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Dunyach-Remy C, Ngba Essebe C, Sotto A, Lavigne JP. Staphylococcus aureus Toxins and Diabetic Foot Ulcers: Role in Pathogenesis and Interest in Diagnosis. Toxins (Basel) 2016; 8:toxins8070209. [PMID: 27399775 PMCID: PMC4963842 DOI: 10.3390/toxins8070209] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2016] [Revised: 06/29/2016] [Accepted: 07/01/2016] [Indexed: 12/17/2022] Open
Abstract
Infection of foot ulcers is a common, often severe and costly complication in diabetes. Diabetic foot infections (DFI) are mainly polymicrobial, and Staphylococcus aureus is the most frequent pathogen isolated. The numerous virulence factors and toxins produced by S. aureus during an infection are well characterized. However, some particular features could be observed in DFI. The aim of this review is to describe the role of S. aureus in DFI and the implication of its toxins in the establishment of the infection. Studies on this issue have helped to distinguish two S. aureus populations in DFI: toxinogenic S. aureus strains (harboring exfoliatin-, EDIN-, PVL- or TSST-encoding genes) and non-toxinogenic strains. Toxinogenic strains are often present in infections with a more severe grade and systemic impact, whereas non-toxinogenic strains seem to remain localized in deep structures and bone involving diabetic foot osteomyelitis. Testing the virulence profile of bacteria seems to be a promising way to predict the behavior of S. aureus in the chronic wounds.
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Affiliation(s)
- Catherine Dunyach-Remy
- Institut National de la Santé Et de la Recherche Médicale U1047, Université de Montpellier, UFR de Médecine, Nîmes 30908, France.
- Service de Microbiologie, Centre Hospitalo-Universitaire Carémeau, Nîmes 30029, France.
| | - Christelle Ngba Essebe
- Institut National de la Santé Et de la Recherche Médicale U1047, Université de Montpellier, UFR de Médecine, Nîmes 30908, France.
| | - Albert Sotto
- Institut National de la Santé Et de la Recherche Médicale U1047, Université de Montpellier, UFR de Médecine, Nîmes 30908, France.
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalo-Universitaire Carémeau, Nîmes 30029, France.
| | - Jean-Philippe Lavigne
- Institut National de la Santé Et de la Recherche Médicale U1047, Université de Montpellier, UFR de Médecine, Nîmes 30908, France.
- Service de Microbiologie, Centre Hospitalo-Universitaire Carémeau, Nîmes 30029, France.
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Hatipoglu M, Mutluoglu M, Turhan V, Uzun G, Lipsky BA, Sevim E, Demiraslan H, Eryilmaz E, Ozuguz C, Memis A, Ay H, Arda B, Uysal S, Motor VK, Kader C, Erturk A, Coskun O, Duygu F, Guler S, Altay FA, Ogutlu A, Bolukcu S, Yildiz S, Kandemir O, Aslaner H, Polat A, Karahocagil MK, Yasar KK, Sehmen E, Kilic S, Sunbul M, Gencer S, Bozkurt F, Yanik T, Oztoprak N, Batirel A, Sozen H, Kilic I, Celik I, Ay B, Tosun S, Kadanali A, Çomoglu S, Denk A, Hosoglu S, Aydin O, Elaldi N, Akalin S, Kandemir B, Akbulut A, Demirdal T, Balik R, Azak E, Sengoz G. Causative pathogens and antibiotic resistance in diabetic foot infections: A prospective multi-center study. J Diabetes Complications 2016; 30:910-6. [PMID: 26965794 DOI: 10.1016/j.jdiacomp.2016.02.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 01/27/2016] [Accepted: 02/16/2016] [Indexed: 11/30/2022]
Abstract
AIM Clinical practice guidelines for the management of diabetic foot infections developed by the Infectious Diseases Society of America (IDSA) are commonly used worldwide. The issue of whether or not these guidelines need to be adjusted for local circumstances, however, has seldom been assessed in large prospective trials. METHODS The Turk-DAY trial was a prospective, multi-center study in which infectious disease specialists from centers across Turkey were invited to participate (NCT02026830). RESULTS A total of 35 centers throughout Turkey enrolled patients in the trial. Overall, investigators collected a total of 522 specimens from infected diabetic foot wounds for culture from 447 individual patients. Among all isolates, 36.4% were gram-positive organisms, with Staphylococcus aureus the most common among these (11.4%). Gram-negative organisms constituted 60.2% of all the isolates, and the most commonly isolated gram-negative was Escherichia coli (15%). The sensitivity rates of the isolated species were remarkably low for several antimicrobials used in the mild infection group. CONCLUSIONS Based on our findings, several of the antimicrobials frequently used for empirical treatment, including some also recommended in the IDSA guidelines, would not be optimal for treating diabetic foot infections in Turkey. Although the IDSA guideline recommendations may be helpful to guide empiric antimicrobial therapy of DFIs, they should be adjusted to local conditions.
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Affiliation(s)
- Mustafa Hatipoglu
- Department of Infectious Diseases and Clinical Microbiology, Canakkale Military Hospital, Canakkale, Turkey
| | - Mesut Mutluoglu
- Department of Underwater and Hyperbaric Medicine, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Uskudar, Turkey
| | - Vedat Turhan
- Department of Infectious Diseases and Clinical Microbiology, Gulhane Military Medical Academy Haydarpasa Training Hospital, Istanbul, Turkey
| | - Gunalp Uzun
- Department of Underwater and Hyperbaric Medicine, Gulhane Military Medical Academy, Ankara, Turkey
| | - Benjamin A Lipsky
- Service of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland; Division of Medical Sciences, Green Templeton College, University of Oxford, Oxford, UK
| | - Erol Sevim
- Department of Infectious Diseases and Clinical Microbiology, Sifa University Medical Faculty Izmir, Turkey
| | - Hayati Demiraslan
- Department of Infectious Diseases, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Esma Eryilmaz
- Department of Infectious Diseases, Faculty of Medicine, Erciyes University, Kayseri, Turkey
| | - Cem Ozuguz
- Department of Infectious Diseases and Clinical Microbiology, Eskisehir Military Hospital, Eskisehir, Turkey
| | - Ali Memis
- Department of Underwater and Hyperbaric Medicine, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Uskudar, Turkey
| | - Hakan Ay
- Department of Underwater and Hyperbaric Medicine, Gulhane Military Medical Academy, Haydarpasa Training Hospital, Uskudar, Turkey
| | - Bilgin Arda
- Department of Infectious Diseases and Clinical Microbiology, Ege University School of Medicine, Izmir, Turkey
| | - Serhat Uysal
- Department of Infectious Diseases and Clinical Microbiology, Ege University School of Medicine, Izmir, Turkey
| | - Vicdan Koksaldi Motor
- Department of Infectious Diseases and Clinical Microbiology, Mustafa Kemal University Medical School, Hatay, Turkey
| | - Cigdem Kader
- Department of Infectious Diseases and Clinical Microbiology, Bozok University School of Medicine, Yozgat, Turkey
| | - Ayse Erturk
- Department of Infectious Diseases and Clinical Microbiology, School of Medicine, Recep Tayyip Erdogan University, Rize, Turkey
| | - Omer Coskun
- Department of Infectious Diseases and Clinical Microbiology, Gulhane Medical Academy, Ankara, Turkey
| | - Fazilet Duygu
- Department of Infectious Diseases and Clinical Microbiology, Gaziosmanpasa University Medical School, Tokat, Turkey
| | - Selma Guler
- Department of Infectious Diseases and Clinical Microbiology, Sutcu Imam University, School of Medicine, Kahramanmaras, Turkey
| | - Fatma Aybala Altay
- Department of Infectious Diseases and Clinical Microbiology, Diskapi Yildirim Beyazit Training & Research Hospital, Ankara, Turkey
| | - Aziz Ogutlu
- Department of Infectious Diseases and Clinical Microbiology, Sakarya University School of Medicine, Sakarya, Turkey
| | - Sibel Bolukcu
- Department of Infectious Diseases and Clinical Microbiology, Haydarpasa Numune Training and Research Hospital, Istanbul, Turkey
| | - Senol Yildiz
- Department of Underwater and Hyperbaric Medicine, Gulhane Military Medical Academy, Ankara, Turkey
| | - Ozlem Kandemir
- Department of Infectious Diseases and Clinical Microbiology, Mersin University School of Medicine, Mersin, Turkey
| | - Halide Aslaner
- Department of Infectious Diseases and Clinical Microbiology, Ankara Numune Training and Research Hospital Ankara, Turkey
| | - Arife Polat
- Department of Infectious Diseases and Clinical Microbiology, Ankara Numune Training and Research Hospital Ankara, Turkey
| | - Mustafa K Karahocagil
- Department of Infectious Diseases and Clinical Microbiology, Yuzuncuyil University School of Medicine, Van, Turkey
| | - Kadriye Kart Yasar
- Department of Infectious Diseases and Clinical Microbiology Istanbul Bakırköy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Turkey
| | - Emine Sehmen
- Department of Infectious Diseases and Clinical Microbiology, Samsun Training and Research Hospital Samsun, Turkey
| | - Sirri Kilic
- Department of Infectious Diseases and Clinical Microbiology, Samsun Training and Research Hospital Samsun, Turkey
| | - Mustafa Sunbul
- Department of Infectious Diseases and Clinical Microbiology, Ondokuz Mayis University School of Medicine, Samsun, Turkey
| | - Serap Gencer
- Department of Infectious Diseases and Clinical Microbiology, Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey
| | - Fatma Bozkurt
- Department of Infectious Diseases and Clinical Microbiology, Dicle University School of Medicine, Diyarbakir, Turkey
| | - Tugba Yanik
