Diabetic foot infections: state-of-the-art

Predictors of surgical management in diabetic foot infections

OBJECTIVE

Early recognition of the need for surgical intervention is crucial in terms of limiting amputation level and decreasing mortality. We aimed to determine the risk factors for limb loss in patients with diabetic foot infection (DFI).

METHOD

Data of hospitalised patients with a DFI between 2010 and 2019 were collected retrospectively from their hospital records. Clinical and laboratory findings were analysed according to the type of treatment.

RESULTS

Data were collected for 401 patients, 280 (69.8%) of whom were male. The mean age was 59.6±11.1 years. Treatment modalities included: medical treatment (36.4%); debridement/drainage (21.9%); minor amputation (17.7%); and major amputation (23.9%). Forefoot infection (odds ratio (OR): 3.347; 95% confidence interval (Cl): 1.408-7.956) and peripheral arterial disease (OR: 4.990; 95% Cl: 1.225-20.324) were found to be significant in predicting limb loss, while duration of diabetes (≥20 years) and absence of forefoot infection were significant predictors of debridement/drainage. Subgroup analysis showed that high leukocyte levels (>16.4K/μl) and forefoot infections were independent predictors for major and minor amputation, respectively.

CONCLUSION

The clinical parameters used in this study are simple, broadly available, cost-effective and promising for predicting limb loss in patients with DFI.

Analysis of Distribution and Drug Susceptibility Test Results of Pathogenic Bacteria in Diabetic Foot Ulcers

INTRODUCTION

This study aimed to determine the pathogen distribution and drug susceptibility of diabetic foot wound secretions in a tertiary hospital in a coastal area of southeastern China to guide clinical antibiotic selection.

METHODS

A retrospective analysis was conducted on 212 patients with diabetic foot hospitalized at Xiamen Third Hospital from 2018 to 2023, and foot wound secretions were collected for microbial culture and drug susceptibility testing.

RESULTS

Among 212 cases of patients with diabetic foot wound secretions, 163 cases (76.9%) were cultured with pathogenic bacteria, and a total of 207 strains of pathogenic bacteria were cultured, including 75 strains (36.23%) of Gram-positive (G+) bacteria, 118 strains of Gram-negative (G-) bacteria (57.00%), 14 strains of fungi (6.76%), 120 cases of single microorganism infection (73.62%), 43 cases of mixed infection (26.38%), and 15 strains of multidrug-resistant bacteria (7.25%). The top three pathogenic bacteria were Staphylococcus aureus, Klebsiella pneumoniae, and Pseudomonas aeruginosa. G+ bacteria were dominated by S. aureus. Drug susceptibility results showed that G+ bacteria were highly susceptible to vancomycin, linezolid, tigecycline, quinupristin/dalfopristin, rifampicin, and furotoxin, and somewhat resistant to penicillin, erythromycin, clindamycin, and cefoxitin. Among G- bacterial infections, Klebsiella pneumoniae, Pseudomonas aeruginosa, Escherichia coli, and Proteus were the major species. Drug susceptibility testing indicated that carbapenems such as imipenem and ertapenem were the most effective antibacterial drugs against G- strains, followed by amikacin, piperacillin, and tazabactams to which these bacteria were also relatively sensitive, while resistance to penicillins and first-generation cephalosporins increased significantly. We isolated one strain of pathogenic bacteria from a Wagner grade 1 ulcer, which was G+ bacteria. In Wagner grade 2 ulcers, the distribution of pathogenic bacteria was mainly G+ bacteria. In Wagner grade 3 and 4 ulcers, the distribution of pathogenic bacteria was mainly G- bacteria, and the increased rate of mixed infection was mainly due to mixed infection of G+ and G-. Two strains of pathogenic bacteria were isolated at Wagner grade 5, which were mixed infections of G+ and G-.

CONCLUSIONS

Pathogenic bacteria in diabetic foot wounds are predominantly G- bacteria, followed by G+ bacteria. As the Wagner ulcer grade increases, the distribution of pathogenic bacteria changes from G+ bacteria to G- bacteria, and the mixed infection rate increases. G+ bacteria are highly susceptible to vancomycin, linezolid, tigecycline, quinupristin/dalfopristin, rifampicin, and furotoxin, and somewhat resistant to penicillin, erythromycin, clindamycin, and cefoxitin. G- bacteria are more sensitive to the antimicrobial drugs ertapenem, imipenem, amikacin, piperacillin tazobactam, and have high resistance to penicillin and first-generation cephalosporins.

Diabetic Foot Infections in the Emergency Department

Diabetic foot infection (DFI) is among the most common diabetic complications requiring hospitalization. Prompt emergency department diagnosis and evidence-based management can prevent eventual amputation and associated disability and mortality. Underlying neuropathy, arterial occlusion, immune dysfunction, and hyperglycemia-associated dehydration and ketoacidosis can all contribute to severity and conspire to make DFI diagnosis and management difficult. Serious complications include osteomyelitis, necrotizing infection, and sepsis. Practice guidelines are designed to assist frontline providers with correct diagnosis, categorization, and treatment decisions. Management generally includes a careful lower extremity examination and plain x-ray, obtaining appropriate tissue cultures, and evidence-based antibiotic selection tailored to severity.

The usefulness of quantitative 99mTc-HMPAO WBC SPECT/CT for predicting lower extremity amputation in diabetic foot infection

We investigated the usefulness of quantitative 99mTc-white blood cell (WBC) single photon emission computed tomography (SPECT)/computed tomography (CT) for predicting lower extremity amputation in diabetic foot infection (DFI). A total of 93 feet of 83 consecutive patients with DFI who underwent WBC SPECT/CT for treatment planning were retrospectively analysed. The clinical and SPECT/CT parameters were collected along with the measurements of the maximum standardized uptake value (SUVmax) at DFI. Statistical logistic regression analysis was performed to explore the predictors of LEA and receiver operating characteristic (ROC) curve was analysed to assess the predictive value of SPECT/CT. The independent predictors of amputation were previous amputation (OR 11.9), numbers of SPECT/CT lesions (OR 2.1), and SUVmax of DFI; either continuous SUVmax (1-increase) (OR 1.3) or categorical SUVmax > 1.1 (OR 21.6). However, the conventional SPECT/CT interpretation failed to predict amputation. In ROC analysis, the SUVmax yielded a fair predictor (area under the curve (AUC) 0.782) of amputation. The model developed from these independent predictors yielded an excellent performance for predicting amputation (AUC 0.873). Quantitative WBC SPECT/CT can provide new information useful for predicting the outcomes and guiding treatment for patients with DFI.

Relationship between Prognostic Nutritional Index and Amputation in Patients with Diabetic Foot Ulcer

The prognostic nutritional index (PNI) is a new marker used to assess a patient's nutritional and immune status. It is calculated using serum albumin levels and total lymphocyte count. The aim of this study was to investigate the relationship between PNI and amputation in patients with diabetic foot ulcer (DFU). Patients with DFU were enrolled in this retrospective study. In our study, a total of 386 patient data, of 110 (28.5%) amputated and 276 (71.5%) non-amputated patients, were statistically analyzed. PNI values were significantly lower in the amputated patient group than in the non-amputee patient group (p < 0.001). According to the ROC analysis results, PNI was significant in the prediction of amputation at an excellent level (AUC = 0.937 (0.911-0.963), p < 0.001). The optimal cut-off point for PNI was found to be 39,005. There was classification success for this cut-off point: sensitivity was calculated as 82.7% (74.1-89) and specificity as 93.1% (89.3-95.7). In the multivariate model, the odds ratio (OR) (95% CI) was calculated as 81.8 (38.5-173.7) for PNI. The PNI was associated with an increase in amputation rate in patients with DFU. By using PNI, patients can be directed to advanced centers and have access to early and appropriate interventions.

Confronting a New Challenge in Plastic Surgery: MDR Infections in Patients with Chronic Wounds

BACKGROUND

The presence of a wound can be anywhere from non-problematic to life-threatening on a severity spectrum, with bacterial infection and resistance playing a major role in the development of chronicity, delaying wound healing. Wound colonization with multiple organisms and the limited number of effective antibiotics place a heavy burden on the healthcare system, with patients going through multiple surgeries during a prolonged hospitalization time. By analyzing the resistance patterns of pluri-bacterial populations and the approach used in managing complex cases, we aim to improve the protocols applied in caring for chronic wounds in our practice and share our experiences and observations.

