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Castro-Martins P, Marques A, Coelho L, Vaz M, Baptista JS. In-shoe plantar pressure measurement technologies for the diabetic foot: A systematic review. Heliyon 2024; 10:e29672. [PMID: 38699042 PMCID: PMC11064085 DOI: 10.1016/j.heliyon.2024.e29672] [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: 07/29/2023] [Revised: 04/11/2024] [Accepted: 04/12/2024] [Indexed: 05/05/2024] Open
Abstract
Introduction Loss of cutaneous protective sensation and high plantar pressures increase the risk for diabetic foot patients. Trauma and ulceration are imminent threats, making assessment and monitoring essential. This systematic review aims to identify systems and technologies for measuring in-shoe plantar pressures, focusing on the at-risk diabetic foot population. Methods A systematic search was conducted across four electronic databases (Scopus, Web of Science, PubMed, Oxford Journals) using PRISMA methodology, covering articles published in English from 1979 to 2024. Only studies addressing systems or sensors exclusively measuring plantar pressures inside the shoe were included. Results A total of 87 studies using commercially available devices and 45 articles proposing new systems or sensors were reviewed. The prevailing market offerings consist mainly of instrumented insoles. Emerging technologies under development often feature configurations with four, six or eight resistive sensors strategically placed within removable insoles. Despite some variability due to the inherent heterogeneity of human gait, these devices assess plantar pressure, although they present significant differences between them in measurement results. Individuals with diabetic foot conditions appears exhibit elevated plantar pressures, with reported peak pressures reaching approximately 1000 kPa. The results also showed significant differences between the diabetic and non-diabetic groups. Conclusion Instrumented insoles, particularly those incorporating resistive sensor technology, dominate the field. Systems employing eight sensors at critical locations represent a pragmatic approach, although market options extend to systems with up to 960 sensors. Differences between devices can be a critical factor in measurement and highlights the importance of individualized patient assessment using consistent measurement devices.
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Affiliation(s)
- Pedro Castro-Martins
- CIETI, ISEP, Polytechnic of Porto, Portugal
- Faculty of Engineering, University of Porto, Portugal
| | - Arcelina Marques
- CIETI, ISEP, Polytechnic of Porto, Portugal
- Institute for Science and Innovation in Mechanical and Industrial Engineering, Porto, Portugal
| | - Luís Coelho
- CIETI, ISEP, Polytechnic of Porto, Portugal
- INESC-TEC, Centre for Robotics in Industry and Intelligent Systems, Porto, Portugal
| | - Mário Vaz
- Faculty of Engineering, University of Porto, Portugal
- Institute for Science and Innovation in Mechanical and Industrial Engineering, Porto, Portugal
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Menekse S. Outcome of Chronic Foot Osteomyelitis Treated With Hyperbaric Oxygen: An Observational Study. INT J LOW EXTR WOUND 2024; 23:80-85. [PMID: 38073097 DOI: 10.1177/15347346231217641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Abstract
Chronic refractory osteomyelitis of the foot stands as a formidable challenge in medical care, associated with significant morbidity and escalating healthcare costs. Traditional therapeutic approaches, including surgical debridement and systemic antibiotics, often fall short, leaving patients and clinicians in search of more efficacious interventions. Hyperbaric oxygen therapy (HBOT), an innovative therapeutic modality, has recently emerged as a promising adjunct therapy, offering a beacon of hope in this therapeutic conundrum. In this groundbreaking observational study, we meticulously analyzed the experiences of 80 patients suffering from chronic refractory osteomyelitis of the foot. Following surgical debridement and tailored antibiotic therapy, each patient was treated with HBOT at 2.5 atmospheres absolute for 120 min, 5 days a week, spanning an average of 50 days. Our primary endpoints focused on complete eradication of infection, recurrence metrics, and any adverse effects linked to HBOT. Astonishingly, 68 of the 80 patients (85%) achieved a total infection clearance, maintaining this status through a mean follow-up period of 36 months, all without a single report of HBOT-induced complications. Our compelling findings advocate that HBOT, synergized with standard surgical and antibiotic regimens, can revolutionize the treatment landscape for chronic refractory osteomyelitis of the foot. Given these promising preliminary results, there's an imperative need for extensive research to delineate the long-term advantages and to fine-tune HBOT protocols, potentially paving the way for a new therapeutic gold standard.
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Affiliation(s)
- Serdar Menekse
- Orthopedic Department, Seyhan State Hospital, Adana, Turkey
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3
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Senneville É, Albalawi Z, van Asten SA, Abbas ZG, Allison G, Aragón-Sánchez J, Embil JM, Lavery LA, Alhasan M, Oz O, Uçkay I, Urbančič-Rovan V, Xu ZR, Peters EJG. Diagnosis of infection in the foot of patients with diabetes: A systematic review. Diabetes Metab Res Rev 2024; 40:e3723. [PMID: 37715722 DOI: 10.1002/dmrr.3723] [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: 07/26/2023] [Accepted: 08/29/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Securing an early accurate diagnosis of diabetic foot infections and assessment of their severity are of paramount importance since these infections can cause great morbidity and potential mortality and present formidable challenges in surgical and antimicrobial treatment. METHODS In June 2022, we searched the literature using PubMed and EMBASE for published studies on the diagnosis of diabetic foot infection (DFI). On the basis of pre-determined criteria, we reviewed prospective controlled, as well as non-controlled, studies in English. We then developed evidence statements based on the included papers. RESULTS We selected a total of 64 papers that met our inclusion criteria. The certainty of the majority of the evidence statements was low because of the weak methodology of nearly all of the studies. The available data suggest that diagnosing diabetic foot infections on the basis of clinical signs and symptoms and classified according to the International Working Group of the Diabetic Foot/Infectious Diseases Society of America scheme correlates with the patient's likelihood of the need for hospitalisation, lower extremity amputation, and risk of death. Elevated levels of selected serum inflammatory markers such as erythrocyte sedimentation rate (ESR), C-reactive protein and procalcitonin are supportive, but not diagnostic, of soft tissue infection. Culturing tissue samples of soft tissues or bone, when care is taken to avoid contamination, provides more accurate microbiological information than culturing superficial (swab) samples. Although non-culture techniques, especially next-generation sequencing, are likely to identify more bacteria from tissue samples including bone than standard cultures, no studies have established a significant impact on the management of patients with DFIs. In patients with suspected diabetic foot osteomyelitis, the combination of a positive probe-to-bone test and elevated ESR supports this diagnosis. Plain X-ray remains the first-line imaging examination when there is suspicion of diabetic foot osteomyelitis (DFO), but advanced imaging methods including magnetic resonance imaging (MRI) and nuclear imaging when MRI is not feasible help in cases when either the diagnosis or the localisation of infection is uncertain. Intra-operative or non-per-wound percutaneous biopsy is the best method to accurately identify bone pathogens in case of a suspicion of a DFO. Bedside percutaneous biopsies are effective and safe and are an option to obtain bone culture data when conventional (i.e. surgical or radiological) procedures are not feasible. CONCLUSIONS The results of this systematic review of the diagnosis of diabetic foot infections provide some guidance for clinicians, but there is still a need for more prospective controlled studies of high quality.