- Department of Infectious Diseases and Clinical Microbiology, Ondokuz Mayis University School of Medicine, Samsun, Turkey
| | - Nefise Oztoprak
- Department of Infectious Diseases and Clinical Microbiology, Antalya Education and Research Hospital, Antalya, Turkey
| | - Ayse Batirel
- Department of Infectious Diseases and Clinical Microbiology, Dr. Lutfi Kirdar Training and Research Hospital, Istanbul, Turkey
| | - Hamdi Sozen
- Department of Infectious Disease, Faculty of Medicine, Mugla Sitki Kocman University, Mugla, Turkey
| | - Inci Kilic
- Department of Infectious Disease, Education and Research Hospital, Kayseri, Turkey
| | - Ilhami Celik
- Department of Infectious Disease, Education and Research Hospital, Kayseri, Turkey
| | - Bengisu Ay
- Department of Infectious Diseases and Clinical Microbiology, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Selma Tosun
- Department of Infectious Diseases and Clinical Microbiology, Izmir Bozyaka Training and Research Hospital, Izmir, Turkey
| | - Ayten Kadanali
- Department of Infectious Diseases and Clinical Microbiology, Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Senol Çomoglu
- Department of Infectious Diseases and Clinical Microbiology, Umraniye Training and Research Hospital, Istanbul, Turkey
| | - Affan Denk
- Department of Infectious Diseases and Clinical Microbiology, Firat University School of Medicine, Elazig, Turkey
| | - Salih Hosoglu
- Department of Infectious Diseases and Clinical Microbiology, Dicle University School of Medicine, Diyarbakir, Turkey
| | - Ozlem Aydin
- Department of Infectious Diseases and Clinical Microbiology, Medeniyet University, Goztepe Training and Research Hospital, Istanbul, Turkey
| | - Nazif Elaldi
- Department of Infectious Diseases and Clinical Microbiology, Cumhuriyet University Medical School, Sivas, Turkey
| | - Serife Akalin
- Department of Infectious Diseases and Clinical Microbiology, Pamukkale University School of Medicine, Denizli, Turkey
| | - Bahar Kandemir
- Department of Infectious Diseases and Clinical Microbiology, Necmettin Erbakan University, Konya, Turkey
| | - Ayhan Akbulut
- Department of Infectious Diseases and Clinical Microbiology, Firat University School of Medicine, Elazig, Turkey
| | - Tuna Demirdal
- Department of Infectious Diseases and Clinical Microbiology, Ataturk Training and Research Hospital, Izmir Katip Celebi University, Izmir, Turkey
| | - Recep Balik
- Department of Infectious Diseases and Clinical Microbiology, Ataturk Training and Research Hospital, Izmir Katip Celebi University, Izmir, Turkey
| | - Emel Azak
- Department of Infectious Diseases, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Gonul Sengoz
- Department of Infectious Diseases and Clinical Microbiology, Haseki Training and Research Hospital, Istanbul, Turkey
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Abstract
The incidence of diabetes and diabetic foot ulcers is increasing significantly in the United States. These ulcers and infections are the result of long-term complications of diabetes including neuropathy and vascular insufficiency. These infections can be classified into mild, limb threatening, and life threatening. This classification helps clarify the expected organisms involved and consequently appropriate, empiric antibiotic therapy. Mild infections are generally caused by Gram-positive organisms and can usually be treated as an outpatient with oral antibiotics. Antibiotics used for mild infections-include cephalexin, clindamycin, and amoxicillin/ clavulanate. Moderate to severe or limb-threatening infections are usually polymicrobial and frequently require hospitalization. These infections are typically treated with more broad-spectrum antibiotics including ampicillin/sulbactam, imipenem, or the combination of clindamycin and a fluoroquinolone. Severe or life-threatening infections also require broad-spectrum antibiotics. Other therapeutic options besides antibiotics include growth factors, such as becaplermin, and various skin substitutes.
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Affiliation(s)
- Curtis L. Smith
- Sparrow Hospital, Department of Pharmacy, 1215 East Michigan Avenue, Lansing, MI 48912
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Abstract
Infection in the neuroischemic foot can lead to cellulitis, which often progresses to necrosis as a result of septic vasculitis. Therefore, it is important to diagnose infection early. However, the signs and symptoms of infection are diminished in the neuroischemic foot. Microbiological investigation is essential. Severe infection needs intravenous antibiotic therapy and urgent assessment of the need for surgical drainage and debridement. Infected neuroischemic feet need vascular assessment and intervention where appropriate. It is important to maintain strict metabolic control and optimize cardiovascular function. Recent modern approaches based on multi-disciplinary clinics have resulted in improved results in the management of infection in the ischemic diabetic foot.
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Branton F, Cathcart E, Bellamy E. A whole health economy approach to reducing MRSA bacteraemia incidence in diabetic foot ulcer patients. J Infect Prev 2016; 17:108-113. [PMID: 28989465 DOI: 10.1177/1757177416633514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 01/02/2016] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Ulceration of the foot is a common problem among diabetic patients. Infection is a major risk in diabetic foot ulcers (DFU) and many of these are caused by Staphylococcus aureus, in particular meticillin-resistant strains (MRSA). The control and management of MRSA remains a significant challenge and all healthcare organisations in England are required to meet Zero Tolerance Objectives for cases of MRSA bacteraemia (MRSAB). This paper describes a collaborative approach across the health economy to investigate factors contributing to the acquisition of MRSA and MRSAB among DFU patients and make improvements to care to reduce the risk of healthcare-associated infections. METHODS A collaborative approach between acute and community healthcare providers and commissioners was used to conduct Root Cause Analysis and drive improvement to prevent MRSA transmission in DFU patients. RESULTS Screening of all DFU patients was initiated after 6 MRSAB were found to be associated with in DFU. In total 15 patients with the same MRSA antibiogram were identified. Following the implementation of actions focused on isolation, wound management, screening and cleaning no further cases were identified. CONCLUSION This outbreak has demonstrated the value of cross-sector collaboration in investigating HCAI in patients with DFU, improving patient care and reducing the risk of MRSA transmission in these vulnerable patents.
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Affiliation(s)
| | | | - Elaine Bellamy
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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56
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Akhi MT, Ghotaslou R, Memar MY, Asgharzadeh M, Varshochi M, Pirzadeh T, Alizadeh N. Frequency of MRSA in diabetic foot infections. Int J Diabetes Dev Ctries 2016. [DOI: 10.1007/s13410-016-0492-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Smith K, Collier A, Townsend EM, O’Donnell LE, Bal AM, Butcher J, Mackay WG, Ramage G, Williams C. One step closer to understanding the role of bacteria in diabetic foot ulcers: characterising the microbiome of ulcers. BMC Microbiol 2016; 16:54. [PMID: 27005417 PMCID: PMC4804642 DOI: 10.1186/s12866-016-0665-z] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Accepted: 03/07/2016] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The aim of this study was to characterise the microbiome of new and recurrent diabetic foot ulcers using 16S amplicon sequencing (16S AS), allowing the identification of a wider range of bacterial species that may be important in the development of chronicity in these debilitating wounds. Twenty patients not receiving antibiotics for the past three months were selected, with swabs taken from each individual for culture and 16S AS. DNA was isolated using a combination of bead beating and kit extraction. Samples were sequenced on the Illumina Hiseq 2500 platform. RESULTS Conventional laboratory culture showed positive growth from only 55 % of the patients, whereas 16S AS was positive for 75 % of the patients (41 unique genera, representing 82 different operational taxonomic units (OTU's). S. aureus was isolated in 72 % of culture-positive samples, whereas the most commonly detected bacteria in all ulcers were Peptoniphilus spp., Anaerococcus spp. and Corynebacterium spp., with the addition of Staphylococcus spp. in new ulcers. The majority of OTU's residing in both new and recurrent ulcers (over 67 %) were identified as facultative or strict anaerobic Gram-positive organisms. Principal component analysis (PCA) showed no difference in clustering between the two groups (new and recurrent ulcers). CONCLUSIONS The abundance of anaerobic bacteria has important implications for treatment as it suggests that the microbiome of each ulcer "starts afresh" and that, although diverse, are not distinctly different from one another with respect to new or recurrent ulcers. Therefore, when considering antibiotic therapy the duration of current ulceration may be a more important consideration than a history of healed ulcer.
