1
|
Villa F, Marchandin H, Lavigne JP, Schuldiner S, Cellier N, Sotto A, Loubet P. Anaerobes in diabetic foot infections: pathophysiology, epidemiology, virulence, and management. Clin Microbiol Rev 2024:e0014323. [PMID: 38819166 DOI: 10.1128/cmr.00143-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024] Open
Abstract
SUMMARYDiabetic foot infections (DFI) are a public health problem worldwide. DFI are polymicrobial, biofilm-associated infections involving complex bacterial communities organized in functional equivalent pathogroups, all including anaerobes. Indeed, multiple pathophysiological factors favor the growth of anaerobes in this context. However, the prevalence, role, and contribution of anaerobes in wound evolution remain poorly characterized due to their challenging detection. Studies based on culture reviewed herein showed a weighted average of 17% of patients with anaerobes. Comparatively, the weighted average of patients with anaerobes identified by 16S rRNA gene sequencing was 83.8%. Culture largely underestimated not only the presence but also the diversity of anaerobes compared with cultivation-independent approaches but both methods showed that anaerobic Gram-negative bacilli and Gram-positive cocci were the most commonly identified in DFI. Anaerobes were more present in deeper lesions, and their detection was associated with fever, malodorous lesions, and ulcer depth and duration. More specifically, initial abundance of Peptoniphilus spp. was associated with ulcer-impaired healing, Fusobacterium spp. detection was significantly correlated with the duration of DFI, and the presence of Bacteroides spp. was significantly associated with amputation. Antimicrobial resistance of anaerobes in DFI remains slightly studied and warrants more consideration in the context of increasing resistance of the most frequently identified anaerobes in DFI. The high rate of patients with DFI-involving anaerobes, the increased knowledge on the species identified, their virulence factors, and their potential role in wound evolution support recommendations combining debridement and antibiotic therapy effective on anaerobes in moderate and severe DFI.
Collapse
Affiliation(s)
- Fanny Villa
- VBIC, INSERM U1047, Univ Montpellier, Service des Maladies Infectieuses et Tropicales, CHU Nîmes, Nîmes, France
| | - Hélène Marchandin
- HydroSciences Montpellier, Univ Montpellier, CNRS, IRD, Service de Microbiologie et Hygiène, Hospitalière, CHU Nîmes, Nîmes, France
| | - Jean-Philippe Lavigne
- VBIC, INSERM U1047, Univ Montpellier, Service de Microbiologie et Hygiène Hospitalière, CHU Nîmes, Nîmes, France
| | - Sophie Schuldiner
- VBIC, INSERM U1047, Univ Montpellier, Service des Maladies Métaboliques et Endocriniennes, CHU Nîmes, Nîmes, France
| | | | - Albert Sotto
- VBIC, INSERM U1047, Univ Montpellier, Service des Maladies Infectieuses et Tropicales, CHU Nîmes, Nîmes, France
| | - Paul Loubet
- VBIC, INSERM U1047, Univ Montpellier, Service des Maladies Infectieuses et Tropicales, CHU Nîmes, Nîmes, France
| |
Collapse
|
2
|
Fejfarová V, Jarošíková R, Antalová S, Husáková J, Wosková V, Beca P, Mrázek J, Tůma P, Polák J, Dubský M, Sojáková D, Lánská V, Petrlík M. Does PAD and microcirculation status impact the tissue availability of intravenously administered antibiotics in patients with infected diabetic foot? Results of the DFIATIM substudy. Front Endocrinol (Lausanne) 2024; 15:1326179. [PMID: 38774229 PMCID: PMC11106387 DOI: 10.3389/fendo.2024.1326179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 04/16/2024] [Indexed: 05/24/2024] Open
Abstract
Aims/hypothesis The aim of this substudy (Eudra CT No:2019-001997-27)was to assess ATB availability in patients with infected diabetic foot ulcers(IDFUs)in the context of microcirculation and macrocirculation status. Methods For this substudy, we enrolled 23 patients with IDFU. Patients were treated with boluses of amoxicillin/clavulanic acid(AMC)(12patients) or ceftazidime(CTZ)(11patients). After induction of a steady ATB state, microdialysis was performed near the IDFU. Tissue fluid samples from the foot and blood samples from peripheral blood were taken within 6 hours. ATB potential efficacy was assessed by evaluating the maximum serum and tissue ATB concentrations(Cmax and Cmax-tissue)and the percentage of time the unbound drug tissue concentration exceeds the minimum inhibitory concentration (MIC)(≥100% tissue and ≥50%/60% tissue fT>MIC). Vascular status was assessed by triplex ultrasound, ankle-brachial and toe-brachial index tests, occlusive plethysmography comprising two arterial flow phases, and transcutaneous oxygen pressure(TcPO2). Results Following bolus administration, the Cmax of AMC was 91.8 ± 52.5 μgmL-1 and the Cmax-tissue of AMC was 7.25 ± 4.5 μgmL-1(P<0.001). The Cmax for CTZ was 186.8 ± 44.1 μgmL-1 and the Cmax-tissue of CTZ was 18.6 ± 7.4 μgmL-1(P<0.0001). Additionally, 67% of patients treated with AMC and 55% of those treated with CTZ achieved tissue fT>MIC levels exceeding 50% and 60%, respectively. We observed positive correlations between both Cmax-tissue and AUCtissue and arterial flow. Specifically, the correlation coefficient for the first phase was r=0.42; (P=0.045), and for the second phase, it was r=0.55(P=0.01)and r=0.5(P=0.021). Conclusions Bactericidal activity proved satisfactory in only half to two-thirds of patients with IDFUs, an outcome that appears to correlate primarily with arterial flow.
Collapse
Affiliation(s)
- Vladimíra Fejfarová
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
- Department of Internal Medicine, Second Faculty of Medicine, Charles University, Prague, Czechia
| | - Radka Jarošíková
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
- Department of Internal Medicine, Second Faculty of Medicine, Charles University, Prague, Czechia
| | - Simona Antalová
- Department of Clinical Pharmacy and Drug Information Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Jitka Husáková
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Veronika Wosková
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Pavol Beca
- Department of Clinical Pharmacy and Drug Information Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Jakub Mrázek
- Laboratory of Anaerobic Microbiology, Institute of Animal Physiology and Genetics, Czech Academy of Sciences, Prague, Czechia
| | - Petr Tůma
- Department of Hygiene, Third Faculty of Medicine, Charles University, Prague, Czechia
| | - Jan Polák
- Department of Pathophysiology, Third Faculty of Medicine, Charles University, Prague, Czechia
| | - Michal Dubský
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Dominika Sojáková
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Věra Lánská
- Diabetes Centre, Institute for Clinical and Experimental Medicine, Prague, Czechia
| | - Martin Petrlík
- Vascular and Internal Medicine Outpatient Clinic, Prague, Czechia
| |
Collapse
|
3
|
Bonnet E, Maulin L, Senneville E, Castan B, Fourcade C, Loubet P, Poitrenaud D, Schuldiner S, Sotto A, Lavigne JP, Lesprit P. Clinical practice recommendations for infectious disease management of diabetic foot infection (DFI) - 2023 SPILF. Infect Dis Now 2024; 54:104832. [PMID: 37952582 DOI: 10.1016/j.idnow.2023.104832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/03/2023] [Indexed: 11/14/2023]
Abstract
In march 2020, the International Working Group on the Diabetic Foot (IWGDF) published an update of the 2015 guidelines on the diagnosis and management of diabetic foot infection (DFI). While we (the French ID society, SPILF) endorsed some of these recommendations, we wanted to update our own 2006 guidelines and specifically provide informative elements on modalities of microbiological diagnosis and antibiotic treatment (especially first- and second-line regiments, oral switch and duration). The recommendations put forward in the present guidelines are addressed to healthcare professionals managing patients with DFI and more specifically focused on infectious disease management of this type of infection, which clearly needs a multidisciplinary approach. Staging of the severity of the infection is mandatory using the classification drawn up by the IWGDF. Microbiological samples should be taken only in the event of clinical signs suggesting infection in accordance with a strict preliminarily established protocol. Empirical antibiotic therapy should be chosen according to the IWGDF grade of infection and duration of the wound, but must always cover methicillin-sensitive Staphylococcus aureus. Early reevaluation of the patient is a fundamental step, and duration of antibiotic therapy can be shortened in many situations. When osteomyelitis is suspected, standard foot radiograph is the first-line imagery examination and a bone biopsy should be performed for microbiological documentation. Histological analysis of the bone sample is no longer recommended. High dosages of antibiotics are recommended in cases of confirmed osteomyelitis.