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Affiliation(s)
- Éric Senneville
- Department of Infectious Diseases, Gustave Dron Hospital, Tourcoing, France
- Univ-Lille, Lille, France
| | - Zaina Albalawi
- Department of Medicine, Division of Endocrinology, Memorial University, St. John's, Newfoundland, Canada
| | - Suzanne A van Asten
- Department of Medical Microbiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Zulfiqarali G Abbas
- Abbas Medical Centre, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Geneve Allison
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - John M Embil
- Alberta Public Laboratories, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Lawrence A Lavery
- Department of Plastic Surgery, Southwestern Medical Center, Dallas, Texas, USA
| | - Majdi Alhasan
- Department of Medicine, Prisma Health-Midlands, Columbia, South Carolina, USA
| | - Orhan Oz
- Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ilker Uçkay
- Department of Infectious Diseases, Balgrist University Hospital, Zurich, Switzerland
| | - Vilma Urbančič-Rovan
- Faculty of Medicine, University Medical Centre, University of Ljubljana, Ljubljana, Slovenia
| | - Zhang-Rong Xu
- Diabetes Centre, The 306th Hospital of PLA, Beijing, China
| | - Edgar J G Peters
- Section of Infectious Diseases, Department of Internal Medicine, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
- Amsterdam Infection & Immunity, Infectious Diseases, Amsterdam, The Netherlands
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4
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Senneville É, Albalawi Z, van Asten SA, Abbas ZG, Allison G, Aragón-Sánchez J, Embil JM, Lavery LA, Alhasan M, Oz O, Uçkay I, Urbančič-Rovan V, Xu ZR, Peters EJG. IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023). Diabetes Metab Res Rev 2024; 40:e3687. [PMID: 37779323 DOI: 10.1002/dmrr.3687] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 06/23/2023] [Indexed: 10/03/2023]
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the management and prevention of diabetes-related foot diseases since 1999. The present guideline is an update of the 2019 IWGDF guideline on the diagnosis and management of foot infections in persons with diabetes mellitus. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used for the development of this guideline. This was structured around identifying clinically relevant questions in the P(A)ICO format, determining patient-important outcomes, systematically reviewing the evidence, assessing the certainty of the evidence, and finally moving from evidence to the recommendation. This guideline was developed for healthcare professionals involved in diabetes-related foot care to inform clinical care around patient-important outcomes. Two systematic reviews from 2019 were updated to inform this guideline, and a total of 149 studies (62 new) meeting inclusion criteria were identified from the updated search and incorporated in this guideline. Updated recommendations are derived from these systematic reviews, and best practice statements made where evidence was not available. Evidence was weighed in light of benefits and harms to arrive at a recommendation. The certainty of the evidence for some recommendations was modified in this update with a more refined application of the GRADE framework centred around patient important outcomes. This is highlighted in the rationale section of this update. A note is also made where the newly identified evidence did not alter the strength or certainty of evidence for previous recommendations. The recommendations presented here continue to cover various aspects of diagnosing soft tissue and bone infections, including the classification scheme for diagnosing infection and its severity. Guidance on how to collect microbiological samples, and how to process them to identify causative pathogens, is also outlined. Finally, we present the approach to treating foot infections in persons with diabetes, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and bone infections; when and how to approach surgical treatment; and which adjunctive treatments may or may not affect the infectious outcomes of diabetes-related foot problems. We believe that following these recommendations will help healthcare professionals provide better care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes-related foot disease.
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Affiliation(s)
- Éric Senneville
- Gustave Dron Hospital, Tourcoing, France
- Univ-Lille France, Lille, France
| | - Zaina Albalawi
- Department of Medicine, Division of Endocrinology, Memorial University, St. John's, Newfoundland and Labrador, Canada
| | - Suzanne A van Asten
- Department of Medical Microbiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Zulfiqarali G Abbas
- Abbas Medical Centre, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Geneve Allison
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - John M Embil
- Department of Medicine, Section of Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lawrence A Lavery
- Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Majdi Alhasan
- Department of Medicine, Prisma Health-Midlands, Columbia, South Carolina, USA
| | - Orhan Oz
- UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ilker Uçkay
- Balgrist University Hospital, Zurich, Switzerland
| | - Vilma Urbančič-Rovan
- Faculty of Medicine, University Medical Centre, University of Ljubljana, Ljubljana, Slovenia
| | | | - Edgar J G Peters
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Section of Infectious Diseases, Amsterdam, the Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, the Netherlands
- Amsterdam Infection & Immunity, Infectious Diseases, Amsterdam, the Netherlands
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5
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Castro-Martins P, Marques A, Coelho L, Vaz M, Costa JT. Plantar pressure thresholds as a strategy to prevent diabetic foot ulcers: A systematic review. Heliyon 2024; 10:e26161. [PMID: 38390156 PMCID: PMC10882031 DOI: 10.1016/j.heliyon.2024.e26161] [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: 05/30/2023] [Revised: 11/22/2023] [Accepted: 02/08/2024] [Indexed: 02/24/2024] Open
Abstract
Background The development of ulcers in the plantar region of the diabetic foot originates mainly from sites subjected to high pressure. The monitoring of these events using maximum allowable pressure thresholds is a fundamental procedure in the prevention of ulceration and its recurrence. Objective The aim of this review was to identify data in the literature that reveal an objective threshold of plantar pressure in the diabetic foot, where pressure is classified as promoting ulceration. The aim is not to determine the best and only pressure threshold for ulceration, but rather to clarify the threshold values most used in clinical practice and research, also considering the devices used and possible applications for offloading plantar pressure. Design A systematic review. Methods The search was performed in three electronic databases, by the PRISMA methodology, for studies that used a pressure threshold to minimize the risk of ulceration in the diabetic foot. The selected studies were subjected to eligibility criteria. Results Twenty-six studies were included in this review. Seven thresholds were identified, five of which are intended for the inside of the shoe: a threshold of average peak pressure of 200 kPa; 25 % and 40-80 % reduction from initial baseline pressure; 32-35 mm Hg for a capillary perfusion pressure; and a matrix of thresholds based on patient risk, shoe size and foot region. Two other thresholds are intended for the barefoot, 450 and 750 kPa. The threshold of 200 kPa of pressure inside the shoe is the most agreed upon among the studies. Regarding the prevention of ulceration and its recurrence, the efficacy of the proposed threshold matrix and the threshold of reducing baseline pressure by 40-80 % has not yet been evaluated, and the evidence for the remaining thresholds still needs further studies. Conclusions Some heterogeneity was found in the studies, especially regarding the measurement systems used, the number of regions of interest and the number of steps to be considered for the threshold. Even so, this review reveals the way forward to obtain a threshold indicative of an effective steppingstone in the prevention of diabetic foot ulcer.
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Affiliation(s)
- Pedro Castro-Martins
- CIETI, ISEP, Polytechnic of Porto, Portugal
- Faculty of Engineering, University of Porto, Portugal
| | - Arcelina Marques
- CIETI, ISEP, Polytechnic of Porto, Portugal
- Institute for Science and Innovation in Mechanical and Industrial Engineering, Porto, Portugal
| | - Luís Coelho
- CIETI, ISEP, Polytechnic of Porto, Portugal
- INESC-TEC, Centre for Robotics in Industry and Intelligent Systems, Porto, Portugal
| | - Mário Vaz
- Faculty of Engineering, University of Porto, Portugal
- Institute for Science and Innovation in Mechanical and Industrial Engineering, Porto, Portugal
| | - José Torres Costa
- Faculty of Engineering, University of Porto, Portugal
- Faculty of Medicine, University of Porto, Portugal
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6
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Bonnet E, Maulin L, Senneville E, Castan B, Fourcade C, Loubet P, Poitrenaud D, Schuldiner S, Sotto A, Lavigne JP, Lesprit P. Clinical practice recommendations for infectious disease management of diabetic foot infection (DFI) - 2023 SPILF. Infect Dis Now 2024; 54:104832. [PMID: 37952582 DOI: 10.1016/j.idnow.2023.104832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/03/2023] [Indexed: 11/14/2023]
Abstract
In march 2020, the International Working Group on the Diabetic Foot (IWGDF) published an update of the 2015 guidelines on the diagnosis and management of diabetic foot infection (DFI). While we (the French ID society, SPILF) endorsed some of these recommendations, we wanted to update our own 2006 guidelines and specifically provide informative elements on modalities of microbiological diagnosis and antibiotic treatment (especially first- and second-line regiments, oral switch and duration). The recommendations put forward in the present guidelines are addressed to healthcare professionals managing patients with DFI and more specifically focused on infectious disease management of this type of infection, which clearly needs a multidisciplinary approach. Staging of the severity of the infection is mandatory using the classification drawn up by the IWGDF. Microbiological samples should be taken only in the event of clinical signs suggesting infection in accordance with a strict preliminarily established protocol. Empirical antibiotic therapy should be chosen according to the IWGDF grade of infection and duration of the wound, but must always cover methicillin-sensitive Staphylococcus aureus. Early reevaluation of the patient is a fundamental step, and duration of antibiotic therapy can be shortened in many situations. When osteomyelitis is suspected, standard foot radiograph is the first-line imagery examination and a bone biopsy should be performed for microbiological documentation. Histological analysis of the bone sample is no longer recommended. High dosages of antibiotics are recommended in cases of confirmed osteomyelitis.