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Affiliation(s)
- Karen Smith
- />School of Health, Nursing and Midwifery, Institute of Healthcare Associated Infection, University of the West of Scotland, Barbour Building, Paisley Campus, Paisley, PA1 2BE UK
| | - Andrew Collier
- />NHS Ayrshire and Arran, University Hospital Ayr, Ayr, UK
| | - Eleanor M. Townsend
- />School of Health, Nursing and Midwifery, Institute of Healthcare Associated Infection, University of the West of Scotland, Barbour Building, Paisley Campus, Paisley, PA1 2BE UK
- />Infection and Immunity Research Group, Glasgow Dental School, School of Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Lindsay E. O’Donnell
- />Infection and Immunity Research Group, Glasgow Dental School, School of Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Abhijit M. Bal
- />NHS Ayrshire and Arran, University Hospital Ayr, Ayr, UK
| | - John Butcher
- />School of Health, Nursing and Midwifery, Institute of Healthcare Associated Infection, University of the West of Scotland, Barbour Building, Paisley Campus, Paisley, PA1 2BE UK
| | - William G. Mackay
- />School of Health, Nursing and Midwifery, Institute of Healthcare Associated Infection, University of the West of Scotland, Barbour Building, Paisley Campus, Paisley, PA1 2BE UK
| | - Gordon Ramage
- />Infection and Immunity Research Group, Glasgow Dental School, School of Medicine, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Craig Williams
- />School of Health, Nursing and Midwifery, Institute of Healthcare Associated Infection, University of the West of Scotland, Barbour Building, Paisley Campus, Paisley, PA1 2BE UK
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CHAUDHRY WAQASNASIR, BADAR RABIA, JAMAL MUHSIN, JEONG JASON, ZAFAR JAMAL, ANDLEEB SAADIA. Clinico-microbiological study and antibiotic resistance profile of mecA and ESBL gene prevalence in patients with diabetic foot infections. Exp Ther Med 2016; 11:1031-1038. [PMID: 26998033 PMCID: PMC4774364 DOI: 10.3892/etm.2016.2996] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 10/13/2015] [Indexed: 12/21/2022] Open
Abstract
Diabetic foot infections (DFIs) constitute a major complication of diabetes mellitus. DFIs contribute to the development of gangrene and non-traumatic lower extremity amputations with a lifetime risk of up to 25%. The aim of the present study was to identify the presence of neuropathy and determine the ulcer grade, microbial profile and phenotypic and genotypic prevalence of the methicillin-resistance gene mecA and extended spectrum β-lactamase (ESBL)-encoding genes in bacterial isolates of DFI in patients registered at the Pakistan Institute of Medical Sciences (Islamabad, Pakistan). The results indicated that 46/50 patients (92%), exhibited sensory neuropathy. The most common isolate was Staphylococcus aureus (25%), followed by Pseudomonas aeruginosa (P. aeruginosa; 18.18%), Escherichia coli (16.16%), Streptococcus species (spp.) (15.15%), Proteus spp. (15.15%), Enterococcus spp. (9%) and Klebsiella pneumoniae (K. pneumoniae; 3%). The prevalence of the mecA gene was found to be 88% phenotypically and 84% genotypically. K. pneumoniae was shown to have the highest percentage of ESBL producers with a prevalence of 66.7% by double disk synergy test, and 100% by the cefotaxime + clavulanic acid/ceftazidime + clavulanic acid combination disk test. P. aeruginosa and K. pneumoniae had the highest (100%) proportion of metallo β-lactamase producers as identified by the EDTA combination disk test. The overall prevalence of β-lactamase (bla)-CTX-M, bla-CTX-M-15, bla-TEM, bla-OXA and bla-SHV genes was found to be 76.9, 76.9, 75.0, 57.7 and 84.6%, respectively, in gram-negative DFI isolates. The prevalence of mecA and ESBL-related genes was found to be alarmingly high in DFIs, since these genes are a major cause of antibiotic treatment failure.
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Affiliation(s)
- WAQAS NASIR CHAUDHRY
- Department of Industrial Biotechnology, Atta-ur-Rahman School of Applied Biosciences, National University of Sciences and Technology, Islamabad 44000, Pakistan
| | - RABIA BADAR
- Department of Industrial Biotechnology, Atta-ur-Rahman School of Applied Biosciences, National University of Sciences and Technology, Islamabad 44000, Pakistan
| | - MUHSIN JAMAL
- Department of Industrial Biotechnology, Atta-ur-Rahman School of Applied Biosciences, National University of Sciences and Technology, Islamabad 44000, Pakistan
| | - JASON JEONG
- Department of Industrial Biotechnology, Atta-ur-Rahman School of Applied Biosciences, National University of Sciences and Technology, Islamabad 44000, Pakistan
| | - JAMAL ZAFAR
- Department of Industrial Biotechnology, Atta-ur-Rahman School of Applied Biosciences, National University of Sciences and Technology, Islamabad 44000, Pakistan
| | - SAADIA ANDLEEB
- Department of Industrial Biotechnology, Atta-ur-Rahman School of Applied Biosciences, National University of Sciences and Technology, Islamabad 44000, Pakistan
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Shahi SK, Kumar A. Isolation and Genetic Analysis of Multidrug Resistant Bacteria from Diabetic Foot Ulcers. Front Microbiol 2016; 6:1464. [PMID: 26779134 PMCID: PMC4700134 DOI: 10.3389/fmicb.2015.01464] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 12/07/2015] [Indexed: 11/13/2022] Open
Abstract
Severe diabetic foot ulcers (DFUs) patients visiting Sir Sunderlal Hospital, Banaras Hindu University, Varanasi, were selected for this study. Bacteria were isolated from swab and deep tissue of 42 patients, for examining their prevalence and antibiotic sensitivity. DFUs of majority of the patients were found infected with Enterococcus spp. (47.61%), Escherichia coli (35.71%), Staphylococcus spp. (33.33%), Alcaligenes spp. (30.95%), Pseudomonas spp. (30.95%), and Stenotrophomonas spp. (30.95%). Antibiotic susceptibility assay of 142 bacteria with 16 antibiotics belonging to eight classes showed the presence of 38 (26.76%) isolates with multidrug resistance (MDR) phenotypes. MDR character appeared to be governed by integrons as class 1 integrons were detected in 26 (68.42%) isolates. Altogether six different arrays of genes (aadA1, aadB, aadAV, dhfrV, dhfrXII, and dhfrXVII) were found within class 1 integron. Gene cassette dhfrAXVII-aadAV (1.6 kb) was present in 12 (3 Gram positive and 9 Gram negative) isolates and was conserved across all the isolates as evident from RFLP analysis. In addition to the presence of class 1 integron, six β-lactamase resistance encoding genes namely bla TEM, bla SHV, bla OXA, bla CTX-M-gp1, bla CTX-M-gp2, and bla CTX-M-gp9 and two methicillin resistance genes namely mecA and femA and vancomycin resistance encoding genes (vanA and vanB) were identified in different isolates. Majority of the MDR isolates were positive for bla TEM (89.47%), bla OXA (52.63%), and bla CTX-M-gp1 (34.21%). To our knowledge, this is the first report of molecular characterization of antibiotic resistance in bacteria isolated from DFUs from North India. In conclusion, findings of this study suggest that class-1 integrons and β-lactamase genes contributed to the MDR in above bacteria.
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Affiliation(s)
- Shailesh K Shahi
- School of Biotechnology, Faculty of Science, Banaras Hindu University Varanasi, India
| | - Ashok Kumar
- School of Biotechnology, Faculty of Science, Banaras Hindu University Varanasi, India
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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: 334] [Impact Index Per Article: 41.8] [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
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61
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Diabetic foot infections: what have we learned in the last 30 years? Int J Infect Dis 2015; 40:81-91. [DOI: 10.1016/j.ijid.2015.09.023] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 09/29/2015] [Accepted: 09/30/2015] [Indexed: 12/21/2022] Open
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62
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Noor S, Zubair M, Ahmad J. Diabetic foot ulcer--A review on pathophysiology, classification and microbial etiology. Diabetes Metab Syndr 2015; 9:192-199. [PMID: 25982677 DOI: 10.1016/j.dsx.2015.04.007] [Citation(s) in RCA: 161] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
As the prevalence of diabetes is increasing globally, secondary complications associated to this endocrinal disorder are also ascending. Diabetic foot ulcers are potentially modifying complications. Disruption of harmony in glucose homeostasis causes hyperglycemic status, results in activation of certain metabolic pathways which in their abnormal state subsequently leads to development of vascular insufficiency, nerve damages headed by ulceration in lower extremity due to plantar pressures and foot deformity. Insult to foot caused by trauma at the affected site goes unnoticeable to patient due to loss of sensation. Among the above mention causes, resistance to infection is also considered as chief modulator of pathophysiological image of diabetic foot lesions. Healing as well as non-healing nature of ulcer relies upon the wound microbial communities and the extent of their pathogenicity. A validated classification system of foot ulcer is primarily necessary for clinicians in management of diabetic foot problems. Another aspect which needs management is proper identification of causative pathogen causing infection. The way of approaches presently employed in the diagnosis for treatment of foot ulcer colonized by different microbes is conventional techniques. Conventional diagnostic methods are widely acceptable since decades. But in recent years newly invented molecular techniques are exploring the use of 16S ribosomal regions specific to prokaryotes in bacterial identification and quantification. Molecular techniques would be a better choice if engaged, in finding the specific species harboring the wound.
