{ "schema_version": 1, "kind": "condition", "id": "gangrene-emergency-referral", "name": "Gangrene and Diabetic Foot (Emergency Referral)", "category": "chronic", "sources": "ADA Standards of Care in Diabetes 2024 · NICE Guideline NG19: Diabetic foot problems 2019 · Gangrene - StatPearls (NCBI Bookshelf NBK560552) - https://www.ncbi.nlm.nih.gov/books/NBK560552/: \"Gas gangrene, typically caused by Clostridium species, is a life-threatening necrotizing infection requiring urgent intervention.\", \"Management includes prompt surgical debridement or amputation, broad-spectrum antibiotics, and, in some cases, intravenous immunoglobulin to bind and neutralize toxins.\" and \"Surgery within 24 hours of admission significantly improves survival.\" · Egyptian National Drug Formulary - Antimicrobial 2023 (piperacillin and tazobactam monograph, p368) · Egyptian National Drug Formulary - Antimicrobial 2023 (vancomycin monograph, p333) · Egyptian National Drug Formulary - Antimicrobial 2023 (piperacillin and tazobactam monograph, p368) - severe infections 4.5 g every 6 to 8 hours by the traditional 30-minute infusion, 4.5 g every 6 hours for Pseudomonas aeruginosa cover, usual maximum 18 g per day. The adult figures are the combined amount of both components. The formulary names ischaemic and diabetic foot infections among the indications. · Egyptian National Drug Formulary - Antimicrobial 2023 (vancomycin monograph, p333) - for life-threatening systemic infection, intermittent infusion of 15 to 20 mg/kg per dose rounded to the nearest 250 mg every 8 to 12 hours, with a 20 to 35 mg/kg loading dose to a maximum of 3 g per dose in a seriously ill patient with suspected or documented MRSA.", "review_status": "reviewed", "verified_against": "Gangrene - StatPearls (NCBI Bookshelf NBK560552) - https://www.ncbi.nlm.nih.gov/books/NBK560552/: \"Gas gangrene, typically caused by Clostridium species, is a life-threatening necrotizing infection requiring urgent intervention.\", \"Management includes prompt surgical debridement or amputation, broad-spectrum antibiotics, and, in some cases, intravenous immunoglobulin to bind and neutralize toxins.\" and \"Surgery within 24 hours of admission significantly improves survival.\" · Egyptian National Drug Formulary - Antimicrobial 2023 (piperacillin and tazobactam monograph, p368) · Egyptian National Drug Formulary - Antimicrobial 2023 (vancomycin monograph, p333) · Egyptian National Drug Formulary - Antimicrobial 2023 (piperacillin and tazobactam monograph, p368) - severe infections 4.5 g every 6 to 8 hours by the traditional 30-minute infusion, 4.5 g every 6 hours for Pseudomonas aeruginosa cover, usual maximum 18 g per day. The adult figures are the combined amount of both components. The formulary names ischaemic and diabetic foot infections among the indications. · Egyptian National Drug Formulary - Antimicrobial 2023 (vancomycin monograph, p333) - for life-threatening systemic infection, intermittent infusion of 15 to 20 mg/kg per dose rounded to the nearest 250 mg every 8 to 12 hours, with a 20 to 35 mg/kg loading dose to a maximum of 3 g per dose in a seriously ill patient with suspected or documented MRSA.", "verified_date": "2026-08", "treatments": [ { "id": 799, "generic": "Piperacillin + Tazobactam", "line": 1, "is_adjunct": false, "form": "injection", "strength_mg": 4500.0, "adult_dose": "4.5 g intravenously every 6 to 8 hours for a severe infection, and every 6 hours where Pseudomonas has to be covered. Maximum 18 g in a day.", "adult_duration": "Reviewed against deep tissue culture and narrowed as soon as the organism is known", "dose_source": "Egyptian National Drug Formulary - Antimicrobial 2023 (piperacillin and tazobactam monograph, p368) - severe infections 4.5 g every 6 to 8 hours by the traditional 30-minute infusion, 4.5 g every 6 hours for Pseudomonas aeruginosa cover, usual maximum 18 g per day. The adult figures are the combined amount of both components. The formulary names ischaemic and diabetic foot infections among the indications.", "rationale": "The gangrene article's empiric regimens include vancomycin with piperacillin-tazobactam, and it asks for initial broad-spectrum coverage of gram-positive, gram-negative and anaerobic organisms, broadened in a patient with diabetes to include MRSA and further gram-negatives. Four 4.5 g products are marketed in Egypt, from PIPERACILLIN-TAZOBACTAM SANDOZ at about 110 EGP to TAZOCIN at about 225 EGP; a 2.25 g presentation is also registered, which matters because the reduced renal doses are written at that strength.", "cautions": [ "GIVEN ALONGSIDE VANCOMYCIN, NOT INSTEAD OF IT. The article's empiric regimen is both drugs; either alone leaves a gap.", "The referral comes first and this is not started in a clinic. The article reports that surgery within 24 hours of admission significantly improves survival, and that prompt debridement or amputation is what controls the source - antibiotics do not substitute for it.", "Contraindicated