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Affiliation(s)
- E Bonnet
- Service des Maladies Infectieuses et Tropicales, CHU Toulouse-Purpan, 31059 Toulouse, France.
| | - L Maulin
- Maladies Infectieuses, CH du Pays d'Aix, 13100 Aix en Provence, France
| | - E Senneville
- Service Universitaire des Maladies Infectieuses, CH Dron, 59200 Tourcoing, France
| | - B Castan
- Service de Médecine Interne et Maladies Infectieuses, CH Périgueux, 24019 Périgueux, France
| | - C Fourcade
- Equipe Mobile d'Infectiologie, Clinique Pasteur, Clinavenir, 31300 Toulouse, France
| | - P Loubet
- Service des Maladies Infectieuses et Tropicales, CHU Caremeau, 30029 Nîmes, France
| | - D Poitrenaud
- Unité Fonctionnelle d'Infectiologie, CH Notre Dame de la Miséricorde, 20000 Ajaccio, France
| | - S Schuldiner
- Service des Maladies Métaboliques et Endocriniennes, CHU Caremeau, 30029 Nîmes, France
| | - A Sotto
- Service des Maladies Infectieuses et Tropicales, CHU Caremeau, 30029 Nîmes, France
| | - J P Lavigne
- Service de Microbiologie et Hygiène Hospitalière, CHU Caremeau, 30029 Nîmes, France
| | - P Lesprit
- Maladies Infectieuses, CHU Grenoble Alpes, 38043, Grenoble, France
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Nieuwland AJ, Waibel FWA, Flury A, Lisy M, Berli MC, Lipsky BA, Uçkay İ, Schöni M. Initial antibiotic therapy for postoperative moderate or severe diabetic foot infections: Broad versus narrow spectrum, empirical versus targeted. Diabetes Obes Metab 2023; 25:3290-3297. [PMID: 37533158 DOI: 10.1111/dom.15228] [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: 04/25/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 08/04/2023]
Abstract
AIM To retrospectively evaluate clinical and microbiological outcomes after combined surgical and medical therapy for diabetic foot infections (DFIs), stratifying between the empirical versus the targeted nature, and between an empirical broad versus a narrow-spectrum, antibiotic therapy. METHODS We retrospectively assessed the rate of ultimate therapeutic failures for each of three types of initial postoperative antibiotic therapy: adequate empirical therapy; culture-guided therapy; and empirical inadequate therapy with a switch to targeted treatment based on available microbiological results. RESULTS We included data from 332 patients who underwent 716 DFI episodes of surgical debridement, including partial amputations. Clinical failure occurred in 40 of 194 (20.6%) episodes where adequate empirical therapy was given, in 77 of 291 (26.5%) episodes using culture-guided (and correct) therapy from the start, and in 73 of 231 (31.6%) episodes with switching from empirical inadequate therapy to culture-targeted therapy. Equally, a broad-spectrum antibiotic choice could not alter this failure risk. Group comparisons, Kaplan-Meier curves and Cox regression analyses failed to show either statistical superiority or inferiority of any of the initial antibiotic strategies. CONCLUSIONS In this study, the microbiological adequacy of the initial antibiotic regimen after (surgical) debridement for DFI did not alter therapeutic outcomes. We recommend that clinicians follow the stewardship approach of avoiding antibiotic de-escalation and start with a narrow-spectrum regimen based on the local epidemiology.
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Affiliation(s)
- Arend J Nieuwland
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Felix W A Waibel
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Andreas Flury
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Marcus Lisy
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Martin C Berli
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Benjamin A Lipsky
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - İlker Uçkay
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Infectiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Unit for Clinical and Applied Research, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Madlaina Schöni
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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8
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Senneville É, Albalawi Z, van Asten SA, Abbas ZG, Allison G, Aragón-Sánchez J, Embil JM, Lavery LA, Alhasan M, Oz O, Uçkay I, Urbančič-Rovan V, Xu ZR, Peters EJG. IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-related Foot Infections (IWGDF/IDSA 2023). Clin Infect Dis 2023:ciad527. [PMID: 37779457 DOI: 10.1093/cid/ciad527] [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: 06/22/2022] [Accepted: 06/23/2023] [Indexed: 10/03/2023] Open
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the management and prevention of diabetes-related foot diseases since 1999. The present guideline is an update of the 2019 IWGDF guideline on the diagnosis and management of foot infections in persons with diabetes mellitus. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used for the development of this guideline. This was structured around identifying clinically relevant questions in the P(A)ICO format, determining patient-important outcomes, systematically reviewing the evidence, assessing the certainty of the evidence, and finally moving from evidence to the recommendation. This guideline was developed for healthcare professionals involved in diabetes-related foot care to inform clinical care around patient-important outcomes. Two systematic reviews from 2019 were updated to inform this guideline, and a total of 149 studies (62 new) meeting inclusion criteria were identified from the updated search and incorporated in this guideline. Updated recommendations are derived from these systematic reviews, and best practice statements made where evidence was not available. Evidence was weighed in light of benefits and harms to arrive at a recommendation. The certainty of the evidence for some recommendations was modified in this update with a more refined application of the GRADE framework centred around patient important outcomes. This is highlighted in the rationale section of this update. A note is also made where the newly identified evidence did not alter the strength or certainty of evidence for previous recommendations. The recommendations presented here continue to cover various aspects of diagnosing soft tissue and bone infections, including the classification scheme for diagnosing infection and its severity. Guidance on how to collect microbiological samples, and how to process them to identify causative pathogens, is also outlined. Finally, we present the approach to treating foot infections in persons with diabetes, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and bone infections; when and how to approach surgical treatment; and which adjunctive treatments may or may not affect the infectious outcomes of diabetes-related foot problems. We believe that following these recommendations will help healthcare professionals provide better care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes-related foot disease.