METHODS

We designed a retrospective study on 212 diabetic and non-diabetic patients, aiming to evaluate the course of chronic wound treatment in our practice. We focused on the impact that MDR bacteria and diabetes have on surgical outcomes and their role in the healing process.

RESULTS

Patients who received empiric antibiotic therapy before being admitted eventually presented with multiple MDR bacteria compared to those who did not receive antibiotics (p = 0.014). The presence of at least one MDR bacteria in the wound bed was associated with ulcers reaching bone (p = 0.02) and was positively correlated with the number of surgeries performed (p < 0.001). Diabetes played a significant role in surgery-related complications (p = 0.02) and hospitalization time (p < 0.001).

CONCLUSIONS

Proper management of chronic wounds requires a comprehensive, multidisciplinary approach and a thorough understanding of antibiotic usage. To address this need, we have developed and implemented a chronic wound treatment protocol in our clinic, with the goal of discharging patients once their ulcers have been treated and closed. A key summary of the protocol presented is to reduce the incidence of MDR bacteria and improve the patient's quality of life.

Evaluation of risk factors associated with hard-to-heal wound infection in a tertiary care hospital

OBJECTIVE

The incidence of hard-to-heal wound infection, especially as a result of multidrug-resistant Gram-negative organisms, has increased in recent years. The reason for the increase is multifactorial and the ability of these pathogenic isolates to form biofilms is one of the important risk factors in wound infection. This study aimed to evaluate the risk factors associated with such cases.

METHOD

This prospective analytical study, conducted over a period of two months, included pus or tissue samples from hospital inpatients with Gram-negative hard-to-heal wound infection. The samples were processed with conventional microbiological techniques. Patient demographic details and the presence of various risk factors were recorded. Biofilm production was detected by tissue culture plate method in the laboratory. The data were analysed using SPSS version 21 (IBM Ltd., US).

RESULTS

The experimental cohort comprised 200 patients. Klebsiella spp. was the most common identified organism, followed by Escherichia coli and Pseudomonas spp. Carbapenem resistance was observed in 106 (53%) strains. Almost 66% of the strains showed biofilm formation. On evaluation of associated risk factors, age (p=0.043), presence of biofilms (p=0.0001), diabetes (p=0.002), hypertension (p=0.02) and medical device use (p=0.008) had significant association, whereas sex, previous surgery and prior antibiotic use had no significant impact on the chronicity of the wound.

CONCLUSION

In this study, chronicity of wounds was observed to be associated with multiple risk factors, especially the biofilm-forming ability of the strain. Biofilms are difficult to eradicate and additional measures, such as physical debridement, are important for resolving chronicity. Knowledge about specific risk factors would also allow clinicians a better understanding of the healing process and drive appropriate wound care interventions.

DECLARATION OF INTEREST

A grant was received from the Indian Council of Medical Research (ICMR) for this work (grant ID: 2017-02686). The authors have no conflicts of interest to declare.

Non-coding RNAs in diabetic foot ulcer- a focus on infected wounds

Diabetes mellitus is associated with a wide range of neuropathies, vasculopathies, and immunopathies, resulting in many complications. More than 30% of diabetic patients risk developing diabetic foot ulcers (DFUs). Non-coding RNAs (ncRNAs), including microRNAs (miRNAs), long non-coding RNAs (lncRNAs), and circular RNAs (circRNAs), play essential roles in various biological functions in the hyperglycaemic environment that determines the development of DFU. Ulceration results in tissue breakdown and skin barrier scavenging, thereby facilitating bacterial infection and biofilm formation. Many bacteria contribute to diabetic foot infection (DFI), including Staphylococcus aureus (S. aureus) et al. A heterogeneous group of "ncRNAs," termed small RNAs (sRNAs), powerfully regulates biofilm formation and DFI healing. Multidisciplinary foot care interventions have been identified for nonhealing ulcers. With an appreciation of the link between disease processes and ncRNAs, a novel therapeutic model of bioactive materials loaded with ncRNAs has been developed to prevent and manage diabetic foot complications.

Diagnosis and treatment of diabetic foot ulcer complicated with lower extremity vasculopathy: Consensus recommendation from the Chinese Medical Association (CMA), Chinese Medical Doctor Association (CMDA)

Diabetic foot ulcer complicated with lower extremity vasculopathy is highly prevalent, slow healing and have a poor prognosis. The final progression leads to amputation, or may even be life-threatening, seriously affecting patients' quality of life. The treatment of lower extremity vasculopathy is the focus of clinical practice and is vital to improving the healing process of diabetic foot ulcers. Recently, a number of clinical trials on diabetic foot ulcers with lower extremity vasculopathy have been reported. A joint group of Chinese Medical Association (CMA) and Chinese Medical Doctor Association (CMDA) expert representatives reviewed and reached a consensus on the guidelines for the clinical diagnosis and treatment of this kind of disease. These guidelines are based on evidence from the literature and cover the pathogenesis of diabetic foot ulcers complicated with lower extremity vasculopathy and the application of new treatment approaches. These guidelines have been put forward to guide practitioners on the best approaches for screening, diagnosing and treating diabetic foot ulcers with lower extremity vasculopathy, with the aim of providing optimal, evidence-based management for medical personnel working with diabetic foot wound repair and treatment.

Initial antibiotic therapy for postoperative moderate or severe diabetic foot infections: Broad versus narrow spectrum, empirical versus targeted

AIM

To retrospectively evaluate clinical and microbiological outcomes after combined surgical and medical therapy for diabetic foot infections (DFIs), stratifying between the empirical versus the targeted nature, and between an empirical broad versus a narrow-spectrum, antibiotic therapy.

METHODS

We retrospectively assessed the rate of ultimate therapeutic failures for each of three types of initial postoperative antibiotic therapy: adequate empirical therapy; culture-guided therapy; and empirical inadequate therapy with a switch to targeted treatment based on available microbiological results.

RESULTS

We included data from 332 patients who underwent 716 DFI episodes of surgical debridement, including partial amputations. Clinical failure occurred in 40 of 194 (20.6%) episodes where adequate empirical therapy was given, in 77 of 291 (26.5%) episodes using culture-guided (and correct) therapy from the start, and in 73 of 231 (31.6%) episodes with switching from empirical inadequate therapy to culture-targeted therapy. Equally, a broad-spectrum antibiotic choice could not alter this failure risk. Group comparisons, Kaplan-Meier curves and Cox regression analyses failed to show either statistical superiority or inferiority of any of the initial antibiotic strategies.

CONCLUSIONS

In this study, the microbiological adequacy of the initial antibiotic regimen after (surgical) debridement for DFI did not alter therapeutic outcomes. We recommend that clinicians follow the stewardship approach of avoiding antibiotic de-escalation and start with a narrow-spectrum regimen based on the local epidemiology.

Detection, management, and prevention of diabetes-related foot disease in the Australian context

Diabetes-related foot disease (DFD) is a widely feared complication among people who live with diabetes. In Australia and globally, rates of disability, cardio-vascular disease, lower extremity amputation, and mortality are significantly increased in patients with DFD. In order to understand and prevent these outcomes, we analyse the common pathogenetic processes of neuropathy, arterial disease, and infection. The review then summarises important management considerations through the interdisciplinary lens. Using Australian and international guidelines, we offer a stepwise, evidence-based practical approach to the care of patients with DFD.

Transverse Tibial Bone Transfer in the Treatment of Diabetes Foot Ulcer: A Pilot Study

Background

The treatment of diabetes-related foot complications is a clinical challenge. The underlying complicating factors of peripheral vascular disease render most diabetic foot ulcers asymptomatic until the ulcer fails to heal and becomes clinically distinct, constituting a significant cause of disability and even death in diabetic patients.

Objective

To evaluate the clinical efficacy of tibial transverse transport (TTT) in the treatment of patients with diabetic foot ulcers.

