diabetic travelers are at risk for other serious infections while traveling abroad on the basis of their predilection for cutaneous Gram-positive infections, neuropathies, vascular compromise, and abnormal phagocytic cell function. Unnoticed foot trauma from new footwear or hiking shoes may lead to diabetic foot ulcers and osteomyelitis. Careful instructions regarding local care of early ulcers, changes of socks to avoid persistent pressure points, and careful wound dressings at night to supplement the use of antibiotics are necessary to prevent cellulitis and lymphangitis. Both staphylococci and Group B streptococci are important pathogens under these circumstances.

Pyomyositis. The diabetic who engages in strenuous sports or long arduous treks adds additional risk factors for the development of serious skeletal muscle infection with Staphylococcus aureus. Strenuous muscle activity, local abrasions, cutaneous infections during travel, infected insect bites, and muscle trauma in particular (Belsky et al., 1994), can predispose to muscle infection in diabetic patients. The same is true for the HIV-infected patient. Pathogens are predominately S. aureus but also include other species such as groups B, C and G streptococci, and occasionally facultative Gram-negative organisms or anaerobes.

Urinary tract infections are more common in women with diabetes, particularly if fluid intake has been decreased. Risk during travel may be associated with increased sexual activity on vacation: Gram-negative enteric flora or enterococci are the major offenders, unless there has been prior use of antibiotics or vaginal can-didasis is present. Upper tract disease (renal carbuncle, perinephric abscess or renal papillary necrosis) occurs more commonly in diabetic patients. It should be anticipated by utilization of a 2 week antibiotic regimen for such infections, rather than short-course therapy.

Community-acquired pneumonia may be more severe in diabetic patients and it may require both hospitalization and broader antibiotic coverage for other organisms which are less common in nondiabetics, such as S. aureus, Gram-negative organisms, or even Mycobacterium tuberculosis. Oral antibiotics may not always prove to be adequate for all infections in diabetics. Nephrotoxic agents must be avoided, particularly when renal insufficiency is already present, as should the additional burden of ototoxic drugs in patients who already have the potential for impaired vision from diabetes.

Immunizations should include annual influenza vaccine and pneumococcal vaccine, in addition to purified protein derivative (PPD) skin testing before and after any travel that includes added tuberculosis risk, such as medical work in endemic regions. The risk of tuberculosis for diabetics is also several-fold higher than that of the general population.

Candidasis. Diabetics readily colonize and develop clinical infections with Candida spp. Patients receiving oral doxycycline for malaria prophylaxis would be at particu larly increased risk, and should be prepared to treat the first appearances of candidal infections.

Melioidosis, insulin and the diabetes connection. The medical literature originating from geographic areas where melioidosis is an endemic disease, such as Southeast Asia and northern Australia, makes frequent reference to its clinical associations with diabetes mellitus. The causative organism, Burkholderia pseudomallei, has a unique ability to bind human insulin, and this bacterial property may underlie a remarkable biological and clinical relationship, with important implications for diabetics traveling to endemic areas (Woods et al., 1993). The geographic distribution of this disease is wider than we had appreciated in the past.

The causative organism gained notoriety during both the French and American involvement in Indo-China, such that by 1973 over 340 cases had been described among American soldiers fighting in Vietnam, with helicopter pilots at greater risk of infection from soil blown around by rotor blades. The geographic extent of disease distribution was later found to reach the northern rice-growing regions of Thailand, Australia and even the Caribbean basin. It continues to expand (Dance, 1999).

B. (formerly Pseudomonas) pseudomallei can be isolated from both soil and water, and it is particularly prevalent in rice paddies during the rainy season. Infections seem to be acquired by several routes, including inoculation and inhalation. Melioidosis is a seasonal disease, with a majority of cases occurring during the rainy seasons among those who are regularly in contact with soil and water. Males predominate and the peak age incidence ranges from ages 40 to 60.

In endemic regions, melioidosis accounts for an unusually high proportion of community-acquired sepsis, being the most common source of fatal community-acquired sepsis in the northern territories of Australia. Most patients have an underlying metabolic or disease process such as alcohol abuse, an immunosuppressive disorder, diabetes mellitus, renal disease, liver disease or pregnancy, although melioidosis does not appear to be an AIDS-associated opportunistic infection. Melioidosis may be localized or disseminated and might only present clinically after many years of bacterial latency.

Travel medicine consultants should be aware that all diabetics (both type I and type II) with the appropriate exposure to infected soil and water are clearly predisposed to severe melioidosis when physiologic insulin levels are not maintained. Although type I diabetes and insulin deficiency do not fully explain the predisposition of all diabetics for melioidosis, human insulin levels do appear to play a unique role in modulating the pathogen-esis of infection and septicemia associated with melioido-sis. Review such emerging epidemiological data and advise travelers, particularly diabetic patients, of the risks of acquiring melioidosis during their travel to endemic regions as this information is further refined.

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