in hypersensitivity to penicillins, cephalosporins or beta-lactamase inhibitors.", "The dose comes down in renal impairment: the formulary gives 4.5 g every 8 hours below a creatinine clearance of 40 mL/min and every 12 hours below 20 mL/min.", "Take deep tissue for culture before the first dose wherever that does not delay it - the article warns that superficial swabs are contaminated by skin flora and that deep swabbing or aspiration of pus is what identifies the organism." ], "peds_mgkg_low": null, "peds_mgkg_high": null, "peds_max_mg": null, "peds_basis": null, "peds_unit": null, "peds_note": "No weight grid is drawn here on purpose, because the formulary states the adult dose as the combined amount of both drugs and the paediatric dose as the piperacillin component alone, and mixing the two would print the wrong number. The formulary's paediatric figures, of piperacillin: from 2 months of age, 240 to 300 mg/kg/day divided into 3 or 4 doses, maximum 16 g/day; neonates 30 weeks or less, 100 mg/kg every 8 hours. A child with gangrene is a paediatric surgical emergency and the dose is calculated by the receiving team.", "peds_min_weight_kg": null, "peds_max_weight_kg": null, "peds_age_min_months": null, "peds_age_max_months": null, "peds_age_bands": null, "peds_doses": null, "brands": [ { "trade_name": "PIPERACILLIN-TAZOBACTAM SANDOZ 4.5 GM PD. FOR I.V. VIAL", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "SANDOZ", "price_egp": 110.5, "pack_count": null, "unit_price": null, "strength_mg": 4500.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "PIPRATAZ 4.5 GM PD. I.V. VIAL", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "LABORATORIO REIG JOFRE > HIKMA PHARMA", "price_egp": 220.0, "pack_count": null, "unit_price": null, "strength_mg": 4500.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "TAZOCIN 4.5 GM PD. FOR I.V. VIAL", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "WYETH > PFIZER", "price_egp": 225.0, "pack_count": null, "unit_price": null, "strength_mg": 4500.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "PIPERACILLIN/TAZOBACTAM KABI 4.5 GM 10 PD. FOR I.V. VIAL", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "FRESENIUS KABI", "price_egp": 2570.0, "pack_count": null, "unit_price": null, "strength_mg": 4500.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null } ], "condition_id": "gangrene-emergency-referral" }, { "id": 800, "generic": "Vancomycin", "line": 1, "is_adjunct": false, "form": "injection", "strength_mg": 1000.0, "adult_dose": "15 to 20 mg/kg per dose, rounded to the nearest 250 mg, by intermittent infusion every 8 to 12 hours. In a seriously ill patient with suspected or documented MRSA a loading dose of 20 to 35 mg/kg on actual body weight, to a maximum of 3 g, may be given first.", "adult_duration": "Adjusted against serum concentrations and narrowed once cultures are back", "dose_source": "Egyptian National Drug Formulary - Antimicrobial 2023 (vancomycin monograph, p333) - for life-threatening systemic infection, intermittent infusion of 15 to 20 mg/kg per dose rounded to the nearest 250 mg every 8 to 12 hours, with a 20 to 35 mg/kg loading dose to a maximum of 3 g per dose in a seriously ill patient with suspected or documented MRSA.", "rationale": "The article pairs vancomycin with piperacillin-tazobactam as an empiric regimen for gas gangrene and necrotising soft tissue infection, and asks for MRSA cover in a patient with diabetes. The formulary lists serious skin and skin structure infection caused by methicillin-resistant staphylococci, and empiric therapy where they are suspected, among its indications. Seven 1 g vials are marketed in Egypt, from VANCOMIX at about 95 EGP to about 204 EGP, and 500 mg vials are registered as well.", "cautions": [ "GIVEN ALONGSIDE PIPERACILLIN-TAZOBACTAM, NOT INSTEAD OF IT.", "The referral and the surgery come first. This is hospital treatment, written here so the referral is an informed one.", "Serum levels have to be monitored, and the formulary asks for early and frequent monitoring whenever empiric doses exceed 4 g/day. Nephrotoxicity and ototoxicity are the reasons.", "The article states that if group A Streptococcus or Clostridium species are identified, the treatment becomes penicillin combined with clindamycin for 10 to 14 days, clindamycin being added to shut down toxin production; it warns that clindamycin alone is not used, because of inducible resistance. That switch is made by the treating team once the organism is known.", "Contraindicated in hypersensitivity to vancomycin.", "The article also records intravenous immunoglobulin as sometimes used to bind and neutralise the toxins of Clostridium, Staphylococcus and Streptococcus species, without stating a dose." ], "peds_mgkg_low": 45.0, "peds_mgkg_high": 60.0, "peds_max_mg": null, "peds_basis": "day", "peds_unit": "mg", "peds_note": "Infants, children and adolescents: 45 to 60 mg/kg/day intravenously divided every 6 to 8 hours, individualised against serum