Methods

A total of 35 patients who met the inclusion criteria were selected as the study group from patients with diabetic foot ulcers diagnosed and treated at our hospital between August 2019 and March 2021 and were treated with TTT, and 35 patients who also met the inclusion criteria were included in the routine group and were given conventional wound debridement. The primary endpoint of this study was clinical efficacy, including pain condition, trauma condition, ankle-brachial index, and peripheral nerve recovery.

Results

Patients receiving TTT showed significantly reduced visual analogue scale (VAS) scores than those with conventional treatment (P<0.05). TTT resulted in a significant reduction of trabecular area and better trabecular healing versus conventional treatment (P<0.05). TTT was associated with significantly higher ankle-brachial index (ABI) and lower Michigan neuropathy screening instrument (MNSI) scores in patients versus conventional debridement (P<0.05).

Conclusion

TTT effectively alleviates the pain of diabetic foot ulcer patients, promotes wound healing, and improves ankle-brachial index and peripheral nerve recovery. In the context of the high amputation rate of diabetic foot ulcers treated by internal medicine, TTT contributes positively to the enhancement of patient prognosis and merits clinical promotion.

Diabetic foot ulcer-a systematic review on relevant microbial etiology and antibiotic resistance in Asian countries

BACKGROUND AND AIMS

Diabetic foot ulcer (DFU) is one of the most common but uncontrolled health issues of diabetic patients that needs more therapeutic considerations. This systematic review aims to study the current status of the etiological agents responsible for DFU, their frequency in some of the most occurring Asian countries, and their antibiotic resistance pattern based on available studies.

METHODS

Here, the literature survey was conducted on all the DFU studies with the records of etiological agents and conventional therapeutic treatment published until March 2021 using Medical Literature Analysis and Retrieval System Online (MEDLINE) and Web of Science Core Collection (WoSCC) database.

RESULTS

Overall, in our study, a total of 73 studies representing 12 Asian countries worldwide have been included. We found that the highest number of studies were reported from India (45%) followed by Pakistan (11%), China, Iran and others. 71% of recent studies reported DFU being attributed to poly-microbial infections while the dominant position was significantly secured by Gram- negative bacteria (77%, p = 0.34). Staphylococcus aureus was found to be the most prevalent isolate followed by Pseudomonas and then Escherichia coli (mean value - 22%, 17%, and 15% respectively). Antibiotic sensitivity pattern was determined based on availability in terms of median resistance (MR) and interquartile range (IQR) which showed the growing resistance developed by both Gram-positive and Gram-negative isolates. Gram positive pathogens were still reported as susceptible to vancomycin (MR 0%, IQR 0-22.8%), linezolid (MR 0%, IQR 0-15.53%) and imipenem (MR 11%, IQR 0-23.53%). Carbapenem genera, colistin, and amikacin were the most effective drugs against Gram-negative pathogens.

CONCLUSION

The findings of this study highly recommend searching for alternative and complementary therapeutic regimens instead of prescribing conventional drugs blindly without investigating the progression of the stages of the ulcer, which may help reduce the medical and economic burden of this disease.

Distribution of Causative Microorganisms in Diabetic Foot Infections: A Ten-Year Retrospective Study in a Tertiary Care Hospital in Central Malaysia

Diabetes mellitus is a global pandemic, especially in Southeast Asia. Diabetic foot infection (DFI) is a common complication of this condition and causes significant morbidity and mortality in those affected. There is a lack of locally published data on the types of microorganisms and empirical antibiotics being prescribed. This paper highlights the importance of local microorganism culture and antibiotic prescription trends among diabetic foot patients in a tertiary care hospital in central Malaysia. This is a retrospective, cross-sectional study of data taken from January 2010 to December 2019 among 434 patients admitted with diabetic foot infections (DFIs) using the Wagner classification. Patients between the ages of 58 and 68 years old had the highest rate of infection. Pseudomonas Aeruginosa, Proteus spp., and Proteus mirabilis appeared to be the most isolated Gram-negative microorganisms, and Staphylococcus aureus, Streptococcus agalactiae, and MRSA appeared to be the most common Gram-positive microorganisms. The most common empirical antibiotics prescribed were ampicillin/sulbactam, followed by ciprofloxacin and ceftazidime, and the most common therapeutic antibiotics prescribed were ampicillin/sulbactam, ciprofloxacin, and cefuroxime. This study could be immensely pertinent in facilitating future empirical therapy guidelines for treating diabetic foot infections.

Influence of Skin Commensals on Therapeutic Outcomes of Surgically Debrided Diabetic Foot Infections-A Large Retrospective Comparative Study

In diabetic foot infections (DFI), the clinical virulence of skin commensals are generally presumed to be low. In this single-center study, we divided the wound isolates into two groups: skin commensals (coagulase-negative staphylococci, micrococci, corynebacteria, cutibacteria) and pathogenic pathogens, and followed the patients for ≥ 6 months. In this retrospective study among 1018 DFI episodes (392 [39%] with osteomyelitis), we identified skin commensals as the sole culture isolates (without accompanying pathogenic pathogens) in 54 cases (5%). After treatment (antibiotic therapy [median of 20 days], hyperbaric oxygen in 98 cases [10%]), 251 episodes (25%) were clinical failures. Group comparisons between those growing only skin commensals and controls found no difference in clinical failure (17% vs. 24 %, p = 0.23) or microbiological recurrence (11% vs. 17 %, p = 0.23). The skin commensals were mostly treated with non-beta-lactam oral antibiotics. In multivariate logistic regression analysis, the isolation of only skin commensals was not associated with failure (odds ratio 0.4, 95% confidence interval 0.1-3.8). Clinicians might wish to consider these isolates as potential pathogens when selecting a targeted antibiotic regimen, which may also be based on oral non-beta-lactam antibiotic agents effective against the corresponding skin pathogens.

Association between the duration of diabetes and gram-negative bacterial infection in diabetic foot infections: a case-control study

This retrospective case-control study was designed to explore the association between the duration of diabetes and gram-negative bacterial infection in diabetic foot infections (DFIs). All DFI patients hospitalized in the Department of Endocrinology in the Sixth Affiliated Hospital of Sun Yat-sen University between 2013 and 2019 with positive microbial culture results were included. Cases were defined as DFI patients whose microbial cultures grew gram-negative bacteria (including polymicrobial flora). Controls were defined as DFI patients whose positive microbial cultures did not grow gram-negative bacteria. Clinical data were extracted from the hospital information system. Stabilized inverse probability weighting was used to balance between-group differences at baseline. Confounders were selected using a directed acyclic graph. Missing data were imputed with the multiple imputation of chained equations method. Odds ratios (ORs) with 95% confidence intervals (CIs) and P_trend for associations between the duration of diabetes and gram-negative bacterial infection were obtained using binomial logistic regression models. The weighted OR of gram-negative bacterial infection for DFI patients with a moderate duration of diabetes (8~19 years) compared with those with a short duration (0~7 years) was 3.87 (95% CI: 1.15 to 13.07), and the OR for those with a longer duration (20~30 + years) was 7.70 (95% CI: 1.45 to 41.00), and there was a dose-response trend with increasing duration of diabetes (weighted P_trend = 0.007). The results demonstrated that a long duration of diabetes might be associated with an increased risk of gram-negative bacterial infection in type 2 diabetes patients with DFI.

Diabetic Foot Infection Characteristics and Antibiotics Susceptibility Patterns in a Regional Hospital in Libya

Introduction Diabetes is a major global health problem, among the top causes of death worldwide. Diabetic foot infection (DFI) is associated with an increased risk of amputation by 155 times and a mortality rate of 57% at 5 years. This study aims to characterize DFI epidemiology in a local hospital and analyze local microbiological patterns and antibiotic susceptibility testing.

Patients and Methods This is a retrospective review of Al Jala hospital Benghazi/Libya medical records. Eligible patients were included, if they had DFI with confirmed tissue/pus samples collections was submitted to the hospital laboratory for microbiology and Antibiotics susceptibility analysis.

