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Abstract
Technical Orthopedics - Chronic Diabetic Foot Wounds Abstract: Chronic foot wounds are a very common and a growing problem. This review focuses on the treatment and the prophylaxis of diabetic foot ulcers from the perspective of technical orthopedics. Diabetic foot ulcers are of great importance for those affected, in particular because of the risk of infections and resulting amputations. With a good prophylaxis and consistent treatment, these complications can often be avoided.
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152
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Yanagiuchi T, Kato T, Hirano K, Toki H, Imura H, Matsubara K, Ushimaru S, Yokoi H, Zen K, Matoba S. Predictors of delayed wound healing after simultaneous endovascular treatment and minor forefoot amputation for chronic limb-threatening ischemia with wound infection. Vascular 2023; 31:333-340. [PMID: 35105193 DOI: 10.1177/17085381211067601] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To assess wound healing after simultaneous endovascular treatment (EVT) and minor forefoot amputation and identify the predictors of delayed wound healing in patients with chronic limb-threatening ischemia (CLTI) and bacterial infections of the wounds. METHODS In this single-center retrospective cohort study, we evaluated 79 consecutive limbs with tissue loss from 73 CLTI patients who underwent simultaneous EVT and minor forefoot amputation between November 2017 and May 2020. To estimate the rate of wound healing after the simultaneous procedure, we used the Kaplan-Meier method. To assess the association between baseline characteristics and delayed wound healing, we used the Cox proportional hazard model. RESULTS All patients who underwent the simultaneous procedure had ischemic wounds with bacterial infection. The rate of wound healing at 6 months reached 82%. The median time for wound healing was 76 days. According to multivariable analysis, Lisfranc/Chopart amputation (hazard ratio (HR) 2.46, 95% confidence interval (CI) 1.09-6.60), absence of above-the-knee (ATK) occlusive lesions (HR 1.89, 95% CI 1.04-3.45), and poor below-the-ankle (BTA) runoff (HR 1.77, 95% CI 1.01-3.11) were independent predictors of delayed wound healing. CONCLUSION Lisfranc/Chopart amputation, absence of ATK occlusive lesions, and poor BTA runoff were independent predictors of delayed wound healing after simultaneous EVT and minor forefoot amputation in patients with CLTI and bacterial infections of the wound.
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Affiliation(s)
| | - Taku Kato
- Department of Cardiology, 13684Rakuwakai Otowa Hospital, Kyoto, Japan
| | - Keita Hirano
- Department of Nephrology, 38049Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Hiroyuki Toki
- Department of Plastic and Reconstructive Surgery, 13684Rakuwakai Otowa Hospital, Kyoto, Japan
| | - Haruki Imura
- Department of Infectious Diseases, 13684Rakuwakai Otowa Hospital, Kyoto, Japan
| | - Kunihiko Matsubara
- Department of Dermatology, 13684Rakuwakai Otowa Kinen Hospital, Kyoto, Japan
| | - Shunpei Ushimaru
- Department of Cardiology, 13684Rakuwakai Otowa Hospital, Kyoto, Japan
| | - Hirokazu Yokoi
- Department of Cardiology, 13684Rakuwakai Otowa Hospital, Kyoto, Japan
| | - Kan Zen
- Department of Cardiovascular Medicine, 12898Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, 12898Kyoto Prefectural University of Medicine, Kyoto, Japan
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153
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Al‐Balas H, Metwalli ZA, Nagaraj A, Sada DM. Is fluoroscopy-guided percutaneous bone biopsy of diabetic foot with suspected osteomyelitis worthwhile? A retrospective study. J Diabetes 2023; 15:332-337. [PMID: 36905125 PMCID: PMC10101831 DOI: 10.1111/1753-0407.13377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/28/2023] [Accepted: 02/19/2023] [Indexed: 03/12/2023] Open
Abstract
BACKGROUND Diabetic foot infection, particularly osteomyelitis, is a major risk factor of amputation in persons with diabetes. Bone biopsy with microbial examination is considered the gold standard of diagnosis of osteomyelitis, providing information about the offending pathogens as well as their antibiotics susceptibility. This allows targeting of these pathogens with narrow spectrum antibiotics, potentially reducing emergence of antimicrobial resistance. Percutaneous fluoroscopy guided bone biopsy allows accurate and safe targeting of the affected bone. METHODS In a single tertiary medical institution and over 9 year period, we performed 170 percutaneous bone biopsies. We retrosepctively reviewed the medical record of these patients including patients' demographics, imaging and biopsy microbiology and pathollogic results. RESULTS Microbiological cultures of 80 samples (47.1%) were positive with 53.8% of the positive culture showed monomicrobial growth and the remaining were polymicrobial. Of the positive bone samples 71.3% grew Gram-positive bacteria. Staphylococcus aureus was the most frequently isolated pathogen from positive bone cultures with almost one third showing methicillin resistence. Enterococcus species were the most frequently isolated pathogens from polymicrobial samples. Enterobacteriaceae species were the most common Gram-negative pathogens and were more common in polymicrobial samples. CONCLUSIONS Percutaneous image-guided bone biopsy is a low-risk, minimally invasive procedure that can provide valuable information about microbial pathogens and therefore enable targeting these pathogens with narrow spectrum antibiotics.
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Affiliation(s)
| | | | | | - David M. Sada
- Baylor College of MedicineHoustonTexasUSA
- Michael E. DeBakey VA Medical CenterHoustonTexasUSA
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154
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Raza MA, Farwa U, Ishaque F, Al-Sehemi AG. Designing of thiazolidinones against chicken pox, monkey pox, and hepatitis viruses: A computational approach. Comput Biol Chem 2023; 103:107827. [PMID: 36805155 PMCID: PMC9922439 DOI: 10.1016/j.compbiolchem.2023.107827] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 02/03/2023] [Accepted: 02/05/2023] [Indexed: 02/14/2023]
Abstract
Computational designing of four different series (D-G) of thiazolidinone was done starting from different amines which was further condensed with various aldehydes. These underwent in silico molecular investigations for density functional theory (DFT), molecular docking, and absorption, distribution metabolism, excretion, and toxicity (ADMET) studies. The different electrochemical parameters of the compounds are predicted using quantum mechanical modeling approach with Gaussian. The docking software was used to dock the compounds against choosing PDB file for chickenpox, human immunodeficiency, hepatitis, and monkeypox virus as 1OSN, 1VZV, 6VLK, 1RTD, 3I7H, 3TYV, 4JU3, and 4QWO, respectively. The molecular interactions were visualized with discovery studio and maximum binding affinity was observed with D8 compounds against 4QWO (-13.383 kcal/mol) while for compound D5 against 1VZV which was -12.713 kcal/mol. Swiss ADME web tool was used to assess the drug-likeness of the designed compounds under consideration, and it is concluded that these molecules had a drug-like structure with almost zero violations.
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Affiliation(s)
- Muhammad Asam Raza
- Department of Chemistry, Hafiz Hayat Campus, University of Gujrat, Gujrat, Pakistan.
| | - Umme Farwa
- Department of Chemistry, Hafiz Hayat Campus, University of Gujrat, Gujrat, Pakistan
| | - Fatima Ishaque
- Department of Chemistry, Hafiz Hayat Campus, University of Gujrat, Gujrat, Pakistan
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155
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Gramberg MCTT, Van Hattem JM, Dijkstra JA, Dros E, Nieuwdorp M, Sabelis LWE, Peters EJG. Effect of Prior Antibiotic Use on Culture Results in People with Diabetes and Foot Osteomyelitis. Antibiotics (Basel) 2023; 12:684. [PMID: 37107046 PMCID: PMC10135220 DOI: 10.3390/antibiotics12040684] [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: 02/17/2023] [Revised: 03/28/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Antibiotic use prior to biopsy acquisition in people with diabetes and osteomyelitis of the foot (DFO) might influence bacterial yield in cultures or induce bacterial resistance. Obtaining reliable culture results is pivotal to guide antibiotics for conservative treatment of DFO. METHODS We prospectively analysed cultures of ulcer bed and percutaneous bone biopsies of people with DFO and investigated if antibiotics administered prior to (<2 months up to 7 days) biopsy acquisition led to more negative cultures or increased resistance in virulent bacteria. We calculated relative risks (RR) and 95% confidence intervals (CIs). We stratified analyses according to biopsy type (ulcer bed or bone). RESULTS We analysed bone and ulcer bed biopsies of 64 people, of whom 29 received prior antibiotics, and found that prior antibiotics did not lead to a higher risk of at least one negative culture (RR 1.3, (CI 0.8-2.0), nor did prior treatment increase the risk of a specific type of negative culture (RR for bone cultures 1.15, (CI 0.75-1.7), RR for ulcer bed cultures 0.92 (CI 0.33-2.6)) or both cultures (RR 1.3 (CI 0.35-4.7), and neither did it increase the risk of antibiotic resistance in the combined bacterial results of ulcer bed and bone cultures (RR 0.64, (CI 0.23-1.8)). CONCLUSIONS Antibiotics administered up to 7 days before obtaining biopsies in people with DFO do not influence culture yield regardless of biopsy type, nor are they associated with more antibiotic resistance.
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Affiliation(s)
- Meryl Cinzía Tila Tamara Gramberg
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine, Section of Infectious Diseases, De Boelelaan 1117, NL-1081HV Amsterdam, The Netherlands
- Amsterdam Institute for Infection and Immunity and Amsterdam Movement Sciences, P.O. Box 22660, NL-1100DD Amsterdam, The Netherlands
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Rehabilitation Medicine, De Boelelaan 1117, NL-1081HV Amsterdam, The Netherlands
- Amsterdam UMC Center for Diabetic Foot Complications (ACDC), P.O. Box 22660, NL-1100DD Amsterdam, The Netherlands
| | - Jarne Marijn Van Hattem
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Medical Microbiology and Infection Prevention, Meibergdreef 9, NL-1100DD Amsterdam, The Netherlands
| | - Jacob Albert Dijkstra
- Department of Pharmacy and Clinical Pharmacology, Amsterdam University Medical Center, NL-1081HV Amsterdam, The Netherlands
| | - Emma Dros
- Department of Pharmacy and Clinical Pharmacology, Amsterdam University Medical Center, NL-1081HV Amsterdam, The Netherlands
| | - Max Nieuwdorp
- Amsterdam UMC Center for Diabetic Foot Complications (ACDC), P.O. Box 22660, NL-1100DD Amsterdam, The Netherlands
- Amsterdam UMC, Location University of Amsterdam, Department of Experimental Vascular Medicine, Meibergdreef 9, NL-1100DD Amsterdam, The Netherlands
| | - Louise Willy Elizabeth Sabelis
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Rehabilitation Medicine, De Boelelaan 1117, NL-1081HV Amsterdam, The Netherlands
- Amsterdam UMC Center for Diabetic Foot Complications (ACDC), P.O. Box 22660, NL-1100DD Amsterdam, The Netherlands
- Amsterdam Movement Sciences, P.O. Box 22660, NL-1100DD Amsterdam, The Netherlands
| | - Edgar Josephus Gerardus Peters
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine, Section of Infectious Diseases, De Boelelaan 1117, NL-1081HV Amsterdam, The Netherlands
- Amsterdam Institute for Infection and Immunity and Amsterdam Movement Sciences, P.O. Box 22660, NL-1100DD Amsterdam, The Netherlands
- Amsterdam UMC Center for Diabetic Foot Complications (ACDC), P.O. Box 22660, NL-1100DD Amsterdam, The Netherlands
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156
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Taki E, Jabalameli F, Tehrani MRM, Feizabadi MM, Halimi S, Sanjari M, Amini MR, Beigverdi R, Emaneini M. Molecular Characteristics of Staphylococcus aureus Strains Isolated from Nasal Cavity and Wound Infections Among Diabetic Patients. Curr Microbiol 2023; 80:147. [PMID: 36961628 DOI: 10.1007/s00284-023-03262-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 03/07/2023] [Indexed: 03/25/2023]
Abstract
Staphylococcus aureus is the most common pathogen contributing to diabetic foot infections (DFI). Nasal transmission of S. aureus potentially increases the risk of endogenous infection. The aim of this study was to determine the genetic diversity and antibiotic resistance profile of S. aureus isolates in nasal and wound samples from diabetic patients. A cross-sectional study was conducted from July 2018 to September 2019. S. aureus was isolated from the anterior nares and wounds of diabetic patients. All S. aureus isolates were characterized by detection of resistance and virulence genes (mecA, ermA, ermC, hla, hlb, hlg, sea, lukDE, pvl), staphylococcal cassette chromosome mec (SCCmec)-typing and staphylococcal protein A (spa)-typing. A total of 34 S. aureus were isolated from the wounds of 115 diabetic patients with DFI. Twenty-four S. aureus isolates were collected from the anterior nares of patients, and thirteen patients had concurrent S. aureus in nasal and wound specimens. The prevalence of methicillin-resistant S. aureus (MRSA) in nasal specimens was noticeable (41.7%), and the most common spa-type in nasal and wound specimens was t14870. Nearly half of the patients with concurrent S. aureus in wound and nasal specimens had similar isolates from both sites. Our data suggest that detection and screening of S. aureus colonization in the nasal cavity may prevent subsequent endogenous infections, particularly with MRSA strains.
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Affiliation(s)
- Elahe Taki
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences, Building No. 7, 100 Poursina St., Keshavarz Blvd, Tehran, 14167-53955, Iran
| | - Fereshteh Jabalameli
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences, Building No. 7, 100 Poursina St., Keshavarz Blvd, Tehran, 14167-53955, Iran
| | - Mohammad Reza Mohajeri Tehrani
- Diabetes Research Center, Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Science Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Mehdi Feizabadi
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences, Building No. 7, 100 Poursina St., Keshavarz Blvd, Tehran, 14167-53955, Iran
| | - Shahnaz Halimi
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences, Building No. 7, 100 Poursina St., Keshavarz Blvd, Tehran, 14167-53955, Iran
| | - Mahnaz Sanjari
- Diabetes Research Center, Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Science Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohammad Reza Amini
- Diabetes Research Center, Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Science Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Reza Beigverdi
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences, Building No. 7, 100 Poursina St., Keshavarz Blvd, Tehran, 14167-53955, Iran
| | - Mohammad Emaneini
- Department of Microbiology, School of Medicine, Tehran University of Medical Sciences, Building No. 7, 100 Poursina St., Keshavarz Blvd, Tehran, 14167-53955, Iran.