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Affiliation(s)
- Éric Senneville
- Gustave Dron Hospital, Tourcoing, France
- Univ-Lille France, Lille, France
| | - Zaina Albalawi
- Department of Medicine, Division of Endocrinology, Memorial University, St. John's, Newfoundland and Labrador, Canada
| | - Suzanne A van Asten
- Department of Medical Microbiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Zulfiqarali G Abbas
- Abbas Medical Centre, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Geneve Allison
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - John M Embil
- Department of Medicine, Section of Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lawrence A Lavery
- Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Majdi Alhasan
- Department of Medicine, Prisma Health-Midlands, Columbia, South Carolina, USA
| | - Orhan Oz
- UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ilker Uçkay
- Balgrist University Hospital, Zurich, Switzerland
| | - Vilma Urbančič-Rovan
- Faculty of Medicine, University Medical Centre, University of Ljubljana, Ljubljana, Slovenia
| | | | - Edgar J G Peters
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Section of Infectious Diseases, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
- Amsterdam Infection & Immunity, Infectious Diseases, Amsterdam, The Netherlands
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9
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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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10
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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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11
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Karthik S, Babu L, Joseph M, Bhatt A, Babu T. Microbiology of diabetic foot osteomyelitis - Is it geographically variable? Foot (Edinb) 2022; 52:101878. [PMID: 35576864 DOI: 10.1016/j.foot.2021.101878] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 07/27/2021] [Accepted: 10/18/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Diabetic foot osteomyelitis (DFO) is a dreaded complication as both diagnosis and treatment of the condition is laborious. However, for proper decision on antibiotics in medical management of DFO, accurate determination of microbes is necessary to narrow the spectrum of coverage and to reduce adverse effects of long-term administration of antibiotics. With differing pattern of use of antimicrobials and their resistance pattern in different countries, it is empirical to determine the microbiological characteristics of bone cultures in DFO from a referral institute in South India. MATERIALS AND METHODS This study was a retrospective chart review of all cases of proven DFO who had consented for debridement and bone culture or those who underwent amputation. Both deep soft tissue (DST) and bone cultures were obtained for aerobic bacteria. Clinical characteristics and site(s) of DFO were recorded. Investigations for peripheral artery disease were performed if clinically indicated. RESULTS In all, 105 patients with DFO were reviewed. Mean age was 62 years and 70% were men. Of those who were screened, 57% had evidence of peripheral arterial disease by arterial doppler. 46% of bone culture samples were sterile. Gram- negative organisms were more common (58%). Following staphylococcus, pseudomonas was the second common isolate. Of total staphylococcal isolates 37% were MRSA and 33% of klebsiella isolates were ESBL producing. Concordance rate between DST and bone cultures was 66%. 90% were mono-bacterial isolates. The commonest site of involvement of DFO was terminal phalanges of toes rather than base of 1st metatarsal. CONCLUSION Widespread use of antibiotics, tropical climate and route of entry of organisms causing DFO differed in our cohort of patients. Further studies from different regions of world would shed light onto different pattern of microbes causing DFO.
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Affiliation(s)
| | - Lakshmi Babu
- Department of Medicine, Silverline Hospital, Kochi, India
| | - Manoj Joseph
- Department of Medicine, Silverline Hospital, Kochi, India
| | | | - Tom Babu
- Department of Endocrinology, Silverline Hospital, Kochi, India
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12
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Grace A, Murphy R, Dillon A, Smith D, Cryan SA, Heise A, Fitzgerald-Hughes D. Modified poly(L-lysine)-based structures as novel antimicrobials for diabetic foot infections, an in-vitro study. HRB Open Res 2022; 5:4. [PMID: 36017374 PMCID: PMC9366240 DOI: 10.12688/hrbopenres.13380.1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/18/2021] [Indexed: 01/13/2023] Open
Abstract
Background: Wound infections occur as sequelae to skin trauma and cause significant hospitalizations, morbidity and mortality. Skin traumas arise more frequently in those with diabetes or cardiovascular disease and in these settings, may be chronic with poorer outcomes including lower limb amputation. Treatment of chronic wound infection is challenging due to antibiotic resistance and biofilm formation by bacteria including
S. aureus and
P. aeruginosa, which are among the most frequent causative pathogens. Managing these challenging infections requires new molecules and modalities.
Methods: We evaluated antimicrobial and anti-biofilm activity of star-shaped poly(L-lysine) (PLL) polymers against
S. aureus and
P. aeruginosa strains and clinical isolates recovered from wounds including diabetic foot wounds (DFW) in a Dublin Hospital in 2019. A star-shaped PLL polypeptide series, specifically G2(8)PLL
20, G3(16)PLL
10, G4(32)PLL
5 with variation in polypeptide chain length and arm-multiplicity, were compared to a linear peptide, PLL
160 with equivalent number of lysine residues.
Results: All PLLs, including the linear polypeptide, were bactericidal at 1μM against
S. aureus 25923 and
P. aeruginosa PAO1, with log reduction in colony forming units/ml between 2.7-3.6. PLL
160 demonstrated similar killing potency against 20
S. aureus and five
P. aeruginosa clinical isolates from DFW, mean log reductions: 3.04 ± 0.16 and 3.96 ± 0.82 respectively after 1 hour incubation. Potent anti-biofilm activity was demonstrated against
S. aureus 25923 but for clinical isolates, low to moderate loss of biofilm viability was shown using PLL
160 and G3(16)PLL
10 at 50 μM (
S. aureus) and 200 μM (
P. aeruginosa) with high inter-isolate variability
. In the star-shaped architecture, antimicrobial activity was retained with incorporation of 5-mer hydrophobic amino-acid modifications to the arms of the polypeptides (series G3(16)PLL
20-coPLT
5, G3(16)PLL
20-coPLI
5, G3(16)PLL
20-coPLP
5).
Conclusion: These polypeptides offer structural flexibility for clinical applications and have potential for further development, particularly in the setting of diabetic foot and other chronic wound infections.
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Affiliation(s)
- Alicia Grace
- Department of Microbiology,, Beaumont Hospital, Dublin, D09V2N0, Ireland
- Department of Clinical Microbiology,, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, The Smurfit Building, Beaumont Hospital, Dublin, D09 YD60, Ireland
| | - Robert Murphy
- Department of Chemistry, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, 123 St. Stephens Green, Dublin 2, D02 YN77, Ireland
| | - Aoife Dillon
- Department of Clinical Microbiology,, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, The Smurfit Building, Beaumont Hospital, Dublin, D09 YD60, Ireland
| | - Diarmuid Smith
- Department of Endocrinology, Diabetes Centre, Beaumont Hospital, Dublin, Ireland, D09 V2N0, Ireland
| | - Sally-Ann Cryan
- SFI Advanced Materials and Bioengineering Research Centre (AMBER), Royal College of Surgeons (RCSI) University of Medicine and Health Sciences and University of Dublin, Trinity College, Dublin, Ireland
- SFI Centre for Research in Medical Devices (CÚRAM), Royal College of Surgeons in Ireland, University of Medicine and Health Sciences and National University of Ireland, Galway, Ireland
- School of Pharmacy & Biomolecular Sciences, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, 123 Saint Stephen's Green, Dublin 2, D02 YN77, Ireland
| | - Andreas Heise
- Department of Chemistry, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, 123 St. Stephens Green, Dublin 2, D02 YN77, Ireland
- SFI Advanced Materials and Bioengineering Research Centre (AMBER), Royal College of Surgeons (RCSI) University of Medicine and Health Sciences and University of Dublin, Trinity College, Dublin, Ireland
- SFI Centre for Research in Medical Devices (CÚRAM), Royal College of Surgeons in Ireland, University of Medicine and Health Sciences and National University of Ireland, Galway, Ireland
| | - Deirdre Fitzgerald-Hughes
- Department of Clinical Microbiology,, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, The Smurfit Building, Beaumont Hospital, Dublin, D09 YD60, Ireland
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13
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Hearne CLJ, Patton D, Moore ZE, Wilson P, Gillen C, O'Connor T. Effectiveness of combined modulated ultrasound and electric current stimulation to treat diabetic foot ulcers. J Wound Care 2022; 31:12-20. [PMID: 35077215 DOI: 10.12968/jowc.2022.31.1.12] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The use of combined ultrasound and electrostimulation (CUSECS) as an adjunct therapy for diabetic foot ulcers (DFUs) is a relatively new concept. This study aimed to investigate if combined ultrasound and electrostimulation is an effective adjunctive treatment for hard-to-heal DFUs when compared with standard wound care. METHODS A randomised controlled pilot study design was used. Patients with hard-to-heal DFUs from two centres were sequentially randomised. For 8 weeks, the experimental group received CUSECS and standard wound care treatment twice a week. The control group received standard wound care treatment once a week. Wound changes were documented using photography, which also facilitated wound size measurement. Self-efficacy, economic cost, quality of life and reoccurrence rates were analysed as secondary objectives. RESULTS The experimental group (n=6) achieved a higher rate of mean wound healing (mean difference (MD): 0.49) when compared to the control group (n=5, MD: 0.01). Two participants completed full healing in the experimental group and one in the control group. There were no statistically significant findings because of the small sample size. There were no direct adverse reactions to this therapy. Quality of life scores improved in the treatment group. There was no significant change in self-efficacy scores. Costs were higher in the experimental group; however, the healing rate was quicker, which could be extrapolated to cost reductions over time. CONCLUSION Results suggest that CUSECS may be a useful adjunctive therapy for treatment of hard-to-heal DFUs. Further large-scale studies are needed to ascertain the effectiveness of CUSECS. The findings here are inconclusive but indicate that CUSECS may offer promise as a treatment.