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Affiliation(s)
- Saba Noor
- Rajiv Gandhi Centre for Diabetes and Endocrinology, Faculty of Medicine, J.N. Medical College, Aligarh Muslim University, Aligarh, 202002, India.
| | - Mohammad Zubair
- Rajiv Gandhi Centre for Diabetes and Endocrinology, Faculty of Medicine, J.N. Medical College, Aligarh Muslim University, Aligarh, 202002, India.
| | - Jamal Ahmad
- Rajiv Gandhi Centre for Diabetes and Endocrinology, Faculty of Medicine, J.N. Medical College, Aligarh Muslim University, Aligarh, 202002, India.
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Cervantes-García E, García-González R, Reséndiz-Albor A, Salazar-Schettino PM. Infections of Diabetic Foot Ulcers With Methicillin-Resistant Staphylococcus aureus. INT J LOW EXTR WOUND 2015; 14:44-9. [DOI: 10.1177/1534734614564053] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Infected diabetic foot is the most common reason for hospitalization and complications in patients with type 2 diabetes mellitus (DM2). Methicillin-resistant Staphylococcus aureus (MRSA) is frequently isolated from such lesions, and its presence is growing, seriously deteriorating the infected patient’s quality of life. The aim of this study was to assess the prevalence of MRSA as well as other microbiota in 100 patients diagnosed with (DM2) and with infected foot ulcers at the Hospital General de Mexico. The main results obtained show a prevalence of Staphylococcus aureus (42%), followed by Escherichia coli (36%) and, in lower percentages, other bacteria. MRSA was predominant (34%), and we conclude that the use of cefoxitin instead of oxacillin as the first-choice antibiotic has an advantage because it is a better inducer of methicillin-resistance expression.
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Zenelaj B, Bouvet C, Lipsky BA, Uçkay I. Do Diabetic Foot Infections With Methicillin-Resistant Staphylococcus aureus Differ From Those With Other Pathogens? INT J LOW EXTR WOUND 2014; 13:263-72. [DOI: 10.1177/1534734614550311] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
There is controversy as to whether or not diabetic foot infections (DFIs) caused by methicillin-resistant Staphylococcus aureus (MRSA) are associated with worse outcomes than DFIs caused by other pathogens. To address this issue we performed a nonsystematic literature search of published articles in English language journals seeking studies reporting on the outcomes of DFIs related to their microbiology. We retrieved 48 articles published from 1999 to 2013 that described a total of 7771 cases of DFI. The overall proportion of DFIs with an isolate of S aureus was about 30%; just over one third of these (11% of all cases) were MRSA strains. Among the DFI cases caused by MRSA 1543 were episodes of soft tissue infections and 113 of osteomyelitis, while non-MRSA organisms caused 5761 soft tissue infections and 354 cases of osteomyelitis. Only 5 of the included articles attempted a comparison between DFI caused by MRSA and those caused by other pathogens, with no clear differences noted. The median total duration of antibiotic therapy for DFI caused by MRSA was 26 days, of which a median of 10 days was given intravenously. Only a few articles reported the proportion of patients with a recurrence, but they often did not differentiate between MRSA and non-MRSA cases. Four publications reported a worse functional or microbiological outcome in MRSA, compared to non-MRSA, cases, but the findings were variable and differences did not seem to be significant. Many trials failed to adjust for case-mix or to definitively demonstrate a relationship between microbiology and outcomes. Few of the articles specifically commented on whether the MRSA isolates were health care- or community-acquired strains. Notwithstanding the substantial limitations of the available literature, there does not appear to be a need for any special treatment for DFI caused by MRSA. The current guidelines for treating according to established international recommendations seem appropriate.
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Affiliation(s)
- Besa Zenelaj
- Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Cindy Bouvet
- Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Benjamin A. Lipsky
- Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- University of Oxford, Oxford, UK
| | - Ilker Uçkay
- Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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Vouillarmet J, Morelec I, Thivolet C. Assessing diabetic foot osteomyelitis remission with white blood cell SPECT/CT imaging. Diabet Med 2014; 31:1093-9. [PMID: 24654798 DOI: 10.1111/dme.12445] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2013] [Revised: 01/13/2014] [Accepted: 03/17/2014] [Indexed: 01/24/2023]
Abstract
AIMS Diabetic foot osteomyelitis is an important risk factor of lower limb amputation. Antibiotic therapy is often effective in preventing surgery. However, the duration of antibiotic therapy is difficult to define in the absence of a marker to diagnose osteomyelitis remission at the end of the treatment. In this study, we assessed the diagnostic performance of white blood cell SPECT/CT imaging for evaluating osteomyelitis remission. PATIENTS AND METHODS Twenty-nine out of 42 episodes of diabetic foot osteomyelitis seen between December 2009 and April 2012 had radiographs, a three-phase bone scintigraphy and a white blood cell SPECT/CT at the end of antibiotic therapy. They were treated with antibiotics alone and considered in clinical remission. White blood cell SPECT/CT results were considered positive when abnormal uptake in the osteomyelitis location was identified. Osteomyelitis remission was defined by the absence of an osteomyelitis relapse after 12 months' follow-up. RESULTS A negative white blood cell SPECT/CT was seen for 22 episodes of osteomyelitis. All of them were in remission. A positive white blood cell SPECT/CT was observed for seven episodes. A relapse occurred in five episodes (71.5%) after a median duration of 4 months (2-7 months). Sensitivity, specificity, positive predictive value and predictive negative value in predicting osteomyelitis relapse after the discontinuation of antibiotic treatment were, respectively, for radiographs 80%, 33%, 20% and 89%; for three-phase bone scintigraphy 100%, 12.5%, 15.5% and 100%; and for the white blood cell SPECT/CT 100%, 91.5%, 71.5% and 100%. CONCLUSION Negative uptake on white blood cell SPECT/CT is a good marker for diagnosis of diabetic foot osteomyelitis remission and might be very useful in guiding antibiotic therapy.
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Affiliation(s)
- J Vouillarmet
- Department of Endocrinology, Diabetes and Nutrition, Oullins, France
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Abstract
Osteomyelitis of the foot and ankle is a common, potentially devastating condition with diagnostic and treatment challenges. Understanding the epidemiology and pathogenesis of osteomyelitis can raise clinical suspicion and guide testing and treatments. History and physical examination, laboratory studies, vascular studies, histologic and microbiologic analyses, and various imaging modalities contribute to diagnosis and treatment. Treatment including empiric broad-spectrum antibiotics and surgery should take a multidisciplinary approach to optimize patient factors, ensure eradication of the infection, and restore function. Optimization of vascular status, soft tissues, limb biomechanics, and physiologic state of the patient must be considered to accelerate and ensure healing.
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Targeting methicillin-resistant Staphylococcus aureus with short salt-resistant synthetic peptides. Antimicrob Agents Chemother 2014; 58:4113-22. [PMID: 24798285 DOI: 10.1128/aac.02578-14] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The seriousness of microbial resistance combined with the lack of new antimicrobials has increased interest in the development of antimicrobial peptides (AMPs) as novel therapeutics. In this study, we evaluated the antimicrobial activities of two short synthetic peptides, namely, RRIKA and RR. These peptides exhibited potent antimicrobial activity against Staphylococcus aureus, and their antimicrobial effects were significantly enhanced by addition of three amino acids in the C terminus, which consequently increased the amphipathicity, hydrophobicity, and net charge. Moreover, RRIKA and RR demonstrated a significant and rapid bactericidal effect against clinical and drug-resistant Staphylococcus isolates, including methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-intermediate S. aureus (VISA), vancomycin-resistant S. aureus (VRSA), linezolid-resistant S. aureus, and methicillin-resistant Staphylococcus epidermidis. In contrast to many natural AMPs, RRIKA and RR retained their activity in the presence of physiological concentrations of NaCl and MgCl2. Both RRIKA and RR enhanced the killing of lysostaphin more than 1,000-fold and eradicated MRSA and VRSA isolates within 20 min. Furthermore, the peptides presented were superior in reducing adherent biofilms of S. aureus and S. epidermidis compared to results with conventional antibiotics. Our findings indicate that the staphylocidal effects of our peptides were through permeabilization of the bacterial membrane, leading to leakage of cytoplasmic contents and cell death. Furthermore, peptides were not toxic to HeLa cells at 4- to 8-fold their antimicrobial concentrations. The potent and salt-insensitive antimicrobial activities of these peptides present an attractive therapeutic candidate for treatment of multidrug-resistant S. aureus infections.
