Expert opinion on the management of infections in the diabetic foot

Diagnostic imaging of the diabetic foot: an EANM evidence-based guidance

PURPOSE

Consensus on the choice of the most accurate imaging strategy in diabetic foot infective and non-infective complications is still lacking. This document provides evidence-based recommendations, aiming at defining which imaging modality should be preferred in different clinical settings.

METHODS

This working group includes 8 nuclear medicine physicians appointed by the European Association of Nuclear Medicine (EANM), 3 radiologists and 3 clinicians (one diabetologist, one podiatrist and one infectious diseases specialist) selected for their expertise in diabetic foot. The latter members formulated some clinical questions that are not completely covered by current guidelines. These questions were converted into statements and addressed through a systematic analysis of available literature by using the PICO (Population/Problem-Intervention/Indicator-Comparator-Outcome) strategy. Each consensus statement was scored for level of evidence and for recommendation grade, according to the Oxford Centre for Evidence-Based Medicine (OCEBM) criteria.

RESULTS

Nine clinical questions were formulated by clinicians and used to provide 7 evidence-based recommendations: (1) A patient with a positive probe-to-bone test, positive plain X-rays and elevated ESR should be treated for presumptive osteomyelitis (OM). (2) Advanced imaging with MRI and WBC scintigraphy, or [18F]FDG PET/CT, should be considered when it is needed to better evaluate the location, extent or severity of the infection, in order to plan more tailored treatment. (3) In a patient with suspected OM, positive PTB test but negative plain X-rays, advanced imaging with MRI or WBC scintigraphy + SPECT/CT, or with [18F]FDG PET/CT, is needed to accurately assess the extent of the infection. (4) There are no evidence-based data to definitively prefer one imaging modality over the others for detecting OM or STI in fore- mid- and hind-foot. MRI is generally the first advanced imaging modality to be performed. In case of equivocal results, radiolabelled WBC imaging or [18F]FDG PET/CT should be used to detect OM or STI. (5) MRI is the method of choice for diagnosing or excluding Charcot neuro-osteoarthropathy; [18F]FDG PET/CT can be used as an alternative. (6) If assessing whether a patient with a Charcot foot has a superimposed infection, however, WBC scintigraphy may be more accurate than [18F]FDG PET/CT in differentiating OM from Charcot arthropathy. (7) Whenever possible, microbiological or histological assessment should be performed to confirm the diagnosis. (8) Consider appealing to an additional imaging modality in a patient with persisting clinical suspicion of infection, but negative imaging.

CONCLUSION

These practical recommendations highlight, and should assist clinicians in understanding, the role of imaging in the diagnostic workup of diabetic foot complications.

Trajectories of Diabetes-Related Sequelae for Identifying Transition Probabilities, and Optimal Timepoints for Prevention of Ulceration, Infection, and Amputation

To reduce diabetes-related complications and to avoid futile procedures, foot and ankle surgeons need to understand the relative timings of catastrophic events, their incidence, and probabilities of transitions between disease states in diabetes in different patient populations. For this study, we tracked medical events (including an initial diagnosis of diabetes, ulcer, wound care, osteomyelitis, amputation, and reamputation, in order of severity) and the time between each such event in patients with diabetes, stratifying by sex, race, and ethnicity. We found that the longest average duration between the different lower extremity states was a diagnosis of diabetes to the occurrence of ulcer at 1137 days (38 months). The average durations of amputation to reamputation, osteomyelitis, wound care, and ulcer were 18, 49, 23, and 18 days, respectively. The length of each disease transition for females was greater, while those of the Hispanic population were shorter than in the total cohort. This knowledge may permit surgeons to time and tailor treatments to their patients, and help patients to address, delay, or avoid complications.

The Differentiation Between Infection and Acute Charcot

The differentiation between acute Charcot neuroarthropathy and infection in the foot and ankle should be supported by multiple criteria. A detailed history and physical examination should always be completed. Plain radiographs should be performed, though advanced imaging, currently MRI, is more helpful in diagnosis. Scintigraphy and PET may become the standard imaging modalities once they are more clinically available due to their reported increased accuracy. Laboratory analysis can also act as a helpful diagnostic tool. Histopathology with culturing should be performed if osteomyelitis is suspected. The prompt diagnosis and initiation of treatment is vital to reducing patient morbidity and mortality.

Hyperbaric Oxygen Therapy for Diabetic Foot Ulcers Based on Wagner Grading: A Systematic Review and Meta-analysis

Background

Diabetic foot ulcers (DFUs) are common complications of uncontrolled diabetes mellitus that can result in infection and amputation of the lower extremities. This study compared the benefits and risks of hyperbaric oxygen therapy with those of other DFU treatments, based on the Wagner grading system.

Methods

Systematic searches for randomly controlled trials using hyperbaric oxygen therapy for DFUs were performed using PubMed, the Cochrane Library, and Embase. Data regarding demographics, wound healing, minor and major amputations, operative debridement, nonhealing wounds, and adverse effects were analyzed based on Wagner grades, using RevMan 5.4.1 and Microsoft Excel.

Results

Hyperbaric oxygen therapy was significantly superior to other treatments for wound healing rates 8 or more weeks after the final treatment (RR = 2.39; 1.87-3.05; P < 0.00001) minor/distal amputations (RR = 0.58; 0.43-0.80; P < 0.007), and major/proximal amputations (RR = 0.31; 0.18-0.52; P < 0.00001) for the 14 studies analyzed. In addition, this therapy increased the rate of complete wound healing for Wagner grades II (RR = 21.11; 3.05-146.03; P = 0.002), III (RR = 19.58; 2.82-135.94, P = 0.003), and IV (RR = 17.53; 2.45-125.44; P = 0.004); decreased the minor/distal amputation rate for grade III (RR = 0.06; 0.01-0.29; P = 0.0004) and the major/proximal amputation rate on for grade IV (RR = 0.08; 0.03-0.25; P < 0.0001); and decreased the operative debridement rate for Wagner grade II (RR = 0.09; 0.01-0.60; P = 0.01).

Conclusions

Moderate-quality evidence revealed that adjunctive hyperbaric oxygen therapy improved DFU wound healing for Wagner grades II, III, and IV; prevented minor and major amputations for grades III and IV, respectively; and prevented operative debridement in grade II wounds.

Clinical practice recommendations for infectious disease management of diabetic foot infection (DFI) - 2023 SPILF

In march 2020, the International Working Group on the Diabetic Foot (IWGDF) published an update of the 2015 guidelines on the diagnosis and management of diabetic foot infection (DFI). While we (the French ID society, SPILF) endorsed some of these recommendations, we wanted to update our own 2006 guidelines and specifically provide informative elements on modalities of microbiological diagnosis and antibiotic treatment (especially first- and second-line regiments, oral switch and duration). The recommendations put forward in the present guidelines are addressed to healthcare professionals managing patients with DFI and more specifically focused on infectious disease management of this type of infection, which clearly needs a multidisciplinary approach. Staging of the severity of the infection is mandatory using the classification drawn up by the IWGDF. Microbiological samples should be taken only in the event of clinical signs suggesting infection in accordance with a strict preliminarily established protocol. Empirical antibiotic therapy should be chosen according to the IWGDF grade of infection and duration of the wound, but must always cover methicillin-sensitive Staphylococcus aureus. Early reevaluation of the patient is a fundamental step, and duration of antibiotic therapy can be shortened in many situations. When osteomyelitis is suspected, standard foot radiograph is the first-line imagery examination and a bone biopsy should be performed for microbiological documentation. Histological analysis of the bone sample is no longer recommended. High dosages of antibiotics are recommended in cases of confirmed osteomyelitis.