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157
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Ron I, Kyin C, Peskin B, Ghrayeb N, Norman D, Ben-Kiki T, Shapira J. Risk Factors for a Failed Transmetatarsal Amputation in Patients with Diabetes. J Bone Joint Surg Am 2023; 105:651-658. [PMID: 36943915 DOI: 10.2106/jbjs.22.00718] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
BACKGROUND Transmetatarsal amputation (TMA) is a well-recognized limb-salvage procedure, often indicated for the treatment of diabetic foot infections. Currently, there is no widespread agreement in the literature with regard to the factors associated with failure of TMA. This study aimed to define risk factors for the failure of TMA, defined as below-the-knee or above-the-knee amputation, in patients with diabetes. METHODS This retrospective cohort study included 341 patients who underwent primary TMA. Patients who had a revision to a higher level (the failed TMA group) were compared with those who did not have failure of the initial amputation (the successful TMA group). RESULTS This study showed a higher frequency of renal impairment, defined as a high creatinine level and/or a previous kidney transplant or need for dialysis, in the failed TMA group (p = 0.002 for both). Furthermore, a Charlson Comorbidity Index (CCI) threshold value of 7.5 was identified as the optimal predictive value for failure of TMA (p = 0.002), and patients with a CCI of >7.5 had a median time of 1.13 months until the initial amputation failed. CONCLUSIONS TMA is associated with a high risk of revision. CCI may be used as a preoperative selection criterion, as 71.8% of patients with a CCI of >7.5 had failure of the TMA. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Itay Ron
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
| | - Cynthia Kyin
- University of Central Florida College of Medicine, Orlando, Florida
| | - Bezalel Peskin
- Orthopedic Department, Rambam Medical Center, Haifa, Israel
| | - Nabil Ghrayeb
- Orthopedic Department, Rambam Medical Center, Haifa, Israel
| | - Doron Norman
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
- Orthopedic Department, Rambam Medical Center, Haifa, Israel
| | - Tal Ben-Kiki
- Orthopedic Department, Rambam Medical Center, Haifa, Israel
| | - Jacob Shapira
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion, Israel Institute of Technology, Haifa, Israel
- Orthopedic Department, Rambam Medical Center, Haifa, Israel
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158
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Matijević T, Talapko J, Meštrović T, Matijević M, Erić S, Erić I, Škrlec I. Understanding the multifaceted etiopathogenesis of foot complications in individuals with diabetes. World J Clin Cases 2023; 11:1669-1683. [PMID: 36970006 PMCID: PMC10037285 DOI: 10.12998/wjcc.v11.i8.1669] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/01/2023] [Accepted: 02/17/2023] [Indexed: 03/07/2023] Open
Abstract
Diabetes mellitus, a chronic disease of metabolism, is characterized by a disordered production or cellular utilization of insulin. Diabetic foot disease, which comprises the spectrum of infection, ulceration, and gangrene, is one of the most severe complications of diabetes and is the most common cause of hospitalization in diabetic patients. The aim of this study is to provide an evidence-based overview of diabetic foot complications. Due to neuropathy, diabetic foot infections can occur in the form of ulcers and minor skin lesions. In patients with diabetic foot ulcers, ischemia and infection are the main causes of non-healing ulcers and amputations. Hyperglycemia compromises the immune system of individuals with diabetes, leading to persistent inflammation and delayed wound healing. In addition, the treatment of diabetic foot infections is challenging due to difficulty in accurate identification of pathogenic microorganisms and the widespread issue of antimicrobial resistance. As a further complicating factor, the warning signs and symptoms of diabetic foot problems can easily be overlooked. Issues associated with diabetic foot complications include peripheral arterial disease and osteomyelitis; accordingly, the risk of these complications in people with diabetes should be assessed annually. Although antimicrobial agents represent the mainstay of treatment for diabetic foot infections, if peripheral arterial disease is present, revascularization should be considered to prevent limb amputation. A multidisciplinary approach to the prevention, diagnosis, and treatment of diabetic patients, including those with foot ulcers, is of the utmost importance to reduce the cost of treatment and avoid major adverse consequences such as amputation.
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Affiliation(s)
- Tatjana Matijević
- Department of Dermatology and Venereology, University Hospital Center Osijek, Osijek 31000, Croatia
| | - Jasminka Talapko
- Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
| | - Tomislav Meštrović
- University Centre Varaždin, University North, Varaždin 42000, Croatia
- Institute for Health Metrics and Evaluation and the Department for Health Metrics Sciences, University of Washington School of Medicine, Seattle, WA 98195, United States
| | - Marijan Matijević
- Department of Surgery, National Memorial Hospital Vukovar, Vukovar 32000, Croatia
| | - Suzana Erić
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
- Department of Radiotherapy and Oncology, Clinical Hospital Center Osijek, Osijek 31000, Croatia
| | - Ivan Erić
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
- Department of Surgery, Osijek University Hospital Centre, Osijek 31000, Croatia
| | - Ivana Škrlec
- Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
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159
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Raja JM, Maturana MA, Kayali S, Khouzam A, Efeovbokhan N. Diabetic foot ulcer: A comprehensive review of pathophysiology and management modalities. World J Clin Cases 2023; 11:1684-1693. [PMID: 36970004 PMCID: PMC10037283 DOI: 10.12998/wjcc.v11.i8.1684] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2022] [Revised: 01/08/2023] [Accepted: 02/17/2023] [Indexed: 03/07/2023] Open
Abstract
Diabetic foot ulcer (DFU) is a debilitating and severe manifestation of uncontrolled and prolonged diabetes that presents as ulceration, usually located on the plantar aspect of the foot. Approximately 15% of individuals with diabetes will eventually develop DFU, and 14%-24% of them will require amputation of the ulcerated foot due to bone infection or other ulcer-related complications. The pathologic mechanisms underlying DFU are comprise a triad: Neuropathy, vascular insufficiency, and secondary infection due to trauma of the foot. Standard local and invasive care along with novel approaches like stem cell therapy pave the way to reduce morbidity, decrease amputations, and prevent mortality from DFU. In this manuscript, we review the current literature with focus on the pathophysiology, preventive options, and definitive management of DFU.
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Affiliation(s)
- Joel M Raja
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN 38119, United States
| | - Miguel A Maturana
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN 38119, United States
| | - Sharif Kayali
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN 38119, United States
| | - Amir Khouzam
- Department of Internal Medicine, University of Tennessee Health Science Center, Memphis, TN 38119, United States
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160
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Carro GV, de Jesus FM, Ricci A. Diabetic Foot Osteomyelitis: Is it all the Same? INT J LOW EXTR WOUND 2023:15347346231160614. [PMID: 36883207 DOI: 10.1177/15347346231160614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
Diabetic foot osteomyelitis (OM) requires a longer duration of therapy, a greater need for surgery and implies a higher rate of recidivism, a higher amputation risk, and lower treatment success. But do all bone infections behave the same way, require the same treatment, or imply the same prognosis? Actually, in clinical practice we can verify there are different clinical presentations of OM. The first one is that associated with the infected diabetic foot attack. It requires urgent surgery and debridement since "time is tissue." Clinical features and radiographs are enough for the diagnosis, and treatment should not be delayed. The second one is related to a sausage toe. It affects phalanges and it can be treated with a 6- or 8-week antibiotic course with a high rate of success. Clinical features and radiographs are sufficient for the diagnosis in this case. The third presentation is OM superimposed to Charcot's neuroarthropathy, which mainly comprises midfoot or hindfoot. It starts with a plantar ulcer in a foot that has developed a deformity. The treatment is based on an accurate diagnosis that often includes magnetic resonance, and requires a complex surgery to preserve the midfoot and to avoid recurrent ulcers or foot instability. The final presentation is that of an OM without large soft tissue compromise secondary to a chronic ulcer or a previous unsuccessful surgery secondary to minor amputation or debridement. There is often a small ulcer with a positive probe to bone test over a bony prominence. Diagnosis is made by clinical features, radiographs, and laboratory tests. Treatment includes antibiotic therapy guided by surgical or transcutaneous biopsy, but this presentation often requires surgery. Different presentations of OM mentioned above need to be recognized because the diagnosis, type of culture, antibiotic treatment, surgical treatment, and prognosis are different upon the presentation.
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Affiliation(s)
| | | | - Anahí Ricci
- Hospital Nacional Prof. A. Posadas, El Palomar, Buenos Aires, Argentina
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161
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Vecchia M, Colaneri M, Sacchi P, Marvulli LN, Salvaderi A, Lanza J, Boschini S, Ragni F, Marone P, Cutti S, Muzzi A, Marena C, Calvi M, Scudeller L, Marone EM, Bruno R. Implementation of an antimicrobial stewardship program in the Vascular Surgery ward of a university tertiary care hospital in Pavia, Northern Italy. BMC Infect Dis 2023; 23:138. [PMID: 36882761 PMCID: PMC9993681 DOI: 10.1186/s12879-023-08061-x] [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: 11/10/2022] [Accepted: 02/07/2023] [Indexed: 03/09/2023] Open
Abstract
PURPOSE The commitment of multidisciplinary teams in antimicrobial stewardship programs (ASPs) is often inadequately considered, especially in surgical wards. We wanted to evaluate clinical, microbiological, and pharmacological outcomes before and after the implementation of an ASP in the Vascular Surgery ward of Fondazione IRCCS Policlinico San Matteo, a tertiary care hospital in Pavia, Italy. METHODS This was a quasi-experimental quality-improvement study. The antimicrobial stewardship activity was conducted twice a week for 12 months and consisted of both prospective audit and feedback of all the ongoing antimicrobial prescriptions by the infectious diseases' consultants and educational meetings for the healthcare workers of the Vascular Surgery ward. For comparison between the study periods, Student t test (Mann-Whitney test for skewed distributions) was used for quantitative variables (ANOVA or Kruskall-Wallis for > 2 groups respectively), and Pearson's chi-squared test (Fisher exact test where appropriate) for categorical variables. 2-tailed tests were used. P-value significance cut-off was 0.05. RESULTS During the 12-month intervention period, among a total number of 698 patients, 186 prescriptions were revised, mostly leading to de-escalating an ongoing antimicrobial therapy (39, 20.97%). A statistically significant reduction in isolates of carbapenem-resistant Pseudomonas aeruginosa (p-value 0.003) and the absence of Clostridioides difficile infections were reported. No statistically significant changes were observed in terms of length of stay and all-cause in-hospital mortality. A significant decrease in the administration of carbapenems (p-value 0.01), daptomycin (p-value < 0.01) and linezolid (p-value 0.43) was registered. A significant reduction in antimicrobial costs was also observed. CONCLUSIONS The implementation of a 12-month ASP brought significant clinical and economic results, highlighting the benefits of a multidisciplinary teamwork.
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Affiliation(s)
- Marco Vecchia
- Division of Infectious Diseases Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.
| | - Marta Colaneri
- Division of Infectious Diseases Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Paolo Sacchi
- Division of Infectious Diseases Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Lea Nadia Marvulli
- Division of Infectious Diseases Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Andrea Salvaderi
- Division of Infectious Diseases Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Jessica Lanza
- Division of Vascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Stefano Boschini
- Division of Vascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Franco Ragni
- Division of Vascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Piero Marone
- Microbiology and Virology Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Sara Cutti
- Medical Direction, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Alba Muzzi
- Medical Direction, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Carlo Marena
- Medical Direction, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Monica Calvi
- Pharmacy Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Luigia Scudeller
- Head, Research and Innovation Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Enrico Maria Marone
- Division of Vascular Surgery Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Medical, Surgical, Diagnostic and Paediatric Science, University of Pavia, Pavia, Italy
| | - Raffaele Bruno
- Division of Infectious Diseases Unit, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy.,Department of Medical, Surgical, Diagnostic and Paediatric Science, University of Pavia, Pavia, Italy
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Liu M, Wei X, Zheng Z, Li Y, Li M, Lin J, Yang L. Recent Advances in Nano-Drug Delivery Systems for the Treatment of Diabetic Wound Healing. Int J Nanomedicine 2023; 18:1537-1560. [PMID: 37007988 PMCID: PMC10065433 DOI: 10.2147/ijn.s395438] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Accepted: 03/14/2023] [Indexed: 03/28/2023] Open
Abstract
Diabetes mellitus (DM) induced wound healing impairment remains a serious health problem and burden on the clinical obligation for high amputation rates. Based on the features of wound microenvironment, biomaterials loading specific drugs can benefit diabetic wound treatment. Drug delivery systems (DDSs) can carry diverse functional substances to the wound site. Nano-drug delivery systems (NDDSs), benefiting from their features related to nano size, overcome limitations of conventional DDSs application and are considered as a developing process in the wound treatment field. Recently, a number of finely designed nanocarriers efficiently loading various substances (bioactive and non-bioactive factors) have emerged to circumvent constraints faced by traditional DDSs. This review describes various recent advances of nano-drug delivery systems involved in mitigating diabetes mellitus-based non-healing wounds.
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Affiliation(s)
- Mengqian Liu
- Department of Burns, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Xuerong Wei
- Department of Burns, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Zijun Zheng
- Department of Burns, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Yicheng Li
- Department of Burns, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Mengyao Li
- Department of Burns, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Jiabao Lin
- Department of Burns, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
| | - Lei Yang
- Department of Burns, Nanfang Hospital, Southern Medical University, Guangzhou, People’s Republic of China
- Correspondence: Lei Yang, Department of Burns, Nanfang Hospital, Southern Medical University, Jingxi Street, Baiyun District, Guangzhou, 510515, People’s Republic of China, Tel +86-20-6164-1841, Email
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163
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Wang G, Lin Z, Li Y, Chen L, Reddy SK, Hu Z, Garza LA. Colonizing microbiota is associated with clinical outcomes in diabetic wound healing. Adv Drug Deliv Rev 2023; 194:114727. [PMID: 36758858 PMCID: PMC10163681 DOI: 10.1016/j.addr.2023.114727] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 02/02/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023]
Abstract
With the development of society and the improvement of life quality, more than 500 million people are affected by diabetes. More than 10 % of people with diabetes will suffer from diabetic wounds, and 80 % of diabetic wounds will reoccur, so the development of new diabetic wound treatments is of great importance. The development of skin microbe research technology has gradually drawn people's attention to the complex relationship between microbes and diabetic wounds. Many studies have shown that skin microbes are associated with the outcome of diabetic wounds and can even be used as one of the indicators of wound prognosis. Skin microbes have also been found to have the potential to treat diabetic wounds. The wound colonization of different bacteria can exert opposing therapeutic effects. It is necessary to fully understand the skin microbes in diabetic wounds, which can provide valuable guidance for clinical diabetic wound treatment.
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Affiliation(s)
- Gaofeng Wang
- Department of Plastic and Aesthetic Surgery, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong Province 510515, China; Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21210, USA.
| | - Zhen Lin
- Department of Plastic and Aesthetic Surgery, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong Province 510515, China
| | - Yue Li
- Department of Plastic and Aesthetic Surgery, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong Province 510515, China
| | - Lu Chen
- Department of Plastic and Aesthetic Surgery, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong Province 510515, China
| | - Sashank K Reddy
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21210, USA; Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - Zhiqi Hu
- Department of Plastic and Aesthetic Surgery, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong Province 510515, China
| | - L A Garza
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21210, USA; Department of Cell Biology, Johns Hopkins University School of Medicine, Baltimore, MD 21210, USA; Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21210, USA.
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164
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Chiu A, Sharma D, Zhao F. Tissue Engineering-Based Strategies for Diabetic Foot Ulcer Management. Adv Wound Care (New Rochelle) 2023; 12:145-167. [PMID: 34939837 PMCID: PMC9810358 DOI: 10.1089/wound.2021.0081] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 10/26/2021] [Indexed: 01/13/2023] Open
Abstract
Significance: Diabetic foot ulcers (DFU) are a mounting problem with the increasingly frail population. Injuries that would otherwise heal are kept open by risk factors such as diabetes, obesity, and age-related conditions, which interferes with the natural wound healing processes. Recent Advances: This review summarizes recent advancements in the field of tissue engineering for the treatment of DFUs. FDA-approved approaches, including signaling-based therapies, stem cell therapies, and skin substitutes are summarized and cutting-edge experimental technologies that have the potential to manage chronic wounds, such as skin printing, skin organogenesis, skin self-assembly, and prevascularization, are discussed. Critical Issues: The standard of care for chronic wounds involves wound debridement, wound dressings, and resolving the underlying cause such as lowering the glycemic index and reducing wound pressure. Current DFU treatments are limited by low wound closure rates and poor regrown skin quality. New adjuvant therapies that facilitate wound closure in place of or in conjunction with standard care are critically needed. Future Directions: Tissue engineering strategies are limited by the plasticity of adult human cells. In addition to traditional techniques, genetic modification, although currently an emerging technology, has the potential to unlock human regeneration and can be incorporated in future therapeutics.