Collapse
Affiliation(s)
- E Bonnet
- Service des Maladies Infectieuses et Tropicales, CHU Toulouse-Purpan, 31059 Toulouse, France.
| | - L Maulin
- Maladies Infectieuses, CH du Pays d'Aix, 13100 Aix en Provence, France
| | - E Senneville
- Service Universitaire des Maladies Infectieuses, CH Dron, 59200 Tourcoing, France
| | - B Castan
- Service de Médecine Interne et Maladies Infectieuses, CH Périgueux, 24019 Périgueux, France
| | - C Fourcade
- Equipe Mobile d'Infectiologie, Clinique Pasteur, Clinavenir, 31300 Toulouse, France
| | - P Loubet
- Service des Maladies Infectieuses et Tropicales, CHU Caremeau, 30029 Nîmes, France
| | - D Poitrenaud
- Unité Fonctionnelle d'Infectiologie, CH Notre Dame de la Miséricorde, 20000 Ajaccio, France
| | - S Schuldiner
- Service des Maladies Métaboliques et Endocriniennes, CHU Caremeau, 30029 Nîmes, France
| | - A Sotto
- Service des Maladies Infectieuses et Tropicales, CHU Caremeau, 30029 Nîmes, France
| | - J P Lavigne
- Service de Microbiologie et Hygiène Hospitalière, CHU Caremeau, 30029 Nîmes, France
| | - P Lesprit
- Maladies Infectieuses, CHU Grenoble Alpes, 38043, Grenoble, France
| |
Collapse
|
4
|
Koch BCP, Zhao Q, Oosterhoff M, van Oldenrijk J, Abdulla A, de Winter BCM, Bos K, Muller AE. The mysteries of target site concentrations of antibiotics in bone and joint infections: what is known? A narrative review. Expert Opin Drug Metab Toxicol 2022; 18:587-600. [PMID: 36008360 DOI: 10.1080/17425255.2022.2117607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Currently, antibiotic treatment is often a standard dosing regimen in bone and joint infections (BJI). However, it remains unknown if exposure at the target-site is adequate. The aim of this review is to gain more insight in the relationship between the target site concentration of antibiotic and the minimal inhibitory concentration to target the bacteria in bone and joint infections (BJI). AREAS COVERED A literature search was performed by Erasmus MC Medical library. Bone, bone tissue and synovial concentration of antibiotics were covered in humans. In addition, we reported number of patients, dose, sampling method, analytical method and tissue and plasma concentrations. We used the epidemiological cut-off value (ECOFF) values of the targeted micro-organisms. If more than 3 publications were available on the antibiotic, we graphically presented ECOFFS values against reported antibiotic concentrations. EXPERT OPINION For most antibiotics the literature is sparse. In addition, a lot of variable and total antibiotic concentrations are published. Ciprofloxacin, cefazolin, cefuroxime, vancomycin and linezolid seem to have adequate average exposure if correlating total concentration to ECOFF, when standard dosing is used. With regards to other antibiotics, results are inconclusive. More extensive pharmacokinetic/pharmacodynamic modeling in BJI is needed.
Collapse
Affiliation(s)
- Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands.,CATOR, Center for Antimicrobial Optimized Treatment Rotterdam.,Rotterdam Clinical Pharmacometrics Group
| | - Qiaolin Zhao
- Department of Hospital Pharmacy, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands.,Rotterdam Clinical Pharmacometrics Group
| | - Maartje Oosterhoff
- Department of Hospital Pharmacy, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jakob van Oldenrijk
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands.,CATOR, Center for Antimicrobial Optimized Treatment Rotterdam.,Rotterdam Clinical Pharmacometrics Group
| | - Brenda C M de Winter
- Department of Hospital Pharmacy, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands.,CATOR, Center for Antimicrobial Optimized Treatment Rotterdam.,Rotterdam Clinical Pharmacometrics Group
| | - Koen Bos
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Anouk E Muller
- CATOR, Center for Antimicrobial Optimized Treatment Rotterdam.,Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands.,Department of Medical Microbiology, Haaglanden Medisch Centrum, The Hague, the Netherlands
| |
Collapse
|
5
|
Urbina T, Razazi K, Ourghanlian C, Woerther PL, Chosidow O, Lepeule R, de Prost N. Antibiotics in Necrotizing Soft Tissue Infections. Antibiotics (Basel) 2021; 10:antibiotics10091104. [PMID: 34572686 PMCID: PMC8466904 DOI: 10.3390/antibiotics10091104] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/08/2021] [Accepted: 09/10/2021] [Indexed: 12/23/2022] Open
Abstract
Necrotizing soft tissue infections (NSTIs) are rare life-threatening bacterial infections characterized by an extensive necrosis of skin and subcutaneous tissues. Initial urgent management of NSTIs relies on broad-spectrum antibiotic therapy, rapid surgical debridement of all infected tissues and, when present, treatment of associated organ failures in the intensive care unit. Antibiotic therapy for NSTI patients faces several challenges and should (1) carry broad-spectrum activity against gram-positive and gram-negative pathogens because of frequent polymicrobial infections, considering extended coverage for multidrug resistance in selected cases. In practice, a broad-spectrum beta-lactam antibiotic (e.g., piperacillin-tazobactam) is the mainstay of empirical therapy; (2) decrease toxin production, typically using a clindamycin combination, mainly in proven or suspected group A streptococcus infections; and (3) achieve the best possible tissue diffusion with regards to impaired regional perfusion, tissue necrosis, and pharmacokinetic and pharmacodynamic alterations. The best duration of antibiotic treatment has not been well established and is generally comprised between 7 and 15 days. This article reviews the currently available knowledge regarding antibiotic use in NSTIs.
Collapse
Affiliation(s)
- Tomas Urbina
- Médecine Intensive Réanimation, Hôpital Saint-Antoine, Assistance Publique-Hôpitaux de Paris (AP-HP), 75571 Paris, France;
- Sorbonne Université, Université Pierre-et-Marie Curie, 75001 Paris, France
| | - Keyvan Razazi
- Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), 94010 Créteil, France;
- Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010 Créteil, France
| | - Clément Ourghanlian
- Service de Pharmacie, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), 94010 Créteil, France;
- Unité Transversale de Traitement des Infections, Département de Prévention, Diagnostic et Traitement des Infections, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), 94010 Créteil, France;
| | - Paul-Louis Woerther
- Département de Prévention, Diagnostic et Traitement des Infections, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), 94010 Créteil, France;
- Research Group Dynamic, Faculté de Santé de Créteil, Université Paris-Est Créteil Val de Marne (UPEC), 94010 Créteil, France;
| | - Olivier Chosidow
- Research Group Dynamic, Faculté de Santé de Créteil, Université Paris-Est Créteil Val de Marne (UPEC), 94010 Créteil, France;
- Service de Dermatologie, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), 94010 Créteil, France
| | - Raphaël Lepeule
- Unité Transversale de Traitement des Infections, Département de Prévention, Diagnostic et Traitement des Infections, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), 94010 Créteil, France;
| | - Nicolas de Prost
- Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris (AP-HP), 94010 Créteil, France;
- Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est Créteil, 94010 Créteil, France
- Correspondence: ; Tel.: +33-1-49-81-23-94
| |
Collapse
|
6
|
Rosa LP, Silva FCD, Luz SCL, Vieira RL, Tanajura BR, Silva Gusmão AGD, de Oliveira JM, Jesus Nascimento FD, Dos Santos NAC, Inada NM, Blanco KC, Carbinatto FM, Bagnato VS. Follow-up of pressure ulcer treatment with photodynamic therapy, low level laser therapy and cellulose membrane. J Wound Care 2021; 30:304-310. [PMID: 33856908 DOI: 10.12968/jowc.2021.30.4.304] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE A pressure ulcer (PU) is an area of tissue trauma caused by continuous and prolonged pressure, often associated with hospitalised patients immobilised due to neurological problems, negatively affecting their quality of life, and burdening the public budget. The aim of this study was to report the follow-up, for 45 weeks, of three patients with neurological lesions due to trauma who subsequently developed PUs, and who were treated with a combination of photodynamic therapy (PDT), low level laser therapy (LLLT) and cellulose membrane (CM). METHOD PDT was mediated by the photosensitiser curcumin on a 1.5% emulsion base. Blue LED light at 450 nm was delivered continuously for 12 minutes at an irradiance of 30mW/cm2 and total energy delivered to the tissue was 22J/cm2. LLLT was performed with 660 nm laser, punctuated and continuous, twice a week with parameters: spot size 0.04cm2, power of 40mW, 10 seconds per point, fluence of 10J/cm2 and irradiance of 1000mW/cm2. RESULTS All PUs had a significant reduction (range: 95.2-100%) of their area after 45 weeks of follow-up and two PUs had complete healing at 20 weeks and 30 weeks. All of the PUs showed a reduction in contamination with the PDT treatments in different proportions. CONCLUSION From the results obtained, we conclude that the combination of PDT, LLLT and CM is a promising treatment for PU healing.
Collapse
Affiliation(s)
- Luciano Pereira Rosa
- Multidisciplinary Health Institute, Federal University of Bahia, Hormindo Barros Street, 58. Candeias. Vitória da Conquista, Bahia, Brazil
| | - Francine Cristina da Silva
- Multidisciplinary Health Institute, Federal University of Bahia, Hormindo Barros Street, 58. Candeias. Vitória da Conquista, Bahia, Brazil
| | - Suzete Carvalho Landulfo Luz
- Multidisciplinary Health Institute, Federal University of Bahia, Hormindo Barros Street, 58. Candeias. Vitória da Conquista, Bahia, Brazil
| | | | - Beatriz Rocha Tanajura
- Multidisciplinary Health Institute, Federal University of Bahia, Hormindo Barros Street, 58. Candeias. Vitória da Conquista, Bahia, Brazil
| | - Alana Gonçalves da Silva Gusmão
- Multidisciplinary Health Institute, Federal University of Bahia, Hormindo Barros Street, 58. Candeias. Vitória da Conquista, Bahia, Brazil
| | - Janeide Muritiba de Oliveira
- Multidisciplinary Health Institute, Federal University of Bahia, Hormindo Barros Street, 58. Candeias. Vitória da Conquista, Bahia, Brazil
| | - Fabiana de Jesus Nascimento
- Multidisciplinary Health Institute, Federal University of Bahia, Hormindo Barros Street, 58. Candeias. Vitória da Conquista, Bahia, Brazil
| | | | | | | | | | | |
Collapse
|
7
|
Biofilms in Diabetic Foot Ulcers: Significance and Clinical Relevance. Microorganisms 2020; 8:microorganisms8101580. [PMID: 33066595 PMCID: PMC7602394 DOI: 10.3390/microorganisms8101580] [Citation(s) in RCA: 88] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Revised: 10/07/2020] [Accepted: 10/11/2020] [Indexed: 12/14/2022] Open
Abstract
Foot infections are the main disabling complication in patients with diabetes mellitus. These infections can lead to lower-limb amputation, increasing mortality and decreasing the quality of life. Biofilm formation is an important pathophysiology step in diabetic foot ulcers (DFU)-it plays a main role in the disease progression and chronicity of the lesion, the development of antibiotic resistance, and makes wound healing difficult to treat. The main problem is the difficulty in distinguishing between infection and colonization in DFU. The bacteria present in DFU are organized into functionally equivalent pathogroups that allow for close interactions between the bacteria within the biofilm. Consequently, some bacterial species that alone would be considered non-pathogenic, or incapable of maintaining a chronic infection, could co-aggregate symbiotically in a pathogenic biofilm and act synergistically to cause a chronic infection. In this review, we discuss current knowledge on biofilm formation, its presence in DFU, how the diabetic environment affects biofilm formation and its regulation, and the clinical implications.