Risk Factors for a Failed Transmetatarsal Amputation in Patients with Diabetes

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.

Microbial sensitivity of the common pathogens for UTIs are declining in diabetic patients compared to non-diabetic patients in Bangladesh: An institution-based retrospective study

Background

Urinary tract infection (UTI) is one of the most recurrent infections in the community and healthcare settings. Although many studies related with microbial sensitivity (MS) of uropathogens (UPs) to antibiotics have been done in Bangladesh, no conclusive study has compared antibiotic sensitivity (AS) to UPs in diabetic and non-diabetic patients. The aim of the study is to find out whether there is a difference in AS in common UPs between diabetic and non-diabetic UTI patients.

Methods

A retrospective review was conducted on 833 patients. The data was collected from different diagnostic centers located within Dhaka city in Bangladesh, and the data was analyzed using convenient statistical tools.

Results

We have studied a total of 833 UTI patients. Out of 833 patients, 664 were diabetic and 169 were non-diabetic patients respectively. Among the studied population, females were found to be more inclined to have UTIs as compared to males. E. coli was found to be the leading UPs in our study. Patients within the age of 20-34 were more vulnerable to UTI in both groups. Imipenem and meropenem showed 100% sensitivity against E. coli, Staphylococcus and Klebsiella in non-diabetic patients, while both antibiotics showed lower sensitivity to the same organisms in diabetic patients. Antibiotics like nitrofurantoin (p ≤ 0.0002), ceftazidime (p ≤ 0.0124) and ceftriaxone (p ≤ 0.0168) showed less sensitivity to E. coli in diabetic UTI patients as compared to non-diabetic UTI patients. Overall sensitivity patterns elucidated that all the studied antibiotics, except ciprofloxacin and levofloxacin, showed lower sensitivity against UPs in diabetic while compared to non-diabetic UTI patients (p= <0.05 to 0.0001).

Conclusion

We found significant difference in microbial sensitivity in patients with diabetes compared to non-diabetic UTI patients. Diabetes changes the pathophysiological state of the uropathogens leading to the declining sensitivity of the antibiotics in diabetic patients with UTIs.

Recent Advances in Nano-Formulations for Skin Wound Repair Applications

Skin injuries caused by accidents and acute or chronic diseases place a heavy burden on patients and health care systems. Current treatments mainly depend on preventing infection, debridement, and hemostasis and on supplementing growth factors, but patients will still have scar tissue proliferation or difficulty healing and other problems after treatment. Conventional treatment usually focuses on a single factor or process of wound repair and often ignores the influence of the wound pathological microenvironment on the final healing effect. Therefore, it is of substantial research value to develop multifunctional therapeutic methods that can actively regulate the wound microenvironment and reduce the oxidative stress level at the wound site to promote the repair of skin wounds. In recent years, various bioactive nanomaterials have shown great potential in tissue repair and regeneration due to their properties, including their unique surface interface effect, small size effect, enzyme activity and quantum effect. This review summarizes the mechanisms underlying skin wound repair and the defects in traditional treatment methods. We focus on analyzing the advantages of different types of nanomaterials and comment on their toxicity and side effects when used for skin wound repair.

The association between bacteria and outcome and the influence of sampling method, in people with a diabetic foot infection

Purpose

Different bacteria lead to divers diabetic foot infections (DFIs), and some bacteria probably lead to higher amputation and mortality risks. We assessed mortality and amputation risk in relation to bacterial profiles in people DFI and investigated the role of sampling method.

Methods

We included people (> 18 years) with DFI in this retrospective study (2011–2020) at a Dutch tertiary care hospital. We retrieved cultures according to best sampling method: (1) bone biopsy; (2) ulcer bed biopsy; and (3) swab. We aggregated data into a composite determinant, consisting of unrepeated bacteria of one episode of infection, clustered into 5 profiles: (1) Streptococcus and Staphylococcus aureus; (2) coagulase-negative Staphylococcus, Cutibacterium, Corynebacterium and Enterococcus; (3) gram-negative; (4) Anaerobic; and (5) less common gram-positive bacteria. We calculated Hazard Ratio’s (HR’s) using time-dependent-Cox regression for the analyses and investigated effect modification by sampling method.

Results

We included 139 people, with 447 person-years follow-up and 459 episodes of infection. Sampling method modified the association between bacterial profiles and amputation for profile 2. HR’s (95% CI’s) for amputation for bacterial profiles 1–5: 0.7 (0.39–1.1); stratified analysis for profile 2: bone biopsy 0.84 (0.26–2.7), ulcer bed biopsy 0.89 (0.34–2.3), swab 5.9*(2.9–11.8); 1.3 (0.78–2.1); 1.6 (0.91–2.6); 1.6 (0.58–4.5). HR’s (95% CI’s) for mortality for bacterial profiles 1–5: 0.89 (0.49–1.6); 0.73 (0.38–1.4); 2.6*(1.4–4.8); 1.1(0.58–2.2); 0.80(0.19–3.3).

Conclusions

In people with DFI, there was no association between bacterial profiles in ulcer bed and bone biopsies and amputation. Only in swab cultures, low-pathogenic bacteria (profile 2), were associated with a higher amputation risk. Infection with gram-negative bacteria was associated with a higher mortality risk. This study underlined the possible negative outcome of DFI treatment based on swabs cultures.

Antibiotic-loaded Bone Cement Combined with Vacuum-assisted Closure Facilitating Wound Healing in Wagner 3-4 Diabetic Foot Ulcers

This study explored the clinical effectiveness of antibiotic-loaded bone cement (ALBC) combined with vacuum-assisted closure (VAC) on the treatment of Wagner 3-4 diabetic foot ulcers (DFUs). This is a retrospective study, including 32 patients with Wagner 3-4 DFUs who had undergone treatment between August 2019 and June 2021. Patient age, sex, Hemoglobin A1c (HbA1c), body mass index (BMI), ankle brachial index (ABI), white blood cells (WBC), C-reactive protein (CRP) levels, comorbidities and wound closure methods were recorded. Patients were divided into the study group and control group according to the treatment modality. Patients in the study group received the combination treatment of ALBC and VAC, while patients in the control group received single VAC treatment. Clinical endpoints were assessed and compared between the two groups, including wound complete healing time and complications after operation. All patients were followed-up 6 months postoperation. Results showed that the mean healing time of the study group (44.20 ± 16.72 days) was shorter than that of the control group (64.00 ± 29.85 days) (P < .05). The infection rate of the study group on the 10th day postoperation was lower than that of the control group (6.67%, 47.06%, P < .05). And there were no significant statistical differences between the two groups in terms of bleeding and necrosis complications postoperation (P = .603, P = .603). Based on the findings, we conclude that the application of ALBC combined with VAC can facilitate wound healing in Wagner 3-4 DFUs patients. It can help to control wound infections and shorten wound healing time.