Results Out of 126 patients, 77 (61.1%) were men, and 49 (38.9%) were women. The mean age was 55.4 years. Incision drainage with debridement was the most common surgical procedure (77.1%). 38.88% of growth was polymicrobial. Gram-negative rods were isolated in 70.9%, and gram-positive cocci in 27.4%. The most commonly isolated bacteria were Pseudomonas aeruginosa (15.9%) and Proteus sps. (14.2%), Staphylococcus aureus (11.3%), and Escherichia coli (10.2%). Methicillin-resistant Staphylococcus aureus (MRSA) constitutes 30% of isolated S. aureus. The most common effective antibiotic for P. aeruginosa was imipenem (90%), for S. aureus was linezolid (100%), and for MRSA was linezolid, vancomycin (100%), and ciprofloxacin 88.8%. Sixty-four percent of total bacterial isolates were MDROs (gram-positive isolates 65.3%, gram-negative isolates 63.6%).

Conclusions The emergence of antibiotic-resistant bacteria is a global health concern. This study attempts to evaluate the local microbiology and antimicrobial susceptibility to tailor the treatment choice for better patient outcomes.

Pseudomonal Diabetic Foot Infections: Vive la Différence?

Objective

To assess the outcomes of diabetic foot infections (DFIs) due to Pseudomonas aeruginosa.

Patients and Methods

From April 24, 2013 to July 31, 2016, we analyzed data from patients prospectively enrolled in our clinical pathway of DFIs, comparing those with infection due to Pseudomonas with those without infection due to Pseudomonas.

Results

Overall, we assessed 1018 cases of DFIs: 392 with osteomyelitis and 626 with only soft tissue infections. The prevalence of P aeruginosa in deep wound cultures was 10% (104/1018); of the 1018 cultures, 22 were monomicrobial, 82 were polymicrobial, and 46 were with osteomyelitis. Overall, the patients were treated with a median of 1 surgical debridement and a total of 20 days of antibiotic therapy. In a comparison of crude groups, the proportion of clinical failures was significantly higher with Pseudomonas than with other pathogens (36/104 [35%] vs 218/914 [24%], respectively; P=.02). A multivariate analysis showed that pseudomonal DFIs did not recur more often than nonpseudomonal DFIs (hazard ratio, 1.0; 95% confidence interval, 0.6-1.7). Among the 104 cases of pseudomonal DFIs, there was no association between failure of treatment and the total duration of antibiotic therapy, duration of intravenous therapy, duration of combined antibiotic therapy with more than 1 agent, or duration of oral (fluoroquinolone) therapy. Among 15 cases of pseudomonal recurrence, 2 (13%) developed resistance to the antibiotic agent used for the index episode.

Conclusion

For DFIs caused by P aeruginosa, other than choosing an antibiotic agent that is active against the organism, it does not appear necessary to treat with a different therapeutic regimen compared with the treatment of nonpseudomonal DFIs. There is no difference!

Neutralizing Staphylococcus aureus Virulence with AZD6389, a Three mAb Combination, Accelerates Closure of a Diabetic Polymicrobial Wound

Nonhealing diabetic foot ulcers (DFU), a major complication of diabetes, are associated with high morbidity and mortality despite current standard of care. Since Staphylococcus aureus is the most common pathogen isolated from nonhealing and infected DFU, we hypothesized that S. aureus virulence factors would damage tissue, promote immune evasion and alter the microbiome, leading to bacterial persistence and delayed wound healing. In a diabetic mouse polymicrobial wound model with S. aureus, Pseudomonas aeruginosa, and Streptococcus pyogenes, we report a rapid bacterial proliferation, prolonged pro-inflammatory response and large necrotic lesions unclosed for up to 40 days. Treatment with AZD6389, a three-monoclonal antibody combination targeting S. aureus alpha toxin, 4 secreted leukotoxins, and fibrinogen binding cell-surface adhesin clumping factor A resulted in full skin re-epithelization 21 days after inoculation. By neutralizing multiple virulence factors, AZD6389 effectively blocked bacterial agglutination and S. aureus-mediated cell killing, abrogated S. aureus-mediated immune evasion and targeted the bacteria for opsonophagocytic killing. Neutralizing S. aureus virulence not only facilitated S. aureus clearance in lesions, but also reduced S. pyogenes and P. aeruginosa numbers, damaging inflammatory mediators and markers for neutrophil extracellular trap formation 14 days post initiation. Collectively, our data suggest that AZD6389 holds promise as an immunotherapeutic approach against DFU complications.

IMPORTANCE Diabetic foot ulcers (DFU) represent a major complication of diabetes and are associated with poor quality of life and increased morbidity and mortality despite standard of care. They have a complex pathogenesis starting with superficial skin lesions, which often progress to deeper tissue structures up to the bone and ultimately require limb amputation. The skin microbiome of diabetic patients has emerged as having an impact on DFU occurrence and chronicity. DFU are mostly polymicrobial, and the Gram-positive bacterium Staphylococcus aureus detected in more than 95% of cases. S. aureus possess a collection of virulence factors which participate in disease progression and may facilitate growth of other pathogens. Here we show in a diabetic mouse wound model that targeting some specific S. aureus virulence factors with a multimechanistic antibody combination accelerated wound closure and promoted full skin re-epithelization. This work opens promising new avenues for the treatment of DFU.

Challenges and innovations in treating chronic and acute wound infections: from basic science to clinical practice

Acute and chronic wound infection has become a major worldwide healthcare burden leading to significantly high morbidity and mortality. The underlying mechanism of infections has been widely investigated by scientist, while standard wound management is routinely been used in general practice. However, strategies for the diagnosis and treatment of wound infections remain a great challenge due to the occurrence of biofilm colonization, delayed healing and drug resistance. In the present review, we summarize the common microorganisms found in acute and chronic wound infections and discuss the challenges from the aspects of clinical diagnosis, non-surgical methods and surgical methods. Moreover, we highlight emerging innovations in the development of antimicrobial peptides, phages, controlled drug delivery, wound dressing materials and herbal medicine, and find that sensitive diagnostics, combined treatment and skin microbiome regulation could be future directions in the treatment of wound infection.

The impact of the length of total and intravenous systemic antibiotic therapy for the remission of diabetic foot infections

OBJECTIVE

We investigated the impact of the total length of systemic antibiotic therapy (ABT) and its initial intravenous (IV) part on clinical failure (CF) and microbiological failure (MF) in diabetic foot infections (DFIs).

METHODS

In this single-center, retrospective, unmatched case-control study, we included DFI episodes treated with a combined surgical-antibiotic approach.

RESULTS

We included 721 DFI episodes, 537 with osteomyelitis (DFO). CF occurred in 191 (26.5%) and MF in 42 (5.8%) episodes. Multivariate Cox regression analysis showed that a short ABT of 8-21 days (hazard ratio [HR] 0.4; 95% CI 0.2-0.7) was inversely associated with CF. This was also applicable for IV ABT with relatively short durations of 2-7 days (HR 0.5; 95% CI 0.3-0.8) or 8-14 days (HR 0.6; 95% CI 0.4-0.9). We failed to detect a minimal threshold of total or IV ABT predictive for CF or MF.

CONCLUSIONS

Compared with total ABT of more than 84 days and IV therapy of more than 14 days, shorter total and IV ABT yielded no enhanced risk of CF or MF. Considering the "bias by indication" that is inherent to retrospective DFI studies, the best study design concerning the duration of ABT would be a stratified, prospective randomized trial, which is currently under way in our medical center.

Short and oral antimicrobial therapy for diabetic foot infection: a narrative review of current knowledge

Diabetic foot infection is a frequent complication in long-standing diabetes mellitus. For antimicrobial therapy of this infection, both the optimal duration and the route of administration are often based more on expert opinion than on published evidence. We reviewed the scientific literature, specifically seeking prospective trials, and aimed at addressing two clinical issues: (1) shortening the currently recommended antibiotic duration and (2) using oral (rather than parenteral) therapy, especially after the patient has undergone debridement and revascularization. We also reviewed some older key articles that are critical to our understanding of the treatment of these infections, particularly with respect to diabetic foot osteomyelitis. Our conclusion is that the maximum duration of antibiotic therapy for osteomyelitis should be no more than to 4-6 weeks and might even be shorter in selected cases. In the future, in addition to conducting randomized trials and propagating national and international guidance, we should also explore innovative strategies, such as intraosseous antibiotic agents and bacteriophages.