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Affiliation(s)
- Caoimhe L Joyce Hearne
- RCSI School of Nursing & Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland.,SWaT Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Declan Patton
- RCSI School of Nursing & Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland.,SWaT Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland.,School of Nursing & Midwifery, Griffith University, Queensland, Australia.,Fakeeh College of Health Sciences, Jeddah, Saudi Arabia
| | - Zena E Moore
- RCSI School of Nursing & Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland.,SWaT Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland.,School of Nursing & Midwifery, Griffith University, Queensland, Australia.,Fakeeh College of Health Sciences, Jeddah, Saudi Arabia.,Lida Institute, Shanghai, China.,Faculty of Medicine and Health Sciences, UGent, Ghent University, Belgium.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Pauline Wilson
- RCSI School of Nursing & Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland.,SWaT Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland.,St James's Hospital, Dublin, Ireland
| | | | - Tom O'Connor
- RCSI School of Nursing & Midwifery, Royal College of Surgeons in Ireland, Dublin, Ireland.,SWaT Research Centre, Royal College of Surgeons in Ireland, Dublin, Ireland.,School of Nursing & Midwifery, Griffith University, Queensland, Australia.,Fakeeh College of Health Sciences, Jeddah, Saudi Arabia.,Lida Institute, Shanghai, China
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14
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The Effects of Silver-Releasing Foam Dressings on Diabetic Foot Ulcer Healing. J Clin Med 2021; 10:jcm10071495. [PMID: 33916790 PMCID: PMC8038333 DOI: 10.3390/jcm10071495] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/22/2021] [Accepted: 03/29/2021] [Indexed: 01/13/2023] Open
Abstract
Diabetic foot ulcers (DFUs) are a serious complication in diabetic patients and lead to high morbidity and mortality. Numerous dressings have been developed to facilitate wound healing of DFUs. This study investigated the wound healing efficacy of silver-releasing foam dressings versus silver-containing cream in managing outpatients with DFUs. Sixty patients with Wagner Grade 1 to 2 DFUs were recruited. The treatment group received silver-releasing foam dressing (Biatain® Ag Non-Adhesive Foam dressing; Coloplast, Humlebaek, Denmark). The control group received 1% silver sulfadiazine (SSD) cream. The ulcer area in the silver foam group was significantly reduced compared with that in the SSD group after four weeks of treatment (silver foam group: 76.43 ± 7.41%, SSD group: 27.00 ± 4.95%, p < 0.001). The weekly wound healing rate in the silver foam group was superior to the SSD group during the first three weeks of treatment (p < 0.05). The silver-releasing foam dressing is more effective than SSD in promoting wound healing of DFUs. The effect is more pronounced in the initial three weeks of the treatment. Thus, silver-releasing foam could be an effective wound dressing for DFUs, mainly in the early period of wound management.
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15
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16
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Hot topics in diabetic foot infection. Int J Antimicrob Agents 2020; 55:105942. [PMID: 32194153 DOI: 10.1016/j.ijantimicag.2020.105942] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 03/05/2020] [Accepted: 03/06/2020] [Indexed: 01/12/2023]
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17
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Zubair M. Prevalence and interrelationships of foot ulcer, risk-factors and antibiotic resistance in foot ulcers in diabetic populations: A systematic review and meta-analysis. World J Diabetes 2020; 11:78-89. [PMID: 32180896 PMCID: PMC7061236 DOI: 10.4239/wjd.v11.i3.78] [Citation(s) in RCA: 16] [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: 08/21/2019] [Revised: 11/21/2019] [Accepted: 01/08/2020] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Diabetic foot ulceration (DFU) is the prime health concern globally. It accounts for the major burden related to disease mortality and morbidity and economic cost. The timely and early recognition of the DFU can help present its occurrence and improve clinical outcomes.
AIM To evaluate interrelationships between foot ulcers, risk factors, and antibiotic resistance among diabetic patients having ulcers in their foot.
METHODS The databases such as PubMed, ERIC, Medline, and Google Scholar were extensively used for the extraction of studies. The selected studies were published within the time-period of 2014-2018. Ten studies were selected, which were found to be completely relevant to the current study.
RESULTS The prevalence of diabetic foot ulcers among the population was evaluated, and the associated risk factors with its prevalence. Moreover, few studies also reported on the bacteria that are found to be most prevailing among diabetic patients. A narrative discussion was drawn through this analysis, which was used to highlight the specific area of research through selected studies, extraction of the significant information that matched with the topic of research, and analysis of problem through the findings of the selected articles. The results helped in assessing significant knowledge regarding the risk factors of diabetic foot ulcers and the role of antimicrobial resistant in its treatment.
CONCLUSION The gram-negative bacteria were found to be the most common reason for diabetic foot ulcers. The study only included 10 studies that are not sufficient to produce generalized results, and no information was reported on the tests required to analyze antimicrobial susceptibility that can guide clinicians to propose better and sound treatment plans. It is evident that most study results depicted that the most common risk factors were found to be hypertension and neuropathy.
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Affiliation(s)
- Mohammad Zubair
- Department of Medical Microbiology, Faculty of Medicine, University of Tabuk, Tabuk 71491, Saudi Arabia
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18
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Peters EJG, Lipsky BA, Senneville É, Abbas ZG, Aragón-Sánchez J, Diggle M, Embil JM, Kono S, Lavery LA, Malone M, Urbančič-Rovan V, Van Asten SA. Interventions in the management of infection in the foot in diabetes: a systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3282. [PMID: 32176437 DOI: 10.1002/dmrr.3282] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/01/2019] [Accepted: 09/19/2019] [Indexed: 12/11/2022]
Abstract
The optimal approaches to managing diabetic foot infections remain a challenge for clinicians. Despite an exponential rise in publications investigating different treatment strategies, the various agents studied generally produce comparable results, and high-quality data are scarce. In this systematic review, we searched the medical literature using the PubMed and Embase databases for published studies on the treatment of diabetic foot infections as of June 2018. This systematic review is an update of previous reviews, the first of which was undertaken in 2010 and the most recent in 2014, by the infection committee of the International Working Group of the Diabetic Foot. We defined the context of literature by formulating clinical questions of interest, then developing structured clinical questions (PICOs) to address these. We only included data from controlled studies of an intervention to prevent or cure a diabetic foot infection. Two independent reviewers selected articles for inclusion and then assessed their relevant outcomes and the methodological quality. Our literature search identified a total of 15 327 articles, of which we selected 48 for full-text review; we added five more studies discovered by means other than the systematic literature search. Among these selected articles were 11 high-quality studies published in the last 4 years and two Cochrane systematic reviews. Overall, the outcomes in patients treated with the different antibiotic regimens for both skin and soft tissue infection and osteomyelitis of the diabetic foot were broadly equivalent across studies, except that treatment with tigecycline was inferior to ertapenem (±vancomycin). Similar outcomes were also reported in studies comparing primarily surgical and predominantly antibiotic treatment strategies in selected patients with diabetic foot osteomyelitis. There is insufficient high-quality evidence to assess the effect of various adjunctive therapies, such as negative pressure wound therapy, topical ointments or hyperbaric oxygen, on infection related outcomes of the diabetic foot. In general, the quality of more recent trial designs are better in past years, but there is still a great need for further well-designed trials to produce higher quality evidence to underpin our recommendations.