The burden of diabetes-related foot disease among older adults in Australia

Diabetes‐related foot disease (DFD) is imposing an enormous burden on the health system and society due to the rapid growth of diabetes worldwide. Given the paucity of robust data on the disease burden of DFD in Australia, this study aimed to estimate the burden of disease due to DFD. The burden of DFD was estimated using the disability‐adjusted life‐years (DALY) approach. Data of 27 931 individuals aged 45 years and older with diabetes residing in New South Wales (NSW) from the 45 and Up Study survey were used in this study by linking it with the emergency department, hospital admissions and the deaths' registry data. The disease burden of DFD was estimated as 8915 DALY in NSW and 27 164 DALY in Australia in 2011. The burden was prominent among males and people aged 65 years and older. Most of the DALY (87%) was attributed to years of life lost or the fatal burden due to diabetes‐related lower limb amputation (DRLEA). The total monetary values of DALY of DFD for NSW and Australia were estimated at approximately AUD 2 billion and AUD 6 billion annually, respectively. Preventative and curative priorities should be given to DRLEA to reduce this burden and target males, especially those aged 65 years and older.

The internal pedal amputation as a salvage procedure in diabetic and ischemic foot infection. A meta-analysis

BACKGROUND

Osteomyelitis of the diabetic foot is a very challenging condition and amputation is often indicated. In some cases where the infection is localized and the surrounding soft tissue is mildly involved, an internal pedal amputation (IPA) based on resection and limited excision of the infected bone have been suggested as a viable option. This systematic review aims to look for the effectiveness of this technique in treating selected cases of diabetic foot osteomyelitis.

METHODS

A systematic literature search was conducted using multiple electronic databases from inception. Eight studies met the inclusion criteria; one retrospective comparative study, six retrospective observational studies and one prospective observational study.

RESULTS

Based on a pooled sample of 545 patients followed over a mean period of 27.7 ± 15.2 months, the weighted results were as follows: (a) healing rate was 87.7% (95% CI = 0.757-0.959), (b) time for healing was 7.1 ± 2.9 weeks, (c) wound infection rate was 5.6% (95% CI = 0.030-0.089), (d) wound dehiscence rate was 8% (95% CI = 0.010-0.204), (e) ulcer recurrence rate was of 10% (95% CI = 0.037-0.188), and (f) amputation rate was 2.8% (95% CI = 0.001-0.085) whilst all were minor amputations.

CONCLUSION

The findings support the selection of toe/ray sparing surgery via IPA as a viable surgical option for selected cases of focal osteomyelitis secondary to diabetic foot infection. The results would indicate that when the ulcer size could be adequately reduced, removing the infected bone while preserving the soft tissue envelope could yield high chance of success with few serious complications.

Social determinants of diabetes-related foot disease among older adults in New South Wales, Australia: evidence from a population-based study

BACKGROUND

Diabetes-related foot is the largest burden to the health sector compared to other diabetes-related complications in Australia, including New South Wales (NSW). Understanding of social determinants of diabetes-related foot disease has not been definitive in Australian studies. This study aimed to investigate the social determinants of diabetes-related foot disease in NSW.

METHODOLOGY

The first wave of the 45 and Up Study survey data was linked with NSW Admitted Patient Data Collection, Emergency Department Data Collection, and Pharmaceutical Benefits Scheme data resulting in 28,210 individuals with diabetes aged 45 years and older in NSW, Australia. Three outcome variables were used: diabetes-related foot disease (DFD), diabetic foot ulcer (DFU), and diabetic foot infection (DFI). They were classified as binary, and survey logistic regression was used to determine the association between each outcome measure and associated factors after adjusting for sampling weights.

RESULTS

The prevalence of DFD, DFU and DFI were 10.8%, 5.4% and 5.2%, respectively, among people with diabetes. Multivariate analyses revealed that the common factors associated with DFD, DFU and DFI were older age (75 years or more), male, single status, background in English speaking countries, and coming from lower-income households (less than AUD 20,000 per year). Furthermore, common lifestyle and health factors associated with DFD, DFU, and DFI were low physical activity (< 150 min of moderate-to-vigorous physical activity per week), history of diabetes for over 15 years, and having cardiovascular disease.

CONCLUSION

Our study showed that about 1 in 10 adults with diabetes aged 45 years and older in NSW reported DFD. Interventions, including the provision of related health services aimed at reducing all forms of DFD in NSW, are recommended to target older individuals with a long history of diabetes, and coming from lower-income households.

Prevalence and Burden of Diabetes-Related Foot Disease in New South Wales, Australia: Evidence from the 45 and Up Study Survey Data Linked with Health Services Data

Diabetes-related foot disease (DFD) is a major public health concern due to the higher risks of hospitalisation. However, estimates of the prevalence of DFD in the general population are not available in Australia. This study aims to estimate the prevalence of DFD and diabetes-related lower-extremity amputation (DLEA) among people aged 45 years and over in New South Wales (NSW), Australia. The NSW 45 and Up Study baseline survey data of 267,086 persons aged 45 years and over, linked with health services' administrative data from 2006 to 2012 were used in our study. Of these, 28,210 individuals had been diagnosed with diabetes, and our study identified 3035 individuals with DFD. The prevalence of DFD, diabetic foot ulcer (DFU), diabetic foot infection (DFI), diabetic gangrene (DG), and DLEA were 10.8% (95%CI: 10.3, 11.2), 5.4% (95% CI: 5.1, 5.8), 5.2% (95%CI: 4.9, 5.5), 0.4% (95%CI: 0.3, 0.5), and 0.9% (95%CI: 0.7, 1.0), respectively. DFD, DFU, DFI, DG, and DLEA were the most common among those who were older, born in Australia, from low-income households (<AUD 20,000), or were without private health insurance. Interventional messages to reduce all forms of DFD should target those who are from high-risk groups.

Combined Antioxidant-Antibiotic Treatment for Effectively Healing Infected Diabetic Wounds Based on Polymer Vesicles

Infected diabetic wounds are difficult to heal due to high reactive oxygen species (ROS) concentrations and recurrent infections. Such wounds can easily deteriorate into a diabetic ulcer, a chronic diabetic complication with a very high mortality rate. Herein, we propose a combined antioxidant-antibiotic therapy based on poly(ε-caprolactone)-block-poly(glutamic acid) polymer vesicle to treat infected diabetic wounds. This was realized by in situ decoration of stable, well-dispersed ceria nanoparticles onto ciprofloxacin (CIP)-loaded polymer vesicles. These resulting CIP-loaded and ceria-decorated polymer vesicles (CIP-Ceria-PVs) exhibited high superoxide dismutase mimetic activity to inhibit superoxide free radicals (the inhibition rate reached ∼50% at an extremely low cerium concentration of 1.25 μg/mL). When the cerium content is in the range of 5-20 μg/mL, the CIP-Ceria-PVs showed the highest protective capability to normal L02 cells from damage of superoxide free radicals. In addition, the CIP-Ceria-PVs exhibited enhanced antibacterial activity (the dosage of CIP in CIP-Ceria-PVs was reduced by 25-50% compared to free CIP). In vivo treatment of infected diabetic wounds was performed on a diabetic mice model. The CIP-Ceria-PVs could effectively cure infected diabetic wounds within 14 days. Overall, a combined antioxidant-antibiotic therapy was proposed by introducing ceria nanoparticles and CIP into polymer vesicles for the treatment of infected diabetic wounds.