Bacteriological Profile and Antibiotic Susceptibility Pattern of Diabetic Foot Infection in a Tertiary Care Hospital in Lampung, Indonesia

Background

Diabetic foot infection (DFI) is a serious complication of diabetes mellitus and identification of the causative bacteria is an essential step in selecting the appropriate antibiotic therapy. This study aimed to evaluate the bacterial pattern and antibiotic susceptibility of the bacteria causing DFI in Lampung Province in Indonesia.

Methods

This study is a retrospective study reviewing the medical records of DFI patients admitted to the Dr Hi Abdul Moeloek Regional General Hospital in 2017–2019. DFI patients with complete medical record data were included in this study. Demographic, clinical, laboratory, wound culture and antibiotic susceptibility data were collected from the medical records using a short structural chart. The data obtained then reviewed.

Results

In this study, 131 DFI patients met the study criteria and were included. Based on the wound culture results, Gram-negative bacteria were obtained in 112 (85.5%) subjects with Enterobacter spp. as the predominant bacteria. Gram-positive bacteria were found in 19 (14.5%) subjects with Staphylococcus spp. as the predominant bacteria. Gram-negative bacteria found in this study showed high susceptibility to amikacin, meropenem and sulbactam/cefoperazone. Meanwhile, the Gram-positive bacteria showed high susceptibility to meropenem, sulbactam/cefoperazone and amikacin.

Conclusion

The findings of the study revealed Enterobacter spp. as the most predominant bacteria causing DFI in the studied population. The highest antibiotic susceptibility was seen for amikacin, meropenem and sulbactam/cefoperazone.

Diabetic Foot Ulcer Infections and Pseudomonas aeruginosa Biofilm Production During the COVID-19 Pandemic

During the different waves of the coronavirus (COVID-19) pandemic, there has been an increased incidence of diabetes mellitus and diabetic foot infections. Among gram-negative bacteria, Pseudomonas aeruginosa is the predominant causative agent for diabetic foot ulcer infections in low-resource countries. P. aeruginosa possesses a variety of virulence factors, including biofilm formation. Biofilm formation is an important benchmark characteristic in the pathophysiology of diabetic foot ulceration. The main objective of the current study was to identify the most commonly isolated organisms and their antibiotic susceptibility patterns in diabetic foot patients during the COVID-19 pandemic. We also determined the genes associated with bacterial persistence and biofilm formation in the predominantly isolated organism. Accordingly, 100 wound swab samples were collected from diabetic foot patients from different hospitals in Alexandria, Egypt. Through phenotypic detection of biofilm formation, 93% (40) of the 43 P. aeruginosa isolates examined were categorized as biofilm producers. Molecular detection of the biofilm-encoding genes among the 43 P. aeruginosa isolates was as follows: algD (100%), pelF (88%) and pslD (49.7%), and this highlights a need for biofilm formation inhibitors to prevent the persistence of bacterial pathogens, and thus achieve better clinical outcomes in diabetic foot ulcer infections.

Microbial Infection and Antibiotic Susceptibility of Diabetic Foot Ulcer in China: Literature Review

OBJECTIVE

To investigate the microbial spectrum isolated from foot ulcers among diabetic patients in China, which was conducted to help clinicians choose optimal antibiotics empirically.

METHOD

The PubMed, MEDLINE, Web of Science, China Biology Medicine (CBM), China National Knowledge Infrastructure (CNKI), WanFang, and VIP databases were searched for studies published between 2015 to 2019, that report primary data on diabetic foot infection (DFI) and antibiotic susceptibility in China.

RESULT

A total of 63 articles about DFI and antibiotic susceptibility tests among diabetic patients in China were included. There were 11,483 patients with an average age of 60.2 ± 10.1 years and a mean course of 10.6 ± 5.0 years between 2010 and 2019, covering most geographical regions of China. The prevalence of Gram-positive (GP) bacteria (43.4%) was lower than that of Gram-negative (GN) (52.4%). The most prevalent pathogens isolated were Staphylococcus aureus (17.7%), Escherichia coli (10.9%), Pseudomonas aeruginosa (10.5%), Klebsiella pneumoniae (6.2%), Staphylococcus epidermidis (5.3%), Enterococcus faecalis (4.9%), and fungus (3.7%). The prevalence of polymicrobial infection was 22.8%. GP bacteria were sensitive to linezolid, vancomycin, and teicoplanin. More than 50% of GN bacteria were resistant to third-generation cephalosporins, while the resistance rates of piperacillin/tazobactam, amikacin, meropenem, and imipenem were relatively low. Among the 6017 strains of the isolated organisms, 20% had multi-drug resistance (MDR). Staphylococcus aureus (30.4%) was the most predominant MDR bacteria, followed by extended-spectrum β-lactamase (ESBL) (19.1%).

CONCLUSION

The microbial infection of foot ulcers among diabetic patients in China is diverse. The microbial spectrum is different in different geographic regions and Staphylococcus aureus is the predominant bacteria. Polymicrobial and MDR bacterial infections on the foot ulcers are common. This study could be valuable in guiding the empirical use of antibiotics for diabetic foot infections.

The association of chronic, enhanced immunosuppression with outcomes of diabetic foot infections

We investigated if a chronic, enhanced immunosuppressed condition, beyond the immunodeficiency related to diabetes, is associated with clinical failures after combined surgical and medical treatment for diabetic foot infection (DFI). This is a case-control cohort study in a tertiary centre for diabetic foot problems, using case-mix adjustments with multivariate Cox regression models. Among 1013 DFI episodes in 586 patients (median age 67 years; 882 with osteomyelitis), we identified a chronic, enhanced immune-suppression condition in 388 (38%) cases: dialysis (85), solid organ transplantation (25), immune-suppressive medication (70), cirrhosis (9), cancer chemotherapy (15) and alcohol abuse (243). Overall, 255 treatment episodes failed (25%). By multivariate analysis, the presence (as compared with absence) of chronic, enhanced immune-suppression was associated with a higher rate of clinical failures in DFI cases (hazard ratio 1.5, 95% confidence interval 1.1-2.0). We conclude that a chronic, enhanced immune-suppressed state might be an independent risk factor for treatment failure in DFI. Validation of this hypothesis could be useful information for both affected patients and their treating clinicians.

Methylene Blue-Based Nano and Microparticles: Fabrication and Applications in Photodynamic Therapy

Methylene blue (MB) has been used in the textile industry since it was first extracted by the German chemist Heinrich Caro. Its pharmacological properties have also been applied toward the treatment of certain diseases such as methemoglobinemia, ifosfamide-induced encephalopathy, and thyroid conditions requiring surgery. Recently, the utilization of MB as a safe photosensitizer in photodynamic therapy (PDT) has received attention. Recent findings demonstrate that photoactivated MB exhibits not only anticancer activity but also antibacterial activity both in vitro and in vivo. However, due to the hydrophilic nature of MB, it is difficult to create MB-embedded nano- or microparticles capable of increasing the clinical efficacy of the PDT. This review aims to summarize fabrication techniques for MB-embedded nano and microparticles and to provide both in vitro and in vivo examples of MB-mediated PDT, thereby offering a future perspective on improving this promising clinical treatment modality. We also address examples of MB-mediated PDT in both cancer and infection treatments. Both in-vitro and in-vivo studies are summarized here to document recent trends in utilizing MB as an effective photosensitizer in PDT. Lastly, we discuss how developing efficient MB-carrying nano- and microparticle platforms would be able to increase the benefits of PDT.

The Influence of Multidrug-Resistant Bacteria on Clinical Outcomes of Diabetic Foot Ulcers: A Systematic Review

Multidrug-resistant organism infections have become important in recent years due to the increased prevalence of diabetic foot ulcers and their possible consequences. This study aimed to systematically review and evaluate ulcer duration, healing time, hospital stay, amputation, and mortality rates in patients with diabetic foot ulcers caused by infection with multidrug-resistant organisms. PubMed, the Cochrane Library, and Web of Science were searched in May 2020 to find observational studies in English about the clinical outcomes of multidrug-resistant organism infection in diabetic foot ulcers. Eight studies met the inclusion criteria, and these studies included 923 patients. The overall methodological quality of the study was moderate. Ulcer duration was described in six studies, and there was no practical association with multidrug-resistant organisms. Two out of three studies reported a longer healing time in multidrug-resistant organism infections than in non-multidrug-resistant organism infections. Clinical outcomes included the duration of hospitalisation, surgeries, amputations, and deaths. Lower limb amputation was the most reported clinical outcome in the included studies, and was more prevalent in the multidrug-resistant organism infections. We concluded that there was not enough evidence that multidrug-resistant organisms hindered the healing of diabetic foot ulcers. In contrast to the clinical outcomes, multidrug-resistant organisms affect both amputation rates and mortality rates.