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Affiliation(s)
- Alvis Chiu
- Department of Biomedical Engineering, Texas A&M University, College Station, Texas, USA
| | - Dhavan Sharma
- Department of Biomedical Engineering, Texas A&M University, College Station, Texas, USA
| | - Feng Zhao
- Department of Biomedical Engineering, Texas A&M University, College Station, Texas, USA
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165
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Schechter MC, Yao Y, Patel M, Andruski R, Rab S, Wong JR, Santamarina G, Fayfman M, Rajani R, Kempker RR. Outpatient Parenteral Antibiotic Therapy for Diabetic Foot Osteomyelitis in an Uninsured and Underinsured Cohort. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2023; 31:e1219. [PMID: 37520685 PMCID: PMC10373103 DOI: 10.1097/ipc.0000000000001219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Background Diabetic foot osteomyelitis (DFO) is usually treated with prolonged outpatient parenteral antibiotic therapy (OPAT). Evaluation and treatment of non-antibiotic aspects of DFO (e.g., peripheral artery disease [PAD]) are also recommended. There is limited data regarding OPAT practice patterns and outcomes for DFO. Methods Single-center observational study of patients receiving OPAT for DFO in a large United States public hospital between January 2017 and July 2019. We abstracted data regarding microbiology test, antibiotics, clinical outcomes, and non-antibiotic DFO management. Results Ninety-six patients were included and some had >1 DFO-OPAT course during the study period (106 DFO-OPAT courses included). No culture was obtained in 40 (38%) of courses. Methicillin-resistant S. aureus (MRSA) was cultured in 15 (14%) and P. aeruginosa in 1 (1%) of DFO-OPAT courses. An antibiotic with MRSA activity (vancomycin or daptomycin) was used in 79 (75%) of courses and a parenteral antibiotic with anti-pseudomonal activity was used in 7 (6%) of courses. Acute kidney injury occurred in 19 (18%) DFO-OPAT courses. An ankle-brachial index measurement was obtained during or 6 months prior to the first DFO-OPAT course for 44 (49%) of patients. Forty-two (44%) patients died or had an amputation within 12 months of their initial hospital discharge. Conclusions We found high rates of empiric antibiotic therapy for DFO and low uptake of the non-antibiotic aspects of DFO care. Better implementation of microbiological tests for DFO in addition to stronger integration of infectious disease and non-infectious diseases care could improve DFO outcomes.
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Affiliation(s)
- Marcos C. Schechter
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA
- Grady Health System, Atlanta, GA
| | - Yutong Yao
- Rollings School of Public Health, Emory University, Atlanta, Georgia
| | | | | | | | | | - Gabriel Santamarina
- Grady Health System, Atlanta, GA
- Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA
- Department of Surgery, Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA
| | - Maya Fayfman
- Grady Health System, Atlanta, GA
- Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Ravi Rajani
- Grady Health System, Atlanta, GA
- Department of Surgery, Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA
| | - Russell R. Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA
- Grady Health System, Atlanta, GA
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Aviatin M, Sauriasari R, Yunir E, Risni HW. Evaluation of the Use of Antimicrobial Therapy for Treating Diabetic Foot Infections in an Indonesia Referral Hospital: A Retrospective Cohort Study. Infect Chemother 2023; 55:80-89. [PMID: 36864766 PMCID: PMC10079441 DOI: 10.3947/ic.2022.0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 12/26/2022] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Diabetic foot infection (DFI) is a common complication of hyperglycemia and is related to prolongation of hospitalization, mortality, high hospitalization costs and decreased quality of life. Antibiotic therapy is one of the most critical factors in the eradication of infection. This study aims to determine the appropriateness of antibiotic use based on the local and international clinical guidelines and its short-term effect on patients' clinical improvement. MATERIALS AND METHODS This retrospective cohort study was conducted using secondary data from DFI inpatients from 1 January 2018 to 31 May 2020, from Dr. Cipto Mangunkusumo Hospital (RSCM), the National Referral Hospital of Indonesia. The Gyssens algorithm was used to help assess the appropriateness of antibiotics. All subjects were type 2 Diabetes Mellitus (T2DM) adult patients diagnosed with DFI. The primary outcome was a clinical improvement of infection after 7 - 14 days of antibiotic use. The clinical improvement of infection was defined by a minimum of three of these criteria: reduced or no purulent secretions, no fever, the area around the wound did not feel warm, no or reduced local oedema, no local pain, reduced redness or erythema, and decreased leukocytes count. RESULTS A total of 113 (63.5%) eligible subjects from a total of 178 were recruited. Among the patients, 51.4% had a duration of T2DM for ≥10 years, 60.2% had uncontrolled hyperglycemia, 94.7% had a history of complications, 22.1% had a history of amputation, and 72.6% had ulcer grade ≥3. Based on the Gyssens algorithm, 54.0% of the subjects were given antibiotics appropriately, while the other 46.0% were not. The proportion of improved patients in the appropriate antibiotics group was higher but not statistically significant than those in the inappropriate group (60.7% vs. 42.3%, P = 0.079). However, the results of the multivariate analysis demonstrated that the appropriate use of antibiotics would increase clinical improvement by 2.6 times, compared to inappropriate use after controlling for the covariates (adjusted odds ratio: 2.616, 95% confidence interval: 1.117 - 6.126, P = 0.027). CONCLUSION Only half of the patients with DFI received appropriate antibiotics, although an appropriate antibiotics usage was independently associated with better short-term clinical improvement in DFI. This suggests that we should effort to improve appropriateness in antibiotics usage in DFI.
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Affiliation(s)
- Memy Aviatin
- Faculty of Pharmacy, Universitas Indonesia, Depok, Indonesia
| | - Rani Sauriasari
- Faculty of Pharmacy, Universitas Indonesia, Depok, Indonesia.
| | - Em Yunir
- Division of Endocrinology, Department of Internal Medicine Dr. Cipto Mangunkusumo National Referral Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia.
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167
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Foussard N, Dari L, Ducasse E, Rigalleau V, Mohammedi K, Caradu C. Lower-limb peripheral arterial disease and amputations in people with diabetes: Risk factors, prognostic value and management. Presse Med 2023; 52:104164. [PMID: 36863662 DOI: 10.1016/j.lpm.2023.104164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/20/2022] [Accepted: 02/17/2023] [Indexed: 03/04/2023] Open
Abstract
Lower-limb peripheral arterial disease (PAD), is a common manifestation of systemic atherosclerosis, resulting from a partial or complete obstruction of at least one lower-limb arteries. PAD is a major endemic disease with an excess risk of major cardiovascular events and death. It also leads to disability, high rates of lower-limb adverse events and non-traumatic amputation. In patients with diabetes, PAD is particularly frequent and has a worse prognosis than in patients without diabetes. The risk factors of PAD are comparable to those for cardiovascular disease. The ankle-brachial index is usually recommended to screen PAD despite its limited performance in patients with diabetes, affected by the presence of peripheral neuropathy, medial arterial calcification, incompressible arteries and infection. Toe brachial index and toe pressure emerge as alternative screening tools. The management of PAD requires strict control of cardiovascular risk factors including diabetes, hypertension and dyslipidaemia, the use of antiplatelet agents and lifestyle management, to reduce cardiovascular adverse events, but few randomized controlled trials have evaluated the benefits of these treatments in PAD. Several advances have been achieved in endovascular and surgical revascularization procedures, with obvious improvement in PAD prognosis. Further studies are required to increase our understanding of the pathophysiology of PAD and to evaluate the interest of different therapeutic strategies in the occurrence and progression of PAD in patients with diabetes. Here, we present a narrative and contemporary review to synthesize the key epidemiology findings, screening and diagnosis methods, and major therapeutic advances regarding PAD in patients with diabetes.
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Affiliation(s)
- Ninon Foussard
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France
| | - Loubna Dari
- University of Bordeaux, Faculty of Medicine, Bordeaux, France; Bordeaux University Hospital, Hôpital Saint-André, Vascular Medicine Department, Bordeaux, France
| | - Eric Ducasse
- University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France; Bordeaux University Hospital, Department of Vascular Surgery, Bordeaux, France
| | - Vincent Rigalleau
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France
| | - Kamel Mohammedi
- Bordeaux University Hospital, Hôpital Haut-Lévêque, Department of Endocrinology, Diabetes and Nutrition, Pessac, France; University of Bordeaux, Faculty of Medicine, Bordeaux, France; INSERM unit 1034, Biology of Cardiovascular Diseases, Pessac, France.
| | - Caroline Caradu
- Bordeaux University Hospital, Department of Vascular Surgery, Bordeaux, France
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Dörr S, Holland-Letz AK, Weisser G, Chatzitomaris A, Lobmann R. Bacterial Diversity, Antibiotic Resistance, and the Risk of Lower Limb Amputation in Younger and Older Individuals With Diabetic Foot Infection. THE INTERNATIONAL JOURNAL OF LOWER EXTREMITY WOUNDS 2023; 22:63-71. [PMID: 33745353 DOI: 10.1177/1534734621992290] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION A diabetic foot infection (DFI) contributes to high mortality and morbidity in diabetics due to its often rapid progressive and intricately treatable infection. DFIs are usually a polymicrobial infection and characterizing the entire bacterial load is still challenging. Prompt and effective treatment of DFI is nevertheless mandatory to safe limbs and lives. It is therefore crucial to know the local pathogen spectrum and its antibiotic susceptibility. METHODS AND MATERIAL For a 12-month period, we investigated 353 individuals with infected diabetic foot ulcer, their bacterial diversity, and antimicrobial susceptibility at fist-time visit in a Diabetic Foot Care Center in southern Germany. RESULTS Cultures yielded 888 species, most of them gram-positive cocci (primary Staphylococcus aureus). The gram-negative sector was mainly formed by Pseudomonas aeruginosa and Enterobacteriacae. Because the prevalence of multiresistant species was surprisingly low (0.9% of isolated strains), we suggest penicillins with β-lactamase inhibitor in case of gram-positive-dominated infection or piperacillin/tazobactam or rather carbapenems with equal efficacy when gram-negative species are involved.
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Affiliation(s)
- Stefan Dörr
- Stuttgart General Hospital, Stuttgart, Germany
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McDermott KM, Srinivas T, Abularrage CJ. Multidisciplinary approach to decreasing major amputation, improving outcomes, and mitigating disparities in diabetic foot and vascular disease. Semin Vasc Surg 2023; 36:114-121. [PMID: 36958892 PMCID: PMC10928649 DOI: 10.1053/j.semvascsurg.2022.11.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 11/05/2022] [Accepted: 11/07/2022] [Indexed: 11/13/2022]
Abstract
Major nontraumatic lower extremity amputation (LEA) is a morbid complication of longstanding or poorly controlled diabetes and/or end-stage peripheral artery disease. Incidence of major LEAs consistently declined during the 1990s and 2000s, but rates have plateaued or increased in many regions during the past decade. Marked racial, ethnic, socioeconomic, and geographic disparities in risk of LEA persist and are related to inequalities in access to care and differential rates of attempted limb preservation. Multidisciplinary diabetic foot care (MDFC) is increasingly recognized as a necessary model for optimal management of patients with diabetic foot and vascular disease. This article reviews the role of MDFC in reducing major LEAs and the specific ways in which MDFC can mitigate disparities in care delivery and limb preservation outcomes. Access to MDFC among vulnerable populations remains a significant barrier to systematic reduction in major LEAs.
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Affiliation(s)
- Katherine M McDermott
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins Hospital, 600 North Wolfe Street, Halsted 668, Baltimore, MD 21287
| | - Tara Srinivas
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins Hospital, 600 North Wolfe Street, Halsted 668, Baltimore, MD 21287
| | - Christopher J Abularrage
- Division of Vascular Surgery and Endovascular Therapy, Johns Hopkins Hospital, 600 North Wolfe Street, Halsted 668, Baltimore, MD 21287.
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Physical Treatment of Diabetic Foot Ulcers—Preliminary Study for Topical Application of Oxygen or Ozone Auxiliary Treatment of Diabetic Foot Ulcers. Dermatol Ther 2023. [DOI: 10.1155/2023/1843995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023]
Abstract
Diabetes mellitus is one of the most common metabolic diseases in which one of the most serious complications is the diabetic foot ulcer (DFU). The aim of the study was to compare the efficacy of two physical therapeutic methods: topical oxygen therapy and topical ozone therapy in the treatment of DFU with the calculation of the financial costs for both applied physical methods. The study included 85 patients, 47 male (55.2%) and 38 female (44.7%) in age range between 40 and 90 years (mean age: 67.82 ± 12.42 years) with hard to heal diabetic foot ulcers. The mean diabetic foot ulcer duration was 3.6 ± 1.23 years. Patients were randomized into two study groups not significantly different in terms of age, body mass index (BMI) value, and baseline ulcer surface area value, who underwent topical oxygen therapy (group I) and topical ozone therapy (group II), respectively. Both the groups underwent a total of 30 daily treatments lasting 30 minutes, in 2 sessions of 15 treatments with a 14-day break between sessions. Progress in wound healing was evaluated by computerized planimetry and the pain intensity was assessed with use of a VAS scale. After the treatment, the ulcer area in group I decreased by an average of 33.25 ± 10.97% and by an average of 28.67 ± 14.47% in group II
. On the other hand, the intensity of pain ailments after the treatment was statistically significantly decreased in group I by an average of 57.13 ± 16.24% while in group II by an average of 40.21 ± 14.53% (
). After application of topical oxygen therapy and topical ozone therapy in the treatment of diabetic foot ulcers a statistically significant reduction in the surface area of treated ulcers in objective planimetric assessment was observed, with local oxygen therapy showing only a slight advantage in this regard. Both compared methods also caused a statistically significant reduction in the pain intensity, while local oxygen therapy shows statistically significantly better analgesic effectiveness. Due to the calculated moderate cost, both applied methods appeared to be cost-effective.
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171
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Tang Y, Huang Y, Luo L, Xu M, Deng D, Fang Z, Zhao X, Chen M. Level of 25-hydroxyvitamin D and vitamin D receptor in diabetic foot ulcer and factor associated with diabetic foot ulcers. Diabetol Metab Syndr 2023; 15:30. [PMID: 36829206 PMCID: PMC9951493 DOI: 10.1186/s13098-023-01002-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/17/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND At present, there is no clinical study to elucidate the correlation between vitamin D deficiency and the incidence of diabetic foot osteomyelitis (DFO).This study aims to clarify levels of 25-hydroxyvitamin D [25(OH)VD] in peripheral blood and vitamin D receptor (VDR) expression in wound margin tissues (T-VDR) of patients with type 2 diabetes mellitus (T2DM) with diabetic foot ulcer (DFU) and DFO, and to determine its correlation with treatment outcomes of DFU and DFO, and and its value as a potential biomarker for the diagnosis of DFU and DFO. METHODS 156 T2DM patients with DFU (DFU group), 100 T2DM patients without DFU (T2DM group), and 100 healthy controls (NC group). The DFU group patients were subdivided into DFO (n = 80) and NDFO groups (n = 76). The level of serum 25(OH)VD was measured via chemiluminescence immunoassay, and T-VDR expression level was determined by quantitative real-time PCR. RESULTS The levels of serum 25(OH)VD in the DFU group were significantly lower than the T2DM group [(10.3 (5.8, 18.7) vs 15.7 (8.6, 24.6) ng/mL, P = 0.002)]. Similarly, the levels of serum 25(OH)VD and T-VDR expression in the DFO group were statistically lower than the NDFO group [9.2 (5.2, 20.5) vs 12.8 (6.9, 22.1) ng/mL, P = 0.006)], [1.96 (0.61, 3.97) vs 3.11 (1.36, 5.11), P = 0.004)], respectively. Furthermore, the levels of serum 25(OH)VD and T-VDR expression in DFU patients were positively correlated with the ulcer healing rate of foot ulcer after 8 weeks of treatment ( P = 0.031, P = 0.016, respectively). Multivariate logistic regression analysis showed that low level of serum 25(OH)VD was an independent risk factor for DFU and DFO (ORDFU = 2.42, ORDFO = 3.05, P = 0.008, 0.001, respectively), and decreased T-VDR expression level was an independent risk factor for DFO (OR = 2.83, P = 0.004). Meanwhile, the ROC curve analysis indicated that the AUC of serum 25(OH)VD level for the diagnosis of DFU and DFO was 0.821 (95% CI, 0.754-0.886, P < 0.001) and 0.786 (95%CI, 0.643-0.867, P < 0.001), respectively. When establishing a diagnosis of DFO, the AUC of T-VDR expression level was 0.703 (95%CI: 0.618-0.853, P < 0.001). CONCLUSIONS The levels of serum 25(OH)VD and T-VDR expression in DFU and DFO decreased. Serum 25(OH)VD and T-VDR are potentially valuable biomarkers for diagnosis and prognosis of DFU and DFO. .