Surgical wound dehiscence complicated by methicillin-resistant Staphylococcus aureus infection in a diabetic patient with femorotibial vascular bypass occlusion

Diabetic patients with critical limb ischaemia may be affected by severe wound and skin ulcer infections. We report a case of a patient with bilateral femorotibial occlusion and methicillin-resistant Staphylococcus aureus infection. The patient was treated with femoroperoneal vascular bypass, debridement of wound dehiscence and targeted antimicrobial therapy for symptom resolution and healing of the wound.

Long-Term Complications after Surgical or Medical Treatment of Predominantly Forefoot Diabetic Foot Osteomyelitis: 1 Year Follow Up

AIM

To compare long-term complications according to the treatment received for management of diabetic foot osteomyelitis (surgical or medical) at 1 year follow up.

DESIGN AND PARTICIPANTS

A prospective observational study was conducted involving 116 patients with diabetic foot osteomyelitis. The patients received surgical or medical treatment based on the principles described in the literature. To register the development of a complication, both groups of treatments were followed-up 1 year after the ulcer had healed.

RESULTS

Ninety-six (82.8%) patients received surgical treatment and 20 (17.2%) medical treatment. No differences were found in the time to healing between both groups of treatment, 15.7 ± 9.2 weeks in the surgical group versus 16.4 ± 12.1 weeks in the medical group; p = 0.103. During follow up, 85 (73.3%) patients developed complications without differences between both groups, 68 (70.8%) in the surgical group versus 17 (85%) in the medical group (p = 0.193). The most common complication in both groups was re-ulceration. We did not observe significant differences comparing complication-free time survival between both treatments (p = 0.665).

CONCLUSION

The onset of complications after healing in patients who suffered from diabetic foot osteomyelitis was not associated with the treatment received. Surgical and medical approaches to the management of diabetic foot osteomyelitis produced similar results in long-term follow up.

Medical Versus Surgical Treatment for the Management of Diabetic Foot Osteomyelitis: A Systematic Review

A systematic review and quality assessment was performed to assess the management of diabetic foot osteomyelitis by medical or surgical treatment. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was used. All selected studies were evaluated using the Cochrane Risk of Bias Tool to assess the risk of bias for randomized controlled trials. The literature was revised using PubMed (Medline) and Embase (Elsevier) up to September 2020 to identify clinical trials assessing medical or surgical treatment to manage diabetic foot osteomyelitis. A total of six clinical trials that met our inclusion criteria, with a total of 308 participants. Healing rate, complete closure of the wound, and type of complications were the outcomes evaluated. Risk of bias assessment showed that only two of the six clinical trials included in the systematic review had a low risk of bias. Based on our findings, we believe that the management of diabetic foot osteomyelitis remains challenging. There are few high-quality clinical trials that both stratify clinical presentations and compare these treatments. We conclude that the available evidence is insufficient to identify the best option to cure diabetic foot osteomyelitis.

Mortality in Patients with Diabetic Foot Ulcers: Causes, Risk Factors, and Their Association with Evolution and Severity of Ulcer

Background: This study reviews the mortality of patients with diabetic foot ulcers (DFU) from the first consultation with a Multidisciplinary Diabetic Foot Team (MDFT) and analyzes the main cause of death, as well as the relevant clinical factors associated with survival. Methods: Data of 338 consecutive patients referred to the MDFT center for a new DFU during the 2008–2014 period were analyzed. Follow-up: until death or until 30 April 2020, for up to 12.2 years. Results: Clinical characteristics: median age was 71 years, 92.9% had type 2 diabetes, and about 50% had micro-macrovascular complications. Ulcer characteristics: Wagner grade 1–2 (82.3%), ischemic (49.2%), and infected ulcers (56.2%). During follow-up, 201 patients died (59.5%), 110 (54.7%) due to cardiovascular disease. Kaplan—Meier curves estimated a reduction in survival of 60% with a 95% confidence interval (95% CI), (54.7–65.3) at 5 years. Cox regression analysis adjusted to a multivariate model showed the following associations with mortality, with hazard ratios (HRs) (95% CI): age, 1.07 (1.05–1.08); HbA1c value < 7% (53 mmol/mol), 1.43 (1.02–2.0); active smoking, 1.59 (1.02–2.47); ischemic heart or cerebrovascular disease, 1.55 (1.15–2.11); chronic kidney disease, 1.86 (1.37–2.53); and ulcer severity (SINBAD system) 1.12 (1.02–1.26). Conclusion: Patients with a history of DFU have high mortality. Two less known predictors of mortality were identified: HbA1c value < 7% (53 mmol/mol) and ulcer severity.

Ultrasound in the Modern Management of the Diabetic Foot Syndrome: A Multipurpose Versatile Toolkit

Ultrasound (US) is a noninvasive and versatile technology that in recent years found acceptance in almost all the medical specialties, with diagnostic and interventional applications. In the diabetic foot syndrome (DFS), US found specific indications mainly in the screening, quantification, and follow-up of the vascular component of the pathology, but also in the study of the deformities and structural modifications induced by neuropathy and in the diagnosis and surgical management of infections, especially those that induce anatomical changes, like abscesses and fasciitis. This review will summarize all these application of US, giving special attention to the vascular aspects, and on the predominant role that US gained in recent times to guide the indication to revascularization, on the new standardized approach to the study of the arterial tree of the limb and the foot, the so-called duplex ultrasound arterial mapping, which significantly increased the utilization of US to plan the revascularizations in this complex pathology. Outside the vascular fields, the diagnosis of neuropathy and infection and the intraoperative use of US in the surgical management of abscesses and fasciitis will be discussed, leaving the last part to the new and interesting applications of US in the management of DFU, a field that is still in evolution, offering new possibilities to the health care professionals involved in the management of these chronic wounds. The variety of applications both in diagnostic and operative fields makes US a rather versatile technology-a toolkit-that should have a special place among those at reach of the specialists of DFS care.

Diagnosing Osteomyelitis: A Histology Guide for Pathologists

Histopathologic examination of bone specimens coupled with bone culture is considered the gold standard for the diagnosis of osteomyelitis (OM). Despite this, studies have demonstrated interpathologist agreement in the diagnosis of OM as low as 30%, largely stemming from a lack of specific definitions and diagnostic criteria. Review of the literature has provided insight into the lifecycle of OM, illustrating the histologic progression of OM phases from acute to chronic, and provides support for defining subcategories of OM. Using an algorithmic histopathologic tool consisting of 15 criteria, each with an associated score, we defined 5 categories of OM: (1) acute OM, (2) acute and chronic OM, (3) chronic OM, (4) chronic active OM, and (5) chronic inactive OM. We reviewed 462 microscopic slides from 263 patients with suspected OM, and for each slide, we determined an algorithm-derived diagnosis, which was then used to calculate a total histopathologic load score (Jupiter score). Algorithm-derived diagnoses recapitulated original clinical diagnoses and diagnosed cases as OM that had not been originally diagnoses. These novel cases were more likely to have subsequent clinical complications. Finally, pathologic load scores were assessed for association with the category of OM.