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Lavery LA, Fontaine JL, Bhavan K, Kim PJ, Williams JR, Hunt NA. Risk factors for methicillin-resistant Staphylococcus aureus in diabetic foot infections. Diabet Foot Ankle 2014; 5:23575. [PMID: 24765246 PMCID: PMC3984406 DOI: 10.3402/dfa.v5.23575] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2013] [Revised: 03/09/2014] [Accepted: 03/10/2014] [Indexed: 11/27/2022]
Abstract
Objective The purpose of this study was to evaluate risk factors for methicillin-resistant Staphylococcus aureus (MRSA) in patients hospitalized for diabetic foot infections. Methods We reviewed hospital admissions for foot infections in patients with diabetes which had nasal swabs, and anaerobic and aerobic tissue cultures at the time of admission. Data collected included patient characteristics and medical history to determine risk factors for developing an MRSA infection in the foot. Results The prevalence of MRSA in these infections was 29.8%. Risk factors for MRSA diabetic foot infections were history of MRSA foot infection, MRSA nasal colonization, and multidrug-resistant organisms (p<0.05). Positive predictive value (PPV) and negative predictive value (NPV) of nasal colonization with MRSA to identify MRSA diabetic foot infections were 66.7% and 80.0% (sensitivity 41%, specificity 90%). Admission from a nursing home was not a significant risk factor. Conclusion Positive nasal swabs are not predictive of the infecting agent; however, a negative nasal swab rules out MRSA as the infecting agent in foot wounds with 90% accuracy.
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Affiliation(s)
- Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Javier La Fontaine
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kavita Bhavan
- Division of Infectious Disease, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Paul J Kim
- Department of Plastic Surgery, Georgetown University, Washington, DC, USA
| | | | - Nathan A Hunt
- Private Practice, Orthopaedic & Spine Center of the Rockies, Fort Collins, CO, USA
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Uçkay I, Gariani K, Pataky Z, Lipsky BA. Diabetic foot infections: state-of-the-art. Diabetes Obes Metab 2014; 16:305-16. [PMID: 23911085 DOI: 10.1111/dom.12190] [Citation(s) in RCA: 94] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 07/05/2013] [Accepted: 07/11/2013] [Indexed: 01/18/2023]
Abstract
Foot infections are frequent and potentially devastating complications of diabetes. Unchecked, infection can progress contiguously to involve the deeper soft tissues and ultimately the bone. Foot ulcers in people with diabetes are most often the consequence of one or more of the following: peripheral sensory neuropathy, motor neuropathy and gait disorders, peripheral arterial insufficiency or immunological impairments. Infection develops in over half of foot ulcers and is the factor that most often leads to lower extremity amputation. These amputations are associated with substantial morbidity, reduced quality of life and major financial costs. Most infections can be successfully treated with optimal wound care, antibiotic therapy and surgical procedures. Employing evidence-based guidelines, multidisciplinary teams and institution-specific clinical pathways provides the best approach to guide clinicians through this multifaceted problem. All clinicians regularly seeing people with diabetes should have an understanding of how to prevent, diagnose and treat foot infections, which requires familiarity with the pathophysiology of the problem and the literature supporting currently recommended care.
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Affiliation(s)
- I Uçkay
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland; Orthopaedic Surgery Service, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
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The microbiologic profile of diabetic foot infections in Turkey: a 20-year systematic review. Eur J Clin Microbiol Infect Dis 2014; 33:871-8. [DOI: 10.1007/s10096-014-2047-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 01/02/2014] [Indexed: 01/08/2023]
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Supp DM, Neely AN. Cutaneous antimicrobial gene therapy: engineering human skin replacements to combat wound infection. ACTA ACUST UNITED AC 2014. [DOI: 10.1586/17469872.3.1.73] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Kosinski MA, Lipsky BA. Current medical management of diabetic foot infections. Expert Rev Anti Infect Ther 2014; 8:1293-305. [DOI: 10.1586/eri.10.122] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Islam S, Cawich SO, Budhooram S, Harnarayan P, Mahabir V, Ramsewak S, Naraynsingh V. Microbial profile of diabetic foot infections in Trinidad and Tobago. Prim Care Diabetes 2013; 7:303-308. [PMID: 23742849 DOI: 10.1016/j.pcd.2013.05.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 05/06/2013] [Accepted: 05/09/2013] [Indexed: 01/09/2023]
Abstract
AIMS To examine the microbiologic profile of diabetic foot infections in order to guide empiric antibiotic choices. METHODS All patients with moderate-severe diabetic foot infections at a tertiary care facility were identified from July 2011 to June 2012. Culture samples were routinely collected before empiric antibiotics were commenced. Retrospective chart review was performed to extract the following data: demographics, clinical details, empiric antibiotic choice and microbiologic data. Descriptive analyses were performed using SPSS 12.0. RESULTS There were 139 patients at a mean age of 56.9 ± 12.4 years. Mixed poly-microbial infections were present in 56.8% of cases. Of 221 organisms isolated, 64.7% were gram-negative aerobes, 32.1% were gram-positive aerobes and 3.2% were obligate anaerobes. Multidrug resistant organisms were encountered in 25.9% of cases and included ESBL producers (11.3%), MRSA (4.5%) and VRE (1.4%). Both ciprofloxacin and ceftazidime had good overall anti-microbial activity against gram-negative (68% and 62%, respectively) and gram-positive pathogens (69% and 48%, respectively). Obligate anaerobes were uncommonly isolated due to institutional constraints. CONCLUSION In this environment, both ciprofloxacin and ceftazidime provide good broad-spectrum anti-microbial activity against the commonly isolated pathogens. Either agent can be used as single agent empiric therapy in patients with moderate/severe diabetic infections in our setting. Although institutional limitations precluded isolation of anaerobes in most cases, there is sufficient evidence for anti-anaerobic agents to be recommended as a part of empiric therapy.
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Affiliation(s)
- Shariful Islam
- Department of Surgery, San Fernando General Hospital, Trinidad and Tobago
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Abstract
Foot infections are common in persons with diabetes mellitus. Most diabetic foot infections occur in a foot ulcer, which serves as a point of entry for pathogens. Unchecked, infection can spread contiguously to involve underlying tissues, including bone. A diabetic foot infection is often the pivotal event leading to lower extremity amputation, which account for about 60% of all amputations in developed countries. Given the crucial role infections play in the cascade toward amputation, all clinicians who see diabetic patients should have at least a basic understanding of how to diagnose and treat this problem.
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Affiliation(s)
- Edgar J G Peters
- Department of Internal Medicine, VU University Medical Center, Room ZH4A35, PO Box 7057, Amsterdam NL-1007MB, The Netherlands.
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Feng SH, Chu YJ, Wang PH, Jun X, Min D, Li XM. Risk Factors and Gene Type for Infections of MRSA in Diabetic Foot Patients in Tianjin, China. INT J LOW EXTR WOUND 2013; 12:106-12. [DOI: 10.1177/1534734613489991] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The objective was to study risk factors and gene type of DF patients infected with MRSA. A total of 429 DF patients were recruited. The patients with S aureus infections were divided into MRSA and MSSA groups. MRSA were genotyped by SCCmec. pvl and lukE-lukD were detected. A total of 559 pathogens were isolated from them, with G+ bacteria firstly(59.0%), followed G- bacilli (37.7%) and true fungi (3.3%). The 3 most frequently isolated pathogens were S aureus (35.2%), S epidermidis (12.3%), and Pseudomonas aeruginosa (11.2%). SCCmec III MRSA and SCCmec IVa MRSA had the same antibacterial spectrum. mecA positive rate was 100%. lukE-lukD and pvl positive rates were 100% and 0%, respectively. 28 strains belonged to SCCmec III and the others belonged to SCCmec IVa. The G+ cocci were the main pathogens, S aureus and S epidermidis were predominant among them. Antibiotic usage in 6 months prior to hospitalization, long course of ulcer, osteomyelitis and hypoproteinemia are risk factors for MRSA. SCCmec IVa is high in proportion to MRSA isolates, suggesting that CA-MRSA has become major pathogen of DF infection. All the MRSA were harboring lukE-lukD, which has been reported to present poor leucotoxin compared to pvl, and may be a response to atypical local inflammatory reaction in DF infection.