concentrations, with the dose reduced in renal impairment. No ceiling is printed above because the formulary states none for this general band; its separate serious-MRSA bands do carry one, and they differ by age: 60 to 80 mg/kg/day divided every 6 hours from 3 months to under 12 years, and 60 to 70 mg/kg/day divided every 6 to 8 hours from 12 years, each to an initial maximum of 3,600 mg/day. Neonates: 15 mg/kg initially, then 10 mg/kg every 12 hours under 1 week of age and every 8 hours from 1 week to 1 month.", "peds_min_weight_kg": null, "peds_max_weight_kg": null, "peds_age_min_months": null, "peds_age_max_months": null, "peds_age_bands": null, "peds_doses": [ { "weight_kg": 10, "low_mg": 450, "high_mg": 600, "capped": false }, { "weight_kg": 20, "low_mg": 900, "high_mg": 1200, "capped": false }, { "weight_kg": 30, "low_mg": 1350, "high_mg": 1800, "capped": false }, { "weight_kg": 40, "low_mg": 1800, "high_mg": 2400, "capped": false } ], "brands": [ { "trade_name": "VANCOMIX 1G I.V. VIAL", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "SIGMA TEC", "price_egp": 95.0, "pack_count": null, "unit_price": null, "strength_mg": 1000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "VANCOLON 1000MG I.V. VIAL", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "JULPHAR", "price_egp": 165.5, "pack_count": null, "unit_price": null, "strength_mg": 1000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "VANCOGUT 1000 MG PD. FOR I.V. INF. VIAL", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "ARABCOMED", "price_egp": 174.0, "pack_count": null, "unit_price": null, "strength_mg": 1000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "VETOVANCIN 1 GM I.V. VIAL", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "SIGMA TEC > VETOPHARM-EGYPT", "price_egp": 176.0, "pack_count": null, "unit_price": null, "strength_mg": 1000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "EDICIN 1 GM PD. FOR I.V. INF. VIAL", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "GLOBAL PHARMACEUTICAL INDUSTRIES", "price_egp": 204.0, "pack_count": null, "unit_price": null, "strength_mg": 1000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "VANCOBACT 1 GM VIAL FOR I.V. INF.", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "ARABCOMED-EGYPT > EGYPHARMA-EGYPT", "price_egp": 204.0, "pack_count": null, "unit_price": null, "strength_mg": 1000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null }, { "trade_name": "VANCOMYCINE VIATRIS 1 GM VIAL", "scientific_name": null, "normalized_ingredient": null, "manufacturer": "VIANAX - GREECE > ONE PHARMA MEDICS", "price_egp": 204.0, "pack_count": null, "unit_price": null, "strength_mg": 1000.0, "exact_strength": true, "exact_form": true, "discontinued": false, "also_contains": null } ], "condition_id": "gangrene-emergency-referral" }, { "id": 801, "generic": "Referral & safety-netting (no drug therapy)", "line": 1, "is_adjunct": false, "form": null, "strength_mg": null, "adult_dose": "Immediate emergency transfer to a hospital with vascular surgery and diabetic foot capabilities for urgent debridement, revascularization assessment, deep tissue culture, and intravenous broad-spectrum antibiotic therapy.", "adult_duration": "Immediate emergency transfer", "dose_source": "Gangrene - StatPearls (NCBI Bookshelf NBK560552) - https://www.ncbi.nlm.nih.gov/books/NBK560552/: \"Gas gangrene, typically caused by Clostridium species, is a life-threatening necrotizing infection requiring urgent intervention.\", \"Management includes prompt surgical debridement or amputation, broad-spectrum antibiotics, and, in some cases, intravenous immunoglobulin to bind and neutralize toxins.\" and \"Surgery within 24 hours of admission significantly improves survival.\"", "rationale": "Diabetic foot gangrene is a time-critical, limb- and life-threatening emergency requiring emergency surgical intervention and parenteral antibiotics rather than primary care management.", "cautions": [ "TIME-CRITICAL SURGICAL EMERGENCY: Wet gangrene, gas gangrene, systemic sepsis, or ascending erythema/crepitus require emergency hospital transport within hours.", "Do NOT delay emergency transfer for outpatient oral antibiotic trials, topical antiseptics, or wound dressings in primary care.", "Assess peripheral arterial pulses (dorsalis pedis, posterior tibial), check for loss of protective sensation, and monitor for systemic inflammatory response syndrome (fever, hypotension, tachycardia)." ], "peds_mgkg_low": null, "peds_mgkg_high": null, "peds_max_mg": null, "peds_basis": null, "peds_unit": null, "peds_note": "Pediatric gangrene (rare, e.g. meningococcemia, purpura fulminans, or severe vascular ischemia) requires immediate emergency transfer to a pediatric intensive care and pediatric surgical center.", "peds_min_weight_kg": null, "peds_max_weight_kg": null, "peds_age_min_months": null, "peds_age_max_months": null, "peds_age_bands": null, "peds_doses": null, "brands": [], "condition_id": "gangrene-emergency-referral" } ] }