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

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

Prospective exploration of the effect of adiposity and associated microbial factors on healing and progression of diabetic foot ulcers in Tanzania: study protocol of a longitudinal cohort study

BACKGROUND

Diabetic foot ulcers (DFUs) are associated with high morbidity and mortality in low-income countries. This coexists with an increasing prevalence of obesity which has been reported to alter antimicrobial susceptibility and potentially affect the outcome of infected foot ulcers. This study aims to determine whether adiposity and local microbial factors affect the progression and healing of foot ulcers in people with type 2 diabetes in hospital settings in Tanzania.

METHODS AND ANALYSIS

A prospective cohort of 300 individuals with type 2 diabetes presenting with DFUs at an outpatient clinic will be enrolled into the study. At baseline, participants will be stratified into normal and high adiposity groups (150 per group) as measured by bioelectrical impedance analysis (BIA). Both groups will receive DFU management according to locally appropriate standards of care and will be followed up for 24 weeks or until complete wound healing, whichever occurs first. The primary end point is complete wound healing at 24 weeks while secondary end points are ulcer progression (worsening or improving), amputation and death. Enrolling 150 participants per group will have a minimum power of 80% to detect a 20% difference in cumulative incidence of complete ulcer healing (at the 5% level of statistical significance) between the normal and high adiposity groups.

ETHICAL CONSIDERATIONS AND DISSEMINATION OF RESULTS

This study will be conducted in compliance with the independent institutional review boards (IRBs), informed consent guidelines, the declaration of Helsinki and International Conference on Harmonisation, Good Clinical Practice Guidelines. Ethical clearance has been granted by the Muhimbili University of Health and Allied Sciences ethical review board (MUHAS Ref. No. DA.282/298/01 .C/). Permissions to conduct the study have been granted by the Abbas Medical Centre and the Muhimbili Academic Medical Centre (MAMC).Progress and results emanating from this work will be communicated to the scientific community through conference presentations, short communications (using journal letters and interesting case reports) and peer-reviewed publications. When necessary, through proper channels, popular means of communication (newspapers, magazines and online communications) will be used to inform policy and the public.

TRIAL REGISTRATION NUMBER

NCT03960255; Pre-results.

Molecular Imaging of Diabetic Foot Infections: New Tools for Old Questions

Diabetic foot infections (DFIs) are a common, complex, and costly medical problem with increasing prevalence. Diagnosing DFIs is a clinical challenge due to the poor specificity of the available methods to accurately determine the presence of infection in these patients. However, failure to perform an opportune diagnosis and provide optimal antibiotic therapy can lead to higher morbidity for the patient, unnecessary amputations, and increased healthcare costs. Novel developments in bacteria-specific molecular imaging can provide a non-invasive assessment of the infection site to support diagnosis, determine the extension and location of the infection, guide the selection of antibiotics, and monitor the response to treatment. This is a review of recent research in molecular imaging of infections in the context of DFI. We summarize different clinical and preclinical methods and the translational implications aimed to improve the care of patients with DFI.

An open-label trial of cryopreserved human umbilical cord in the treatment of complex diabetic foot ulcers complicated by osteomyelitis

Clinical trials of potential new therapies for diabetic foot ulcers rarely enroll patients whose wounds extend to muscle, fascia, or bone with clinical and radiographic evidence of underlying osteomyelitis. An open‐label, multicenter trial of cryopreserved human umbilical cord (TTAX01) was undertaken in 32 subjects presenting with such complex wounds with a mean duration of 6.1 ± 9.0 (range: 0.2–47.1) months and wound area at screening of 3.8 ± 2.9 (range: 1.0–9.6) cm². Aggressive surgical debridement at baseline resulted in 17 minor amputations and an increase in mean wound area to 7.4 ± 5.8 (range: 1.1–28.6) cm². All subjects were placed on systemic antibiotics for at least 6 weeks in conjunction with baseline application of TTAX01. Repeat applications were made at no less than 4‐week intervals over the 16‐week trial. Initial closure occurred in 18 of 32 (56%) wounds, with 16 (50%) of these having confirmed closure in 16 weeks with a median of one‐product application. Cases with biopsy confirmed osteomyelitis (n = 20) showed initial closure in 12 (60%) wounds and confirmed closure in 10 (50%) wounds. Four of the five ulcers presenting as recurrences experienced confirmed closure. Mean overall time to healing was 12.8 ± 4.3 weeks. Mean wound area reduction from baseline was 91% for all wounds. Of the 16 wounds without confirmed closure during the 16‐week treatment period, five (31.3%) achieved 99–100% wound area reduction by their final visit. The product was well tolerated. Two minor amputations occurred during the study period due to recurrent or persistent osteomyelitis; however, there were no major amputations.

Oral amoxicillin-clavulanate for treating diabetic foot infections

AIM

To assess amoxicillin-clavulanate (AMC) for the oral therapy of diabetic foot infections (DFIs), especially for diabetic foot osteomyelitis (DFO).

METHODS

We performed a retrospective cohort analysis among 794 DFI episodes, including 339 DFO cases.

RESULTS

The median duration of antibiotic therapy after surgical debridement (including partial amputation) was 30 days (DFO, 30 days). Oral AMC was prescribed for a median of 20 days (interquartile range, 12-30 days). The median ratio of oral AMC among the entire antibiotic treatment was 0.9 (interquartile range, 0.7-1.0). After a median follow-up of 3.3 years, 178 DFIs (22%) overall recurred (DFO, 75; 22%). Overall, oral AMC led to 74% remission compared with 79% with other regimens (χ² -test; P = 0.15). In multivariate analyses and stratified subgroup analyses, oral AMC resulted in similar clinical outcomes to other antimicrobial regimens, when used orally from the start, after an initial parenteral therapy, or when prescribed for DFO.

CONCLUSIONS

Oral AMC is a reasonable option when treating patients with DFIs and DFOs.

A study to identify bacteriological profile and other risk factors among diabetic and non-diabetic foot ulcer patients in a Guyanese hospital setting

Diabetic foot infection is a global epidemic and a major public health concern. Development of microbial resistance to many antimicrobial agents in foot ulcer leads to serious complications. Therefore, the study aims to identify the microbiological profile and the potential risk factors among diabetic and non-diabetic foot ulcer patients. A prospective cross sectional study was carried out among 183 ulcer patients from diabetic foot clinic and wound dressing clinic at the public health hospital, Guyana. A total of 254 bacteria were isolated from the study with an average of 1.4 organism per lesion. Gram negative bacteria (63.0%) were prevalent than gram positive bacteria (37.0%) in this study. Among DF patients, Pseudomonas aeruginosa (18.8%) was the most common isolate followed by Escherichia coli (13.9%) among gram negative group. Were as MRSA (12.1%) followed by MSSA (7.9%) dominated among gram positive group in diabetic foot patients. Almost 42.1% (95% CI 34.8-49.6) of the infections were caused by poly-microbial. Interestingly, a stepwise logistic regression model determined increasing age and lack of health education as independent risk factor identified for acquiring an MDR wound infection (OR = 1.1; p ≥ 0.05; 95% CI 1.0-1.1). Mild, moderate and severe infection among MDR and NMDR patients were recorded as 45.3% (95% CI 32.8-58.3), 26.5% (95% CI 16.3-39.1), 28.1% (95% CI 17.6-40.8) and 51.3% (95% CI 41.9-60.5), 32.8% (95% CI 24.4-42.0), 16.0% (95% CI 9.9-23.8). Therefore, it is concluded that there's an urgent need for surveillance of resistant bacteria in diabetic foot infections to reduce the risk of major complications.

