Resistant, recurring and deep infections

What are these problems?

This page is about infections that are not simple: an infection that has not cleared after one or two courses of treatment, one that comes back after a while, or one that has reached a deeper place such as the bone, a foot wound or a surgical site.

Antimicrobial resistance means a germ (a bacterium or fungus) has found a way to withstand the medicines that should kill it. The important point is that it is the germ that has become resistant, not your body. The WHO and CDC say a resistant infection is harder, and sometimes impossible, to treat, and treating it may need stronger medicines with more side effects. Misuse of antibiotics is one of the main causes of this.

Some familiar examples:

• Recurrent urinary infection. The NHS calls an infection that returns after treatment, or that happens twice in six months or three times in twelve, recurrent.
• Bone infection. Severe pain (often in the leg), swelling, warmth and redness (redness is less visible on dark skin), and fever. The sources say it usually clears if treated early, but left untreated it can lead to lasting damage to the bone.
• Diabetic foot wound. When feeling in the foot is reduced, a small cut or blister goes unnoticed and may become infected.
• Infection after an operation. Redness and pain around the surgical site, cloudy discharge from the wound, or fever.
• Infection of the skin and the tissue under it (cellulitis). Skin that is painful, hot and swollen.

Who should see a doctor?

• someone who has taken one or two courses of antibiotics and has not got better
• someone whose infection has come back several times after clearing
• a person with diabetes who has a foot wound or reduced feeling in the foot
• someone who has redness, pain, discharge or fever after an operation
• someone with pain, swelling and warmth over a bone or joint
• someone with an implanted device, a catheter or a treatment line in the body who has developed signs of infection
• someone whose body defences are weak and whose infection is clearing slowly

The sources say people over 65, men with a urinary infection, people with diabetes and people with a weak immune system should show a urinary infection to a doctor early and not wait.

How is it investigated?

The aim is to know which germ is involved and which medicine it responds to. The usual steps are:

1. History. Which infections you have had, which antibiotics you have taken and for how long, and whether you have recently been in hospital or travelled. The CDC says to tell the doctor if you have also received care in another country recently.
2. Examination. The problem area, the skin, any wound, and your general condition.
3. Tests. Blood and urine tests and, if needed, a culture: a sample of blood, urine or wound fluid that is examined in the laboratory to identify the germ and find out which medicine works on it. The NHS says a urine test does not always show an infection, so one negative test is not always the end of the matter.
4. Imaging, when a bone or deep tissue infection is suspected. The NHS mentions plain X-ray, CT, MRI and sometimes a bone biopsy.

What does treatment generally look like?

Treatment differs with the type and site of the infection and the germ. The principles the sources repeat are:

• The medicine must suit the germ and the site of infection. The WHO counts choosing the wrong medicine as one of the reasons germs become resistant.
• Deep infections need longer treatment. For a bone infection, for example, antibiotics usually continue for weeks (the NHS gives 4 to 6 weeks, and up to 12 in severe cases).
• Do not leave the course unfinished. The sources stress that even if you feel better, you should finish the course as directed. If you have side effects, tell your doctor instead of stopping on your own.
• An infection that does not improve with medicine must not be left. The CDC says that in diabetes, a foot infection that does not respond to treatment may end in amputation, and early treatment greatly lowers this risk. This is another reason to come early.
• The underlying cause also needs attention: blood sugar in diabetes, foot care, and the causes behind a recurrent urinary infection.

With severe resistance, the choice of medicines is smaller. The doctor decides this based on your test results.

What can you do yourself?

• Before the visit, gather the papers for all your earlier tests and cultures, and write a list of the medicines you have taken, with dates.
• Do not start or stop an antibiotic on your own, and do not use other people’s medicines or leftovers from before. The CDC also says not to take other people’s medicines or save them for later.
• If you have diabetes, look at your feet every day (use a mirror for the sole, or ask someone to help). Watch for redness, swelling, blisters, sores and colour changes. The CDC says to show any sign to a doctor without waiting for your next appointment.
• After an operation, ask before you leave hospital who to contact if there is a problem. Wash your hands before and after touching the wound, and do not let others touch the dressing without washing their hands.
• For urinary infection, according to the NHS: drink plenty of fluids (especially water), avoid holding urine in, and empty your bladder completely. Talk to your doctor about supplements such as cranberry.

When to seek urgent care

Call 115 (Iran’s emergency number) or go to the emergency department if you have any of these with an infection:

• confusion, unusual drowsiness or slurred speech
• very fast breathing or shortness of breath
• skin that is blue, pale, cold and clammy
• severe shivering
• a very fast heartbeat
• purple patches on the skin

These can be signs of sepsis (a dangerous reaction of the body to infection). The other signs are in the guide on when to seek urgent care. If you notice a new sore, redness, swelling or warmth in your foot, show it to a doctor the same day.

Every patient’s treatment plan is different. Ask your doctor about your own situation.