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Affiliation(s)
- Ying Tang
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui People’s Republic of China
| | - Yixuan Huang
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui People’s Republic of China
| | - Li Luo
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui People’s Republic of China
| | - Murong Xu
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui People’s Republic of China
| | - Datong Deng
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui People’s Republic of China
| | - Zhaohui Fang
- Department of Endocrinology, The First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, Anhui People’s Republic of China
| | - Xiaotong Zhao
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui People’s Republic of China
| | - Mingwei Chen
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui People’s Republic of China
- Department of Endocrinology, The First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, Anhui People’s Republic of China
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Radellini S, Vigneri E, Smeraldi L, Dinoto E, Guercio G, Richiusa P, Almasio PL, Guarnotta V, Salzillo R, Giordano C. Evidence of greater severity of diabetic foot ulcers during COVID-19 pandemic: A real-life single-centre cohort study. Diabetes Metab Res Rev 2023:e3626. [PMID: 36814044 DOI: 10.1002/dmrr.3626] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 02/06/2023] [Accepted: 02/14/2023] [Indexed: 02/24/2023]
Abstract
AIMS In the Sars-Cov-2 pandemic era, patients with diabetes mellitus (DM) manifested more severe forms of Sars-Cov-2 with greater mortality than non-diabetic patients. Several studies documented more aggressive forms of diabetic foot ulcers (DFU) during the pandemic period even though the results were not unanimously confirmed. The aim of this study was to evaluate the clinical-demographic differences between a cohort of Sicilian diabetic patients hospitalised for DFU in the pre-pandemic 3 years and a cohort of patients hospitalised in the pandemic 2 years. MATERIALS AND METHODS One hundred and eleven patients from the pre-pandemic period 2017-2019 (Group A) and 86 patients from the pandemic period 2020-2021 (Group B) with DFU, admitted to the division of Endocrinology and Metabolism of the University Hospital of Palermo, were retrospectively evaluated. The clinical assessment of the type, staging and grading of the lesion, and the infective complication from DFU was performed. RESULTS No differences in HbA1c values were observed between the two groups. Group B showed a significantly higher prevalence of male subjects (p = 0.010), neuro-ischaemic ulcers (p < 0.001), deep ulcers with involvement of bones (p < 0.001), white blood count levels (p < 0.001), and reactive C protein (p = 0.001) compared to group A. CONCLUSIONS Our data show that in the COVID-19 pandemic, a greater severity of ulcers requiring a significantly greater number of revascularisations and more expensive therapy, but without an increase in the amputation rate, was observed. These data provide novel information on the impact of the pandemic on diabetic foot ulcer risk and progression.
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Affiliation(s)
- Stefano Radellini
- Section of Endocrinology, Diabetology and Metabolism, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE), Division of "Malattie Endocrine, del Ricambio e della Nutrizione", Università degli studi di Palermo, Palermo, Italy
| | - Enrica Vigneri
- Section of Endocrinology, Diabetology and Metabolism, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE), Division of "Malattie Endocrine, del Ricambio e della Nutrizione", Università degli studi di Palermo, Palermo, Italy
| | - Lucia Smeraldi
- Section of Endocrinology, Diabetology and Metabolism, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE), Division of "Malattie Endocrine, del Ricambio e della Nutrizione", Università degli studi di Palermo, Palermo, Italy
| | - Ettore Dinoto
- Department of Surgical, Oncological and Oral Sciences, Vascular Surgery Unit, AOUP Policlinico 'P. Giaccone', University of Palermo, Palermo, Italy
| | - Giovanni Guercio
- Department of Surgical Oncological and Stomatological Disciplines, Division of Surgery, University of Palermo, Palermo, Italy
| | - Pierina Richiusa
- Section of Endocrinology, Diabetology and Metabolism, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE), Division of "Malattie Endocrine, del Ricambio e della Nutrizione", Università degli studi di Palermo, Palermo, Italy
| | - Piero Luigi Almasio
- Section of Gastroenterology and Hepatology, Dipartimento di Promozione della Salute, Materno-Infantile, Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro", PROMISE, Università degli Studi di Palermo, Palermo, Italy
| | - Valentina Guarnotta
- Section of Endocrinology, Diabetology and Metabolism, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE), Division of "Malattie Endocrine, del Ricambio e della Nutrizione", Università degli studi di Palermo, Palermo, Italy
| | - Riccardo Salzillo
- Section of Endocrinology, Diabetology and Metabolism, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE), Division of "Malattie Endocrine, del Ricambio e della Nutrizione", Università degli studi di Palermo, Palermo, Italy
| | - Carla Giordano
- Section of Endocrinology, Diabetology and Metabolism, Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza "G. D'Alessandro" (PROMISE), Division of "Malattie Endocrine, del Ricambio e della Nutrizione", Università degli studi di Palermo, Palermo, Italy
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Turzańska K, Adesanya O, Rajagopal A, Pryce MT, Fitzgerald Hughes D. Improving the Management and Treatment of Diabetic Foot Infection: Challenges and Research Opportunities. Int J Mol Sci 2023; 24:ijms24043913. [PMID: 36835330 PMCID: PMC9959562 DOI: 10.3390/ijms24043913] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Revised: 02/03/2023] [Accepted: 02/08/2023] [Indexed: 02/17/2023] Open
Abstract
Diabetic foot infection (DFI) management requires complex multidisciplinary care pathways with off-loading, debridement and targeted antibiotic treatment central to positive clinical outcomes. Local administration of topical treatments and advanced wound dressings are often used for more superficial infections, and in combination with systemic antibiotics for more advanced infections. In practice, the choice of such topical approaches, whether alone or as adjuncts, is rarely evidence-based, and there does not appear to be a single market leader. There are several reasons for this, including a lack of clear evidence-based guidelines on their efficacy and a paucity of robust clinical trials. Nonetheless, with a growing number of people living with diabetes, preventing the progression of chronic foot infections to amputation is critical. Topical agents may increasingly play a role, especially as they have potential to limit the use of systemic antibiotics in an environment of increasing antibiotic resistance. While a number of advanced dressings are currently marketed for DFI, here we review the literature describing promising future-focused approaches for topical treatment of DFI that may overcome some of the current hurdles. Specifically, we focus on antibiotic-impregnated biomaterials, novel antimicrobial peptides and photodynamic therapy.
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Affiliation(s)
- Kaja Turzańska
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Education and Research Centre, Beaumont Hospital, D09 YD60 Dublin, Ireland
| | - Oluwafolajimi Adesanya
- School of Molecular and Cellular Biology, University of Illinois Urbana-Champaign, Champaign, IL 61801, USA
| | - Ashwene Rajagopal
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Education and Research Centre, Beaumont Hospital, D09 YD60 Dublin, Ireland
| | - Mary T. Pryce
- School of Chemical Sciences, Dublin City University, D09 V209 Dublin, Ireland
| | - Deirdre Fitzgerald Hughes
- Department of Clinical Microbiology, Royal College of Surgeons in Ireland University of Medicine and Health Sciences, Education and Research Centre, Beaumont Hospital, D09 YD60 Dublin, Ireland
- Correspondence: ; Tel.: +353-1-8093711
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Liette MD, Crisologo PA, Masadeh S, Yang SH, Bergmann CB, Caldwell CC, Henning JA. A Prospective Analysis of the SVS WIfI Classification System to Stratify Immediate and 1-Year Patient Outcomes. J Foot Ankle Surg 2023:S1067-2516(23)00035-2. [PMID: 36933979 DOI: 10.1053/j.jfas.2023.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 01/24/2023] [Accepted: 02/05/2023] [Indexed: 03/20/2023]
Abstract
The purpose of this study was to prospectively enroll patients that presented to the emergency department with a lower extremity infection, stratify risk and record outcomes. Risk stratification was performed based on the Society of Vascular Surgery Wound, foot Infection, and Ischemia (WIfI) classification system. This study aimed to establish the efficacy and validity of this classification in predicting patient outcomes during immediate hospitalization and throughout a 1 year follow up. A total of 152 patients were enrolled in the study and of these, 116 met the inclusion criteria and had at least 1 year of follow up for analysis. Each patient was assigned a WIfI score based on wound, ischemia, and foot infection severity according to the classification guidelines. Patient demographics as well as all podiatric and vascular procedures were recorded. The major end points of the study were rates of proximal amputation, time to wound healing, surgical procedures, surgical dehiscence, readmission rates, and mortality. A difference in rates of healing (p = .04), surgical dehiscence (p < .01), and 1 year mortality (p = .01) with increasing WIfI stage as well as across the individual component scores was noted. This analysis further supports the application of the WIfI classification system early during patient care to stratify risk and identify the need for early intervention and a multispecialty team approach to potentially improve outcomes in the severe multicomorbid patient.
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Affiliation(s)
- Michael D Liette
- Resident Physician, University of Cincinnati Medical Center, Cincinnati, OH.
| | - Peter A Crisologo
- Assistant Professor of Surgery University of Cincinnati Medical Center, Cincinnati, OH
| | - Suhail Masadeh
- Associate Professor of Surgery University of Cincinnati Medical Center, Director of Podiatric Surgery Residency University of Cincinnati Medical Center, Chief of Surgical Podiatry Cincinnati Veteran Affairs Medical Center, Cincinnati, OH
| | - Sung H Yang
- Assistant Professor of Surgery University of Cincinnati Medical Center, Cincinnati, OH
| | - Christian B Bergmann
- Postdoctoral Research Fellow, University of Cincinnati, Medical Center, Cincinnati, OH
| | - Charles C Caldwell
- Professor of Surgery, Director, Division of Research, University of Cincinnati, OH
| | - Jordan A Henning
- Staff Podiatrist Cincinnati, Veterans Affairs Medical Center, Cincinnati, OH
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175
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Osteomyelitis of the Lower Limb: Diagnostic Accuracy of Dual-Energy CT versus MRI. Diagnostics (Basel) 2023; 13:diagnostics13040703. [PMID: 36832191 PMCID: PMC9955987 DOI: 10.3390/diagnostics13040703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/07/2023] [Accepted: 02/08/2023] [Indexed: 02/15/2023] Open
Abstract
BACKGROUND MRI is the preferred imaging technique for the identification of osteomyelitis. The key element for diagnosis is the presence of bone marrow edema (BME). Dual-energy CT (DECT) is an alternative tool which is able to identify BME in the lower limb. PURPOSE To compare the diagnostic performance of DECT and MRI for osteomyelitis, using clinical, microbiological, and imaging data as reference standards. MATERIALS AND METHODS This prospective single-center study enrolled consecutive patients with suspected bone infections undergoing DECT and MRI imaging from December 2020 to June 2022. Four blinded radiologists with various experience levels (range of 3-21 years) evaluated the imaging findings. Osteomyelitis was diagnosed in the presence of BMEs, abscesses, sinus tracts, bone reabsorption, or gaseous elements. The sensitivity, specificity, and AUC values of each method were determined and compared using a multi-reader multi-case analysis. A p value < 0.05 was considered significant. RESULTS In total, 44 study participants (mean age 62.5 years ± 16.5 [SD], 32 men) were evaluated. Osteomyelitis was diagnosed in 32 participants. For the MRI, the mean sensitivity and specificity were 89.1% and 87.5%, while for the DECT they were 89.0% and 72.9%, respectively. The DECT demonstrated a good diagnostic performance (AUC = 0.88), compared with the MRI (AUC = 0.92) (p = 0.12). When considering each imaging finding alone, the best accuracy was achieved by considering BME (AUC for DECT 0.85 versus AUC of MRI of 0.93, with p = 0.07), followed by the presence of bone erosions (AUC 0.77 for DECT and 0.53 for MRI, with p = 0.02). The inter-reader agreement of the DECT (k = 88) was similar to that of the MRI (k = 90). CONCLUSION Dual-energy CT demonstrated a good diagnostic performance in detecting osteomyelitis.
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Ozer Balin S, Aşan MA, Ozcan EC, Uğur K, Şenol A. The Course of Diabetic Foot Infection in Elderly Patients: Data of Patients From Turkey. INT J LOW EXTR WOUND 2023:15347346231155584. [PMID: 36740918 DOI: 10.1177/15347346231155584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
With the aging population, it is expected that diabetes and related complications will increase rapidly. The aim of this study was to examine the signs and symptoms of diabetic foot infection in elderly individuals. Patients with diabetic foot infection were grouped as mild, moderate, and severe. Patients aged <65 years and those who did not meet the diagnosis of diabetic foot infection were excluded from the study. Only the first applications of patients who applied to the hospital multiple times with diabetic foot infection diagnosis were evaluated. 314 patients were included in the study. The mean age of the patients was 71.5 (±12). The number of patients aged 75 and over was 125 (39.8%). Of the patients, 25.7% had mild, 61.7% moderate, and 12.4% severe clinical forms. 131 (41.7%) of the patients had osteomyelitis. Amputation was performed in 112 of the patients. Antibiotic treatment was given to 102 patients only. While 89 patients died, a significant correlation was found between all groups between amputation rate and mortality frequency and clinical severity of diabetic foot infection (P < .001). In our study, it was observed that the clinical severity of diabetic foot infection was more severe and the overall mortality rate was higher in geriatric patients. In light of all these data, it can be concluded that an early and comprehensive roadmap should be followed in geriatric patients with diabetic foot infection who have an increased risk of morbidity and mortality.
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Affiliation(s)
- Safak Ozer Balin
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, 64177Firat University, Elazig, Turkey
| | - Mehmet Ali Aşan
- Department of Infectious Diseases and Clinical Microbiology, Faculty of Medicine, 64177Firat University, Elazig, Turkey
| | - Erhan Cahit Ozcan
- Department of Plastic and Reconstructive Surgery, Faculty of Medicine, 64177Firat University, Elazig, Turkey
| | - Kader Uğur
- Department of Endocrinology and Metabolic Diseases, Faculty of Medicine, 64177Firat University, Elazig, Turkey
| | - Arzu Şenol
- Department of Infectious Diseases and Clinical Microbiology, 290817University of Health Sciences Fethi Sekin City Hospital, Elazig, Turkey
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Armstrong DG, Edmonds ME, Serena TE. Point-of-care fluorescence imaging reveals extent of bacterial load in diabetic foot ulcers. Int Wound J 2023; 20:554-566. [PMID: 36708275 PMCID: PMC9885466 DOI: 10.1111/iwj.14080] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/24/2022] [Accepted: 11/28/2022] [Indexed: 01/29/2023] Open
Abstract
Elevated levels of bacteria, including biofilm, increase the risk of chronic wound infection and inhibit healing. Addressing asymptomatic high bacterial loads is challenged by a lack of clinical terminology and diagnostic tools. This post-hoc multicenter clinical trial analysis of 138 diabetic foot ulcers investigates fluorescence (FL)-imaging role in detecting biofilm-encased and planktonic bacteria in wounds at high loads. The sensitivity and specificity of clinical assessment and FL-imaging were compared across bacterial loads of concern (104 -109 CFU/g). Quantitative tissue culture confirmed the total loads. Bacterial presence was confirmed in 131/138 ulcers. Of these, 93.9% had loads >104 CFU/g. In those wounds, symptoms of infection were largely absent and did not correlate with, or increase proportionately with, bacterial loads at any threshold. FL-imaging increased sensitivity for the detection of bacteria across loads 104 -109 (P < .0001), peaking at 92.6% for >108 CFU/g. Imaging further showed that 84.2% of ulcers contained high loads in the periwound region. New terminology, chronic inhibitory bacterial load (CIBL), describes frequently asymptomatic, high bacterial loads in diabetic ulcers and periwound tissues, which require clinical intervention to prevent sequelae of infection. We anticipate this will spark a paradigm shift in assessment and management, enabling earlier intervention along the bacterial-infection continuum and supporting improved wound outcomes.