Systematic review of randomized controlled trials on antibiotic treatment for osteomyelitis in diabetes

AIM

To evaluate the efficacy of antibiotic therapy in osteomyelitis treatment among people with diabetes.

METHODS

A systematic search of PubMed, EMBASE, AMED, Web of Science, the WHO trial registry, Cochrane library databases, and ClinicalTrials.gov, in addition to hand-searching, was undertaken in July 2018. Two reviewers independently extracted data. The studies' methodological quality was assessed using the modified Jadad scale. Descriptive analysis was performed.

RESULTS

Seven randomized controlled trials, with 393 participants in total, were included. The antibiotic regimens, treatments and follow-up durations varied among the trials. The total scores showed that the overall methodological quality of the seven studies was high, despite two studies showing some flaws in double-blinding and withdrawals/drop-outs. Of four studies comparing different antibiotic regimens, three implied a similar remission effect, while one implied that ertapenem ± vancomycin treatment showed a higher remission rate than tigecycline treatment; this conclusion was not robust because of low power and small sample size. In the other three studies, which included two different doses of ciprofloxacin, an antibiotics group and a conservative surgical group, and two durations of the same antibiotic strategy, no significant differences in remission were reported between the groups. No difference was observed in the analyses of microbiological outcomes, superinfections and relapse, except adverse events.

CONCLUSIONS

There is no definitive evidence supporting the superiority of any particular antibiotic agent, dose, or administration duration in the treatment of osteomyelitis in diabetes. As the included studies had some flaws and limitations, further research is necessary.

Phenolic Compounds from Humulus lupulus as Natural Antimicrobial Products: New Weapons in the Fight against Methicillin Resistant Staphylococcus aureus, Leishmania mexicana and Trypanosoma brucei Strains

New anti-infective agents are urgently needed to fight microbial resistance. Methicillin-resistant Staphylococcus aureus (MRSA) strains are particularly responsible for complicated pathologies that are difficult to treat due to their virulence and the formation of persistent biofilms forming a complex protecting shell. Parasitic infections caused by Trypanosoma brucei and Leishmania mexicana are also of global concern, because of the mortality due to the low number of safe and effective treatments. Female inflorescences of hop produce specialized metabolites known for their antimicrobial effects but underexploited to fight against drug-resistant microorganisms. In this study, we assessed the antimicrobial potential of phenolic compounds against MRSA clinical isolates, T. brucei and L. mexicana. By fractionation process, we purified the major prenylated chalcones and acylphloroglucinols, which were quantified by UHPLC-UV in different plant parts, showing their higher content in the active flowers extract. Their potent antibacterial action (MIC < 1 µg/mL for the most active compound) was demonstrated against MRSA strains, through kill curves, post-antibiotic effects, anti-biofilm assays and synergy studies with antibiotics. An antiparasitic activity was also shown for some purified compounds, particularly on T. brucei (IC₅₀ < 1 to 11 µg/mL). Their cytotoxic activity was assessed both on cancer and non-cancer human cell lines.

How to Create a Hot Foot Line to Prevent Diabetes-Related Amputations: Instant Triage for Emergency Department and Inpatient Consultations

Emergency department visits for lower extremity complications of diabetes are extremely common throughout the world. Surprisingly, recent data suggest that such visits generate an 81.2% hospital admission rate with an annual bill of at least $1.2 billion in the United States alone. The likelihood of amputation and other subsequent adverse outcomes is strongly associated with three factors: 1) wound severity (degree of tissue loss), 2) ischemia, and 3) foot infection. Using these factors, this article outlines the basic principles needed to create an evidence-based, rapid foot assessment for diabetic foot ulcers presenting to the emergency department, and suggests the establishment of a "hot foot line" for an organized, expeditious response from limb salvage team members. We present a nearly immediate assessment and referral system for patients with atraumatic tissue loss below the knee that has the potential to vastly expedite lower extremity triage in the emergency room setting through greater collaboration and organization.

A meta-analysis of the relationship between foot local characteristics and major lower extremity amputation in diabetic foot patients

OBJECTIVE

To clarify and quantify risk factors among local characteristics of the foot for major amputation in diabetic foot patients.

METHODS

Articles published before January 2018 on PubMed and Embase were conducted observational studies about risk factors for major amputation in patients with diabetic foot were retrieved and systematically reviewed by using Stata 12.0 statistical software.

RESULTS

A total of 4668 major amputees and 65 831 controls were reported in 18 observational studies. Across the studies, the overall odds ratios (ORs) and 95% confidence intervals (CIs) of significant risk factors are ulcer reaching bone (OR, 11.796; 95% CI, 6.905-20.152), gangrene (OR, 6.487; 95% CI, 4.088-10.293), hindfoot position (OR, 3.913; 95% CI, 2.254-6.795), decreased ankle-brachial index (ABI) (OR, 2.522; 95% CI, 1.805-3.523), infection (OR, 2.516; 95% CI, 1.708-3.706), peripheral arterial disease (PAD) (OR, 2.114; 95% CI, 1.326-3.372). While there is no significant difference in the size of the ulcer, neuropathy, Charcot foot, osteomyelitis and intermittent claudication (OR, 1.15; 95% CI, 0.85-1.54).

CONCLUSION

Factors among local characteristics of the foot associated with major amputation in patients with diabetic foot are the ulcer reaching bone, gangrene, hindfoot position, decreased ABI, infection, and PAD, a negative risk factor for the risk of amputation. Further studies are required to provide more details of foot local characteristics.

Concordance Between Bone Pathology and Bone Culture for the Diagnosis of Osteomyelitis in the Presence of Charcot Neuro-Osteoarthropathy

The diagnosis of osteomyelitis (OM) is a challenging but critical pathology to uncover in patients with concomitant Charcot neuro-osteoarthropathy (CN). The reference standard to diagnose OM is bone biopsy for histopathologic and microbiologic examination. The presence of CN, however, can have a negative effect on the accuracy of either method to identify OM. The aim of the present study was to examine the concordance between bone pathology and bone cultures in the presence of CN in the diagnosis of OM. A total of 286 patients with diabetes mellitus (DM) and CN were identified retrospectively, with 48 patients identified with OM. OM was confirmed by radiographs, magnetic resonance imaging, erythrocyte sedimentation rate, and C-reactive protein, positive probe-to-bone test results, and intraoperative inspection. Seventy matched pairs of bone pathology and cultures with complete data were compared and analyzed. Statistical analysis included concordance, positive predictive value, negative predictive value, sensitivity, specificity, and kappa coefficient. Concordance between bone pathology and bone culture was 41.4%, with agreement in 29 of 70 paired specimens. The diagnostic test accuracy of histopathologic examination to diagnose OM in CN bone in our study was 51.4%. The diagnostic test accuracy of microbiologic examination to diagnose OM in CN bone was 50%. The positive predictive value was 72.2%. The negative predictive value was 44.1%. The sensitivity was 57.8%. The specificity was 60.0%. The kappa coefficient was 0.165. The reference standard method of histopathologic and microbiologic examination of bone specimens has little concordance and can lead to inaccurate or inconclusive information. The low sensitivity and specificity demonstrated in the present study does not support the use of the current reference standard method of bone biopsy for histologic and microbiologic diagnosis of OM when CN is present. Thus, a diagnosis of OM in patients with CN should only be considered in the presence of strong clinical, laboratory, and imaging correlates.