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Affiliation(s)
- Edgar J G Peters
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine, Amsterdam Infection and Immunity Institute, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Benjamin A Lipsky
- Department of Medicine, University of Washington, Seattle, Washington
| | | | - Zulfiqarali G Abbas
- Abbas Medical Centre, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Mathew Diggle
- Alberta Public Laboratories, University of Alberta Hospital, Edmonton, Canada
| | - John M Embil
- University of Manitoba, Winnipeg, Manitoba, Alberta, Canada
| | - Shigeo Kono
- WHO-Collaborating Centre for Diabetes, National Hospital Organization Kyoto Medical Centre, Kyoto, Japan
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, Texas
| | - Matthew Malone
- School of Medicine, Infectious Diseases and Microbiology, South West Sydney Local Health District, Western Sydney University, Sydney, Australia
| | - Vilma Urbančič-Rovan
- Faculty of Medicine, University Medical Centre, University of Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Suzanne A Van Asten
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
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19
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Senneville É, Lipsky BA, Abbas ZG, Aragón-Sánchez J, Diggle M, Embil JM, Kono S, Lavery LA, Malone M, van Asten SA, Urbančič-Rovan V, Peters EJG. Diagnosis of infection in the foot in diabetes: a systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3281. [PMID: 32176440 DOI: 10.1002/dmrr.3281] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/01/2019] [Accepted: 09/19/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND Securing an early accurate diagnosis of diabetic foot infections and assessment of their severity are of paramount importance since these infections can cause great morbidity and potentially mortality and present formidable challenges in surgical and antimicrobial treatment. METHODS In June 2018, we searched the literature using PuEbMed and EMBASE for published studies on the diagnosis of diabetic foot infection. On the basis of predetermined criteria, we reviewed prospective controlled, as well as noncontrolled, studies in any language, seeking translations for those not in English. We then developed evidence statements on the basis of the included papers. RESULTS From the 4242 records screened, we selected 35 papers that met our inclusion criteria. The quality of all but one of the evidence statements was low because of the weak methodology of nearly all of the studies. The available data suggest that diagnosing diabetic foot infections on the basis of clinical signs and symptoms and classified according to the International Working Group of the Diabetic Foot scheme correlates with the patient's likelihood of ulcer healing, of lower extremity amputation, and risk of death. Elevated levels of selected serum inflammatory markers are supportive, but not diagnostic, of soft tissue or bone infection. In patients with suspected diabetic foot osteomyelitis, both a positive probe-to-bone test and an elevated erythrocyte sedimentation rate are strongly associated with its presence. Culturing tissue samples of soft tissues or bone, when care is taken to avoid contamination, provides more accurate microbiological information than culturing superficial (swab) samples. Plain X-ray remains the first-line imaging examination when there is suspicion of diabetic foot osteomyelitis, but advanced imaging methods help in cases when either the diagnosis or the localization of infection is uncertain. CONCLUSION The results of this first reported systematic review on the diagnosis of diabetic foot infections provide some guidance for clinicians, but there is a need for more prospective controlled studies of high quality.
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Affiliation(s)
- Éric Senneville
- Gustave Dron Hospital, Tourcoing, France
- Lille University, France
| | | | - Zulfiqarali G Abbas
- Abbas Medical Centre, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Mathew Diggle
- Alberta Public Laboratories, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - John M Embil
- University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shigeo Kono
- WHO-Collaborating Centre for Diabetes, National Hospital Organization Kyoto Medical Centre, Kyoto, Japan
| | - Lawrence A Lavery
- University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, TX
| | - Matthew Malone
- School of Medicine, Infectious Diseases and Microbiology, Western Sydney University, Sydney, New South Wales, Australia
- South West Sydney Local Health District, Sydney, New South Wales, Australia
| | - Suzanne A van Asten
- Faculty of Medicine, University Medical Centre, University of Ljubljana, Ljubljana, Slovenia
| | - Vilma Urbančič-Rovan
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Edgar J G Peters
- Department of Internal Medicine, Section of Infectious Diseases, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Infection and Immunity Institute, Amsterdam, The Netherlands
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20
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Lipsky BA, Senneville É, Abbas ZG, Aragón-Sánchez J, Diggle M, Embil JM, Kono S, Lavery LA, Malone M, van Asten SA, Urbančič-Rovan V, Peters EJG. Guidelines on the diagnosis and treatment of foot infection in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 2020; 36 Suppl 1:e3280. [PMID: 32176444 DOI: 10.1002/dmrr.3280] [Citation(s) in RCA: 300] [Impact Index Per Article: 75.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/01/2019] [Accepted: 05/20/2019] [Indexed: 12/17/2022]
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the diagnosis and treatment of foot infection in persons with diabetes and updates the 2015 IWGDF infection guideline. On the basis of patient, intervention, comparison, outcomes (PICOs) developed by the infection committee, in conjunction with internal and external reviewers and consultants, and on systematic reviews the committee conducted on the diagnosis of infection (new) and treatment of infection (updated from 2015), we offer 27 recommendations. These cover various aspects of diagnosing soft tissue and bone infection, including the classification scheme for diagnosing infection and its severity. Of note, we have updated this scheme for the first time since we developed it 15 years ago. We also review the microbiology of diabetic foot infections, including how to collect samples and to process them to identify causative pathogens. Finally, we discuss the approach to treating diabetic foot infections, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and for bone infections, when and how to approach surgical treatment, and which adjunctive treatments we think are or are not useful for the infectious aspects of diabetic foot problems. For this version of the guideline, we also updated four tables and one figure from the 2016 guideline. We think that following the principles of diagnosing and treating diabetic foot infections outlined in this guideline can help clinicians to provide better care for these patients.