Collapse
|
8
|
Assessment of the Risk Factors of Multidrug-Resistant Organism Infection in Adults With Type 1 or Type 2 Diabetes and Diabetic Foot Ulcer. Can J Diabetes 2019; 44:342-349. [PMID: 32005564 DOI: 10.1016/j.jcjd.2019.10.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 10/19/2019] [Accepted: 10/21/2019] [Indexed: 11/21/2022]
Abstract
OBJECTIVES To our knowledge, this is the first review to analyze the literature identifying risk factors for multidrug-resistant organism (MDRO) infection in patients with diabetic foot ulcer. The purpose of this study was to collect the currently published data to determine the most commonly and consistently identified risk factors for MDRO infection. METHODS PubMed, MEDLINE, BIOSIS, Web of Science and the Cochrane Library electronic databases were searched. The last search updated was in September 2019. The evaluated outcomes included age, male sex, type of diabetes, diabetes duration, level of glycated hemoglobin, ulcer type, wound duration, ulcer size, ulcer grade, osteomyelitis, previous antibiotic therapy and previous hospitalization. The standard mean difference or the odds ratio (OR) was calculated for continuous or dichotomous data, respectively. The quality of the studies was assessed, and meta-analyses were performed with Cochrane Collaboration's RevMan 5.0 software. RESULTS A total of 11 studies, including 1,229 patients provided evidence for 6 possible risk factors for MDRO infection. Ischemic ulcer (OR, 0.50; 95% confidence interval [CI], 0.35 to 0.71), ulcer size (standard mean difference, -0.27; 95% CI, -0.46 to -0.08), ulcer grade (OR, 0.36; 95% CI, 0.15 to 0.83), osteomyelitis (OR, 0.33; 95% CI, 0.25 to 0.45), previous antibiotic therapy (OR, 0.08; 95% CI, 0.04 to 0.14) and previous hospitalization (OR, 0.15; 95% CI, 0.08 to 0.28) were identified as risk factors for MDRO infection in patients with diabetic foot ulcer. CONCLUSIONS Our meta-analysis indicated that ischemic ulcer, ulcer size, ulcer grade, osteomyelitis, previous antibiotic therapy and previous hospitalization were associated with MDRO infection in patients with diabetic foot ulcer.
Collapse
|
9
|
Martinelli N, Curci V, Quarantiello A, Saldalamacchia G. The benefits of antimicrobial photodynamic therapy with RLP068 in the management of diabetic foot ulcers. Drugs Context 2019; 8:212610. [PMID: 31516535 PMCID: PMC6726360 DOI: 10.7573/dic.212610] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 07/30/2019] [Accepted: 07/31/2019] [Indexed: 12/27/2022] Open
Abstract
This article is the first part of a literature review concerning diabetic foot ulcers and the use of antimicrobial photodynamic therapy (PDT). Diabetic foot ulcers are associated with high morbidity, mortality, and healthcare costs. Natural healing is often delayed by microbial infection or colonisation, which might lead to serious complications, such as amputation. Furthermore, antibiotic treatment could have limited success because of the development of bacterial resistance and severely limited drug delivery to the ulcer due to vascular damage. PDT has antimicrobial effects and has been used to reduce the total and pathogenic microbial load in diabetic ulcers without inducing bacterial resistance. It is safe and can be used to improve outcomes. A clinical trial demonstrated that PDT with RLP068 reduced the microbial load of diabetic ulcers in 62 patients. This article reports previously published evidence and presents four, unpublished, clinical cases treated in the real-life setting.
Collapse
Affiliation(s)
- Nicolò Martinelli
- IRCCS Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi, 4, 20161 Milan, Italy
| | - Vincenzo Curci
- Dipartimento Interdivisione di Cura del Piede Diabetico, Istituto Clinico Città Studi di Milano, Via Jommelli 17, 20131, Milan, Italy
| | - Antonella Quarantiello
- Dipartimento Interdivisione di Cura del Piede Diabetico, Istituto Clinico Città Studi di Milano, Via Jommelli 17, 20131, Milan, Italy
| | - Gennaro Saldalamacchia
- Dipartimento di Medicina Interna, UOS "Piede Diabetico", UOC di Diabetologia, Azienda Ospedaliera Universitaria Policlinico "Federico II", Via Pansini 5, 80100 Napoli, Italy
| |
Collapse
|
10
|
Chambers J, Page-Sharp M, Salman S, Dyer J, Davis TME, Batty KT, Manning L. Ertapenem for osteoarticular infections in obese patients: a pharmacokinetic study of plasma and bone concentrations. Eur J Clin Pharmacol 2018; 75:511-517. [PMID: 30511329 DOI: 10.1007/s00228-018-2597-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 11/04/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE Ertapenem is used off-label to treat osteoarticular infections but there are few pharmacokinetic (PK) data to guide optimal dosing strategies in patients who may be obese with multiple co-morbidities including diabetes and peripheral vascular disease. METHODS Participants undergoing lower limb amputation or elective joint arthroplasty received a dose of intravenous ertapenem prior to surgery. Eight plasma samples were collected over 24 h, together with at least one bone sample per patient. Ertapenem concentrations in plasma and bone were measured using liquid-chromatography/mass-spectroscopy and analysed using non-linear mixed effects PK modelling. RESULTS Plasma and bone concentrations were obtained from 10 participants. The final population PK model showed that a fat free body mass was the most appropriate body size adjustment. Ertapenem diffused rapidly into bone but concentrations throughout the 24 h dosing period were on average 40-fold higher in plasma, corresponding to a bone to plasma ratio of 0.025, and highly variable between individuals. Simulations demonstrated a high probability of target attainment (PTA) for free plasma concentrations when the minimum inhibitory concentrations (MIC) were ≤ 0.25 mg/L. By contrast, at MICs of 0.5 mg/L and ≥ 1 mg/L, the fractions of patients attaining this target was ~ 80% and 40%, respectively. In bone, the PTA was ≤ 45% when the MIC was ≥ 0.25 mg/L. CONCLUSION Local bone and free plasma concentrations appear adequate for osteoarticular infections where Enterobacteriaceae are the main causative pathogens, but for Staphylococcus aureus and other bacteria, conventional dosing may lead to inadequate PTA.
Collapse
Affiliation(s)
- Jonathan Chambers
- Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Madhu Page-Sharp
- School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, Western Australia, Australia
| | - Sam Salman
- Faculty of Health and Medical Sciences, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - John Dyer
- Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Timothy M E Davis
- Faculty of Health and Medical Sciences, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Kevin T Batty
- School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, Western Australia, Australia
| | - Laurens Manning
- Faculty of Health and Medical Sciences, Harry Perkins Research Institute, Fiona Stanley Hospital, University of Western Australia, PO Box 404, Bull Creek 6149, Murdoch, Western Australia, Australia.
| |
Collapse
|
11
|
Hurlow JJ, Humphreys GJ, Bowling FL, McBain AJ. Diabetic foot infection: A critical complication. Int Wound J 2018; 15:814-821. [PMID: 29808598 PMCID: PMC7949853 DOI: 10.1111/iwj.12932] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 03/24/2018] [Accepted: 04/10/2018] [Indexed: 02/05/2023] Open
Abstract
The number of people in the world with diabetes has nearly quadrupled in the past 40 years. Current data show that 25% of these diabetics will develop a foot ulcer in their lifetime and that the cost of care for a diabetic foot ulcer (DFU) is over twice that of any other chronic ulcer aetiology. Microbial biofilm has been linked to both wound chronicity and infection. Close to 1 in 2 diabetics with a DFU are predicted to go on to develop a diabetic foot infection (DFI). The majority of these DFIs have been found to evolve even before the diabetic individual has received an initial referral for expert DFU management. Of these infected DFUs, less than half have been shown to heal over the next year; many of these individuals will require costly hospitalisation, and current data show that far too many DFIs will require extremity amputation to achieve infection resolution. The development of an infection in a DFU is critical at least in part because paradigms of infection prevention and management are evolving. The effectiveness of our current practice standards is being challenged by a growing body of research related to the prevalence and recalcitrance of the microbes in biofilm to topical and systemic antimicrobials. This article will review the magnitude of current challenges related to DFI prevention and management along with what is currently considered to be standard of care. These ideas will be compared and contrasted with what is known about the biofilm phenotype; then, considerations to support progress towards the development of more cost-effective protocols of care are highlighted.