How good are clinicians in predicting the presence of Pseudomonas spp. in diabetic foot infections? A prospective clinical evaluation

Introduction

The most frequently prescribed empirical antibiotic agents for mild and moderate diabetic foot infections (DFIs) are amino-penicillins and second-generation cephalosporins that do not cover Pseudomonas spp. Many clinicians believe they can predict the involvement of Pseudomonas in a DFI by visual and/or olfactory clues, but no data support this assertion.

Methods

In this prospective observational study, we separately asked 13 experienced (median 11 years) healthcare workers whether they thought the Pseudomonas spp. would be implicated in the DFI. Their predictions were compared with the results of cultures of deep/intraoperative specimens and/or the clinical remission of DFI achieved with antibiotic agents that did not cover Pseudomonas.

Results

Among 221 DFI episodes in 88 individual patients, intraoperative tissue cultures grew Pseudomonas in 22 cases (10%, including six bone samples). The presence of Pseudomonas was correctly predicted with a sensitivity of 0.32, specificity of 0.84, positive predictive value of 0.18 and negative predictive value 0.92. Despite two feedbacks of the interim results and a 2-year period, the clinicians' predictive performance did not improve.

Conclusion

The combined visual and olfactory performance of experienced clinicians in predicting the presence of Pseudomonas in a DFI was moderate, with better specificity than sensitivity, and did not improve over time. Further investigations are needed to determine whether clinicians should use a negative prediction of the presence of Pseudomonas in a DFI, especially in settings with a high prevalence of pseudomonal DFIs.

A multiomics approach to identify host-microbe alterations associated with infection severity in diabetic foot infections: a pilot study

Diabetic foot infections (DFIs) are a major cause of hospitalization and can lead to lower extremity amputation. In this pilot study, we used a multiomics approach to explore the host–microbe complex within DFIs. We observed minimal differences in the overall microbial composition between PEDIS infection severities, however Staphylococcus aureus and Streptococcus genera were abundant and highly active in most mild to moderate DFIs. Further, we identified the significant enrichment of several virulence factors associated with infection pathogenicity belonging to both Staphylococcus aureus and Streptococcus. In severe DFIs, patients demonstrated a greater microbial diversity and differential gene expression demonstrated the enrichment of multispecies virulence genes suggestive of a complex polymicrobial infection. The host response in patients with severe DFIs was also significantly different as compared to mild to moderate DFIs. This was attributed to the enrichment of host genes associated with inflammation, acute phase response, cell stress and broad immune-related responses, while those associated with wound healing and myogenesis were significantly depleted.

Escherichia coli Isolated from Diabetic Foot Osteomyelitis: Clonal Diversity, Resistance Profile, Virulence Potential, and Genome Adaptation

This study assessed the clonal diversity, the resistance profile and the virulence potential of Escherichia coli strains isolated from diabetic foot infection (DFI) and diabetic foot osteomyelitis (DFOM). A retrospective single-centre study was conducted on patients diagnosed with E. coli isolated from deep DFI and DFOM at Clinique du Pied Diabétique Gard-Occitanie (France) over a two-year period. Phylogenetic backgrounds, virulence factors (VFs) and antibiotic resistance profiles were determined. Whole-genome analysis of E. coli strains isolated from same patients at different periods were performed. From the two-years study period, 35 E. coli strains isolated from 33 patients were analysed; 73% were isolated from DFOM. The majority of the strains belonged to the virulent B2 and D phylogenetic groups (82%). These isolates exhibited a significant higher average of VFs number than strains belonging to other groups (p < 0.001). papG2 gene was significantly more detected in strains belonging to B2 phylogroup isolated from DFI compared to DFOM (p = 0.003). The most prevalent antibiotic resistance pattern was observed for ampicillin (82%), cotrimoxazole (45%), and ciprofloxacin (33%). The genome analysis of strains isolated at two periods in DFOM showed a decrease of the genome size, and this decrease was more important for the strain isolated at nine months (vs. four months). A shared mutation on the putative acyl-CoA dehydrogenase-encoding gene aidB was observed on both strains. E. coli isolates from DFOM were highly genetically diverse with different pathogenicity traits. Their adaptation in the bone structure could require genome reduction and some important modifications in the balance virulence/resistance of the bacteria.

Is routine measurement of the serum C-reactive protein level helpful during antibiotic therapy for diabetic foot infection?

Clinicians frequently monitor serum C-reactive protein (CRP) levels during therapy for diabetic foot infections (DFIs), but evidence supporting this is unclear. Using a database from prospective controlled DFI trials, with fixed duration of antibiotic therapy, we correlated the CRP levels at study enrolment and at end of therapy (EOT). Among 159 DFI episodes, 93 involved the bone and 66 the soft tissues. Overall, treatment cured 122 infections (77%), while 37 episodes (23%) recurred after a median of 53 days. The median CRP in the groups with cure versus failure differed minimally at enrolment (median 67 vs. 81 mg/L) or EOT (7 vs. 10 mg/L). Similarly, there was negligible difference in the percentage of CRP levels that normalized at EOT (39% vs. 35%). In our prospective cohorts, a blunt iterative monitoring of CRP during DFI treatment, without correlation with clinical findings, failed to predict treatment failures.

Diabetic foot infection and osteomyelitis. Are deep-tissue cultures necessary?

Introduction

Diabetic foot infections (DFIs) are common and difficult to treat. The objective of this study was to compare swab and tissue cultures as indicators of appropriate treatment of DFIs.

Methods

This is a prospective study conducted during a 4-year period. All patients with DFIs and/or diabetic foot osteomyelitis (DFO) admitted to the University Hospital of Heraklion, Greece, were included. Clinical data were collected, while cultures taken with swabs and/or tissue biopsies were used as indicators of the microbiological cause and the appropriate treatment.

Results

In total, 83 individuals (62.7% males) with mean age of 72 years, were enrolled. Coexisting osteomyelitis was present in 18.1%. From tissue and pus cultures, 131 and 176 pathogens, respectively, were isolated. Gram-positive aerobes were the most common microorganisms, followed by Gram-negatives. Infection was polymicrobial in 40 (70.2%) out of 57 patients with tissue culture and in 54 (75.0%) out of 72 with pus culture. Microbiological results from tissue cultures were compatible with those from pus at a rate of 80%, while in cases of osteomyelitis concordance reached 100%. Multidrug-resistant organisms (MDROs) were isolated from 32 (24.4%) tissue and 44 (25%) pus cultures (p=0.910). Initial empirical antimicrobial treatment was considered inappropriate in 44.6% of cases.

Conclusions

A high concordance between easily taken swab cultures and those taken by biopsy was noted, especially in DFO. This was helpful for early change to appropriate treatment in cases where MDROs were isolated and empirical treatment was inappropriate. Further research is needed to confirm this observation in clinical practice.

Gram-Negative Skin and Soft Tissue Infections

Skin and soft tissue infections (SSTIs) frequently are encountered in clinical practice, and gram-negative bacilli (GNB) constitute an underrated portion of their etiology. The rate of GNB-causing SSTIs is increasing, especially with the rise in antimicrobial resistance. Although the diagnosis of SSTIs mostly is clinical, rapid diagnostic modalities can shorten the time to initiating proper therapy and improving outcomes. Novel antibiotics are active against GNB SSTIs and can be of great value in the management. This review provides an overview of the role of GNB in SSTIs and summarizes their epidemiology, risk factors, outcome, and clinical management.