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Affiliation(s)
- David G. Armstrong
- Department of SurgeryKeck School of Medicine of University of Southern CaliforniaLos AngelesCaliforniaUSA
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178
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Chanderraj R, Baker JM, Kay SG, Brown CA, Hinkle KJ, Fergle DJ, McDonald RA, Falkowski NR, Metcalf JD, Kaye KS, Woods RJ, Prescott HC, Sjoding MW, Dickson RP. In critically ill patients, anti-anaerobic antibiotics increase risk of adverse clinical outcomes. Eur Respir J 2023; 61:13993003.00910-2022. [PMID: 36229047 PMCID: PMC9909213 DOI: 10.1183/13993003.00910-2022] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 09/16/2022] [Indexed: 01/16/2023]
Abstract
BACKGROUND Critically ill patients routinely receive antibiotics with activity against anaerobic gut bacteria. However, in other disease states and animal models, gut anaerobes are protective against pneumonia, organ failure and mortality. We therefore designed a translational series of analyses and experiments to determine the effects of anti-anaerobic antibiotics on the risk of adverse clinical outcomes among critically ill patients. METHODS We conducted a retrospective single-centre cohort study of 3032 critically ill patients, comparing patients who did and did not receive early anti-anaerobic antibiotics. We compared intensive care unit outcomes (ventilator-associated pneumonia (VAP)-free survival, infection-free survival and overall survival) in all patients and changes in gut microbiota in a subcohort of 116 patients. In murine models, we studied the effects of anaerobe depletion in infectious (Klebsiella pneumoniae and Staphylococcus aureus pneumonia) and noninfectious (hyperoxia) injury models. RESULTS Early administration of anti-anaerobic antibiotics was associated with decreased VAP-free survival (hazard ratio (HR) 1.24, 95% CI 1.06-1.45), infection-free survival (HR 1.22, 95% CI 1.09-1.38) and overall survival (HR 1.14, 95% CI 1.02-1.28). Patients who received anti-anaerobic antibiotics had decreased initial gut bacterial density (p=0.00038), increased microbiome expansion during hospitalisation (p=0.011) and domination by Enterobacteriaceae spp. (p=0.045). Enterobacteriaceae were also enriched among respiratory pathogens in anti-anaerobic-treated patients (p<2.2×10-16). In murine models, treatment with anti-anaerobic antibiotics increased susceptibility to Enterobacteriaceae pneumonia (p<0.05) and increased the lethality of hyperoxia (p=0.0002). CONCLUSIONS In critically ill patients, early treatment with anti-anaerobic antibiotics is associated with increased mortality. Mechanisms may include enrichment of the gut with respiratory pathogens, but increased mortality is incompletely explained by infections alone. Given consistent clinical and experimental evidence of harm, the widespread use of anti-anaerobic antibiotics should be reconsidered.
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Affiliation(s)
- Rishi Chanderraj
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Medicine Service, Infectious Diseases Section, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Jennifer M Baker
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Stephen G Kay
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Christopher A Brown
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Institute for Research on Innovation and Science, Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
| | - Kevin J Hinkle
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Daniel J Fergle
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Roderick A McDonald
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Nicole R Falkowski
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Joseph D Metcalf
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Keith S Kaye
- Division of Infectious Diseases, Department of Medicine, Rutgers-New Jersey Medical School, Newark, NJ, USA
| | - Robert J Woods
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Medicine Service, Infectious Diseases Section, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
- Computational Medicine and Bioinformatics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Hallie C Prescott
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- VA Center for Clinical Management Research, Ann Arbor, MI, USA
| | - Michael W Sjoding
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Computational Medicine and Bioinformatics, University of Michigan Medical School, Ann Arbor, MI, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI, USA
- Weil Institute for Critical Care Research and Innovation, Ann Arbor, MI, USA
| | - Robert P Dickson
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA
- Weil Institute for Critical Care Research and Innovation, Ann Arbor, MI, USA
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179
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Lee RA, Stripling JT, Spellberg B, Centor RM. Short-course antibiotics for common infections: what do we know and where do we go from here? Clin Microbiol Infect 2023; 29:150-159. [PMID: 36075498 DOI: 10.1016/j.cmi.2022.08.024] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/27/2022] [Accepted: 08/29/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Over the past 25 years, researchers have performed >120 randomized controlled trials (RCTs) illustrating short courses to be non-inferior to long courses of antibiotics for common bacterial infections. OBJECTIVE We sought to determine whether clinical data from RCTs affirm the mantra of 'shorter is better' for antibiotic durations in 7 common infections: pneumonia, urinary tract infection, intra-abdominal infection, bacteraemia, skin and soft tissue infection, bone and joint infections, pharyngitis and sinusitis. SOURCES Published RCTs comparing short- versus long-course antibiotic durations were identified through searches of PubMed and clinical guideline documents. CONTENT Short-course antibiotic durations consistently result in similar treatment success rates as longer antibiotic courses among patients with community-acquired pneumonia, complicated urinary tract infections in women, gram-negative bacteraemia, and skin and soft tissue infections when the diagnosis is confirmed, appropriate antimicrobials are used, and patients show clinical signs of improvement. For patients with osteomyelitis, 6 weeks of antibiotics is adequate for the treatment of osteomyelitis in the absence of implanted foreign bodies and surgical debridement. Whether durations can be further shortened with debridement is unclear, although small studies are promising. IMPLICATIONS With few exceptions, short courses were non-inferior to long courses; future research should focus on appropriately defining the patient population, ensuring the correct choice and dose of antimicrobials and developing meaningful outcomes relevant for frontline clinicians.
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Affiliation(s)
- Rachael A Lee
- Department of Medicine, Division of Infectious Diseases, University of Alabama Heersink School of Medicine, Birmingham, AL, USA; Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA.
| | - Joshua T Stripling
- Department of Medicine, Division of Infectious Diseases, University of Alabama Heersink School of Medicine, Birmingham, AL, USA; Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA
| | - Brad Spellberg
- Los Angeles County + University of Southern California Medical Center, Los Angeles, CA, USA
| | - Robert M Centor
- Birmingham Veterans Affairs Medical Center, Birmingham, AL, USA; Department of Medicine, University of Alabama Heersink School of Medicine, Birmingham, AL, USA
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Wan J, Bao Y, Hou LJ, Li GJ, Du LJ, Ma ZH, Yang GK, Hou Y, Li ZX, Yang Y. lncRNA ANRIL accelerates wound healing in diabetic foot ulcers via modulating HIF1A/VEGFA signaling through interacting with FUS. J Gene Med 2023; 25:e3462. [PMID: 36346049 DOI: 10.1002/jgm.3462] [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: 05/18/2022] [Revised: 09/06/2022] [Accepted: 10/22/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Diabetic foot ulcer (DFU) is a frequently diagnosed complication of diabetes, and remains a heathcare burden worldwide. However, the pathogenesis of DFU is still largely unclear. The objective of this study is to delineate the function and underlying mechanism of lncRNA antisense non coding RNA in the INK4 locus (ANRIL) in endothelial progenitor cells (EPCs) and DFU mice. METHODS The DFU mouse model was established, and EPCs were subjected to high glucose (HG) treatment to mimic diabetes. qRT-PCR or western blot was employed to detected the expression of ANRIL, HIF1A, FUS and VEGFA. CCK-8 and Annexin V/PI staining were used to monitor cell proliferation and apoptosis. Wound healing, Transwell invasion and tube formation assays were conducted to assess cell migration, invasion and angiogenesis, respectively. The association between ANRIL and FUS was verified by RNA pull-down and RIP assays. Luciferase and ChIP assays were employed to investigate HIF1A-mediated transcriptional regulation of VEGFA and ANRIL. The histological alterations of DFU wound healing were observed by H&E and Masson staining. RESULTS ANRIL was downregulated in peripheral blood samples of DFU patients, DFU mice and HG-treated EPCs. Mechanistically, ANRIL regulated HIFA mRNA stability via recruiting FUS. VEGFA and ANRIL were transcriptionally regulated by HIF1A. Functional experiments revealed that HG suppressed EPC proliferation, migration, invasion and tube formation, but promoted apoptosis via ANRIL/HIF1A axis. ANRIL accelerated DFU wound healing via modulating HIF1A expression in vivo. CONCLUSION ANRIL accelerated wound healing in DFU via modulating HIF1A/VEGFA signaling in a FUS-dependent manner.
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Affiliation(s)
- Jia Wan
- Department of Vascular Surgery, The Affiliated Hospital of Yunnan University, Kunming, Yunnan Province, P.R. China
| | - Yan Bao
- Department of Vascular Surgery, The Affiliated Hospital of Yunnan University, Kunming, Yunnan Province, P.R. China
| | - Li-Juan Hou
- Department of Vascular Surgery, The Affiliated Hospital of Yunnan University, Kunming, Yunnan Province, P.R. China
| | - Guo-Jian Li
- Department of Vascular Surgery, The Affiliated Hospital of Yunnan University, Kunming, Yunnan Province, P.R. China
| | - Ling-Juan Du
- Department of Vascular Surgery, The Affiliated Hospital of Yunnan University, Kunming, Yunnan Province, P.R. China
| | - Zhen-Huan Ma
- Department of Vascular Surgery, The Affiliated Hospital of Yunnan University, Kunming, Yunnan Province, P.R. China
| | - Guo-Kai Yang
- Department of Vascular Surgery, The Affiliated Hospital of Yunnan University, Kunming, Yunnan Province, P.R. China
| | - Yi Hou
- Department of Vascular Surgery, The Affiliated Hospital of Yunnan University, Kunming, Yunnan Province, P.R. China
| | - Zhao-Xiang Li
- Department of Vascular Surgery, The Affiliated Hospital of Yunnan University, Kunming, Yunnan Province, P.R. China
| | - Yong Yang
- Department of Vascular Surgery, The Affiliated Hospital of Yunnan University, Kunming, Yunnan Province, P.R. China
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Álvaro-Afonso FJ, García-Álvarez Y, Tardáguila-García A, García-Madrid M, López-Moral M, Lázaro-Martínez JL. Bacterial Diversity and Antibiotic Resistance in Patients with Diabetic Foot Osteomyelitis. Antibiotics (Basel) 2023; 12:antibiotics12020212. [PMID: 36830123 PMCID: PMC9951858 DOI: 10.3390/antibiotics12020212] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
This study analysed the bacterial diversity, antibiotic susceptibility, and resistance in patients with complications of diabetic foot osteomyelitis (DFO). A retrospective observational study was carried out between September 2019 and September 2022 and involved 215 outpatients with a diagnosis of DFO at a specialized diabetic foot unit. A total of 204 positive bone cultures were isolated, including 62.7% monomicrobial cultures, and 37.3% were formed with at least two microorganisms. We observed that Proteus spp., Coagulase-negative staphylococci (CoNS), Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, and Corynebacterium were the most frequently isolated microorganisms and accounted for more than 10% of the DFO cases. With stratification by Gram-positive (GP) and Gram-negative (GN) bacteria, we observed that 91.6% of cultures presented at least one GP bacteria species, and 50.4% presented at least one GN bacteria species. The most common GP species were CoNS (29%), S. aureus (25.8%), and Corynebacterium spp. (14%). The most frequent GN species consisted of Proteus spp. (32%), P. aeruginosa (23.3%), and E. coli (17.5%). The main antibiotics with resistance to GP-dominated infections were penicillins without β-lactamase inhibitor, and those in GN-dominated infections were sulfonamides and penicillins without β-lactamase. Significant differences were not observed in mean healing time in DFU with acute osteomyelitis (12.76 weeks (4.50;18)) compared to chronic osteomyelitis (15.31 weeks (7;18.25); p = 0.101) and when comparing cases with soft tissue infection (15.95 (6;20)) and those without such an infection (16.59 (7.25;19.75), p = 0.618). This study shows that when treatment of DFO is based on early surgical treatment, the type of DFO and the presence of soft infection are not associated with different or worse prognoses.
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Affiliation(s)
- Francisco Javier Álvaro-Afonso
- Diabetic Foot Unit, Clínica Universitaria de Podología, Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - Yolanda García-Álvarez
- Diabetic Foot Unit, Clínica Universitaria de Podología, Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
- Correspondence: ; Tel.: +34-913941609
| | - Aroa Tardáguila-García
- Diabetic Foot Unit, Clínica Universitaria de Podología, Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - Marta García-Madrid
- Diabetic Foot Unit, Clínica Universitaria de Podología, Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - Mateo López-Moral
- Diabetic Foot Unit, Clínica Universitaria de Podología, Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - José Luis Lázaro-Martínez
- Diabetic Foot Unit, Clínica Universitaria de Podología, Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
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Soldevila-Boixader L, Fernández AP, Laguna JM, Uçkay I. Local Antibiotics in the Treatment of Diabetic Foot Infections: A Narrative Review. Antibiotics (Basel) 2023; 12:antibiotics12010124. [PMID: 36671326 PMCID: PMC9854429 DOI: 10.3390/antibiotics12010124] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/03/2023] [Accepted: 01/05/2023] [Indexed: 01/11/2023] Open
Abstract
Along with the increasing global burden of diabetes, diabetic foot infections (DFI) and diabetic foot osteomyelitis (DFO) remain major challenges for patients and society. Despite progress in the development of prominent international guidelines, the optimal medical treatment for DFI and DFO remains unclear as to whether local antibiotics, that is, topical agents and local delivery systems, should be used alone or concomitant to conventional systemic antibiotics. To better inform clinicians in this evolving field, we performed a narrative review and summarized key relevant observational studies and clinical trials of non-prophylactic local antibiotics for the treatment of DFI and DFO, both alone and in combination with systemic antibiotics. We searched PubMed for studies published between January 2000 and October 2022, identified 388 potentially eligible records, and included 19 studies. Our findings highlight that evidence for adding local antibiotic delivery systems to standard DFO treatment remains limited. Furthermore, we found that so far, local antibiotic interventions have mainly targeted forefoot DFO, although there is marked variation in the design of the included studies. Suggestive evidence emerging from observational studies underscores that the addition of local agents to conventional systemic antibiotics might help to shorten the clinical healing time and overall recovery rates in infected diabetic foot ulcers, although the effectiveness of local antibiotics as a standalone approach remains overlooked. In conclusion, despite the heterogeneous body of evidence, the possibility that the addition of local antibiotics to conventional systemic treatment may improve outcomes in DFI and DFO cannot be ruled out. Antibiotic stewardship principles call for further research to elucidate the potential benefits of local antibiotics alone and in combination with conventional systemic antibiotics for the treatment of DFI and DFO.
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Affiliation(s)
- Laura Soldevila-Boixader
- Infectiology, Unit for Applied and Clinical Research, Balgrist University Hospital, 8008 Zurich, Switzerland
- Infectious Diseases Department, Bellvitge University Hospital, 08907 Hospitalet de Llobregat, Barcelona, Spain
- Correspondence:
| | - Alberto Pérez Fernández
- Orthopedics Department, Head of the Foot and Ankle Unit and Coordinator of Diabetic Foot Unit, Bellvitge University Hospital, 08907 Hospitalet de Llobregat, Barcelona, Spain
| | - Javier Muñoz Laguna
- EBPI-UZWH Musculoskeletal Epidemiology Research Group, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
- University Spine Centre Zurich (UWZH), Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Ilker Uçkay
- Infectiology, Unit for Applied and Clinical Research, Balgrist University Hospital, 8008 Zurich, Switzerland
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183
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Aagaard TV, Lindberg K, Brorson S, Madsen UR, Skou ST. A 12-Week Supervised Exercise Therapy Program for Patients with Diabetic Foot Ulcers: Program Development and Preliminary Feasibility. INT J LOW EXTR WOUND 2023:15347346221149786. [PMID: 36604981 DOI: 10.1177/15347346221149786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Exercise therapy helps improve glycaemic control and insulin sensitivity and may be relevant in treating patients with diabetic foot ulcers (DFUs). This study describes the development of a 12-week exercise therapy program for patients with DFUs and the preliminary feasibility of the program focusing on the program's inclusion, adherence, and safety. The development process is built on knowledge from a published systematic review on exercise for people with DFUs and a grounded theory study on the main concerns of people with DFUs regarding physical activity. The development involved doctors, wound care nurses, podiatrists, and feedback from patients and physical therapists using semi-structured interviews. The program was designed as a combination of aerobic and resistance training exercises. The aerobic exercise phase on the stationary bike of 30-minute duration was aimed at a moderate intensity. Resistance exercises were conducted with a 15-repetition maximum approach (four to five sets per trial) throughout the 12-week period. Three patients were included and received the exercise intervention. Except for recruitment and retention rates, acceptance levels were met for all other research progression criteria. Patients found the intervention relevant, wanted further guidance on continuing exercising, and would have liked the intervention closer to their home for example, a municipality setting. Although the exercise therapy program for patients with DFUs was developed in a thorough process with the inclusion of available evidence and the involvement of patients and other stakeholders conclusions on feasibility are limited due to the low recruitment rate. A reconsideration of the setting is needed in future exercise intervention studies.