Collapse
Affiliation(s)
- Jennifer J Hurlow
- Division of Pharmacy and Optometry, Faculty of Biology, Medicine and HealthThe University of ManchesterManchesterUK
| | - Gavin J Humphreys
- Division of Pharmacy and Optometry, Faculty of Biology, Medicine and HealthThe University of ManchesterManchesterUK
| | - Frank L Bowling
- Faculty of Medical & Human SciencesUniversity of ManchesterManchesterUK
- Manchester Foundation TrustDepartment of Diabetes & Vascular SurgeryManchesterUK
| | - Andrew J McBain
- Division of Pharmacy and Optometry, Faculty of Biology, Medicine and HealthThe University of ManchesterManchesterUK
| |
Collapse
|
12
|
Rosa LP, da Silva FC, Vieira RL, Tanajura BR, da Silva Gusmão AG, de Oliveira JM, dos Santos NAC, Bagnato VS. Application of photodynamic therapy, laser therapy, and a cellulose membrane for calcaneal pressure ulcer treatment in a diabetic patient: A case report. Photodiagnosis Photodyn Ther 2017; 19:235-238. [DOI: 10.1016/j.pdpdt.2017.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 06/08/2017] [Accepted: 06/14/2017] [Indexed: 10/19/2022]
|
13
|
Optimizing the treatment of osteomyelitis with antimicrobial drugs: current concepts. CURRENT ORTHOPAEDIC PRACTICE 2017. [DOI: 10.1097/bco.0000000000000477] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
14
|
Lozano-Alonso S, Linares-Palomino JP, Vera-Arroyo B, Bravo-Molina A, Hernández-Quero J, Ros-Díe E. Evaluación de la capacidad de difusión tisular de antibióticos en isquemia de miembros inferiores. Enferm Infecc Microbiol Clin 2016; 34:477-83. [DOI: 10.1016/j.eimc.2015.10.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2015] [Revised: 10/06/2015] [Accepted: 10/13/2015] [Indexed: 11/27/2022]
|
15
|
Tůma P, Jaček M, Fejfarová V, Polák J. Electrophoretic stacking for sensitive determination of antibiotic ceftazidime in human blood and microdialysates from diabetic foot. Anal Chim Acta 2016; 942:139-145. [PMID: 27720117 DOI: 10.1016/j.aca.2016.09.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2016] [Revised: 08/29/2016] [Accepted: 09/10/2016] [Indexed: 12/30/2022]
Abstract
An electrophoretic stacking method has been developed for monitoring the therapeutic level of the antibiotic ceftazidime in blood plasma and microdialysates taken from peripheral soft tissues of the lower limbs of patients with diabetic foot syndrome. The biological samples are treated by addition of acetonitrile in an amount of 75% v/v and injected into a capillary in a large volume; after turning on the separation voltage, the residual acetonitrile is forced out of the capillary by the application of hydrodynamic pressure. The clinical samples were separated in an optimised background electrolyte composed of 50 mM chloroacetic acid +20% v/v methanol +0.5% v/v INST coating solution. The attained LOD for ceftazidime equalled 0.42 μg mL-1 (0.8 μM) and the migration time equalled 3.75 min when using a 25 μm capillary with minimum length of 31.5 cm. The separation was controlled by a maximum voltage of +30 kV and the movement of the analyte was accelerated by a pressure of 50 mbar. The RSD values for intra-day repeatability of the migration time and peak area are 0.14% and 3.8%, respectively; the inter-day values equalled 0.25% for the migration time and 7.3% for peak area, respectively. Pharmacological studies revealed that ceftazidime passes from the blood circulation to the peripheral tissues of the lower limbs with an efficiency of 20%. The introduction of CE control of ceftazidime level in diabetic foot represents a very important improvement in achieving the targeted therapeutic effect.
Collapse
Affiliation(s)
- Petr Tůma
- Charles University in Prague, Third Faculty of Medicine, Department of Biochemistry, Cell and Molecular Biology, Ruská 87, 100 00 Prague 10, Czech Republic.
| | - Martin Jaček
- Charles University in Prague, Third Faculty of Medicine, Department of Biochemistry, Cell and Molecular Biology, Ruská 87, 100 00 Prague 10, Czech Republic
| | - Vladimíra Fejfarová
- Institute for Clinical and Experimental Medicine, Diabetes Center, Vídeňská 1958, 140 21 Prague 4, Czech Republic
| | - Jan Polák
- Charles University in Prague, Third Faculty of Medicine, Center for Research on Diabetes, Metabolism and Nutrition, Ruská 87, Prague 10000, Czech Republic; 2nd Internal Medicine Department, Vinohrady Teaching Hospital, Šrobárova 50, Prague 10034, Czech Republic
| |
Collapse
|
16
|
Roth-Albin I, Mai SHC, Ahmed Z, Cheng J, Choong K, Mayer PV. Outcomes Following Advanced Wound Care for Diabetic Foot Ulcers: A Canadian Study. Can J Diabetes 2016; 41:26-32. [PMID: 27634016 DOI: 10.1016/j.jcjd.2016.06.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Accepted: 06/21/2016] [Indexed: 01/07/2023]
Abstract
OBJECTIVES Data concerning outcomes of Canadian patients with diabetic foot ulcers (DFUs) are limited. The objectives of this study were to evaluate the healing rates and identify the predictors of poor outcomes following advanced wound care in patients presenting with DFUs. METHODS We conducted retrospective cohort study of adult patients who had DFUs and were referred to a single Canadian advanced diabetic foot and wound care centre between January 1, 2010, and December 31, 2010. The primary outcome was the healing rate at 52 weeks. The generalized estimating equation model was used to identify potential risk factors associated with delayed healing of DFUs. RESULTS Of the 40 patients for whom there were complete follow ups, 35 (87.5%) had healing of all DFUs by 52 weeks. Predictors of poor healing were the presence of chronic ulcers, ulcer sizes >1 cm2, peripheral vascular disease and multiple ulcers at first presentation. Of the patients, 7.1% required amputation, and 8.9% of patients receiving our treatment died before 52 weeks. At 52 weeks of follow up, 16 of 17 recurrent ulcers and 68 of 108 pre-existing ulcers had healed. Compared to the unadjusted healing rate of preexisting ulcers (63.0%), the unadjusted healing rate of recurrent ulcers (94.1%) was significantly higher (p=0.01). CONCLUSIONS Our findings demonstrate that patients with DFUs in Canada who receive early and continued care from specialized, outpatient, advanced wound care centres experience significantly improved rates of healing of recurrent DFUs compared to pre-existing DFUs.
Collapse
Affiliation(s)
| | - Safiah H C Mai
- Faculty of Health Science, McMaster University, Hamilton, Ontario, Canada
| | - Zeeshan Ahmed
- Department of Internal Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Ji Cheng
- Biostatistics Unit, St. Joseph's Healthcare Hamilton and Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Karen Choong
- Department of Pediatrics, Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | | |
Collapse
|
17
|
Leone A, Cassar-Pullicino VN, Semprini A, Tonetti L, Magarelli N, Colosimo C. Neuropathic osteoarthropathy with and without superimposed osteomyelitis in patients with a diabetic foot. Skeletal Radiol 2016; 45:735-54. [PMID: 26883537 DOI: 10.1007/s00256-016-2339-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2015] [Revised: 01/10/2016] [Accepted: 01/17/2016] [Indexed: 02/02/2023]
Abstract
Soft tissue and bone infection involving the foot is one of the most common long-term complications of diabetes mellitus, implying a serious impairment in quality of life for patients in the advanced stages of the disease. Neuropathic osteoarthropathy often coexists and differentiating between these two entities is commonly challenging, but crucial, as the management may differ substantially. The importance of correct diagnosis cannot be understated and effective management requires a multidisciplinary approach owing to the complicated nature of therapy in such patients. A missed diagnosis has a high likelihood of major morbidity for the patient, including limb amputation, and over-diagnosis results in a great socioeconomic challenge for healthcare systems, the over-utilization of healthcare resources, and the unwise use of antibiotics. Diagnosis is largely based on clinical signs supplemented by various imaging modalities such as radiography, MR imaging, and hybrid imaging techniques such as F-18 fluorodeoxyglucose-positron emission tomography. In the interests of the management of diabetic foot complications, this review article is aimed on the one hand at providing radiologists with important clinical knowledge, and on the other hand to equip clinicians with relevant radiological semiotics.
Collapse
Affiliation(s)
- Antonio Leone
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy.
| | - Victor N Cassar-Pullicino
- Department of Diagnostic Imaging, The Robert Jones and Agnes Hunt Orthopaedic and District Hospital, Oswestry, Shropshire, UK
| | - Alessia Semprini
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy
| | - Laura Tonetti
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy
| | - Nicola Magarelli
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy
| | - Cesare Colosimo
- Institute of Radiology, School of Medicine, Catholic University, Largo A. Gemelli 1, 00168, Rome, Italy
| |
Collapse
|
18
|
Shiota J, Ohura N, Higashikawa S, Yamato T, Kasahara H, Itatani K, Tagawa H. Presepsin as a predictor of critical colonization in CLI hemodialysis patients. Wound Repair Regen 2016; 24:189-94. [PMID: 26464025 DOI: 10.1111/wrr.12371] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 10/10/2015] [Indexed: 12/01/2022]
Abstract
Infection during critical limb ischemia (CLI) is a challenging issue. Plasma presepsin is a novel biomarker for infection, which is related to bacterial phagocytosis by macrophages. The purpose of this study was to investigate the validity of presepsin as an indicator and predictor for early detection of infectious CLI. A retrospective observational study was conducted among 20 CLI patients (Rutherford 5 and 6) on hemodialysis (HD). Twenty CLI patients on HD (mean age 70.7 ± 5.6 years, male 85%) and 15 healthy patients on HD without CLI and infection (control group) were analyzed. All CLI patients received appropriate revascularization and plastic surgical treatment. CLI patients were classified into two groups: the healing group with complete epithelialization without discharge and the nonhealing group with infection signs. Plasma presepsin was measured and compared among the two groups and the control group using an automated immunoanalyzer, PATHFAST, based on a noncompetitive chemiluminescent enzyme immunoassay. The median plasma presepsin and its interquartile range were 1,320 (1,055-1,465) pg/mL in the control group, 1,320 (1,050-1,613) pg/mL in the healing group and 3,193 (2,519-3,832) pg/mL in the nonhealing group. The plasma presepsin concentrations were significantly higher in the nonhealing group compared with the control group (p < 0.001) and the healing group (p < 0.01). A receiver operating characteristic curve analysis revealed that presepsin had highest accuracy (0.979) among various inflammatory markers, including C-reactive protein and the white blood cell count. The diagnostic cutoff value of 2,083 pg/mL was able to distinguish the nonhealing group and healing group with a sensitivity of 100% and a specificity of 88.9%. Our results suggest that plasma presepsin may be useful for predicting "critical colonization" and "infection" in nonhealing CLI in HD patients, therefore, the definitive cutoff value may be used for determinating the indication for reintervention and/or major limb amputation.