Three versus six weeks of antibiotic therapy for diabetic foot osteomyelitis: A prospective, randomized, non-inferiority pilot trial

BACKGROUND

In patients with diabetic foot osteomyelitis (DFO) who underwent surgical debridement, we investigated whether a short (3 weeks), compared with a long (6 weeks) duration of systemic antibiotic treatment is associated with non-inferior results for clinical remission and adverse events (AE).

METHODS

In this prospective, randomized, non-inferiority, pilot trial, we randomized (allocation 1:1), patients with DFO after surgical debridement to either a 3-week or a 6-week course of antibiotic therapy. The minimal duration of follow-up after end of therapy was two months. We compared outcomes using Cox regression and non-inferiority analyses (25% margin, power 80%).

RESULTS

Among 93 enrolled patients (18% females; median age 65 years), 44 were randomized to the 3-week arm and 49 to the 6-week arm. The median number of surgical debridement was 1 (range, 0-2 interventions). In the intention-to-treat (ITT) population, remission occurred in 37 (84%) of the patients in the 3-week arm compared to 36 (73%) in the 6-week arm (p=0.21). The number of AE was similar in the two study arms (17/44 vs. 16/49; p=0.51), as were the remission incidences in the per-protocol (PP) population (33/39 vs. 32/43; p=0.26). In multivariate analysis, treatment with the shorter antibiotic course was not significantly associated with remission (for the ITT population, hazard ratio 1.1, 95%CI 0.6-1.7; for the PP population hazard ratio 0.8, 95%CI 0.5-1.4).

CONCLUSIONS

In this randomized, controlled pilot trial, a post-debridement systemic antibiotic therapy course for DFO of 3-weeks gave similar (and statistically non-inferior) incidences of remission and AE to a course of 6 weeks.

The Association between Cognitive Impairment and Diabetic Foot Care: Role of Neuropathy and Glycated Hemoglobin

Diabetes mellitus is associated with impairment in cognitive functions which can complicate adherence to self-care behaviors. We evaluated the incidence of cognitive impairment in patients with diabetes mellitus to determine the strength of the association between diabetic foot (a complication that occurs in about 10% of diabetic patients), adherence to the clinician’s recommendations, glycemic control, and cognitive function. A prospective study was carried out in a probabilistic sample of older patients with diabetic foot living in three nursing homes. Cognitive functions were evaluated by the MMSE (Mini-Mental State Examination), the Trail Making test (TMT), and the Michigan neuropathy screening instrument (MNSI). There were no significant associations between cognitive function and neuropathy or foot alterations, although glycated hemoglobin (HB1Ac > 7%) significantly (p < 0.05) associated with MMSE and adherence to treatment in the 1 month follow-up visit. Receiver operating characteristic curve analysis showed that both HB1Ac and the MNSI score significantly (p < 0.05) discriminate subsequent adherence to treatment for foot complication, with a sensitivity of 80.0–73.3% and specificity 70.6–64.7%, respectively. Proper control of foot complications in diabetic patients involves appropriate glycemic control and less severe neuropathy, and seems to be unrelated to cognitive dysfunction, and warrants further studies in order to tailor appropriate treatments to central and peripheral nervous system disorders. Poor glycemic control (Hb1Ac level > 7%) and a neuropathy score of 5.5 in the MNSI are the best-cut off points to discriminate poor adherence to the clinician’s recommendations for self-care behaviors in people with diabetic foot complication. In this study, we observed that foot disorders were associated with impaired global cognitive function in elderly patients (aged ≥ 65). Podiatrists and physicians should consider cognitive dysfunction as an important chronic complication in the management of diabetic foot.

Microbiologic characteristics and antibiotic resistance rates of diabetic foot infections

PURPOSE

the purpose of this research was to identify the sociodemographic and microbiological characteristics and antibiotic resistance rates of patients with diabetic foot infections, hospitalized in an emergency reference center.

METHODS

it was an observational and transversal study. The sociodemographic data were collected by direct interview with the patients. During the surgical procedures, specimens of tissue of the infected foot lesions were biopsied to be cultured, and for bacterial resistance analysis.

RESULTS

the sample consisted of 105 patients. The majority of patierns were men, over 50 years of age, married and with low educational level. There was bacterial growth in 95 of the 105 tissue cultures. In each positive culture only one germ was isolated. There was a high prevalence of germs of the Enterobacteriaceae family (51,5%). Gram-negative germs were isolated in 60% of cultures and the most individually isolated germs were the Gram-positive cocci, Staphylococcus aureus (20%) and Enterococcus faecalis (17,9%). Regarding antibiotic resistance rates, a high frequency of Staphylococcus aureus resistant to methicillin (63,0%) and to ciprofloxacin (55,5%) was found; additionally, 43,5% of the Gram-negative isolated germs were resistant to ciprofloxacin.

CONCLUSIONS

the majority of patients were men, over 50 years of age, married and with low educational level. The most prevalent isolated germs from the infected foot lesions were Gram-negative bacteria, resistant to ciprofloxacin, and the individually most isolated germ was the methicillin resistant Staphylococcus aureus.

[Treatment of diabetic foot with vaccum sealing drainage combined with transverse tibial bone transport]

OBJECTIVE

To summarize the effectiveness and experience of Wanger grade 3-5 diabetic foot treated with vacuum sealing drainage (VSD) combined with transverse tibial bone transport.

METHODS

Between March 2015 and January 2018, 21 patients with refractory diabetic foot who failed conservative treatment were treated with VSD combined with transverse tibial bone transport. There were 15 males and 6 females, aged 55-88 years (mean, 65 years). The diabetes history was 8-15 years (mean, 12.2 years). The duration of diabetic foot ranged from 7 to 84 days (mean, 35.3 days). The size of diabetic foot ulcer before operation ranged from 2 cm×2 cm to 8 cm×5 cm. According to Wanger classification, 8 cases were rated as grade 3, 11 cases as grade 4, and 2 cases as grade 5. Among the 21 cases, angiography of lower extremity before operation was performed in 5 cases, CT angiography of lower extremity in 16 cases, all of which indicated that the arteries below the knee were narrowed to varying degrees and not completely blocked. Preoperative foot skin temperature was (29.28±0.77)℃, C-reactive protein was (38.03±31.23) mg/L, leukocyte count was (9.44±2.21)×10 9/L, and the visual analogue scale (VAS) score was 6.8±1.5, and ability of daily living (Barthel index) was 54.3±10.3.

RESULTS

After operation, 2 patients with Wanger grade 4 and smoking history failed treatment and had an major amputation (amputation above ankle joint) at 30 days and 45 days after operation, respectively. One patient with Wanger grade 5 and chronic heart failure died of cardiac arrest at 60 days after operation. The remaining 18 patients were followed up 6-24 months (mean, 9.2 months). The external fixator was removed at 40-62 days after operation, with an average of 46 days. All the wounds healed, with a healing time of 50-120 days (mean, 62.5 days). The pain of 18 patients' feet was relieved obviously, and there was no recurrence of ulcer in situ or other parts. There was no complication such as tibial fracture and ischemic necrosis of lower leg skin after operation. After ulcer healing, the foot skin temperature was (30.86±0.80)℃, C-reactive protein was (22.90±18.42) mg/L, VAS score was 2.4±1.2, and Barthel index was 77.3±4.6, all showing significant differences when compared with preoperative ones ( P<0.05); the leukocyte count was (8.91±1.72)×10 9/L, showing no significant difference ( t=1.090, P=0.291).

CONCLUSION

VSD combined with transverse tibial bone transport can effectively promote the healing of Wanger grade 3-5 diabetic foot wounds, but smokers, unstable blood glucose control, and chronic heart failure patients have the risk of failure.

Principles and practice of antibiotic stewardship in the management of diabetic foot infections

PURPOSE OF REVIEW

Systemic antibiotic therapy in persons with a diabetic foot infection (DFI) is frequent, increasing the risk of promoting resistance to common pathogens. Applying principles of antibiotic stewardship may help avoid this problem.

RECENT FINDINGS

We performed a systematic review of the literature, especially seeking recently published studies, for data on the role and value of antibiotic stewardship (especially reducing the spectrum and duration of antibiotic therapy) in community and hospital populations of persons with a DFI.