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Affiliation(s)
- Shu-Hong Feng
- 2011 Collaborative Innovation Center of Tianjin for Medical Epigenetics, The Key Laboratory of Hormones and Development (Ministry of Health), Department of Diabetic Foot, Metabolic Diseases Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, China
| | - Yue-Jie Chu
- 2011 Collaborative Innovation Center of Tianjin for Medical Epigenetics, The Key Laboratory of Hormones and Development (Ministry of Health), Department of Diabetic Foot, Metabolic Diseases Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, China
| | - Peng-Hua Wang
- 2011 Collaborative Innovation Center of Tianjin for Medical Epigenetics, The Key Laboratory of Hormones and Development (Ministry of Health), Department of Diabetic Foot, Metabolic Diseases Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, China
| | - Xu Jun
- 2011 Collaborative Innovation Center of Tianjin for Medical Epigenetics, The Key Laboratory of Hormones and Development (Ministry of Health), Department of Diabetic Foot, Metabolic Diseases Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, China
| | - Ding Min
- 2011 Collaborative Innovation Center of Tianjin for Medical Epigenetics, The Key Laboratory of Hormones and Development (Ministry of Health), Department of Diabetic Foot, Metabolic Diseases Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, China
| | - Xue-Mei Li
- 2011 Collaborative Innovation Center of Tianjin for Medical Epigenetics, The Key Laboratory of Hormones and Development (Ministry of Health), Department of Diabetic Foot, Metabolic Diseases Hospital & Tianjin Institute of Endocrinology, Tianjin Medical University, Tianjin, China
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Suaya JA, Eisenberg DF, Fang C, Miller LG. Skin and soft tissue infections and associated complications among commercially insured patients aged 0-64 years with and without diabetes in the U.S. PLoS One 2013; 8:e60057. [PMID: 23593162 PMCID: PMC3622669 DOI: 10.1371/journal.pone.0060057] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2012] [Accepted: 02/22/2013] [Indexed: 02/07/2023] Open
Abstract
Introduction Skin and soft tissue infections (SSTIs) are common infections occurring in ambulatory and inpatient settings. The extent of complications associated with these infections by diabetes status is not well established. Methods Using a very large repository database, we examined medical and pharmacy claims of individuals aged 0–64 between 2005 and 2010 enrolled in U.S. health plans. Diabetes, SSTIs, and SSTI-associated complications were identified by ICD-9 codes. SSTIs were stratified by clinical category and setting of initial diagnosis. Results We identified 2,227,401 SSTI episodes, 10% of which occurred in diabetic individuals. Most SSTIs were initially diagnosed in ambulatory settings independent from diabetes status. Abscess/cellulitis was the more common SSTI group in diabetic and non-diabetic individuals (66% and 59%, respectively). There were differences in the frequencies of SSTI categories between diabetic and non-diabetic individuals (p<0.01). Among SSTIs diagnosed in ambulatory settings, the SSTI-associated complication rate was over five times higher in people with diabetes than in people without diabetes (4.9% vs. 0.8%, p<0.01) and SSTI-associated hospitalizations were 4.9% and 1.1% in patients with and without diabetes, respectively. Among SSTIs diagnosed in the inpatient setting, bacteremia/endocarditis/septicemia/sepsis was the most common associated complication occurring in 25% and 16% of SSTIs in patients with and without diabetes, respectively (p<0.01). Conclusions Among persons with SSTIs, we found SSTI-associated complications were five times higher and SSTI-associated hospitalizations were four times higher, in patients with diabetes compared to those without diabetes. SSTI prevention efforts in individuals with diabetes may have significant impact on morbidity and healthcare resource utilization.
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Affiliation(s)
- Jose A Suaya
- GlaxoSmithKlineVaccines, Philadelphia, Pennsylvania, United States of America.
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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.
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Affiliation(s)
- Abida Malik
- Department of Microbiology, Faculty of Medicine, JN Medical College, Aligarh Muslim University, Aligarh 202002, India.
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Djahmi N, Messad N, Nedjai S, Moussaoui A, Mazouz D, Richard JL, Sotto A, Lavigne JP. Molecular epidemiology of Staphylococcus aureus strains isolated from inpatients with infected diabetic foot ulcers in an Algerian University Hospital. Clin Microbiol Infect 2013; 19:E398-404. [PMID: 23521557 DOI: 10.1111/1469-0691.12199] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Revised: 01/17/2013] [Accepted: 02/12/2013] [Indexed: 12/17/2022]
Abstract
Staphylococcus aureus is the most common pathogen cultured from diabetic foot infection (DFI). The consequence of its spread to soft tissue and bony structures is a major causal factor for lower-limb amputation. The objective of the study was to explore ecological data and epidemiological characteristics of S. aureus strains isolated from DFI in an Algerian hospital setting. Patients were included if they were admitted for DFI in the Department of Diabetology at the Annaba University Hospital from April 2011 to March 2012. Ulcers were classified according to the Infectious Diseases Society of America/International Working Group on the Diabetic Foot classification system. All S. aureus isolates were analysed. Using oligonucleotide arrays, S. aureus resistance and virulence genes were determined and each isolate was affiliated to a clonal complex. Among the 128 patients, 277 strains were isolated from 183 samples (1.51 isolate per sample). Aerobic Gram-negative bacilli were the most common isolated organisms (54.9% of all isolates). The study of ecological data highlighted the extremely high rate of multidrug-resistant organisms (MDROs) (58.5% of all isolates). The situation was especially striking for S. aureus [(85.9% were methicillin-resistant S. aureus (MRSA)], Klebsiella pneumonia (83.8%) and Escherichia coli (60%). Among the S. aureus isolates, 82.2% of MRSA belonged to ST239, one of the most worldwide disseminated clones. Ten strains (13.7%) belonged to the European clone PVL+ ST80. ermA, aacA-aphD, aphA, tetM, fosB, sek, seq, lukDE, fnbB, cap8 and agr group 1 genes were significantly associated with MRSA strains (p <0.01). The study shows for the first time the alarming prevalence of MDROs in DFI in Algeria.
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Affiliation(s)
- N Djahmi
- Faculty of Medicine, National Institute of Health and Medical Research, U1047, Montpellier 1 University, Nîmes cedex 02, France
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Co-therapy using lytic bacteriophage and linezolid: effective treatment in eliminating methicillin resistant Staphylococcus aureus (MRSA) from diabetic foot infections. PLoS One 2013; 8:e56022. [PMID: 23418497 PMCID: PMC3572146 DOI: 10.1371/journal.pone.0056022] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Accepted: 01/08/2013] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Staphylococcus aureus remains the predominant pathogen in diabetic foot infections and prevalence of methicillin resistant S.aureus (MRSA) strains further complicates the situation. The incidence of MRSA in infected foot ulcers is 15-30% and there is an alarming trend for its increase in many countries. Diabetes acts as an immunosuppressive state decreasing the overall immune functioning of body and to worsen the situation, wounds inflicted with drug resistant strains represent a morbid combination in diabetic patients. Foot infections caused by MRSA are associated with an increased risk of amputations, increased hospital stay, increased expenses and higher infection-related mortality. Hence, newer, safer and effective treatment strategies are required for treating MRSA mediated diabetic foot infections. The present study focuses on the use of lytic bacteriophage in combination with linezolid as an effective treatment strategy against foot infection in diabetic population. METHODOLOGY Acute hindpaw infection with S.aureus ATCC 43300 was established in alloxan induced diabetic BALB/c mice. Therapeutic efficacy of a well characterized broad host range lytic bacteriophage, MR-10 was evaluated alone as well as in combination with linezolid in resolving the course of hindpaw foot infection in diabetic mice. The process of wound healing was also investigated. RESULTS AND CONCLUSIONS A single administration of phage exhibited efficacy similar to linezolid in resolving the course of hindpaw infection in diabetic animals. However, combination therapy using both the agents was much more effective in arresting the entire infection process (bacterial load, lesion score, foot myeloperoxidase activity and histopathological analysis). The entire process of tissue healing was also hastened. Use of combined agents has been known to decrease the frequency of emergence of resistant mutants, hence this approach can serve as an effective strategy in treating MRSA mediated foot infections in diabetic individuals who do not respond to conventional antibiotic therapy.
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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.
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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.
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Murphy CR, Quan V, Kim D, Peterson E, Whealon M, Tan G, Evans K, Meyers H, Cheung M, Lee BY, Mukamel DB, Huang SS. Nursing home characteristics associated with methicillin-resistant Staphylococcus aureus (MRSA) Burden and Transmission. BMC Infect Dis 2012; 12:269. [PMID: 23095678 PMCID: PMC3528666 DOI: 10.1186/1471-2334-12-269] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 10/17/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND MRSA prevalence in nursing homes often exceeds that in hospitals, but reasons for this are not well understood. We sought to measure MRSA burden in a large number of nursing homes and identify facility characteristics associated with high MRSA burden. METHODS We performed nasal swabs of residents from 26 nursing homes to measure MRSA importation and point prevalence, and estimate transmission. Using nursing home administrative data, we identified facility characteristics associated with MRSA point prevalence and estimated transmission risk in multivariate models. RESULTS We obtained 1,649 admission and 2,111 point prevalence swabs. Mean MRSA point prevalence was 24%, significantly higher than mean MRSA admission prevalence, 16%, (paired t-test, p<0.001), with a mean estimated MRSA transmission risk of 16%.In multivariate models, higher MRSA point prevalence was associated with higher admission prevalence (p=0.005) and higher proportions of residents with indwelling devices (p=0.01). Higher estimated MRSA transmission risk was associated with higher proportions of residents with diabetes (p=0.01) and lower levels of social engagement (p=0.03). CONCLUSIONS MRSA importation was a strong predictor of MRSA prevalence, but MRSA burden and transmission were also associated with nursing homes caring for more residents with chronic illnesses or indwelling devices. Frequent social interaction among residents appeared to be protective of MRSA transmission, suggesting that residents healthy enough to engage in group activities do not incur substantial risks of MRSA from social contact. Identifying characteristics of nursing homes at risk for high MRSA burden and transmission may allow facilities to tailor infection control policies and interventions to mitigate MRSA spread.