Collapse
Affiliation(s)
- Jun Shiota
- Department of Internal Medicine, Kichijoji Asahi Hospital, Tokyo, Japan
| | - Norihiko Ohura
- Department of Plastic, Reconstructive and Aesthetic Surgery, Kyorin University School of Medicine, Tokyo, Japan
| | | | - Tsunee Yamato
- Department of Internal Medicine, Kichijoji Asahi Hospital, Tokyo, Japan
| | - Hitoshi Kasahara
- Department of Internal Medicine, Kichijoji Asahi Hospital, Tokyo, Japan
| | - Keiichi Itatani
- Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hitoshi Tagawa
- Department of Internal Medicine, Kichijoji Asahi Hospital, Tokyo, Japan
| |
Collapse
|
19
|
Lipsky BA, Aragón-Sánchez J, Diggle M, Embil J, Kono S, Lavery L, Senneville É, Urbančič-Rovan V, Van Asten S, Peters EJG. IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes. Diabetes Metab Res Rev 2016; 32 Suppl 1:45-74. [PMID: 26386266 DOI: 10.1002/dmrr.2699] [Citation(s) in RCA: 332] [Impact Index Per Article: 41.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Benjamin A Lipsky
- Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- University of Oxford, Oxford, UK
| | | | - Mathew Diggle
- Nottingham University Hospitals Trust, Nottingham, UK
| | - John Embil
- University of Manitoba, Winnipeg, MB, Canada
| | - Shigeo Kono
- WHO-collaborating Centre for Diabetes, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan
| | - Lawrence Lavery
- University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, TX, USA
| | | | | | - Suzanne Van Asten
- University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, TX, USA
- VU University Medical Centre, Amsterdam, The Netherlands
| | | |
Collapse
|
20
|
In Vitro Pharmacodynamics of Vancomycin against Methicillin-Susceptible and -Resistant Staphylococcus aureus: Considering the Variability in Observed Tissue Exposure. Antimicrob Agents Chemother 2015; 60:955-61. [PMID: 26621619 DOI: 10.1128/aac.01553-15] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Accepted: 11/20/2015] [Indexed: 01/24/2023] Open
Abstract
Vancomycin is considered a first-line antibiotic for complicated skin and skin structure infections (cSSSI) because of the risk of methicillin-resistant Staphylococcus aureus (MRSA). The vancomycin exposure of tissue can vary widely in patients with cSSSI, yet most models test only the average exposure. The in vitro pharmacodynamic model was used to simulate three tissue exposure levels attained by administering vancomycin at 1 g every 12 h (q12h), based on the median (50th), 25th, and 10th percentile tissue area under the concentration-time curve (AUC) values observed during an in vivo microdialysis study of diabetic patients. Four clinical isolates (two of MRSA [vancomycin MIC, 1 and 2 μg/ml] and two of methicillin-susceptible S. aureus [MSSA] [MIC, 1 and 2 μg/ml]) were evaluated. Experiments were performed over 72 h in duplicate. Time-kill curves were constructed, and the area under the bacterial killing and regrowth curve (AUBC) during the final 24-h dosing interval (48 to 72 h) (AUBC48-72) was calculated. Reductions in the 72-h number of CFU/ml and AUBC48-72 at the different exposure levels were compared. Target tissue vancomycin exposure levels for the 50th (AUC0-12, 102.0 ± 9.1 μg · h/ml), 25th (AUC0-12, 44.3 ± 1.8 μg · h/ml), and 10th (AUC0-12, 25.3 ± 3.1 μg · h/ml) percentiles were obtained in all studies. No differences in the 72-h number of CFU or AUBC were observed between exposure levels when all of the isolates were analyzed together. However, for the two MRSA isolates, the 10th percentile exposure level achieved a lower 72-h number of CFU/ml (-1.4 ± 0.4 log10 CFU/ml, P = 0.007) and a greater AUBC48-72 (97.1 ± 20.0 log10 CFU · h/ml, P = 0.011) than the higher exposure levels. The majority of the tissue exposure levels achieved with a vancomycin dosing regimen of 1 g q12h resulted in substantial killing of MSSA and MRSA; however, the lowest exposure levels observed in a minority of the population may explain the poor vancomycin response.
Collapse
|
21
|
Zeun P, Gooday C, Nunney I, Dhatariya K. Predictors of Outcomes in Diabetic Foot Osteomyelitis Treated Initially With Conservative (Nonsurgical) Medical Management. INT J LOW EXTR WOUND 2015; 15:19-25. [DOI: 10.1177/1534734615596892] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The optimal way to manage diabetic foot osteomyelitis remains uncertain, with debate in the literature as to whether it should be managed conservatively (ie, nonsurgically) or surgically. We aimed to identify clinical variables that influence outcomes of nonsurgical management in diabetic foot osteomyelitis. We conducted a retrospective study of consecutive patients with diabetes presenting to a tertiary center between 2007 and 2011 with foot osteomyelitis initially treated with nonsurgical management. Remission was defined as wound healing with no clinical or radiological signs of osteomyelitis at the initial or contiguous sites 12 months after clinical and/or radiological resolution. Nine demographic and clinical variables including osteomyelitis site and presence of foot pulses were analyzed. We identified 100 cases, of which 85 fulfilled the criteria for analysis. After a 12-month follow-up period, 54 (63.5%) had achieved remission with nonsurgical management alone with a median (interquartile range) duration of antibiotic treatment of 10.8 (10.1) weeks. Of these, 14 (26%) were admitted for intravenous antibiotics. The absence of pedal pulses in the affected foot (n = 34) was associated with a significantly longer duration of antibiotic therapy to achieve remission, 8.7 (7.1) versus 15.9 (13.3) weeks ( P = .003). Osteomyelitis affecting the metatarsal was more likely to be amputated than other sites of the foot ( P = .016). In line with previous data, we have shown that almost two thirds of patients presenting with osteomyelitis healed without undergoing surgical bone resection.
Collapse
Affiliation(s)
- Paul Zeun
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Catherine Gooday
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | | | - Ketan Dhatariya
- Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| |
Collapse
|
22
|
Brownrigg JRW, Schaper NC, Hinchliffe RJ. Diagnosis and assessment of peripheral arterial disease in the diabetic foot. Diabet Med 2015; 32:738-47. [PMID: 25764390 DOI: 10.1111/dme.12749] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2015] [Indexed: 01/20/2023]
Abstract
Approximately half of all patients with a diabetic foot ulcer have co-existing peripheral arterial disease. Identifying peripheral arterial disease among patients with foot ulceration is important, given its association with failure to heal, amputation, cardiovascular events and increased risk of premature mortality. Infection, oedema and neuropathy, often present with ulceration, may adversely affect the performance of diagnostic tests that are reliable in patients without diabetes. Early recognition and expert assessment of peripheral arterial disease allows measures to be taken to reduce the risk of amputation and cardiovascular events, while determining the need for revascularization to promote ulcer healing. When peripheral arterial disease is diagnosed, the extent of perfusion deficit should be measured. Patients with a severe perfusion deficit, likely to affect ulcer healing, will require further imaging to define the anatomy of disease and indicate whether a revascularization procedure is appropriate.
Collapse
Affiliation(s)
| | - N C Schaper
- Division of Endocrinology, Department of Medicine, Maastricht University Medical Centre, The Netherlands
| | | |
Collapse
|
23
|
Bassetti M, Baguneid M, Bouza E, Dryden M, Nathwani D, Wilcox M. European perspective and update on the management of complicated skin and soft tissue infections due to methicillin-resistant Staphylococcus aureus after more than 10 years of experience with linezolid. Clin Microbiol Infect 2014; 20 Suppl 4:3-18. [DOI: 10.1111/1469-0691.12463] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
|
24
|
Ji X, Jin P, Chu Y, Feng S, Wang P. Clinical characteristics and risk factors of diabetic foot ulcer with multidrug-resistant organism infection. INT J LOW EXTR WOUND 2014; 13:64-71. [PMID: 24520007 DOI: 10.1177/1534734614521236] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The objective was to determine multidrug-resistant organisms' (MDROs) profile in diabetic foot ulcers (DFU), antibiotic resistance of MDROs, and to find the potential risk factors for infection with MDROs. In 157 patients with DFU admitted to Tianjin Metabolic Disease Hospital, China, from January 2011 to January 2012, microbiological specimens were taken on admission. The patients were divided into 2 groups according to the infection of MDROs. Potential risk factors for MDRO-positive specimens were examined using univariate and multivariate analyses. Seventy-eight MDRO strains were isolated from patients in the MDRO+ group, among which the top 3 were Staphylococcus aureus (16.7%), Enterobacter spp (16.7%), and Pseudomonas aeruginosa (15.4%). Most of the MDROs were resistant to at least 8 kinds of commonly used antibiotics. Gram-negative MDROs showed 23% to 50% resistance to third-generation cephalosporins. The resistant rates of Gram-positive MDROs to fluoroquinolone were more than 70%; penicillin and semisynthetic penicillin were 57% to 100% resistant. Previous hospitalization (odds ratio [OR] = 3.000; 95% confidence interval [CI] = 1.100-8.182; P = .032), previous duration of antibiotic therapy (OR = 1.078; 95% CI = 1.001-1.160; P = .046), ulcer type (OR = 7.185; 95% CI = 2.115-24.408; P = .002), ulcer size (OR = 1.403; 95% CI = 1.042-1.888; P = .026), and osteomyelitis (OR = 3.390; 95% CI = 1.178-9.756; P = .024) were associated with MDRO infection in patients with DFU.