SUMMARY

We found very few publications specifically concerning antibiotic stewardship in persons with a DFI. The case-mix of these patients is substantial and infection plays only one part among several chronic problems. As with other types of infections, attempting to prevent infections and avoiding or reducing the spectrum and duration of antibiotic therapy are perhaps the best ways to reduce antibiotic prescribing in the DFI population. The field is complex and necessitates knowledge over the current scientific literature and clinical experience. On a larger scale, clinical pathways, guidelines, and recommendations are additionally supportive.

A novel intraoperative technique seeding morselized bone tissue into pediatric blood culture bottles improves microbiological diagnosis in patients with foot and ankle osteomyelitis

BACKGROUND

Osteomyelitis, particularly cases involving the foot and ankle, is a challenging situation that frequently leads to amputations and major sequelae. Targeted antibiotics treating an identified pathogen are key to a successful outcome; however, traditional culture methods for bone tissue have poor sensitivity. This study prospectively compared a novel method for obtaining and processing infected bone tissue with the standard technique.

METHODS

107 patients presenting with a diagnosis of osteomyelitis of the foot and ankle between 2008 and 2017 were prospectively included. Diagnosis was done according to clinical, laboratory and imaging findings. We obtained paired samples of bone tissue from all patients; they were processed through a usual culture method (UCM), but they were also morselized and seeded into pediatric blood culture bottles (PBCBs). We compared the culture yield and the number of agents detected using both the McNemar and the Mann-Whitney tests, respectively.

RESULTS

We studied 107 patients (63 with diabetic foot infection and 44 with nondiabetic osteomyelitis). The causative agent was identified in 60.7% of cases using the UCM and in 97.2% of cases using PBCBs (p < 0.001). We detected a mean of 1.05 ± 1.03 bacteria using the UCM and 1.67 ± 0.92 bacteria using PBCBs (p < 0.01).

CONCLUSION

Cultures using morselized bone seeded in PBCBs identified the causative agent in a significantly larger percentage than the UCM. Additionally, this method identified a larger number of pathogen agents. A better agent identification method has advantages such as identifying more specific antibiotic treatment in these cases.

Management of diabetic foot infections in the light of recent literature and new international guidelines

Introduction: In May 2019 the International Working Group on the Diabetic Foot (IWGDF) launched their quadrennially updated guidelines on the management of diabetic foot infections (DFIs). Concomitantly, the number of new publications regarding DFI increased.Areas covered: The IWGDF committee developed and addressed key questions and produced evidence-based recommendations related to diagnosing and treating DFIs. This narrative review provides an overview of this new guideline and also of other recently published literature in the field of DFIs.Expert opinion: The 2019 IWGDF guidelines provide an authoritative, international, evidence-based approach to diagnosing and treating DFIs. The 27 recommendations are supported by systematic reviews of both diagnosis and interventions. Our review of this guideline, along with other recent publications in the field, allows us to offer state-of-the-art guidance for caring for these difficult infections. As the evidence base for management of DFIs remains suboptimal, we need further research to improve the management of DFIs.

Antimicrobial stewardship opportunities among inpatients with diabetic foot infections: microbiology results from a tertiary hospital multidisciplinary unit

Among 125 inpatients with diabetic foot infections managed by a multidisciplinary foot ulcer unit, knowledge of methicillin-resistant Staphylococcus aureus colonisation status assisted decision-making to prescribe appropriately or with-hold empiric anti-methicillin-resistant Staphylococcus aureus therapy. Despite adherence to national guidelines, apparent overuse of anti-pseudomonal therapy was frequent, providing potential antimicrobial stewardship opportunities.

Cost of Diabetic Foot Ulcer Management in China: A 7-Year Single-Center Retrospective Review

BACKGROUND

The cost of care for diabetic foot ulcers has became a global economic burden. The study aimed to analyze diabetic foot ulcer cost changes over time and to identify factors associated with these variables, so as to strengthen and improve the management of diabetic foot ulcers.

METHODS

We retrospectively analyzed the data in the electronic medical record system of our wound treatment center. The homepage of the system was queried using the national clinical version 2.0 disease diagnosis code (ICD-10), the data of patient's basic information were exported. Through the statistics and analysis of these data, the socioeconomic changes and possible risk factors of diabetic foot ulcers management in recent years were obtained.

RESULTS

There were 3654 patients included in the study, an average of 522 per year. The total cost per patient increased from ¥15,535.58 in 2014 to ¥42,040.60 in 2020, with an average of ¥21,826.91. The average length of stay between 14.29 days and 31.4 days from 2014 to 2020, with an average of 18.10 days. Besides, the average incidence of peripheral arterial disease in diabetic foot ulcers patients admitted was as high as 81.9%, and the average amputation rate was 9.9%. The study reflected the total cost and length of stay of diabetic foot patients increased significantly from 2014 to 2020, which were related to age (>85 years), gender (male), peripheral arterial disease, amputation (P < 0.05).

CONCLUSION

A heavy cost from diabetic foot ulcers and its complications was significantly increased yearly, which was related to older age, co-morbidity, amputation and duration of hospitalization. The prevention and treatment of diabetic foot ulcers have a long way to go, early comprehensive prevention and multi-disciplinary cooperation may still be an effective way.

Monitoring of external predisposing factors for Diabetic Foot: A literature review and physicians' perspectives

Background: Diabetic foot is one of the most important complications of diabetes caused by the existence of some destructive factors in different anatomical locations of feet. Management and monitoring of these factors are very important to decrease or avoid ulcerating lesions of the foot. The purpose of this study is to identify and introduce the predisposing factors and anatomical locations associated with these destructive factors. Methods: First, we conducted a comprehensive review of different databases to identify the factors and associated anatomical locations from the previous studies. Then, we designed a questionnaire and invited physicians and specialists to express their perspectives on these factors and locations. The data were analyzed using SPSS version 23. Frequency, percentage, mean and standard deviation of these variables were calculated. Results: Based on the literature review, four factors, including pressure, moisture and sweat, temperature, and acceleration were identified as factors destructive to the tissues of the diabetic foot and worsen ulcers. The view of specialists approved the results of the literature review. Besides, there was an insignificant difference between the results of the literature review and the specialists' view in terms of anatomical locations that need to be continuously monitored. Conclusion: Monitoring the pressure in heel, first metatarsal, and first metatarsal head; moisture and sweat under the fingers, hallux and heels as well as the temperature at the first metatarsal, first metatarsal head, and the third metatarsal head are important in preventing ulceration, destructing the foot tissue, and accelerating the treatment process.

Changing perioperative prophylaxis during antibiotic therapy and iterative debridement for orthopedic infections?

Background

Perioperative antibiotic prophylaxis in non-infected orthopedic surgery is evident, in contrast to prophylaxis during surgery for infection. Epidemiological data are lacking for this particular situation.

Methods and findings

It is a single-center cohort on iterative surgical site infections (SSIs) in infected orthopedic patients. We included 2480 first episodes of orthopedic infections (median age 56 years and 833 immune-suppressed): implant-related infections (n = 648), osteoarticular infections (1153), and 1327 soft tissue infections. The median number of debridement was 1 (range, 1–15 interventions). Overall, 1617 infections (65%) were debrided once compared to 862 cases that were operated multiple times (35%). Upon iterative intraoperative tissue sampling, we detected pathogens in 507 cases (507/862; 59%), of which 241 (242/507; 48%) corresponded to the initial species at the first debridement. We witnessed 265 new SSIs (11% of the cohort) that were resistant to current antibiotic therapy in 174 cases (7% of the cohort). In multivariate analysis, iterative surgical debridements that were performed under current antibiotic administration were associated with new SSIs (odds ratio 1.6, 95%CI 1.2–2.2); mostly occurring after the 2^nd debridement. However, we failed to define an ideal hypothetic prophylaxis during antibiotic therapy to prevent further SSIs.

Conclusions

Selection of new pathogens resistant to ongoing antibiotic therapy occurs frequently during iterative debridement in orthopedic infections, especially after the 2^nd debridement. The new pathogens are however unpredictable. The prevention, if feasible, probably relies on surgical performance and wise indications for re-debridement instead of new maximal prophylactic antibiotic coverage in addition to current therapeutic regimens.