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Affiliation(s)
- Courtney R Murphy
- Division of Infectious Diseases and Health Policy Research Institute, University of California-Irvine School of Medicine, Irvine, CA, USA.
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83
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Tian M, Jiang YZ, Niu YW, Xiao YR, Lu SL, Wang XQ. A Severely Infected Diabetic Foot Treated Successfully Without Using Systemic Antibiotics. INT J LOW EXTR WOUND 2012; 11:296-8. [DOI: 10.1177/1534734612458286] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
About 50% to 70% of all lower extremity amputations are related to diabetes infection. And antibiotic therapy is routinely used for all infected wounds to reduce the mortality of diabetic foot. Here, we report a case of diabetic foot with acute and deep severe infection. During hospital therapy, we used negative pressure therapy and extensive debridement without systemic antibiotic application, and we successfully rescued a foot from amputation. Negative pressure therapy and extensive debridement are very important and effective methods to control infection and promote wound healing in diabetes foot.
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Affiliation(s)
- Ming Tian
- Jiaotong University, Shanghai, People’s Republic of China
| | - Yu-Zhi Jiang
- Jiaotong University, Shanghai, People’s Republic of China
| | - Yi-Wen Niu
- Jiaotong University, Shanghai, People’s Republic of China
| | - Yu-Rui Xiao
- Jiaotong University, Shanghai, People’s Republic of China
| | - Shu-Liang Lu
- Jiaotong University, Shanghai, People’s Republic of China
| | - Xi-Qiao Wang
- Jiaotong University, Shanghai, People’s Republic of China
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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: 1089] [Impact Index Per Article: 90.8] [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.
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Affiliation(s)
- Benjamin A Lipsky
- Department of Medicine, University of Washington, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.
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85
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Mutluoglu M, Uzun G, Turhan V, Gorenek L, Ay H, Lipsky BA. How reliable are cultures of specimens from superficial swabs compared with those of deep tissue in patients with diabetic foot ulcers? J Diabetes Complications 2012; 26:225-9. [PMID: 22520404 DOI: 10.1016/j.jdiacomp.2012.03.015] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2011] [Revised: 01/16/2012] [Accepted: 03/13/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE To assess the reliability of cultures of superficial swabs (SS) by comparing them with cultures of concomitantly obtained deep tissue (DT) specimens in patients with diabetic foot ulcers. METHODS We reviewed clinical and microbiological data from patients with diabetes who presented during a two-year period to our hyperbaric medicine center with a foot ulcer. We identified patients who had at least one concomitantly collected SS and DT pair of specimens sent for culture. RESULTS A total of 89 culture pairs were available from 54 eligible patients, 33 (61.1%) of whom were hospitalized. Wounds were infected in 47 (87.0%) of the patients and 28 (51.9%) patients had received antibiotic therapy within the previous month. Overall, 65 (73%) of the SS and DT pairs had identical culture results, but in 11 (16.9%) cases the cultures were sterile; thus, only 54 (69.2%) of the 78 culture-positive pairs had identical results. Compared with DT, SS cultures yielded ≥1 extra organism in 10 (11.2%) cases, missed at least one organism in 8 (9.0%), and were completely different in 6 (6.7%). When compared to DT culture results, SS cultures had a positive predictive value of 84.4%, negative predictive value of 44.0%, and overall accuracy of 73.0%. CONCLUSIONS In patients with diabetic foot ulcers, results of specimens for culture taken by SS did not correlate well with those obtained by DT. This suggests that SS specimens may be less reliable for guiding antimicrobial therapy than DT specimens.
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Affiliation(s)
- Mesut Mutluoglu
- Department of Underwater and Hyperbaric Medicine, GATA Haydarpasa Teaching Hospital, 34668, Uskudar, Istanbul, Turkey.
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86
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Paisley AN, Kalavalapalli S, Subudhi CPK, Chadwick PR, Chadwick PJ, Young B. Real time presence of a microbiologist in a multidisciplinary diabetes foot clinic. Diabetes Res Clin Pract 2012; 96:e1-3. [PMID: 22226078 DOI: 10.1016/j.diabres.2011.11.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2011] [Revised: 11/24/2011] [Accepted: 11/28/2011] [Indexed: 11/29/2022]
Abstract
Multidisciplinary foot-care teams (MDFT) are recommended in the management of severe diabetic foot disease [1]. However, even though infection is often the dominant immediate risk, it is rare to have real time input from a microbiologist. We highlight the value of a microbiologist as a MDFT member.
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88
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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.
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Affiliation(s)
- Mohammad Zubair
- Department of Microbiology, Jawaharlal Nehru Medical College, Aligarh Muslim University, Aligarh, India
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89
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Two-Year Foot Care Program for Minority Patients with Type 2 Diabetes Mellitus of Zhuang Tribe in Guangxi, China. Can J Diabetes 2012. [DOI: 10.1016/j.jcjd.2011.08.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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90
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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: 133] [Impact Index Per Article: 11.1] [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.
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Affiliation(s)
- B A Lipsky
- VA Puget Sound Health Care System, University of Washington, Seattle, WA 98108, USA.
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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]
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Tascini C, Piaggesi A, Tagliaferri E, Iacopi E, Fondelli S, Tedeschi A, Rizzo L, Leonildi A, Menichetti F. Microbiology at first visit of moderate-to-severe diabetic foot infection with antimicrobial activity and a survey of quinolone monotherapy. Diabetes Res Clin Pract 2011; 94:133-9. [PMID: 21824673 DOI: 10.1016/j.diabres.2011.07.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2011] [Revised: 06/23/2011] [Accepted: 07/11/2011] [Indexed: 11/23/2022]
Abstract
Samples from 1295 patients with diabetic foot infection were evaluated; 4332 samples were collected with an average of 3.3 samples per patient. Fifty-seven percent of patients had a 2B ulcer and 23% had a 3B ulcer according to Texas University Classification. In 64.2% of samples collected at first visit an etiologic agent was identified. About 40% of the positive samples were polymicrobial. Gram positive bacteria were more frequently isolated (52.6%), Staphylococcus aureus was the most frequently isolated single agent (29.9%) and MRSA was 22% of S. aureus. Enterococcus spp., mainly Enterococcus faecalis, were 9.9%, all vancomycin susceptible except 2 isolates. Streptococci were 4.6%, more than 60% Streptococcus agalactiae. Gram negative rods were 40.6%, with enterobacteria 23.5% and Pseudomonas aeruginosa 10.3%. Anaerobes were only 0.3%, probably due to culture methods applied in our laboratory. Cotrimoxazole, rifampin and doxycycline were still active against S. aureus. ESBL producers, among enterobacteria, were 10%, mainly Escherichia coli and Proteus spp. Only colistin had a rate of susceptibility against P. aeruginosa above 90%. Levofloxacin had the best clinical activity with respect to the other quinolones, but when it failed, selected more resistant strains with respect to moxifloxacin among S. aureus and with respect to ciprofloxacin among P. aeruginosa.