Collapse
Affiliation(s)
- Xiaoyan Ji
- 1Tianjin Medical University, Tianjin, China
| | | | | | | | | |
Collapse
|
25
|
Mannucci E, Genovese S, Monami M, Navalesi G, Dotta F, Anichini R, Romagnoli F, Gensini G. Photodynamic topical antimicrobial therapy for infected foot ulcers in patients with diabetes: a randomized, double-blind, placebo-controlled study--the D.A.N.T.E (Diabetic ulcer Antimicrobial New Topical treatment Evaluation) study. Acta Diabetol 2014; 51:435-40. [PMID: 24352342 DOI: 10.1007/s00592-013-0533-3] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2013] [Accepted: 11/13/2013] [Indexed: 01/04/2023]
Abstract
This study was designed to assess the antimicrobial effect and tolerability of a single dose of a photo-activated gel containing RLP068 in the treatment for infected foot ulcers in subjects with diabetes. A randomized, double-blind, parallel series, placebo-controlled phase IIa trial was performed with three concentrations of RLP068 (0.10, 0.30, and 0.50 %), measuring total and pathogen microbial load on Day 1 (before and 1 h after topical gel application and photoactivation with 689 nm red light), on Days 3, 8, and 15, as add-on to systemic treatment with amoxicillin and clavulanic acid. Blood samples were also drawn 1, 2, and 48 h after administration for the assessment of systemic drug absorption. The trial was performed on 62 patients aged ≥18 years, with type 1 or type 2 diabetes and infected foot ulcer, with an area of 2-15 cm(2) and a maximum diameter ≤4.6 cm. A dose-dependent reduction in total microbial load was observed (-1.92 ± 1.21, -2.94 ± 1.60, and -3.00 ± 1.82 LogCFU/ml for 0.10, 0.30, and 0.50 % RPL068 vs. -1.00 ± 1.02 LogCFU/ml with placebo) immediately after illumination, with a progressive fading of the effect during follow-up. No safety issues emerged from the analysis of adverse events. Systemic absorption of RLP068 was negligible. Photodynamic antimicrobial treatment with RLP068 of infected diabetic foot ulcers is well tolerated and produces a significant reduction in germ load. Further clinical trials are needed to verify the efficacy of this approach as add-on to systemic antibiotic treatment.
Collapse
|
26
|
Abstract
AIM To study the difference in antimicrobial resistance profile among biofilm producing and non-producing microorganisms isolated from diabetic foot ulcer in a tertiary care hospital in North India. METHODOLOGY We performed a prospective study on 162 DFU in patients treated in a multidisciplinary based diabetes and endocrinology center of JNMCH, AMU, Aligarh, India during the period of December 2008-March 2011. Detailed history and physical examination was carried out for every subject. Patient's profile, grade of DFU, co-morbidities and complications, laboratory data and final outcome were collected. Standard methods of sample collection and identification of microorganism were adopted. Risk factors for biofilm producing infections were determined by univariate analysis with 95% of CI. P value <0.05 were considered as significant. RESULTS The overall biofilm producing infection rate among DFU was 67.9%. On univariate analysis, significant risk factors for biofilm producing infection were male sex [P=0.015, OR 2.35, RR 1.71], duration of diabetes [P<0.006, OR 4.0, RR 2.7], duration of ulcer >1 month [P<0.02, OR 2.26, RR 1.72], size of ulcer >4 cm(2) [P<0.05, OR 2.03, RR 1.54], Grade II ulcer [P<0.06, OR 1.87, RR 1.63], necrotic ulcer [P<0.002, OR 5.79, RR 3.59], previous antibiotic use [P<0.007, OR 4.24, RR 2.74], subcutaneous infection [P<0.06, OR 1.87, RR 1.63], HbA1c >7% [P<0.04, OR 3.19, RR1.87] and polymicrobial infection [P<0.001, OR 6.64, RR 3.21] were significant risk factors. CONCLUSIONS Treating the DFU by shifting from the planktonic model of microbiology to the biofilm model was recommended. With this new scientific approaches along with coordination of clinical and laboratory efforts, education, and research, it is possible to imagine overcoming much of biofilm disease.
Collapse
Affiliation(s)
- Abida Malik
- Department of Microbiology, Faculty of Medicine, JN Medical College, Aligarh Muslim University, Aligarh 202002, India.
| | | | | |
Collapse
|
27
|
Schaper NC, Dryden M, Kujath P, Nathwani D, Arvis P, Reimnitz P, Alder J, Gyssens IC. Efficacy and safety of IV/PO moxifloxacin and IV piperacillin/tazobactam followed by PO amoxicillin/clavulanic acid in the treatment of diabetic foot infections: results of the RELIEF study. Infection 2012. [PMID: 23180507 PMCID: PMC3566391 DOI: 10.1007/s15010-012-0367-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim was to compare the efficacy and safety of two antibiotic regimens in patients with diabetic foot infections (DFIs). METHODS Data of a subset of patients enrolled in the RELIEF trial with DFIs requiring surgery and antibiotics were evaluated retrospectively. DFI was diagnosed on the basis of the modified Wagner, University of Texas, and PEDIS classification systems. Patients were randomized to receive either intravenous/oral moxifloxacin (MXF, N = 110) 400 mg q.d. or intravenous piperacillin/tazobactam 4.0/0.5 g t.d.s. followed by oral amoxicillin/clavulanate 875/125 mg b.d. (PIP/TAZ-AMC, N = 96), for 7-21 days until the end of treatment (EOT). The primary endpoint was clinical cure rates in the per-protocol (PP) population at the test-of-cure visit (TOC, 14-28 days after EOT). RESULTS There were no significant differences between the demographic characteristics of PP patients in either treatment group. At TOC, MXF and PIP/TAZ-AMC had similar efficacy in both the PP and intent-to-treat (ITT) populations: MXF: 76.4 % versus PIP/TAZ-AMC: 78.1 %; 95 % confidence interval (CI) -14.5 %, 9.0 % in the PP population; MXF: 69.9 % versus PIP/TAZ-AMC: 69.1 %; 95 % CI -12.4 %, 12.1 % in the ITT population. The overall bacteriological success rates were similar in both treatment groups (MXF: 71.7 % versus PIP/TAZ-AMC: 71.8 %; 95 % CI -16.9 %, 10.7 %). A similar proportion of patients (ITT population) experienced any adverse events in both treatment groups (MXF: 30.9 % versus PIP/TAZ-AMC: 31.8 %, respectively). Death occurred in three MXF-treated patients and one PIP/TAZ-AMC-treated patient; these were unrelated to the study drugs. CONCLUSION Moxifloxacin has shown favorable safety and efficacy profiles in DFI patients and could be an alternative antibiotic therapy in the management of DFI. CLINICAL TRIAL NCT00402727.
Collapse
Affiliation(s)
- N C Schaper
- Department of Internal Medicine, Division of Endocrinology, CARIM and CAPHRI Institute, Maastricht University Medical Center+, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.
| | | | | | | | | | | | | | | |
Collapse
|
28
|
Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJG, Armstrong DG, Deery HG, Embil JM, Joseph WS, Karchmer AW, Pinzur MS, Senneville E. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2012; 54:e132-73. [PMID: 22619242 DOI: 10.1093/cid/cis346] [Citation(s) in RCA: 1062] [Impact Index Per Article: 88.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds. Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.
Collapse
Affiliation(s)
- Benjamin A Lipsky
- Department of Medicine, University of Washington, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
29
|
Zubair M, Malik A, Ahmad J. Study of plasmid-mediated extended-spectrum β-lactamase-producing strains of enterobacteriaceae, isolated from diabetic foot infections in a North Indian tertiary-care hospital. Diabetes Technol Ther 2012; 14:315-24. [PMID: 22225456 DOI: 10.1089/dia.2011.0197] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
AIM This study evaluated the incidence and factors responsible for plasmid-mediated extended-spectrum β-lactamase (ESBL) infection among patients with diabetic foot ulcer (DFU). SUBJECTS AND METHODS A prospective study was conducted on 162 DFU inpatients treated in a multidisciplinary-based diabetes and endocrinology center at Jawaharlal Nehru Medical College of Aligarh Muslim University, Aligarh, India, during the period of December 2008-March 2011. Detailed history and patient's profile, grade of DFU, co-morbidities and complications, laboratory data, and final outcome were collected. Standard methods were used for culture identification, sensitivity testing, and ESBL detection. Polymerase chain reaction for bla genes was performed, and the risk factors for bla gene positivity were determined by univariate analysis with 95% confidence interval. RESULTS In total, 127 (78.3%) Enterobacteriaceae members were isolated. The most common isolate was Escherichia coli (71; 55.9%), followed by Klebsiella sp. (33; 25.9%) and Proteus sp. (13; 10.2%). By phenotypic methods, 67.8% were ESBL producers. In the molecular detection of ESBLs, 81.9% were found to be positive for the bla gene, of which bla(CTX-M) showed 81.8% positivity, followed by bla(TEM) (50%) and bla(SHV) (46.9%). In a univariate analysis, bla gene-positive status was associated with low-density lipoprotein-cholesterol (>100 mg/dL) (P<0.004, odds ratio 13.4, relative risk 8.65) and triglycerides (>200 mg/dL) (P<0.003, odds ratio 6.5, relative risk 4.11). CONCLUSION ESBL constitutes a major threat to currently available β-lactam therapy, leading to complications in DFUs. Aminoglycosides, cephalosporin, and β-lactam inhibitor drugs would probably be more appropriate empirical agents after establishing the patient's history of previous antibiotic use. The detection of ESBL should be done on a routine basis.
Collapse
Affiliation(s)
- Mohammad Zubair
- Department of Microbiology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India
| | | | | |
Collapse
|
30
|
Abstract
The European Study Group on Diabetes and the Lower Extremity is a collaborative, multi-disciplinary network of 14 centres from ten countries. In 2003-2004, all patients treated in the participating centres because of a new diabetic foot ulcer (n=1232) were included in a prospective observational study. Subjects attended follow-up visits on a monthly basis until final outcome: healing of the foot, lower-leg amputation, death or non-healing after 1 year. During all visits, data were recorded on standardized case record forms by investigators who were trained during several plenary meetings and on-site visits. Unique aspects of the study were its size, the pan-European scope and the integrated/holistic approach for a multi-organ disease. In this review, the main findings of the study and its implications for diabetic foot care are discussed.