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Affiliation(s)
- Thomas Vedste Aagaard
- Department of Physiotherapy and Occupational Therapy, 53163Holbaek Hospital, Holbaek, Denmark
- Department of Orthopaedic Surgery, 53163Holbaek Hospital, Holbaek, Denmark
- Department of Orthopaedic Surgery, Centre for Evidence-Based Orthopaedics, Zealand University Hospital, Koge, Denmark
| | - Kajsa Lindberg
- Health and Rehabilitation Centre Vanloese, Copenhagen Municipality, Copenhagen, Denmark
| | - Stig Brorson
- Department of Orthopaedic Surgery, Centre for Evidence-Based Orthopaedics, Zealand University Hospital, Koge, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Ulla Riis Madsen
- Department of Orthopaedic Surgery, 53163Holbaek Hospital, Holbaek, Denmark
- REHPA, Danish Knowledge Centre for Rehabilitation and Palliative Care, University of Southern Denmark, Odense, Denmark
| | - Søren T Skou
- Department of Physiotherapy and Occupational Therapy, The Research Unit PROgrez, Naestved-Slagelse-Ringsted Hospitals, Slagelse, Denmark
- Department of Sports Science and Clinical Biomechanics, Research Unit for Musculoskeletal Function and Physiotherapy, University of Southern Denmark, Odense, Denmark
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Bhasin A, Krueger KM, Williams J, Gulati R, Sisler N, Galvin S. Management patterns and outcomes of patients hospitalized with diabetic foot ulcers at one tertiary care hospital. Intern Emerg Med 2023; 18:185-191. [PMID: 36474123 DOI: 10.1007/s11739-022-03166-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022]
Abstract
A diabetic foot ulcer is present in approximately 2.4% of hospitalized patients. Care for diabetic foot ulcers is highly variable. We sought to describe care practice patterns and risk factors for poor outcomes for patients hospitalized with a diabetic foot ulcer in our institution, an 894-bed tertiary care academic hospital located in downtown Chicago, IL. We conducted a retrospective cohort study of patients hospitalized with a diabetic foot ulcer between March 3rd, 2018 and December 31st, 2019. We categorized patients into having an uncomplicated ulcer or a complicated ulcer with cellulitis, wound infection, osteomyelitis, or gangrene. We evaluated rates of diagnostic resource utilization (imaging, cultures, biopsies, and antibiotics) and outcomes of osteomyelitis, amputation, and death. There were 305 patients of interest in the study cohort. A complicated lower extremity ulcer was found in 79% of patients. Amputation was required in 25% of patients, 21% were readmitted, and 13% died. Imaging was obtained in less than 50% of all patients, and in 60% or less of those with osteomyelitis. Bone biopsies were rarely acquired. Empiric antibiotics were prescribed in 77% of patients with osteomyelitis. Male, Black or African-American patients, and those with high Charlson score had the highest risk of poor outcomes. Care practices for patients hospitalized with diabetic foot ulcers were highly variable. Future interventions should target standardization to improve outcomes, with particular attention to health inequities as vulnerable populations have a higher risk of poor outcomes.
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Affiliation(s)
- Ajay Bhasin
- Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, 211 E. Ontario, Suite 700, Chicago, IL, 60611, US.
- Division of Hospital Based Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, US.
| | - Karen Marie Krueger
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, US
| | - Janna Williams
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, US
| | - Reeti Gulati
- Northwestern University Feinberg School of Medicine, Chicago, IL, US
| | - Nathan Sisler
- Northwestern University Feinberg School of Medicine, Chicago, IL, US
| | - Shannon Galvin
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, US
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185
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Zhu Y, Lu J, Wang S, Xu D, Wu M, Xian S, Zhang W, Tong X, Liu Y, Huang J, Jiang L, Guo X, Xie S, Gu M, Jin S, Ma Y, Huang R, Xiao S, Ji S. Mapping intellectual structure and research hotspots in the field of fibroblast-associated DFUs: a bibliometric analysis. Front Endocrinol (Lausanne) 2023; 14:1109456. [PMID: 37124747 PMCID: PMC10140415 DOI: 10.3389/fendo.2023.1109456] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Accepted: 02/27/2023] [Indexed: 05/02/2023] Open
Abstract
Background Diabetic foot ulcers (DFUs) are one of the most popular and severe complications of diabetes. The persistent non-healing of DFUs may eventually contribute to severe complications such as amputation, which presents patients with significant physical and psychological challenges. Fibroblasts are critical cells in wound healing and perform essential roles in all phases of wound healing. In diabetic foot patients, the disruption of fibroblast function exacerbates the non-healing of the wound. This study aimed to summarize the hotspots and evaluate the global research trends on fibroblast-related DFUs through bibliometric analysis. Methods Scientific publications on the study of fibroblast-related DFUs from January 1, 2000 to April 27, 2022 were retrieved from the Web of Science Core Collection (WoSCC). Biblioshiny software was primarily performed for the visual analysis of the literature, CiteSpace software and VOSviewer software were used to validate the results. Results A total of 479 articles on fibroblast-related DFUs were retrieved. The most published countries, institutions, journals, and authors in this field were the USA, The Chinese University of Hong Kong, Wound Repair and Regeneration, and Seung-Kyu Han. In addition, keyword co-occurrence networks, historical direct citation networks, thematic map, and the trend topics map summarize the research hotspots and trends in this field. Conclusion Current studies indicated that research on fibroblast-related DFUs is attracting increasing concern and have clinical implications. The cellular and molecular mechanisms of the DFU pathophysiological process, the molecular mechanisms and therapeutic targets associated with DFUs angiogenesis, and the measures to promote DFUs wound healing are three worthy research hotspots in this field.
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Affiliation(s)
- Yushu Zhu
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
- Research Unit of Critical Techniques for Treatment of Burns and Combined Burns and Trauma Injury, Chinese Academy of Medical Sciences, Shanghai, China
| | - Jianyu Lu
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
- Research Unit of Critical Techniques for Treatment of Burns and Combined Burns and Trauma Injury, Chinese Academy of Medical Sciences, Shanghai, China
| | - Siqiao Wang
- School of Medicine, Tongji University, Shanghai, China
| | - Dayuan Xu
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
- Research Unit of Critical Techniques for Treatment of Burns and Combined Burns and Trauma Injury, Chinese Academy of Medical Sciences, Shanghai, China
| | - Minjuan Wu
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
- Research Unit of Critical Techniques for Treatment of Burns and Combined Burns and Trauma Injury, Chinese Academy of Medical Sciences, Shanghai, China
| | - Shuyuan Xian
- School of Medicine, Tongji University, Shanghai, China
| | - Wei Zhang
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
- Research Unit of Critical Techniques for Treatment of Burns and Combined Burns and Trauma Injury, Chinese Academy of Medical Sciences, Shanghai, China
| | - Xirui Tong
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
- Research Unit of Critical Techniques for Treatment of Burns and Combined Burns and Trauma Injury, Chinese Academy of Medical Sciences, Shanghai, China
| | - Yifan Liu
- School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jie Huang
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
- Research Unit of Critical Techniques for Treatment of Burns and Combined Burns and Trauma Injury, Chinese Academy of Medical Sciences, Shanghai, China
| | - Luofeng Jiang
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
- Research Unit of Critical Techniques for Treatment of Burns and Combined Burns and Trauma Injury, Chinese Academy of Medical Sciences, Shanghai, China
| | - Xinya Guo
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
- Research Unit of Critical Techniques for Treatment of Burns and Combined Burns and Trauma Injury, Chinese Academy of Medical Sciences, Shanghai, China
| | - Sujie Xie
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
- Research Unit of Critical Techniques for Treatment of Burns and Combined Burns and Trauma Injury, Chinese Academy of Medical Sciences, Shanghai, China
| | - Minyi Gu
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
- Research Unit of Critical Techniques for Treatment of Burns and Combined Burns and Trauma Injury, Chinese Academy of Medical Sciences, Shanghai, China
| | - Shuxin Jin
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
- Research Unit of Critical Techniques for Treatment of Burns and Combined Burns and Trauma Injury, Chinese Academy of Medical Sciences, Shanghai, China
| | - Yicheng Ma
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
- Research Unit of Critical Techniques for Treatment of Burns and Combined Burns and Trauma Injury, Chinese Academy of Medical Sciences, Shanghai, China
| | - Runzhi Huang
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
- Research Unit of Critical Techniques for Treatment of Burns and Combined Burns and Trauma Injury, Chinese Academy of Medical Sciences, Shanghai, China
- *Correspondence: Runzhi Huang, ; Shizhao Ji, ; Shichu Xiao,
| | - Shichu Xiao
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
- Research Unit of Critical Techniques for Treatment of Burns and Combined Burns and Trauma Injury, Chinese Academy of Medical Sciences, Shanghai, China
- *Correspondence: Runzhi Huang, ; Shizhao Ji, ; Shichu Xiao,
| | - Shizhao Ji
- Department of Burn Surgery, The First Affiliated Hospital of Naval Medical University, Shanghai, China
- Research Unit of Critical Techniques for Treatment of Burns and Combined Burns and Trauma Injury, Chinese Academy of Medical Sciences, Shanghai, China
- *Correspondence: Runzhi Huang, ; Shizhao Ji, ; Shichu Xiao,
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186
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Liu W, Song L, Sun W, Fang W, Wang C. Distribution of microbes and antimicrobial susceptibility in patients with diabetic foot infections in South China. Front Endocrinol (Lausanne) 2023; 14:1113622. [PMID: 36761201 PMCID: PMC9904418 DOI: 10.3389/fendo.2023.1113622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/10/2023] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND To investigate the distribution of microbes and drug susceptibility in patients with diabetic foot infections (DFI) and provide guidance for clinical empirical treatment and the rational selection of antibacterial drugs. METHODS Retrospective analysis of the pathogenic bacterium distribution and antimicrobial susceptibility isolated from 581 DFI patients with different Wagner grades. RESULTS The 534 positive samples included 473 cases (88.58%)) of monomicrobial infections and 61 cases (11.42%) of polymicrobial infections before antibiotic therapy. A total of 656 strains were cultivated, including 387 (58.99%) strains of gram-positive organisms (GPOs), 235 (35.82%) gram-negative bacilli (GNB), and 21 (3.20%) fungal strains. Polymicrobial infections mainly occurred in patients with Wagner grade 3-4 ulcers. GPOs were predominant in Wagner grades 1-3 (grade 1: 96.67%, grade 2: 76.52%, grade 3 62.81%), and the most common was Staphylococcus aureus (grade 1: 31.66%, grade 2: 33.04%, grade 3 35.53%). GNB were predominant in grades 4-5 (grade 4: 51.46%, grade 5:60%), and the most common GNB in Wagner grades 4-5 was Proteus (grade 4:27.88%, grade 5: 42.86%), while the most common GPO was Enterococcus (grade 4:34.48%, grade 5:25.00%). Staphylococcus (including MRSA) and Enterococcus were still highly sensitive to vancomycin, linezolid, and tigecycline. Most GNB were still highly sensitive to meropenem, tigecycline, ertapenem, and amikacin. Proteus was most sensitive to amikacin (97.14%), followed by meropenem (92%) and ertapenem (80%). CONCLUSION The distribution of microbes and antimicrobial susceptibility in DFI patients varied with different Wagner grades. The most appropriate antimicrobial therapy should be selected based on the pathogen culture and antimicrobial susceptibility.
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Affiliation(s)
| | | | | | - Weijin Fang
- *Correspondence: Weijin Fang, ; Chun Jiang Wang,
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187
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Park C, Mishra R, Vigano D, Macagno M, Rossotti S, D’Huyvetter K, Garcia J, Armstrong DG, Najafi B. Smart Offloading Boot System for Remote Patient Monitoring: Toward Adherence Reinforcement and Proper Physical Activity Prescription for Diabetic Foot Ulcer Patients. J Diabetes Sci Technol 2023; 17:42-51. [PMID: 35048739 PMCID: PMC9846414 DOI: 10.1177/19322968211070850] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND A critical factor in healing diabetic foot ulcers is patient adherence to offloading devices. We tested a smart offloading boot (SmartBoot) combined with a smartwatch app and cloud dashboard to remotely monitor patient adherence and activity. In addition, the impact of SmartBoot on balance, gait, and user experience was investigated. METHODS Fourteen volunteers (31.6±8.7 years; 64% female) performed natural activities (eg, sitting, standing, walking) with and without the SmartBoot for approximately 30 minutes. All participants completed balance tests, 10-meter walking tests at slow, normal, and fast pace while wearing the SmartBoot, and a user experience questionnaire. The accuracy of real-time adherence reporting was assessed by comparing the SmartBoot and staff observation. Center of mass (COM) sway and step counts were measured using a validated wearable system. RESULTS Average sensitivity, specificity, and accuracy for adherence and non-adherence were 90.6%, 88.0%, and 89.3%, respectively. The COM sway area was significantly smaller with the SmartBoot than without the SmartBoot regardless of test condition. Step count error was 4.4% for slow waking, 36.2% for normal walking, 16.0% for fast walking. Most participants agreed that the SmartBoot is easy to use, relatively comfortable, nonintrusive, and innovative. CONCLUSIONS To our knowledge, this is the first smart offloading system that enables remote patient monitoring and real-time adherence and activity reporting. The SmartBoot enhanced balance performance, likely due to somatosensory feedback. Questionnaire results highlight SmartBoot's technical and clinical potential. Future studies warrant clinical validation of real-time non-adherence alerting to improve wound healing outcomes in people with diabetic foot ulcers.
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Affiliation(s)
- Catherine Park
- Interdisciplinary Consortium on
Advanced Motion Performance, Michael E. DeBakey Department of Surgery, Baylor
College of Medicine, Houston, TX, USA
- VA HSR&D, Center for Innovations in
Quality, Effectiveness, and Safety, Michael E. DeBakey VA Medical Center, Houston,
TX, USA
- Big Data Scientist Training Enhancement
Program, VA Office of Research and Development, Washington, DC, USA
| | - Ramkinker Mishra
- Interdisciplinary Consortium on
Advanced Motion Performance, Michael E. DeBakey Department of Surgery, Baylor
College of Medicine, Houston, TX, USA
| | | | | | | | - Karen D’Huyvetter
- Southwestern Academic Limb Salvage
Alliance, Keck School of Medicine, University of Southern California, Los Angeles,
CA, USA
| | - Jason Garcia
- Southwestern Academic Limb Salvage
Alliance, Keck School of Medicine, University of Southern California, Los Angeles,
CA, USA
| | - David G. Armstrong
- Southwestern Academic Limb Salvage
Alliance, Keck School of Medicine, University of Southern California, Los Angeles,
CA, USA
- National Center for Rehabilitation at
Rancho Los Amigos, Downey, CA, USA
| | - Bijan Najafi
- Interdisciplinary Consortium on
Advanced Motion Performance, Michael E. DeBakey Department of Surgery, Baylor
College of Medicine, Houston, TX, USA
- Bijan Najafi, PhD, Interdisciplinary
Consortium on Advanced Motion Performance, Michael E. DeBakey Department of
Surgery, Baylor College of Medicine, 7200 Cambridge St, Houston, TX 77030, USA.