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Affiliation(s)
- Benjamin A Lipsky
- Department of Medicine, University of Washington, Seattle, Washington
- Green Templeton College, University of Oxford, Oxford, UK
| | | | - Zulfiqarali G Abbas
- Abbas Medical Centre, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Mathew Diggle
- Alberta Public Laboratories, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - John M Embil
- University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shigeo Kono
- WHO-collaborating Centre for Diabetes, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matthew Malone
- South West Sydney Local Health District, School of Medicine, Infectious Diseases and Microbiology, Western Sydney University, Sydney, New South Wales, Australia
| | | | - Vilma Urbančič-Rovan
- Faculty of Medicine, University Medical Centre, University of Ljubljana, Ljubljana, Slovenia
| | - Edgar J G Peters
- Department of Internal Medicine, Infection and Immunity Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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21
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Gao L, Wang J, Yin Y. [Interpretation of 2019 International Working Group on Diabetic Foot guidelines on the prevention and management of diabetic foot disease]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:16-20. [PMID: 31939228 DOI: 10.7507/1002-1892.201906014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
The 8th World International Symposium on the Diabetic Foot (ISDF) Conference which was sponsored by the International Working Group on Diabetic Foot (IWGDF) was held in the Hague between May 22nd and May 25th, 2019. The conference issued the 2019 IWGDF guidelines on the prevention and management of diabetic foot disease. The update to the 2015 edition of the guidelines involves the following 6 chapters: prevention of foot ulcers in patients with diabetes; offloading foot ulcers in patients with diabetes; diagnosis, prognosis, and management of peripheral arterial disease in patients with a foot ulcer and diabetes; diagnosis and treatment of foot infection in patients with diabetes; interventions to enhance healing of foot ulcers in patients with diabetes; classification of diabetic foot ulcers. This guideline has been changed more than the previous edition. In this paper, the guidelines will be interpreted to provide cutting-edge information for domestic diabetic foot researchers.
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Affiliation(s)
- Lei Gao
- Department of Orthopaedic Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, P.R.China
| | - Jiangning Wang
- Department of Orthopaedic Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038,
| | - Yefeng Yin
- Department of Orthopaedic Surgery, Beijing Shijitan Hospital, Capital Medical University, Beijing, 100038, P.R.China
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Mohseni S, Aalaa M, Atlasi R, Mohajeri Tehrani MR, Sanjari M, Amini MR. The effectiveness of negative pressure wound therapy as a novel management of diabetic foot ulcers: an overview of systematic reviews. J Diabetes Metab Disord 2019; 18:625-641. [PMID: 31890688 DOI: 10.1007/s40200-019-00447-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 10/03/2019] [Indexed: 12/17/2022]
Abstract
Background Diabetic foot ulcer (DFU) is one the serious disabling conditions in patients with diabetes. Several approaches are available to manage DFU including Negative Pressure Wound Therapy (NPWT). The objective of this overview is systematically reviewing the related reviews about the effectiveness, safety, and cost benefits of NPWT interventions. Methods In October 2018, electronic databases including Medline, Embase, Scopous, Web of Science, the Cochrane Library and Google scholar were searched for systematic reviews about the NPWT's effectiveness and safety in DFUs. The Assessment of Multiple Systematic Reviews 2 (AMSTAR2) checklist was used for the appraisal of the systematic reviews. According to this checklist the studies were categorized as high, moderate, low and critically low quality. Results The electronic searches yielded 6889 studies. After excluding duplicates and those not fellfield the inclusion criteria, 23 systematic reviews were considered. The sample size of the reviews ranged between 20 and 2800 patients published since 2004 to 2018. Twenty systematic reviews (86.95%) included only randomized clinical trials (RCT). Regarding the AMSTAR-2 checklist, 7 studies were assigned to high quality, 8 were categorized as low quality and 8 studies belonged to the critically low quality groups. Accordingly, three, two and one out of seven high quality studies approved the effectiveness, safety and cost benefit of the NPWT therapy, respectively. However, some of them declared that there is some flaws in RCTs designing. Conclusion This overview illustrated that either systematic reviews or the included RCTs had wide variety of quality and heterogeneity in order to provide high level of evidence. Hence, well-designed RCTs as well as meta-analysis are required to shade the light on different aspects of NPWT.
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Affiliation(s)
- Shahrzad Mohseni
- 1Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Maryam Aalaa
- 2Center for Educational Research in Medical Sciences (CERMS), Department of Medical Education, School of Medicine, Iran University of Medical Sciences (IUMS), Tehran, Iran
| | - Rasha Atlasi
- 1Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohamad Reza Mohajeri Tehrani
- 1Endocrinology and Metabolism Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Mahnaz Sanjari
- 3Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,4Endocrinology and Metabolism Research Institute, next to Dr. Shariati Hospital, North Kargar Ave, Tehran, 1411713137 Iran
| | - Mohamad Reza Amini
- 3Diabetes Research Center, Endocrinology and Metabolism Clinical Sciences Institute, Tehran University of Medical Sciences, Tehran, Iran.,4Endocrinology and Metabolism Research Institute, next to Dr. Shariati Hospital, North Kargar Ave, Tehran, 1411713137 Iran
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Marturano JE, Lowery TJ. ESKAPE Pathogens in Bloodstream Infections Are Associated With Higher Cost and Mortality but Can Be Predicted Using Diagnoses Upon Admission. Open Forum Infect Dis 2019; 6:ofz503. [PMID: 31844639 PMCID: PMC6902016 DOI: 10.1093/ofid/ofz503] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Accepted: 11/21/2019] [Indexed: 11/15/2022] Open
Abstract
Background ESKAPE bacteria are thought to be especially resistant to antibiotics, and their resistance and prevalence in bloodstream infections are rising. Large studies are needed to better characterize the clinical impact of these bacteria and to develop algorithms that alert clinicians when patients are at high risk of an ESKAPE infection. Methods From a US data set of >1.1 M patient encounters, we evaluated if ESKAPE pathogens produced worse outcomes than non-ESKAPE pathogens and if an ESKAPE infection could be predicted using simple word group algorithms built from decision trees. Results We found that ESKAPE pathogens represented 42.2% of species isolated from bloodstream infections and, compared with non-ESKAPE pathogens, were associated with a 3.3-day increase in length of stay, a $5500 increase in cost of care, and a 2.1% absolute increase in mortality (P < 1e-99). ESKAPE pathogens were not universally more resistant to antibiotics, but only to select antibiotics (P < 5e-6), particularly against common empiric therapies. In addition, simple word group algorithms predicted ESKAPE pathogens with a positive predictive value of 7.9% to 56.2%, exceeding 4.8% by random guessing (P < 1e-99). Conclusions Taken together, these data highlight the pathogenicity of ESKAPE bacteria, potential mechanisms of their pathogenicity, and the potential to predict ESKAPE infections upon admission. Implementing word group algorithms could enable earlier and targeted therapies against ESKAPE bacteria and thus reduce their burden on the health care system.
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Tchero H, Kangambega P, Fluieraru S, Bekara F, Teot L. Management of infected diabetic wound: a scoping review of guidelines. F1000Res 2019; 8:737. [PMID: 32528649 PMCID: PMC7265589 DOI: 10.12688/f1000research.18978.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/08/2019] [Indexed: 12/03/2022] Open
Abstract
Background: Various international guidelines and recommendations are available for management of diabetic foot infections. We present a review of the guidelines and recommendations for management of these infections. Methods: A systematic literature search was conducted through MEDLINE, CENTRAL, EMBASE, LILACS, DARE, and national health bodies. Based on the review of fifteen documents, we present details on the importance of suspecting and diagnosing skin, superficial infections, and bone infections in diabetics. Results: The guidelines recommend classifying the infections based on severity to guide the treatment. While antibiotics have shown the best results, other treatments like hyperbaric oxygen therapy and negative wound pressure have been debated. It is suggested that a team of specialists should be in-charge of managing the infected wounds. Infectious Diseases Society of America (IDSA) 2012 guidelines are widely followed world-over. All guidelines and reviews have consistent suggestions on the assessment of the severity of infection, diagnosis, start, selection, and duration of antibiotic therapy. Conclusions: It is reasonable to conclude that the IDSA 2012 guidelines are commonly followed across the world. There is a consensus among the Australian guidelines, Canadian guidelines, IDSA 2012, National Institute for Health and Care Excellence (NICE) 2015, and International Working Group on the Diabetic Foot (IWGDF) 2016 guidelines on the management of infected wounds for patients with diabetes mellitus.