Collapse
Affiliation(s)
- N C Schaper
- Department of Internal Medicine, Division of Endocrinology, Research Schools CAPHRI and CARIM, Maastricht University Medical Centre, Maastricht, The Netherlands.
| |
Collapse
|
31
|
Lipsky BA, Peters EJG, Senneville E, Berendt AR, Embil JM, Lavery LA, Urbančič-Rovan V, Jeffcoate WJ. Expert opinion on the management of infections in the diabetic foot. Diabetes Metab Res Rev 2012; 28 Suppl 1:163-78. [PMID: 22271739 DOI: 10.1002/dmrr.2248] [Citation(s) in RCA: 147] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
This update of the International Working Group on the Diabetic Foot incorporates some information from a related review of diabetic foot osteomyelitis (DFO) and a systematic review of the management of infection of the diabetic foot. The pathophysiology of these infections is now well understood, and there is a validated system for classifying the severity of infections based on their clinical findings. Diagnosing osteomyelitis remains difficult, but several recent publications have clarified the role of clinical, laboratory and imaging tests. Magnetic resonance imaging has emerged as the most accurate means of diagnosing bone infection, but bone biopsy for culture and histopathology remains the criterion standard. Determining the organisms responsible for a diabetic foot infection via culture of appropriately collected tissue specimens enables clinicians to make optimal antibiotic choices based on culture and sensitivity results. In addition to culture-directed antibiotic therapy, most infections require some surgical intervention, ranging from minor debridement to major resection, amputation or revascularization. Clinicians must also provide proper wound care to ensure healing of the wound. Various adjunctive therapies may benefit some patients, but the data supporting them are weak. If properly treated, most diabetic foot infections can be cured. Providers practising in developing countries, and their patients, face especially challenging situations.
Collapse
Affiliation(s)
- B A Lipsky
- VA Puget Sound Health Care System, University of Washington, Seattle, WA 98108, USA.
| | | | | | | | | | | | | | | |
Collapse
|
32
|
Abstract
BACKGROUND Infection of foot ulcers is a common, often severe and costly complication in diabetes. Many factors linked to the host, mainly immune defects, neuropathy and arteriopathy, as well as bacteria-related factors, interact in a complex way and account for the susceptibility of diabetic individuals to foot infections, the severity of such infections and difficulty to treat them. METHODS This article reviews these factors, in the light of data from the literature and from our own results. RESULTS DFIs are not as simple as previously suggested, and new concepts must be considered, especially the virulence potential of isolates and bacterial communications through biofilms. CONCLUSION The development of new tools from molecular biology is a critical step to better understand and manage these infections.
Collapse
Affiliation(s)
- Jean-Louis Richard
- Department of Diabetology and Nutritional Diseases, Medical Centre, University Hospital of Nîmes, 30240, Le Grau du Roi, France.
| | | | | |
Collapse
|
33
|
|
34
|
Blanes J, Clará A, Lozano F, Alcalá D, Doiz E, Merino R, González del Castillo J, Barberán J, Zaragoza R, García Sánchez J. Documento de consenso sobre el tratamiento de las infecciones en el pie del diabético. ANGIOLOGIA 2012. [DOI: 10.1016/j.angio.2011.11.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
35
|
Spellberg B, Lipsky BA. Systemic antibiotic therapy for chronic osteomyelitis in adults. Clin Infect Dis 2011; 54:393-407. [PMID: 22157324 DOI: 10.1093/cid/cir842] [Citation(s) in RCA: 285] [Impact Index Per Article: 21.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The standard recommendation for treating chronic osteomyelitis is 6 weeks of parenteral antibiotic therapy. However, oral antibiotics are available that achieve adequate levels in bone, and there are now more published studies of oral than parenteral antibiotic therapy for patients with chronic osteomyelitis. Oral and parenteral therapies achieve similar cure rates; however, oral therapy avoids risks associated with intravenous catheters and is generally less expensive, making it a reasonable choice for osteomyelitis caused by susceptible organisms. Addition of adjunctive rifampin to other antibiotics may improve cure rates. The optimal duration of therapy for chronic osteomyelitis remains uncertain. There is no evidence that antibiotic therapy for >4-6 weeks improves outcomes compared with shorter regimens. In view of concerns about encouraging antibiotic resistance to unnecessarily prolonged treatment, defining the optimal route and duration of antibiotic therapy and the role of surgical debridement in treating chronic osteomyelitis are important, unmet needs.
Collapse
Affiliation(s)
- Brad Spellberg
- Division of General Internal Medicine, Los Angeles Biomedical Research Institute at Harbor-UCLA, Torrance, CA 90502, USA.
| | | |
Collapse
|
36
|
Abstract
The prevalence of diabetes has been increasing at an alarming rate worldwide. Treatment of diabetes-related complications adds a huge financial burden on our health services, made worse in the current financial climate. The Eurodiale (European Study Group on Diabetes and the Lower Extremity) study was a prospective observational study conducted in 14 European centers in 2003 to 2004 and included data on characteristics of diabetic patients with foot ulcers, diagnostic and management procedures, health care organization, quality of life, and resource use. This was the first large multicenter study, included 1232 patients, and used an integrated approach for a multiorgan disease. The study has provided new insights into the intricacies involved in managing diabetic foot ulcers and how care can be improved. It has shown the differences in quality of care provided in different centers and also highlighted the need for more specific guidance related to diabetic foot disease.
Collapse
Affiliation(s)
- Simeen Akhtar
- Tameside Hospital NHS Foundation Trust, Fountain Street, Ashton-under-Lyne, Lancashire OL6 9RW, UK
| | | | | | | |
Collapse
|
37
|
&NA;. Choose antibacterial carefully when treating methicillin-resistant Staphylococcus aureus diabetic foot infections. DRUGS & THERAPY PERSPECTIVES 2011. [DOI: 10.2165/11601700-000000000-00000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
|
38
|
Zubair M, Malik A, Ahmad J. Clinico-microbiological study and antimicrobial drug resistance profile of diabetic foot infections in North India. Foot (Edinb) 2011; 21:6-14. [PMID: 21130641 DOI: 10.1016/j.foot.2010.10.003] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 10/11/2010] [Accepted: 10/19/2010] [Indexed: 02/04/2023]
Abstract
The study was carried out in diabetic patients with foot ulcer to determine the microbiological profile of infected ulcer, antibiotic resistance of the isolates and to find out the potential risk factors for infection with multidrug resistance and the outcome of these infections. A detailed clinical history and physical examination was carried out in each patient. Pus samples for bacterial culture were collected from 102 patients admitted with diabetic foot infections. All patients had ulcer with Texas grades 1-3. Seventeen patients (16.6%) had coexisting osteomyelitis. Aerobic gram negative bacilli were tested for extended spectrum β lactamase (ESBL) production by phenotypic and genotypic methods. Staphylococcus isolates were tested for susceptibility to oxacillin and cefoxitin by disk method. Potential risk factors for MDRO positive samples were explored. Gram negative aerobes were most frequently isolated (63.8%), followed by gram positive aerobes (36.1%) and anaerobes (31.4%). Forty five percent of patients were positive for MDROs. ESBL production and methicillin resistant was noted in 68.5% and 43.2% of bacterial isolates respectively. 34.5% gram negative strains were positive for bla(CTX-M) gene followed by bla(SHV) (23%) and bla(TEM) (7.4%). Among the anaerobic organism 17(31.4%) from 54 patients, most commonly isolated were Peptostreptococcus sp. (35.2%). MDRO positive status was associated with the presence of neuropathy (P<0.001), osteomyelitis (P<0.03), and ulcer size >4 cm(2) (P<0.01) [corrected] but not with patients characteristic, ulcer type and type of diabetes, or duration of hospital stay. Poor glycemic control in 68.6% patients, duration of infection>1 month (36.2%) and ulcer size >4 cm(2) (75.4%) were independently associated with risk of MDR organisms infection.
Collapse
Affiliation(s)
- Mohammad Zubair
- Department of Microbiology, Faculty of Medicine, J.N. Medical College, Aligarh Muslim University, UP, West, India. mohammad
| | | | | |
Collapse
|
39
|
Powlson AS, Coll AP. The treatment of diabetic foot infections. J Antimicrob Chemother 2011; 65 Suppl 3:iii3-9. [PMID: 20876626 DOI: 10.1093/jac/dkq299] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Successful treatment of infection in the feet of patients with diabetes mellitus remains a challenge. Although the diagnosis of infection remains a clinical decision, presentation in feet rendered insensate from diabetic neuropathy plus co-existing vascular insufficiency means presentation is often atypical. Wounds frequently yield polymicrobial growth and differentiating commensal from pathogenic organisms can be difficult; isolates from diabetic foot wounds are often multidrug resistant. Affected patients often have many other co-morbidities, which not only affect the choice of appropriate antimicrobial regimen but also impede healing. Further, much contention surrounds the management of osteomyelitis, with the merits and role of surgery still undecided. In this review we briefly consider the epidemiology and pathogenesis of diabetic foot disease, before discussing emerging best microbiological practice and how this fits with the multidisciplinary approach required to tackle this difficult clinical problem.
Collapse
Affiliation(s)
- Andrew S Powlson
- Wolfson Diabetes and Endocrine Clinic, Institute of Metabolic Science, Box 281, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | | |
Collapse
|
40
|
Eleftheriadou I, Tentolouris N, Argiana V, Jude E, Boulton AJ. Methicillin-resistant Staphylococcus aureus in diabetic foot infections. Drugs 2010; 70:1785-97. [PMID: 20836573 DOI: 10.2165/11538070-000000000-00000] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Diabetic foot ulcers are often complicated by infection. Among pathogens, Staphylococcus aureus predominates. The prevalence of methicillin-resistant S. aureus (MRSA) in infected foot ulcers is 15-30% and there is an alarming trend for increase in many countries. There are also data that recognize new strains of MRSA that are resistant to vancomycin. The risk for MRSA isolation increases in the presence of osteomyelitis, nasal carriage of MRSA, prior use of antibacterials or hospitalization, larger ulcer size and longer duration of the ulcer. The need for amputation and surgical debridement increases in patients infected with MRSA. Infections of mild or moderate severity caused by community-acquired MRSA can be treated with cotrimoxazole (trimethoprim/sulfamethoxazole), doxycycline or clindamycin when susceptibility results are available, while severe community-acquired or hospital-acquired MRSA infections should be managed with glycopeptides, linezolide or daptomycin. Dalbavancin, tigecycline and ceftobiprole are newer promising antimicrobial agents active against MRSA that may also have a role in the treatment of foot infections if more data on their efficacy and safety become available.