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188
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Variables That Could Influence Healing Time in Patients with Diabetic Foot Osteomyelitis. J Clin Med 2023; 12:jcm12010345. [PMID: 36615145 PMCID: PMC9820935 DOI: 10.3390/jcm12010345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/27/2022] [Accepted: 12/29/2022] [Indexed: 01/03/2023] Open
Abstract
AIM To compare the healing time in patients with diabetic foot osteomyelitis according to the presence or absence of clinical signs of infection, variation of blood parameters, the presence of different radiological signs, and the treatment received for the management of osteomyelitis. METHODS A prospective observational study was carried out in a specialised Diabetic Foot Unit between November 2014 and November 2018. A total of 116 patients with osteomyelitis were included in the study (treated by either a surgical or medical approach). During the baseline visit, we assessed the diagnosis of osteomyelitis, demographic characteristics and medical history, vascular and neurological examination, clinical signs of infection, increased blood parameters, radiological signs of osteomyelitis, and the treatment to manage osteomyelitis. We analysed the association between the presence of clinical signs of infection, variation of blood parameters, presence of radiological signs, and treatment received for management of osteomyelitis with the healing time. RESULTS The mean time to ulcer healing was 15.8 ± 9.7 weeks. Concerning healing times, we did not find an association with the presence of clinical signs of infection or with the increase in blood parameters, except in the case of eosinophils, which with higher values appear to increase the healing time (U = 66, z = -2.880, p = 0.004). Likewise, no relationship has been found between healing time and the appearance of the different radiological signs of osteomyelitis, nor depending on the treatment administered for the management of osteomyelitis. CONCLUSION High levels of eosinophils are associated with a longer healing time of diabetic foot ulcers complicated with osteomyelitis, finding no other factors related to increased healing time.
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189
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McCreery RJ, Lyden E, Anderson M, Van Schooneveld TC. Impact of a syndrome-specific antibiotic stewardship intervention on antipseudomonal antibiotic use in inpatient diabetic foot infection management. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2023; 3:e39. [PMID: 36960089 PMCID: PMC10028944 DOI: 10.1017/ash.2023.123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 01/23/2023] [Accepted: 01/23/2023] [Indexed: 03/06/2023]
Abstract
Objective To demonstrate that a syndromic stewardship intervention can safely reduce antipseudomonal antibiotic use in the treatment of inpatient diabetic foot infections (DFIs). Intervention and method From November 2017 through March 2018, we performed an antimicrobial stewardship intervention that included creation of a DFI best-practice guideline, implementation of an electronic medical record order set, and targeted education of key providers. We conducted a retrospective before-and-after study evaluating guideline adherent antipseudomonal antibiotic use 1 year before and after the intervention using interrupted time-series analysis. Setting University of Nebraska Medical Center, a 718-bed academic medical center in Omaha, Nebraska. Patients The study included 193 adults aged ≥19 years (105 in the preintervention group and 88 in the postintervention group) admitted to non-intensive care units whose primary reason for antibiotic treatment was diabetic foot infection (DFI). Results Guideline-adherent use of antipseudomonal antibiotics increased from 39% before the intervention to 68% after the intervention (P ≤ .0001). Antipseudomonal antibiotic use decreased from 538 days of therapy (DOT) per 1,000 DFI patient days (PD) before the intervention to 272 DOT per 1,000 DFI PD after the intervention (P < .0001), with a statistically significant decrease in both level of use and slope of change. We did not detect any changes in length of stay, readmission, amputation rate, subsequent positive Clostridioides difficile testing, or mortality. Conclusions Our 3-component intervention of guideline creation, implementation of an order set, and targeted education was associated with a significant decrease in antipseudomonal antibiotic use in the management of inpatient DFIs. DFIs are common and should be considered as opportunities for syndromic stewardship intervention.
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Affiliation(s)
- Randy J. McCreery
- Department of Internal Medicine, Section of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska
- Author for correspondence: Randy J. McCreery, MD, University of Nebraska Medical Center, S 42nd St & Emile St, Omaha, NE68198. E-mail: . Or Trevor Van Schooneveld, MD, University of Nebraska Medical Center, S 42nd St & Emile St, Omaha, NE 68198. E-mail:
| | - Elizabeth Lyden
- College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska
| | - Matthew Anderson
- College of Public Health, University of Nebraska Medical Center, Omaha, Nebraska
| | - Trevor C. Van Schooneveld
- Department of Internal Medicine, Section of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska
- Author for correspondence: Randy J. McCreery, MD, University of Nebraska Medical Center, S 42nd St & Emile St, Omaha, NE68198. E-mail: . Or Trevor Van Schooneveld, MD, University of Nebraska Medical Center, S 42nd St & Emile St, Omaha, NE 68198. E-mail:
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190
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Rai V, Agrawal DK. Male or female sex: considerations and translational aspects in diabetic foot ulcer research using rodent models. Mol Cell Biochem 2022. [DOI: 10.1007/s11010-022-04642-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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191
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Weng B, Oskooilar Y, Zakhary B, Chiu CA, Wu P, Mulligan N, Sutjita M. Evaluating Predictive Value of Surgical Resected Proximal Bone Margins in Diabetic Foot Osteomyelitis With Clinical Outcomes at 1 Year. Open Forum Infect Dis 2022; 10:ofac689. [PMID: 36632419 PMCID: PMC9830536 DOI: 10.1093/ofid/ofac689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/23/2022] [Indexed: 12/28/2022] Open
Abstract
Background Osteomyelitis of the diabetic foot remains a significant complication that may result in the need for amputation. Proximal surgical margin histopathology after limb-sparing amputation could be used to guide antimicrobial duration and prognostic management but remains debatable. Here we evaluate if negative proximal bone margins predict outcomes of diabetic foot osteomyelitis at 1 year. Methods A retrospective study assessed adults with diabetes undergoing limb-sparing foot amputations from September 2016 to September 2019. Patients required histopathology confirmation of osteomyelitis, proximal margin histopathology report, and documented electronic medical record follow-up through 12 months. The primary outcome evaluated if no further amputation at the same site was required in the following 12 months. Results Of 92 patients, 57 (61.9%) had pathology-confirmed negative margins for osteomyelitis. Patients with negative margins required less frequent subsequent amputations at the same site within 12 months compared to positive margins (86.0% vs 65.7%; P = .003). Antibiotic duration was shorter in patients with negative margins (mean, 18 vs 30 days; P = .001). Negative-margin patients also noted lower rates of readmission at 12 months (26.3% vs 51.4%; P = .015) for site-specific complications. Staphylococcus aureus was more predominant in patients with positive versus negative margins (57.1% vs 29.8%; P = .017). Conclusions Negative proximal bone margin by histopathology was associated with lower frequency of further amputations at the index surgical site within 12 months. This group also received shorter courses of antibiotic therapy. It was also associated with lower rates of readmission at 12 months for surgical-site complications. Proximal margin histopathology results potentially can be integrated to guide antimicrobial duration and decrease the frequency of further amputation at the original site.
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Affiliation(s)
- Bruce Weng
- Correspondence: Bruce Weng, DO, Infectious Disease - Department of Internal Medicine, Riverside University Health System, 26520 Cactus Ave, Moreno Valley, CA 92555, USA ()
| | - Yasmin Oskooilar
- Department of Internal Medicine, University of California, Riverside, California, USA
| | - Bishoy Zakhary
- Comparative Effectiveness and Clinical Outcomes Research Center, Riverside University Health System, Moreno Valley, California, USA
| | - Chiao An Chiu
- Department of Pharmacy, Riverside University Health System, Moreno Valley, California, USA
| | - Patrick Wu
- Division of Infectious Diseases, Department of Internal Medicine, Riverside University Health System, Moreno Valley, California, USA
- Department of Internal Medicine, University of California, Riverside, California, USA
| | - Nikki Mulligan
- Department of Pharmacy, Riverside University Health System, Moreno Valley, California, USA
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192
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Ryan EC, Crisologo PA, Oz OK, Fontaine JL, Wukich DK, Malone M, Lavery LA. Incidence and Recovery of Acute Kidney Injury in Diabetic and Nondiabetic Patients with Foot Infections. J Am Podiatr Med Assoc 2022; 112:446965. [PMID: 33141881 DOI: 10.7547/20-167] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 10/24/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the incidence and recovery of acute kidney injury (AKI) in patients admitted to the hospital with and without diabetes mellitus (DM) with foot infections. METHODS We retrospectively reviewed 294 patients with DM and 88 without DM admitted to the hospital with foot infections. The Kidney Disease: Improving Global Outcomes guidelines were used to define AKI. Recovery was divided into three categories: full, partial, and no recovery within 90 days of the index AKI. RESULTS The AKI incidence was 3.0 times higher in patients with DM (DM 48.5% versus no DM 23.9%; 95% confidence interval [CI], 1.74-5.19; P < .01). Acute kidney injury incidence was similar at each stage in people with and without DM (stage 1, DM 58.1% versus no DM 47.6%; stage 2, DM 23.3% versus no DM 33.3%, and stage 3, DM 18.6% versus no DM 19.1%). Twenty-nine patients with diabetes had a second AKI event and four had a third event. In patients without DM, one patient had a second AKI. Cumulative AKI incidence was 4.7 times higher in people with DM (DM 60.9% versus no DM 25.0%; 95% CI, 2.72-8.03; P < .01). Patients with diabetes progressed to chronic kidney disease or in chronic kidney disease stage 39.4% of the time. Patients without diabetes progressed 16.7% of the time, but this trend was not significant (P = .07). Complete recovery was 3.8 times more likely in patients without diabetes (95% CI, 1.26-11.16; P = .02). CONCLUSIONS Acute kidney injury incidence is higher in patients with diabetes, and complete recovery after an AKI is less likely compared to patients without diabetes.
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Affiliation(s)
- Easton C Ryan
- *University of Texas Southwestern Medical School, Dallas, TX
| | - Peter Andrew Crisologo
- †Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Orhan K Oz
- ‡Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Javier La Fontaine
- †Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Dane K Wukich
- §Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Matthew Malone
- ¶South West Sydney Limb Preservation and Wound Research Academic Unit, South Western Sydney Local Health District, Sydney, New South Wales, Australia
| | - Lawrence A Lavery
- †Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX
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193
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Jhaveri VV, Sullivan C, Ward A, Giurini JM, Karchmer AW, Stillman IE, Davis RB, Freed JA, LaSalvia MT, Stead W. More Specialties, Fewer Problems: Using Collaborative Competency Between Infectious Diseases, Podiatry, and Pathology to Improve the Care of Patients with Diabetic Foot Osteomyelitis. J Am Podiatr Med Assoc 2022; 112:461851. [PMID: 33630067 DOI: 10.7547/20-178] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 10/16/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Diabetic foot osteomyelitis is a common infection where treatment involves multiple services, including infectious diseases, podiatry, and pathology. Despite its ubiquity in the hospital, consensus on much of its management is lacking. METHODS Representatives from infectious diseases, podiatry, and pathology interested in quality improvement developed multidisciplinary institutional recommendations culminating in an educational intervention describing optimal diagnostic and therapeutic approaches to diabetic foot osteomyelitis (DFO). Knowledge acquisition was assessed by preintervention and postintervention surveys. Inpatients with forefoot DFO were retrospectively reviewed before and after intervention to assess frequency of recommended diagnostic and therapeutic maneuvers, including appropriate definition of surgical bone margins, definitive histopathology reports, and unnecessary intravenous antibiotics or prolonged antibiotic courses. RESULTS A postintervention survey revealed significant improvements in knowledge of antibiotic treatment duration and the role of oral antibiotics in managing DFO. There were 104 consecutive patients in the preintervention cohort (April 1, 2018, to April 1, 2019) and 32 patients in the postintervention cohort (November 5, 2019, to March 1, 2020), the latter truncated by changes in hospital practice during the coronavirus disease 2019 pandemic. Noncategorizable or equivocal disease reports decreased from before intervention to after intervention (27.0% versus 3.3%, respectively; P = .006). We observed nonsignificant improvement in correct bone margin definition (74.0% versus 87.5%; P = .11), unnecessary peripherally inserted central catheter line placement (18.3% versus 9.4%; P = .23), and unnecessary prolonged antibiotics (21.9% versus 5.0%; P = .10). In addition, by working as an interdisciplinary group, many solvable misunderstandings were identified, and processes were adjusted to improve the quality of care provided to these patients. CONCLUSIONS This quality improvement initiative regarding management of DFO led to improved provider knowledge and collaborative competency between these three departments, improvements in definitive pathology reports, and nonsignificant improvement in several other clinical endpoints. Creating collaborative competency may be an effective local strategy to improve knowledge of diabetic foot infection and may generalize to other common multidisciplinary conditions.
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Affiliation(s)
- Vimal V Jhaveri
- *Division of Infectious Diseases, Department of Medicine, Boston, MA.,¶Harvard Medical School, Boston, MA
| | - Christopher Sullivan
- †Division of Podiatry, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Ashley Ward
- ‡Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA.,¶Harvard Medical School, Boston, MA
| | - John M Giurini
- †Division of Podiatry, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, MA
| | - Adolf W Karchmer
- *Division of Infectious Diseases, Department of Medicine, Boston, MA.,¶Harvard Medical School, Boston, MA
| | - Isaac E Stillman
- ‡Department of Pathology, Beth Israel Deaconess Medical Center, Boston, MA.,¶Harvard Medical School, Boston, MA
| | - Roger B Davis
- ‖Division of General Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.,¶Harvard Medical School, Boston, MA
| | - Jason A Freed
- §Division of Hematology and Hematologic Malignancies, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA.,¶Harvard Medical School, Boston, MA
| | - Mary T LaSalvia
- *Division of Infectious Diseases, Department of Medicine, Boston, MA.,¶Harvard Medical School, Boston, MA.,#Co-senior author
| | - Wendy Stead
- *Division of Infectious Diseases, Department of Medicine, Boston, MA.,¶Harvard Medical School, Boston, MA.,#Co-senior author
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194
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Hu YJ, Song CS, Jiang N. Single nucleotide variations in the development of diabetic foot ulcer: A narrative review. World J Diabetes 2022; 13:1140-1153. [PMID: 36578869 PMCID: PMC9791576 DOI: 10.4239/wjd.v13.i12.1140] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2022] [Revised: 11/24/2022] [Accepted: 12/05/2022] [Indexed: 12/15/2022] Open
Abstract
Diabetes mellitus has become a global health problem, and the number of patients with diabetic foot ulcers (DFU) is rapidly increasing. Currently, DFU still poses great challenges to physicians, as the treatment is complex, with high risks of infection, recurrence, limb amputation, and even death. Therefore, a comprehensive understanding of DFU pathogenesis is of great importance. In this review, we summarized recent findings regarding the DFU development from the perspective of single-nucleotide variations (SNVs). Studies have shown that SNVs located in the genes encoding C-reactive protein, interleukin-6, tumor necrosis factor-alpha, stromal cell-derived factor-1, vascular endothelial growth factor, nuclear factor erythroid-2-related factor 2, sirtuin 1, intercellular adhesion molecule 1, monocyte chemoattractant protein-1, endothelial nitric oxide synthase, heat shock protein 70, hypoxia inducible factor 1 alpha, lysyl oxidase, intelectin 1, mitogen-activated protein kinase 14, toll-like receptors, osteoprotegerin, vitamin D receptor, and fibrinogen may be associated with the development of DFU. However, considering the limitations of the present investigations, future multi-center studies with larger sample sizes, as well as in-depth mechanistic research are warranted.