Necrotizing Soft Tissue Infections in the Vasculopathic Patient: Review of Literature

Background:

Necrotizing soft tissue infection is a surgical emergency associated with high mortality. Its presence in patients with risk factors for peripheral arterial disease such as diabetes mellitus is consistently associated with significantly poorer outcomes. Though it has been over a century since it was initially described in the literature, mortality rates remain high and treatment regimens are not standardized.

Materials and methods:

PubMed and Cochrane databases were searched for articles pertaining to necrotizing soft tissue infections. Articles were screened for relevance with the intent to compare outcomes in prospective studies of patients with diabetes mellitus or peripheral arterial disease. Patient demographics, clinical findings, mortality, rates of amputation, and morbidity were intended to be compared.

Results:

857 articles were identified, 165 duplicates were removed, and 6 prospective trials were identified for inclusion. Due to significant paucity of data, patient heterogeneity, and lack of standardization for surgical management, a descriptive review of the literature in relation to necrotizing soft tissue infections was pursued, with a focus on high-risk patients with peripheral arterial disease or diabetes mellitus.

Conclusions:

Early aggressive surgical intervention or major amputation may reduce mortality at the cost of increased disability and poorer quality of life in the long term, and may be appropriate in vasculopaths with poorly controlled diabetes and rapidly progressive fulminant infection. However, there is a deficiency in high-level evidence supporting surgical decision-making in this setting, with no standardized protocols for amputation. Future research will be needed to clarify the patient population who would benefit from radical amputation versus intention for limb salvage.

Comparison of Vacuum-Assisted Closure Therapy and Conventional Dressing on Wound Healing in Patients with Diabetic Foot Ulcer: A Randomized Controlled Trial

Background:

Vacuum-assisted closure (VAC) therapy has been shown to be beneficial in a variety of wounds. However, evidence of its benefit in diabetic foot ulcers (DFUs), especially with respect to Indian population, is sparse.

Methodology:

This randomized controlled trial included DFUs of Wagner's Grades 1 and 2. Patients were further stratified with respect to DFU size <10 cm and ≥10 cm. Patients with vascular disease, osteomyelitis, and bilateral DFUs were excluded from the study. The enrolled patients were randomized to receive VAC therapy or conventional dressing. The time to wound healing, granulation tissue formation, and complications such as pain, infection, and bleeding were compared between the two groups.

Results:

A total of sixty patients were randomized, of which 27 in each group were analyzed. The mean time to healing in days was significantly less in VAC group (22.52 vs. 3.85; P < 0.0001). Mean time to achieve 75%–100% granulation tissue cover was significantly less in VAC group (23.33 vs. 32.15; P < 0.0001). Rate of granulation tissue formation was also found to be significantly better in VAC group (2.91 cm²/day vs. 2.16 cm²/day; P = 0.0306). There was no difference between the two groups with respect to wound infection and bleeding which are commonly attributed to VAC therapy. VAC therapy group had significantly lesser pain at week 3 (Visual Analog Scale score 3 vs. 4; P = 0.004).

Conclusion:

VAC therapy significantly decreases the time to complete wound healing, hastens granulation tissue formation, and reduces the ulcer area compared to conventional dressing. The study did not find any significant increase in the bleeding and infection in the VAC therapy group.

Antimicrobial susceptibility pattern of aerobes in diabetic foot ulcers in a South-Indian tertiary care hospital

PURPOSE

Diabetic foot infections (DFIs) are major public health concerns. In the view of the ever increasing burden of multidrug-resistant (MDR) organisms, improving the use of antimicrobial agents (AMAs) is a national priority. Objective of the study was to determine antimicrobial susceptibility (AMS) pattern of aerobes in DFIs.

METHODS

A cross-sectional study was conducted for a period of 3 years at Department of Surgery, Kasturba hospital, Manipal, India during which, 260 diabetic foot ulcer (DFU) patients admitted in the general surgery wards were enrolled for the study. These patients' culture specimens were observed as Gram-stained smears and cultured aerobically on blood agar and MacConkey agar plates. AMS test was performed by disc diffusion technique according to Clinical and Laboratory Standards Institute (CLSI) guidelines.

RESULTS

A total of 354 microbes were isolated from the ulcer wounds of 213 diabetic foot patients, with an average of 1.7 organisms per lesion. Monomicrobial infections were less common (n=81; 31.2%) than polymicrobial infections (n=132; 50.7%). Gram-negative bacteria were the most common among the isolates (n=192; 54.2%). Aerobic Gram-positive Cocci accounted for 162 (45.8%) of all isolates. On the other hand, Staphylococcus aureus was the most frequently isolated aerobe (n=106; 29.9%) followed by Pseudomonas aeruginosa (n=91; 25.7%).

CONCLUSION

AMS data from our study recommends that doxycycline would be the appropriate choice as single drug for empirical coverage for Gram-positive organisms. The most appropriate antibiotic for Gram-negative organisms is meropenem. One of the critical observations is the presence of Acinetobacter, an MDR isolated from DFIs, which is either relatively or totally resistant to all the AMAs tested.

Performance of the automated multiplex PCR Unyvero implant and tissue infections system in the management of diabetic foot osteomyelitis

AIM

We evaluated the performance of Unyvero implant and tissue infections system (ITI) application (Curetis) to diagnose Diabetic Foot Osteomyelitis (DFOM).

PATIENTS & METHODS

The study was conducted in the Diabetic Foot reference center of Nîmes University Hospital (France) from 1 December 2016 to 31 May 2017. We compared the Unyvero ITI PCR to conventional culture and alternative molecular approaches.

RESULTS

A total of 79 patients with DFOM were included: 177 microorganisms were isolated by culture, 146 detected by PCR, resulting in a concordance level of 66.7% (65.0-68.4). Discrepant results were obtained for 45 samples, with 59 microorganisms being detected by PCR only (18 samples) or by culture only (27 samples).

CONCLUSION

Unyvero ITI PCR represents an interesting additional diagnosis solution to manage DFOM.