Collapse
Affiliation(s)
- Ioanna Eleftheriadou
- Department of Propaedeutic and Internal Medicine, Athens University Medical School, Greece
| | | | | | | | | |
Collapse
|
41
|
Byren I, Peters EJG, Hoey C, Berendt A, Lipsky BA. Pharmacotherapy of diabetic foot osteomyelitis. Expert Opin Pharmacother 2009; 10:3033-47. [DOI: 10.1517/14656560903397398] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
|
42
|
Edmonds M. The treatment of diabetic foot infections: focus on ertapenem. Vasc Health Risk Manag 2009; 5:949-63. [PMID: 19997576 PMCID: PMC2788600 DOI: 10.2147/vhrm.s3162] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2009] [Indexed: 12/15/2022] Open
Abstract
Clinically, 3 distinct stages of diabetic foot infection may be recognized: localized infection, spreading infection and severe infection. Each of these presentations may be complicated by osteomyelitis. Infection can be caused by Gram-positive aerobic, and Gram-negative aerobic and anaerobic bacteria, singly or in combination. The underlying principles are to diagnose infection, culture the bacteria responsible and treat aggressively with antibiotic therapy. Localized infections with limited cellulitis can generally be treated with oral antibiotics on an outpatient basis. Spreading infection should be treated with systemic antibiotics. Severe deep infections need urgent admission to hospital for wide-spectrum intravenous antibiotics. Clinical and microbiological response rates have been similar in trials of various antibiotics and no single agent or combination has emerged as most effective. Recently, clinical and microbiological outcomes for patients treated with ertapenem were equivalent to those for patients treated with piperacillin/tazobactam. It is also important to judge the need for debridement and surgery, to assess the arterial supply to the foot and consider revascularization either by angioplasty or bypass if the foot is ischemic. It is also important to achieve metabolic control. Thus infection in the diabetic foot needs full multidisciplinary treatment.
Collapse
Affiliation(s)
- Michael Edmonds
- Diabetic Foot Clinic, King's College Hospital, Denmark Hill, London, UK.
| |
Collapse
|
43
|
|
44
|
Emerging Evidence for Neuroischemic Diabetic Foot Ulcers: Model of Care and How to Adapt Practice. INT J LOW EXTR WOUND 2009; 8:82-94. [DOI: 10.1177/1534734609336948] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Although neuropathic ulceration remains the commonest type of foot ulcers among patients with diabetes, recent data suggest that ischemic (and therefore, neuroischemic) ulcers are on the rise. The high prevalence and incidence of diabetes and its attendant foot complications, coupled with the current trend where increasingly diabetes care is being provided by general practitioners (primary care physicians) would mean that primary care practices are expected to see greater numbers of diabetic foot ulcer patients. Unfortunately, these settings are frequently ill-equipped to appropriately manage diabetic foot ulcers either due to lack of adequately trained personnel and access to multidisciplinary foot care teams. Whereas neuropathic foot ulceration may appear to be less challenging, neuroischemic or ischemic ulcers portend a higher risk of adverse outcomes, including non-healing, infection, amputation, and death. The last 2 decades have witnessed a paradigm shift from neuropathy as the main etiological factor in diabetic foot disease to an ever-increasing preponderance of ischemic and/or neuroischemic ulceration. Available literature does not always consider the limited access primary care practices have to specialized multidisciplinary foot care teams. Additionally, in the case of neuroischemic and/or ischemic ulcers, existing guidelines on their diagnosis and management are varied and unclear. This review aimed at providing a simple understanding to the complex evidence base for diagnosing and treating neuroischemic and/or ischemic ulcers in a primary care setting. It emphasizes the need for urgent vascular review in all patients with ischemic/ neuroischemic ulcers and advocates effective participation of vascular specialists in diabetic foot clinics and combined ward rounds.
Collapse
|
45
|
Galkowska H, Podbielska A, Olszewski WL, Stelmach E, Luczak M, Rosinski G, Karnafel W. Epidemiology and prevalence of methicillin-resistant Staphylococcus aureus and Staphylococcus epidermidis in patients with diabetic foot ulcers: focus on the differences between species isolated from individuals with ischemic vs. neuropathic foot ulcers. Diabetes Res Clin Pract 2009; 84:187-93. [PMID: 19269053 DOI: 10.1016/j.diabres.2009.02.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2008] [Revised: 02/02/2009] [Accepted: 02/09/2009] [Indexed: 11/22/2022]
Abstract
We examined whether foot ischemia or neuropathy with diabetic foot ulcer (DFU) promote selection of staphylococci species, evaluated frequency of MRSA and MRSE among strains yielded from patients with DFU and assessed multidrug resistance of isolates. Patients with DFU and foot osteomyelitis were divided into ischemic foot ulcer (IFU, n=21) and neuropathic foot ulcer (NFU, n=29) groups. Frequency of Staphylococcus epidermidis yielded from curettage of IFU was higher compared with NFU (P<0.05). S. epidermidis was also more frequently isolated from the toe web surface of patients with IFU compared with NFU (55% vs. 17.9%, respectively) and healthy volunteers (HV, n=20) (17.6%, P<0.05). These mostly MRSE strains (83.3-100%) originating from DFU patients were multidrug resistant (88.8%). Also, most of MRSA isolates were multidrug resistant (70.3%). Higher rates of MSSA from DFU patients than HV showed resistance to antimicrobials. This is the first report indicating that diabetic patients with IFU differ with NFU patients in higher frequency of S. epidermidis skin colonization and ulcer infection. We suggest that IFU should be defined as separate disease state of DFU and S. epidermidis should be appreciated as a nosocomial pathogen.
Collapse
Affiliation(s)
- Hanna Galkowska
- Department of Surgical Research & Transplantology, Medical Research Center, Polish Academy of Sciences, 02-106 Warsaw, 5 Pawinskiego str, Poland.
| | | | | | | | | | | | | |
Collapse
|
46
|
Kraemer JL, Worm PV, Faria MDB, Maulaz A. Brain abscess following ischemic stroke with secondary hemorrhage. ARQUIVOS DE NEURO-PSIQUIATRIA 2009; 66:104-6. [PMID: 18392430 DOI: 10.1590/s0004-282x2008000100028] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Jorge Luiz Kraemer
- Department of Neurosurgery, Hospital São José, Santa Casa de Misericórdia de Porto Alegre, Porto Alegre, RS, Brazil
| | | | | | | |
Collapse
|
47
|
Landersdorfer CB, Bulitta JB, Kinzig M, Holzgrabe U, Sörgel F. Penetration of Antibacterials into Bone. Clin Pharmacokinet 2009; 48:89-124. [DOI: 10.2165/00003088-200948020-00002] [Citation(s) in RCA: 216] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
|
48
|
Prompers L, Schaper N, Apelqvist J, Edmonds M, Jude E, Mauricio D, Uccioli L, Urbancic V, Bakker K, Holstein P, Jirkovska A, Piaggesi A, Ragnarson-Tennvall G, Reike H, Spraul M, Van Acker K, Van Baal J, Van Merode F, Ferreira I, Huijberts M. Prediction of outcome in individuals with diabetic foot ulcers: focus on the differences between individuals with and without peripheral arterial disease. The EURODIALE Study. Diabetologia 2008; 51:747-55. [PMID: 18297261 PMCID: PMC2292424 DOI: 10.1007/s00125-008-0940-0] [Citation(s) in RCA: 589] [Impact Index Per Article: 36.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2007] [Accepted: 01/03/2008] [Indexed: 12/22/2022]
Abstract
AIMS/HYPOTHESIS Outcome data on individuals with diabetic foot ulcers are scarce, especially in those with peripheral arterial disease (PAD). We therefore examined the clinical characteristics that best predict poor outcome in a large population of diabetic foot ulcer patients and examined whether such predictors differ between patients with and without PAD. METHODS Analyses were conducted within the EURODIALE Study, a prospective cohort study of 1,088 diabetic foot ulcer patients across 14 centres in Europe. Multiple logistic regression modelling was used to identify independent predictors of outcome (i.e. non-healing of the foot ulcer). RESULTS After 1 year of follow-up, 23% of the patients had not healed. Independent baseline predictors of non-healing in the whole study population were older age, male sex, heart failure, the inability to stand or walk without help, end-stage renal disease, larger ulcer size, peripheral neuropathy and PAD. When analyses were performed according to PAD status, infection emerged as a specific predictor of non-healing in PAD patients only. CONCLUSIONS/INTERPRETATION Predictors of healing differ between patients with and without PAD, suggesting that diabetic foot ulcers with or without concomitant PAD should be defined as two separate disease states. The observed negative impact of infection on healing that was confined to patients with PAD needs further investigation.
Collapse
Affiliation(s)
- L Prompers
- Division of Endocrinology, Department of Internal Medicine, University Hospital Maastricht, P. Debeyelaan 25, P.O. Box 5800, 6202 AZ, Maastricht, the Netherlands.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
49
|
García-Rodríguez JÁ. Documento de consenso sobre el tratamiento antimicrobiano de las infecciones en el pie diabético. ANGIOLOGIA 2008. [DOI: 10.1016/s0003-3170(08)02003-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
|
50
|
Barie PS, Eachempati SR. Infections of Skin and Soft Tissue. Surgery 2008. [DOI: 10.1007/978-0-387-68113-9_12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|