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Affiliation(s)
- Yan-Jun Hu
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Southern Medical University Nanfang Hospital, Guangzhou 510515, Guangdong Province, China
| | - Chen-Sheng Song
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Southern Medical University Nanfang Hospital, Guangzhou 510515, Guangdong Province, China
| | - Nan Jiang
- Division of Orthopaedics and Traumatology, Department of Orthopaedics, Southern Medical University Nanfang Hospital, Guangzhou 510515, Guangdong Province, China
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195
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Pappachan JM, Cassidy B, Fernandez CJ, Chandrabalan V, Yap MH. The role of artificial intelligence technology in the care of diabetic foot ulcers: the past, the present, and the future. World J Diabetes 2022; 13:1131-1139. [PMID: 36578875 PMCID: PMC9791570 DOI: 10.4239/wjd.v13.i12.1131] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 11/01/2022] [Accepted: 12/01/2022] [Indexed: 12/15/2022] Open
Abstract
Foot ulcers are common complications of diabetes mellitus and substantially increase the morbidity and mortality due to this disease. Wound care by regular monitoring of the progress of healing with clinical review of the ulcers, dressing changes, appropriate antibiotic therapy for infection and proper offloading of the ulcer are the cornerstones of the management of foot ulcers. Assessing the progress of foot ulcers can be a challenge for the clinician and patient due to logistic issues such as regular attendance in the clinic. Foot clinics are often busy and because of manpower issues, ulcer reviews can be delayed with detrimental effects on the healing as a result of a lack of appropriate and timely changes in management. Wound photographs have been historically useful to assess the progress of diabetic foot ulcers over the past few decades. Mobile phones with digital cameras have recently revolutionized the capture of foot ulcer images. Patients can send ulcer photographs to diabetes care professionals electronically for remote monitoring, largely avoiding the logistics of patient transport to clinics with a reduction on clinic pressures. Artificial intelligence-based technologies have been developed in recent years to improve this remote monitoring of diabetic foot ulcers with the use of mobile apps. This is expected to make a huge impact on diabetic foot ulcer care with further research and development of more accurate and scientific technologies in future. This clinical update review aims to compile evidence on this hot topic to empower clinicians with the latest developments in the field.
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Affiliation(s)
- Joseph M Pappachan
- Department of Endocrinology & Metabolism, Lancashire Teaching Hospitals NHS Trust, Preston PR2 9HT, United Kingdom
- Faculty of Science and Engineering, Manchester Metropolitan University, Manchester M15 6BH, United Kingdom
| | - Bill Cassidy
- Faculty of Science and Engineering, Manchester Metropolitan University, Manchester M15 6BH, United Kingdom
| | | | - Vishnu Chandrabalan
- Department of Data Science, Lancashire Teaching Hospitals NHS Trust, Preston PR2 9HT, United Kingdom
| | - Moi Hoon Yap
- Faculty of Science and Engineering, Manchester Metropolitan University, Manchester M15 6BH, United Kingdom
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196
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Yang L, Rong GC, Wu QN. Diabetic foot ulcer: Challenges and future. World J Diabetes 2022; 13:1014-1034. [PMID: 36578870 PMCID: PMC9791573 DOI: 10.4239/wjd.v13.i12.1014] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Revised: 10/07/2022] [Accepted: 11/29/2022] [Indexed: 12/15/2022] Open
Abstract
Diabetic foot ulcers (DFUs) have become one of the important causes of mortality and morbidity in patients with diabetes, and they are also a common cause of hospitalization, which places a heavy burden on patients and society. The prevention and treatment of DFUs requires multidisciplinary management. By controlling various risk factors, such as blood glucose levels, blood pressure, lipid levels and smoking cessation, local management of DFUs should be strengthened, such as debridement, dressing, revascularization, stem cell decompression and oxygen therapy. If necessary, systemic anti-infection treatment should be administered. We reviewed the progress in the clinical practice of treating DFUs in recent years, such as revascularization, wound repair, offloading, stem cell transplantation, and anti-infection treatment. We also summarized and prospectively analyzed some new technologies and measurements used in the treatment of DFUs and noted the future challenges and directions for the development of DFU treatments.
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Affiliation(s)
- Li Yang
- Department of Endocrinology, Dazu Hospital of Chongqing Medical University, The People's Hospital of Dazu, Chongqing 402360, China
| | - Gui-Chuan Rong
- Department of Gynaecology, Dazu Hospital of Chongqing Medical University, The People's Hospital of Dazu, Chongqing 402360, China
| | - Qi-Nan Wu
- Department of Endocrinology, Dazu Hospital of Chongqing Medical University, The People's Hospital of Dazu, Chongqing 402360, China
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197
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Deng X, Wang S, Yang Y, Chen A, Lu J, Hao J, Wu Y, Lu Q. Reduced macula microvascular densities may be an early indicator for diabetic peripheral neuropathy. Front Cell Dev Biol 2022; 10:1081285. [PMID: 36568975 PMCID: PMC9788121 DOI: 10.3389/fcell.2022.1081285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 11/22/2022] [Indexed: 12/13/2022] Open
Abstract
Purpose: To assess the alteration in the macular microvascular in type 2 diabetic patients with peripheral neuropathy (DPN) and without peripheral neuropathy (NDPN) by optical coherence tomography angiography (OCTA) and explore the correlation between retinal microvascular abnormalities and DPN disease. Methods: Twenty-seven healthy controls (42 eyes), 36 NDPN patients (62 eyes), and 27 DPN patients (40 eyes) were included. OCTA was used to image the macula in the superficial vascular complex (SVC) and deep vascular complex (DVC). In addition, a state-of-the-art deep learning method was employed to quantify the microvasculature of the two capillary plexuses in all participants using vascular length density (VLD). Results: Compared with the healthy control group, the average VLD values of patients with DPN in SVC (p = 0.010) and DVC (p = 0.011) were significantly lower. Compared with NDPN, DPN patients showed significantly reduced VLD values in the SVC (p = 0.006) and DVC (p = 0.001). Also, DPN patients showed lower VLD values (p < 0.05) in the nasal, superior, temporal and inferior sectors of the inner ring of the SVC when compared with controls; VLD values in NDPN patients were lower in the nasal section of the inner ring of SVC (p < 0.05) compared with healthy controls. VLD values in the DVC (AUC = 0.736, p < 0.001) of the DPN group showed a higher ability to discriminate microvascular damage when compared with NDPN. Conclusion: OCTA based on deep learning could be potentially used in clinical practice as a new indicator in the early diagnosis of DM with and without DPN.
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Affiliation(s)
- Xiaoyu Deng
- The Affiliated People’s Hospital of Ningbo University, Ningbo, China
| | - Shiqi Wang
- The Affiliated People’s Hospital of Ningbo University, Ningbo, China
| | - Yan Yang
- The Affiliated People’s Hospital of Ningbo University, Ningbo, China
| | - Aizhen Chen
- The Affiliated People’s Hospital of Ningbo University, Ningbo, China
| | - Jinger Lu
- The Affiliated People’s Hospital of Ningbo University, Ningbo, China
| | - Jinkui Hao
- Cixi Institute of Biomedical Engineering, Ningbo Institute of Materials Technology and Engineering, Chinese Academy of Sciences, Ningbo, China
| | - Yufei Wu
- The Affiliated People’s Hospital of Ningbo University, Ningbo, China
| | - Qinkang Lu
- The Affiliated People’s Hospital of Ningbo University, Ningbo, China
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198
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Xu J, Li S, Sun Y, Bao B, Zhu T, Kang Q, Zheng X, Wen G. Triplanar osteotomy combined with proximal tibial transverse transport to accelerate healing of recalcitrant diabetic foot ulcers. J Orthop Surg Res 2022; 17:528. [PMID: 36482382 PMCID: PMC9733084 DOI: 10.1186/s13018-022-03410-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 11/16/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Management of recalcitrant diabetic foot ulcers remains challenging. Tibial transverse transport (TTT) is an effective method for enhancing the healing of foot ulcers. This retrospective study reports a novel triplanar osteotomy in the tibia and assesses the clinical outcomes of TTT for diabetic foot ulcers. METHODS Fifty-nine patients with recalcitrant diabetic foot ulcers were divided into the TTT (32 patients) and control (27 patients) groups. In the TTT group, the patients underwent triplanar osteotomy of the proximal tibia, followed by 2 weeks of medial distraction and 2 weeks of lateral distraction. In the control group, the patients received conventional management, including debridement, revascularization, and reconstruction. Ulcer healing and healing time, amputation, recurrence, and complications were assessed at an 18-month follow-up visit. Computed tomography angiography (CTA) was used to evaluate vessel changes in the lower limbs of patients in the TTT group. RESULTS The TTT group was superior to the control group in the healing rate (90.6% [29/32] vs. 66.7% [18/27]) and the healing time (4.6 ± 1.7 months vs. 7.4 ± 2.5 months), respectively. The proportions of amputation and recurrence in the TTT group were lower than that in the control group, without statistical difference. After triplanar osteotomy and transverse distraction, CTA demonstrated an increase in small vessels in the wound and ipsilateral limb. All patients achieved satisfactory union of the osteotomized bone fragment after removal of the external fixator. CONCLUSIONS Triplanar osteotomy combined with proximal tibial transverse distraction accelerates wound healing and limb salvage caused by severe and recalcitrant diabetic foot ulcers. Triplanar osteotomy not only increases the bone contact area, which is beneficial for rapid bone reconstruction, but also preserves the vascularization of the bone fragment and substantially facilitates capillary angiogenesis during distraction. These results suggest that triplanar osteotomy followed by tibial transverse distraction is an effective method for treating diabetic foot ulcers.
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Affiliation(s)
- Jia Xu
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Xuhui District, Shanghai, 200233, China
| | - Shanyu Li
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Xuhui District, Shanghai, 200233, China
| | - Yunchu Sun
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Xuhui District, Shanghai, 200233, China
| | - Bingbo Bao
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Xuhui District, Shanghai, 200233, China
| | - Tianhao Zhu
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Xuhui District, Shanghai, 200233, China
| | - Qinglin Kang
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Xuhui District, Shanghai, 200233, China
| | - Xianyou Zheng
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Xuhui District, Shanghai, 200233, China.
| | - Gen Wen
- Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, 600 Yishan Road, Xuhui District, Shanghai, 200233, China.
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199
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Pham TT, Andrey DO, Stampf S, Burkhard SH, Hirzel C, Tschopp J, Ullrich K, Strahm C, Schreiber PW, Boillat-Blanco N, Garzoni C, Khanna N, Manuel O, Mueller NJ, Suva D, van Delden C, Uçkay I, Neofytos D. Epidemiology and outcomes of bone and joint infections in solid organ transplant recipients. Am J Transplant 2022; 22:3031-3046. [PMID: 36031963 PMCID: PMC10087422 DOI: 10.1111/ajt.17184] [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: 04/03/2022] [Revised: 08/23/2022] [Accepted: 08/24/2022] [Indexed: 01/25/2023]
Abstract
Bone and joint infection (BJI) epidemiology and outcomes in solid organ transplant recipients (SOTr) remain largely unknown. We aim to describe BJI in a multi-center cohort of SOTr (Swiss Transplant Cohort Study). All consecutive SOTr with BJI (01.05.2008-31.12.2019) were included. A nested case-control study to identify risk factors for BJI was performed. Among 4482 patients, 61 SOTr with 82 BJI were included, at an incidence of 1.4% (95% CI 1.1-1.7), higher in heart and kidney-pancreas SOTr (Gray's test p < .01). Although BJI were predominately late events (median of 18.5 months post-SOT), most infections occurred during the first year post-transplant in thoracic SOTr. Diabetic foot osteomyelitis was the most frequent infection (38/82, 46.3%), followed by non-vertebral osteomyelitis (26/82, 31.7%). Pathogens included Gram-positive cocci (70/131, 53.4%), Gram-negative bacilli (34/131, 26.0%), and fungi (9/131, 6.9%). BJI predictors included male gender (OR 2.94, 95% CI 1.26-6.89) and diabetes (OR 2.97, 95% CI 1.34-6.56). Treatment failure was observed in 25.9% (21/81) patients and 1-year mortality post-BJI diagnosis was 14.8% (9/61). BJI remain a rare event in SOTr, associated with subtle clinical presentations, high morbidity and relapses, requiring additional studies in the future.
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Affiliation(s)
- Truong-Thanh Pham
- Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland.,Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Diego O Andrey
- Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland
| | - Susanne Stampf
- Clinic for Transplantation Immunology and Nephrology (Swiss Transplant Cohort Study), University Hospital of Basel, Basel, Switzerland
| | - Sara H Burkhard
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Cédric Hirzel
- Department of Infectious Diseases, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Johnathan Tschopp
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Kathrin Ullrich
- Division of Infectious Diseases and Hospital Epidemiology, University and University Hospital of Basel, Basel, Switzerland
| | - Carol Strahm
- Division of Infectious Diseases and Hospital Epidemiology, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Peter W Schreiber
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Noémie Boillat-Blanco
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Christian Garzoni
- Departments of Internal Medicine and Infectious Disease, Clinica Luganese, Lugano, Switzerland
| | - Nina Khanna
- Division of Infectious Diseases and Hospital Epidemiology, University and University Hospital of Basel, Basel, Switzerland
| | - Oriol Manuel
- Infectious Diseases Service, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.,Transplantation Center, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Nicolas J Mueller
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
| | - Domizio Suva
- Division of Orthopaedics and Trauma Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Christian van Delden
- Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland.,Transplant Infectious Diseases Unit, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
| | - Ilker Uçkay
- Infectious Diseases, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Dionysios Neofytos
- Division of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland.,Transplant Infectious Diseases Unit, University Hospitals of Geneva and Faculty of Medicine, Geneva, Switzerland
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Serena TE, Gould L, Ousey K, Kirsner RS. Reliance on Clinical Signs and Symptoms Assessment Leads to Misuse of Antimicrobials: Post hoc Analysis of 350 Chronic Wounds. Adv Wound Care (New Rochelle) 2022; 11:639-649. [PMID: 34714159 PMCID: PMC9527054 DOI: 10.1089/wound.2021.0146] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 10/09/2021] [Indexed: 01/29/2023] Open
Abstract
Objectives: Bacteria frequently impede wound healing and cause infection. Clinicians rely on clinical signs and symptoms (CSS) to assess for bacteria at the point of care, and inform prescription of antibiotics and other antimicrobials. Yet, robust evidence suggests that CSS has poor sensitivity for detection of problematic bacterial burden and infection, hindering antimicrobial stewardship efforts. This study evaluated CSS-based antimicrobial prescribing practices across 14 wound care centers. Approach: Data were analyzed from the fluorescence assessment and guidance (FLAAG) trial, a study of 350 chronic wounds across 20 clinicians. Clinicians reviewed patient history and assessed for CSS using the International Wound Infection Institute infection checklist. Wounds with >3 criteria or any overwhelming symptom were considered CSS+. Bacterial levels were confirmed with quantitative tissue culture of wound biopsies. Results: Antimicrobials (including dressings, topicals, and systemic antibiotics) were prescribed at a similar rate for wounds identified as CSS+ (75.0%) and CSS- (72.8%, p = 0.76). Antimicrobial dressings, the most frequently prescribed antimicrobial, were prescribed at a similar rate for CSS+ (83.3%) and CSS- (89.5%, p = 0.27) wounds. In 33.3% of patients prescribed systemic antibiotics, no CSS were present. Prescribing patterns did not correlate with bacterial load. Innovation: This study is the first to evaluate antimicrobial prescribing trends in a large, multisite cohort of chronic wound patients. Conclusions: Reliance on CSS to diagnose clinically significant bacterial burden in chronic wounds leads to the haphazard use of antimicrobials. Improved methods of identifying bacterial burden and infection are needed to enhance antimicrobial stewardship efforts in wound care. Clinicaltrials.gov ID. NCT03540004.
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Affiliation(s)
- Thomas E Serena
- SerenaGroup® Research Foundation, Cambridge, Massachusetts, USA
| | - Lisa Gould
- South Shore Health Department of Surgery (or Brown Alpert Department of Medicine), Weymouth, Massachusetts, USA
| | - Karen Ousey
- School of Human and Health Sciences, University of Huddersfield, West Yorkshire, United Kingdom
| | - Robert S Kirsner
- Dr. Phillip Frost Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
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