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Affiliation(s)
- Carlo Tascini
- U.O. Malattie Infettive, Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
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93
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Gyssens IC, Dryden M, Kujath P, Nathwani D, Schaper N, Hampel B, Reimnitz P, Alder J, Arvis P. A randomized trial of the efficacy and safety of sequential intravenous/oral moxifloxacin monotherapy versus intravenous piperacillin/tazobactam followed by oral amoxicillin/clavulanate for complicated skin and skin structure infections. J Antimicrob Chemother 2011; 66:2632-42. [PMID: 21896561 PMCID: PMC3191944 DOI: 10.1093/jac/dkr344] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
OBJECTIVES The primary aim of the RELIEF study was to evaluate the efficacy and safety of two sequential intravenous (iv)/oral regimens: moxifloxacin iv/oral versus piperacillin/tazobactam (TZP) iv followed by oral amoxicillin/clavulanate (AMC). PATIENTS AND METHODS The study had a prospective, randomized, double-dummy, double-blind, multicentre design. Patients ≥18 years were prospectively stratified according to complicated skin and skin structure infection (cSSSI) subtype/diagnosis (major abscess, diabetic foot infection, wound infection or infected ischaemic ulcer), surgical intervention and severity of illness. Diagnoses and disease severity were based on predetermined criteria, documented by repeated photographs, and confirmed by an independent data review committee. Patients were randomized to receive either 400 mg of moxifloxacin iv once daily followed by 400 mg of moxifloxacin orally once daily or 4.0/0.5 g of TZP iv thrice daily followed by 875/125 mg of AMC orally twice daily for 7-21 days. The primary efficacy variable was clinical response at test of cure (TOC) for the per-protocol (PP) population. Clinical efficacy was assessed by the data review committee based on repeated photographs and case descriptions. Clinical trials registry number: NCT 00402727. RESULTS A total of 813 patients were randomized. Clinical success rates at TOC were similar for moxifloxacin and TZP-AMC in the PP [320/361 (88.6%) versus 275/307 (89.6%), respectively; P = 0.758] and intent-to-treat (ITT) [350/426 (82.2%) versus 305/377 (80.9%), respectively; P = 0.632] populations. Thus, moxifloxacin was non-inferior to TZP-AMC. Bacteriological success rates were high in both treatment arms [moxifloxacin: 432/497 (86.9%) versus TZP-AMC: 370/429 (86.2%), microbiologically valid (MBV) population]. Moxifloxacin was non-inferior to TZP-AMC at TOC in both the MBV and the ITT populations. Both treatments were well tolerated. CONCLUSIONS Once-daily iv/oral moxifloxacin monotherapy was clinically and bacteriologically non-inferior to iv TZP thrice daily followed by oral AMC twice daily in patients with cSSSIs.
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Affiliation(s)
- Inge C Gyssens
- Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands.
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94
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Abstract
Patients with diabetes are prone to ulcerations of the lower extremities, frequently complicated by infection, and are then reliant upon their caregivers for preservation of their limbs without the dreaded outcome of amputation. The enormous tolls of foot infections in diabetes, in terms of both health-related quality of life issues and associated economic burdens, have only been fully realized within the last few decades, and it is anticipated that these burdens will only increase over time. Early and appropriate antibiotic treatment targeting the most likely etiologic pathogens is a cornerstone of management of foot infections in diabetes, but these decisions are now complicated by the emergence of resistant organisms, particularly methicillin-resistant Staphylococcus aureus and multidrug-resistant Gram-negative species. This review will examine the impact of foot infections in diabetes and the overall care and management of the diabetes patient with foot infection, including the potential value of emerging antibiotic therapies within the milieu of antibiotic resistance.
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Affiliation(s)
- David G Armstrong
- Department of Surgery, University of Arizona College of Medicine, Tucson, Arizona 85724-5072, USA.
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Zubair M, Malik A, Ahmad J. The impact of creatinine clearance on the outcome of diabetic foot ulcers in north Indian tertiary care hospital. Diabetes Metab Syndr 2011; 5:120-125. [PMID: 22813563 DOI: 10.1016/j.dsx.2012.02.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
AIM Wound healing has been reported to be poor in diabetic patients with impaired kidney functions that usually accompanies retinopathy and neuropathy. The insensitive foot is vulnerable to repeated trauma and development of ulcer precedes 70-80% of non-traumatic lower extremity amputation. The present study was aimed to study the impact of creatinine clearance (CCre) on the outcome of diabetic foot ulcers (DFU). MATERIALS AND METHODS Data from 162 DFU patients admitted to Rajiv Gandhi Centre for Diabetes and Endocrinology of J.N. Medical College, Aligarh Muslim University, Aligarh, India, between December 2009 and March 2011 were analyzed. Detailed history and patient's profile, grade of DFU, co-morbidities and complications, laboratory data, microbiological profile and final outcome were collected. CCre was calculated according to MDRD formula. RESULTS The study revealed that, DFU healing was worst in patients with decreased CCre than in those who had normal CCre. Other factors associated with poor outcome were, higher grade of ulcer, infection type (subcutaneous and osteomyelitis) and biofilm infection. Amputation rates were also found to be higher in those with poor renal functions. CONCLUSIONS The results suggest that CCre is an important factor affecting wound healing in patients with DFUs. The automatic reporting of eGFR each time a serum creatinine concentration is requested will increase the awareness of significant kidney dysfunction in clinical practice especially in DFU patients and appropriate measures will improve the outcome.
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Affiliation(s)
- Mohammad Zubair
- Department of Microbiology, Faculty of Medicine, J.N. Medical College, Aligarh Muslim University, Aligarh 202002, India
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96
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&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]
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97
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Management of patients hospitalized for diabetic foot infection: Results of the French OPIDIA study. DIABETES & METABOLISM 2011; 37:208-15. [DOI: 10.1016/j.diabet.2010.10.003] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/05/2010] [Revised: 09/28/2010] [Accepted: 10/01/2010] [Indexed: 11/19/2022]
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Lima AF, Costa LB, Silva JLD, Maia MBS, Ximenes ECPA. Interventions for wound healing among diabetic patients infected with Staphylococcus aureus: a systematic review. SAO PAULO MED J 2011; 129:165-70. [PMID: 21755251 PMCID: PMC10866311 DOI: 10.1590/s1516-31802011000300007] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2010] [Revised: 01/27/2010] [Accepted: 02/18/2011] [Indexed: 11/22/2022] Open
Abstract
CONTEXT AND OBJECTIVE Staphylococcus aureus is the most frequent agent isolated in diabetic foot infections and may be associated with changes to wound healing times. The aim of this study was to perform a systematic review of the literature, including studies that assessed the efficacy of any clinical or surgical intervention, as well as oral or topical therapy for diabetic ulcers infected with S. aureus. DESIGN AND SETTING Systematic review with a search conducted in databases. METHODS We conducted a systematic review with a comprehensive search in the Lilacs, SciELO, PubMed/Medline, Old Medline, Embase and Cochrane Library databases, for articles published from 1966 to 2010. The articles selected were limited to studies on diabetic patients with wounds infected with S. aureus for whom their healing was followed up, with the use of either antibiotics or experimental treatments. Animal studies and those that did not report the wound healing, as well as review articles, were excluded. RESULTS Five studies that met the inclusion and exclusion criteria were analyzed. CONCLUSIONS There are few studies reporting the healing of wounds infected with S. aureus in diabetic patients, although this is the most commonly found pathogen in this type of wound and it frequently consists of methicillin-resistant S. aureus (MRSA). There is insufficient evidence to support early use of broad-spectrum antibiotics against MRSA to promote healing of diabetic ulcers, since antibiotic resistance may develop from such treatment. This highlights the need for further studies on the subject.
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Affiliation(s)
- Anacássia Fonseca Lima
- Microorganism Physiology and Biochemistry Laboratory, Universidade Federal de Pernambuco, Recife, Brazil.
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Richard JL, Sotto A, Lavigne JP. New insights in diabetic foot infection. World J Diabetes 2011; 2:24-32. [PMID: 21537457 PMCID: PMC3083903 DOI: 10.4239/wjd.v2.i2.24] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2010] [Revised: 08/28/2010] [Accepted: 09/04/2010] [Indexed: 02/05/2023] Open
Abstract
Foot ulcers are common in diabetic patients, have a cumulative lifetime incidence rate as high as 25% and frequently become infected. The spread of infection to soft tissue and bone is a major causal factor for lower-limb amputation. For this reason, early diagnosis and appropriate treatment are essential, including treatment which is both local (of the foot) and systemic (metabolic), and this requires coordination by a multidisciplinary team. Optimal treatment also often involves extensive surgical debridement and management of the wound base, effective antibiotic therapy, consideration for revascularization and correction of metabolic abnormalities such as hyperglycemia. This article focuses on diagnosis and management of diabetic foot infections in the light of recently published data in order to help clinicians in identification, assessment and antibiotic therapy of diabetic foot infections.
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Affiliation(s)
- Jean-Louis Richard
- Jean-Louis Richard, Department of Nutritional Diseases and Diabetology, Medical Centre, University Hospital of Nîmes, Le Grau du Roi 30240, France
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Abstract
Diabetic foot infections are a common and often serious problem, accounting for more hospital bed days than any other complication of diabetes. Despite advances in antibiotic drug therapy and surgical management, these infections continue to be a major risk factor for amputations of the lower extremity. Although a variety of wound size and depth classification systems have been adapted for use in codifying diabetic foot ulcerations, none are specific to infection. In 2003, the International Working Group on the Diabetic Foot developed guidelines for managing diabetic foot infections, including the first severity scale specific to these infections. The following year, the Infectious Diseases Society of America published their diabetic foot infection guidelines. Herein, we review some of the critical points from the Executive Summary of the Infectious Diseases Society of America document and provide a commentary following each issue to update the reader on any pertinent changes that have occurred since publication of the original document in 2004. The importance of a multidisciplinary limb salvage team, apropos of this special issue jointly published by the American Podiatric Medical Association and the Society for Vascular Surgery, cannot be overstated.
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Affiliation(s)
- Warren S Joseph
- Journal of the American Podiatric Medical Association, Bethesda, MD, USA.
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