Diabetic foot infection: A critical complication

The number of people in the world with diabetes has nearly quadrupled in the past 40 years. Current data show that 25% of these diabetics will develop a foot ulcer in their lifetime and that the cost of care for a diabetic foot ulcer (DFU) is over twice that of any other chronic ulcer aetiology. Microbial biofilm has been linked to both wound chronicity and infection. Close to 1 in 2 diabetics with a DFU are predicted to go on to develop a diabetic foot infection (DFI). The majority of these DFIs have been found to evolve even before the diabetic individual has received an initial referral for expert DFU management. Of these infected DFUs, less than half have been shown to heal over the next year; many of these individuals will require costly hospitalisation, and current data show that far too many DFIs will require extremity amputation to achieve infection resolution. The development of an infection in a DFU is critical at least in part because paradigms of infection prevention and management are evolving. The effectiveness of our current practice standards is being challenged by a growing body of research related to the prevalence and recalcitrance of the microbes in biofilm to topical and systemic antimicrobials. This article will review the magnitude of current challenges related to DFI prevention and management along with what is currently considered to be standard of care. These ideas will be compared and contrasted with what is known about the biofilm phenotype; then, considerations to support progress towards the development of more cost-effective protocols of care are highlighted.

Diabetic Foot Infections: Update on Management

PURPOSE OF REVIEW

Diabetic foot infections (DFIs) are common in patients with diabetes mellitus complicated by foot ulcers and can be classified in different categories based on their severity. In this report, we present the diagnosis and management of DFIs according to their classification.

RECENT FINDINGS

While appropriate antibiotic regiments and surgical techniques for the treatment of DFIs are well established, new technologies and techniques for example in medical imaging, wound care modalities, and supplementary therapy approaches show potentially promising results in preventing DFIs. As with every complex disease, fine tuning DFI management can be challenging as it requires careful evaluation of different parameters. It demands timely action, close collaboration of different specialties, and patient cooperation.

Serum procollagen type 1 N propeptide: A novel diagnostic test for diabetic foot osteomyelitis - A case-control study

Background:

The objective of the study was to determine whether serum levels of procollagen type 1 N propeptide (P1NP), a bone formation turnover marker, differs between diabetic foot ulcer with osteomyelitis (DFO) and diabetic foot ulcers without osteomyelitis serving as controls. It was also aimed to assess the usefulness of P1NP in diagnosing DFO compared to other common inflammatory markers.

Materials and Methods:

A case–control study was designed comparing the aforementioned groups. Patients were classified as osteomyelitis and controls based on the International Working Group diagnostic criteria. Serum P1NP and three other inflammatory markers, namely, C-reactive protein (CRP), white blood cells (WBC), and platelets were analyzed on patients with DFO and controls.

Results:

The mean serum P1NP levels were significantly higher in the DFO group (n: 16), 10.5 ± 5.2 (ng/ml), than the control group (n: 11) 3.1 ± 2.8 (ng/ml), P = 0.001. P1NP showed the highest sensitivity/specificity 86.7%/80% compared to 70.6%/80%, 56.2%/45.4%, and 50%/37% for CRP, WBC and platelets, respectively. Receiver operator characteristic curves showed the best value of area under the curve of 0.9 for P1NP compared to 0.85, 0.54, and 0.46 for CRP, WBC, and platelets.

Conclusion:

We found marked elevation of serum P1NP in diabetic foot ulcer with bone infection with potential value in using it to diagnose DFO.

Managing diabetic foot infections: a survey of Australasian infectious diseases clinicians

Background

Diabetic foot infections (DFI) present a major morbidity, mortality and economic challenge for the tertiary health sector. However, lack of high quality evidence for specific treatment regimens for patients with DFIs may result in inconsistent management. This study aimed to identify DFI caseload proportion and patterns of clinical practice of Infectious Diseases (ID) Physicians and Trainees within Australia and New Zealand.

Methods

A cross-sectional online survey of Australian and New Zealand ID Physicians and Trainees was undertaken, to estimate the overall ID caseload devoted to patients with DFIs and assess clinicians' management practices of patients with DFIs.

Results

Approximately 28% (142/499) of ID Physicians and Trainees from Australia and New Zealand responded to the survey. DFI made up 19.2% of all ID consultations. Involvement in multidisciplinary teams (MDT) was common as 77.5% (93/120) of those responding indicated their patients had access to an inpatient or outpatient MDT. Significant heterogeneity of antimicrobial treatments was reported, with 82 unique treatment regimens used by 102 respondents in one scenario and 76 unique treatment regimens used by 101 respondents in the second scenario. The duration of therapy and the choice of antibiotics for microorganisms isolated from superficial swabs also varied widely.

Conclusions

Patients with DFIs represent a significant proportion of an ID clinician's caseload. This should be reflected in the ID training program. Large heterogeneity in practice between clinicians reflects a lack of evidence from well-designed clinical trials for patients with DFI and highlights the need for management guidelines informed by future trials.

Diabetic foot syndrome: Charcot arthropathy or osteomyelitis? Part I: Clinical picture and radiography

One of significant challenges faced by diabetologists, surgeons and orthopedists who care for patients with diabetic foot syndrome is early diagnosis and differentiation of bone structure abnormalities typical of these patients, i.e. osteitis and Charcot arthropathy. In addition to clinical examination, the patient's medical history and laboratory tests, imaging plays a significant role. The evaluation usually begins with conventional radiographs. In the case of osteomyelitis, radiography shows osteopenia, lytic lesions, cortical destruction, periosteal reactions as well as, in the chronic phase, osteosclerosis and sequestra. Neurogenic arthropathy, however, presents an image resembling rapidly progressing osteoarthritis combined with aseptic necrosis or inflammation. The image includes: bone destruction with subluxations and dislocations as well as pathological fractures that lead to the presence of bone debris, osteopenia and, in the later phase, osteosclerosis, joint space narrowing, periosteal reactions, grotesque osteophytes and bone ankylosis. In the case of an unfavorable course of the disease and improper or delayed treatment, progression of these changes may lead to significant foot deformity that might resemble a "bag of bones". Unfortunately, radiography is non-specific and frequently does not warrant an unambiguous diagnosis, particularly in the initial phase preceding bone destruction. For these reasons, alternative imaging methods, such as magnetic resonance tomography, scintigraphy, computed tomography and ultrasonography, are also indicated.

Ex Vivo Tracer Efficacy in Optical Imaging of Staphylococcus Aureus Nuclease Activity

The key to effective treatment of bacterial infections is a swift and reliable diagnosis. Current clinical standards of bacterial diagnosis are slow and laborious. There are several anatomical imaging modalities that can detect inflammation, but none can distinguish between bacterial and sterile inflammation. Novel tracers such as smart activatable fluorescent probes represent a promising development that allow fast and specific testing without the use of ionizing radiation. Previously, a smart activatable probe was developed that is a substrate for the micrococcal nuclease as produced by Staphylococcus aureus. In the present study, the function of this probe was validated. Practical applicability in terms of sensitivity was assessed by incubation of the probe with 26 clinical S. aureus isolates, and probe specificity was verified by incubation with 30 clinical isolates and laboratory strains of various bacterial pathogens. The results show that the nuclease-specific probe was activated by all tested S. aureus isolates and laboratory strains with a threshold of ~106-107 cells/mL. The probe was also activated by certain opportunistic staphylococci. We therefore propose that the studied nuclease probe represents a significant step forward to address the need for a rapid, practical, and precise method to detect infections caused by S. aureus.