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Affiliation(s)
- Huidi Tchero
- Trauma & Orthopaedic Surgery, CH Saint Martin, Saint Martin, Guadeloupe
| | - Pauline Kangambega
- Endocrinology & Metabolism, CHRU de Pointe-A-Pitre, Pointe-A-Pitre, Guadeloupe
| | - Sergiu Fluieraru
- Reconstructive and Plastic Surgery, CHRU Montpellier, Montpellier, France
| | - Farid Bekara
- Reconstructive and Plastic Surgery, CHRU Montpellier, Montpellier, France
| | - Luc Teot
- Reconstructive and Plastic Surgery, CHRU Montpellier, Montpellier, France
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Xing K, Huang G, Hua S, Xu G, Li M. Systematic review of randomized controlled trials on antibiotic treatment for osteomyelitis in diabetes. Diabet Med 2019; 36:546-556. [PMID: 30785639 DOI: 10.1111/dme.13935] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/18/2019] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- K Xing
- Department of Orthopaedic Oncology, Honghui Hospital, Xi'an Jiaotong University, College of Medicine, Xi'an, Shaanxi, China
| | - G Huang
- Department of Orthopaedic Oncology, Honghui Hospital, Xi'an Jiaotong University, College of Medicine, Xi'an, Shaanxi, China
| | - S Hua
- Department of Rheumatism and Immunity Branch, Xi an No. 5 Hospital, Xi'an, Shaanxi, China
| | - G Xu
- Department of Neurosurgery, First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi, China
| | - M Li
- Department of Paediatric Orthopedics, Honghui Hospital, Xi'an Jiaotong University, College of Medicine, Xi'an, Shaanxi, China
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Eleftheriadou I, Tentolouris A, Tentolouris N, Papanas N. Advancing pharmacotherapy for diabetic foot ulcers. Expert Opin Pharmacother 2019; 20:1153-1160. [PMID: 30958725 DOI: 10.1080/14656566.2019.1598378] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Standard treatment for diabetic foot ulcers (DFUs) includes off-loading, debridement, moisture balance, management of infection and peripheral arterial disease (PAD) as well as adequate glycemic control. The outcomes so far are unsatisfactory. AREAS COVERED Herein, the authors provide an outline of newer pharmacological agents for the management of DFUs and give their expert perspectives on future treatment strategies. EXPERT OPINION Evidence-based healthcare calls for high quality evidence from large RCTs before the implementation of new guidelines for the management of DFUs. Empagliflozin and liraglutide can be recommended for glucose control in patients with DFUs and PAD, while intensive lipid lowering therapy with evolocumab when primary cholesterol goals are not met could be offered to patients with DFUs. Further clinical studies are warranted to develop a structured algorithm for the treatment of DFUs that fail to heal after four weeks of current standard of care. Sucrose octasulfate dressings, becaplermin gel, and platelet-rich plasma (PRP) could also be considered as advanced treatment options for the management of hard to heal DFUs.
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Affiliation(s)
- Ioanna Eleftheriadou
- a Diabetes Centre, First Department of Propaedeutic Internal Medicine , Medical School, National and Kapodistrian University of Athens, Laiko General Hospital , Athens , Greece
| | - Anastasios Tentolouris
- a Diabetes Centre, First Department of Propaedeutic Internal Medicine , Medical School, National and Kapodistrian University of Athens, Laiko General Hospital , Athens , Greece
| | - Nikolaos Tentolouris
- a Diabetes Centre, First Department of Propaedeutic Internal Medicine , Medical School, National and Kapodistrian University of Athens, Laiko General Hospital , Athens , Greece
| | - Nikolaos Papanas
- b Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine , Democritus University of Thrace , Alexandroupolis , Greece
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Rastogi A, Bhansali A, Ramachandran S. Efficacy and Safety of Low-Frequency, Noncontact Airborne Ultrasound Therapy (Glybetac) For Neuropathic Diabetic Foot Ulcers: A Randomized, Double-Blind, Sham-Control Study. INT J LOW EXTR WOUND 2019; 18:81-88. [PMID: 30836809 DOI: 10.1177/1534734619832738] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The diabetic foot ulcer (DFU) healing rates remain dismally low. Therefore, many adjunctive therapies have been evaluated including ultrasound therapy. The prior studies with noncontact, low-frequency ultrasound were retrospective, single arm, unblinded, or with historical controls. The aim of the present study was to compare the efficacy of noncontact, low-frequency airborne ultrasound (Glybetac) therapy with sham therapy added to standard treatment in patients with neuropathic, clinically infected, or noninfected DFU (wound size >2 cm2), Wagner grades 2 and 3. Patients received ultrasound or sham therapy for 28 days dosed daily for first 6 days followed by twice a week for next 3 weeks along with standard of care. The primary outcome was percentage of patients with at least >50% decrease in wound area at 4 week of intervention. Fifty-eight patients completed the study protocol. The duration of wound was 15.8 ± 11.2 weeks and 12.1 ± 10.9 weeks and wound area of 11.3 ± 8.2 cm2 and 14.8 ± 13.8 cm2 ( P = .507) in the ultrasound and sham groups, respectively. A >50% reduction in wound area was observed in 97.1% and 73.1% subjects ( P = .042) in ultrasound and sham groups, respectively. Wound contraction was faster in the first 2 weeks with ultrasound therapy, 5.3 cm2, compared with 3.0 cm2 ( P = .025) with sham treatment. Overall, wound area reduction of 69.4 ± 23.2% and 59.6 ± 24.9% ( P = .126) was observed at 4 weeks in the ultrasound and sham groups, respectively. We conclude that the airborne low-frequency ultrasound therapy improves and hastens the healing of chronic neuropathic DFU when combined with standard wound care.
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Affiliation(s)
- Ashu Rastogi
- 1 Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anil Bhansali
- 1 Post Graduate Institute of Medical Education and Research, Chandigarh, India
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Gariani K, Lebowitz D, von Dach E, Kressmann B, Lipsky BA, Uçkay I. Remission in diabetic foot infections: Duration of antibiotic therapy and other possible associated factors. Diabetes Obes Metab 2019; 21:244-251. [PMID: 30129109 DOI: 10.1111/dom.13507] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/30/2018] [Accepted: 08/16/2018] [Indexed: 12/15/2022]
Abstract
AIM To determine the most appropriate duration of antibiotic therapy for diabetic foot infections (DFIs). METHODS Using a clinical pathway for adult patients with DFIs (retrospective cohort analysis), we created a cluster-controlled Cox regression model to assess factors related to remission of infection, emphasizing antibiotic-related variables. We excluded total amputations as a result of DFI and DFI episodes with a follow-up time of <2 months. RESULTS Among 1018 DFI episodes in 482 patients, we identified 392 episodes of osteomyelitis, 626 soft tissue infections, 246 large abscesses, 322 episodes of cellulitis and 335 episodes of necrosis; 313 cases involved revascularization. Patients underwent surgical debridement for 824 episodes (81%), of which 596 (59%) required amputation. The median total duration of antibiotic therapy was 20 days. After a median follow-up of 3 years, 251 of the episodes (24.7%) were followed by ≥1 additional episode(s). Comparing patients with and without additional episodes, risk of recurrence was lower in those who underwent amputation, had type 1 diabetes, or underwent revascularization. On multivariate analysis including the entire study population, risk of remission was inversely associated with type 1 diabetes (hazard ratio [HR] 0.3, 95% confidence interval [CI] 0.2-0.6). Neither duration of antibiotic therapy nor parenteral treatment affected risk of recurrence (HR 1.0, 95% CI 0.99-1.01 for both). Similarly, neither >3 weeks versus <3 weeks of therapy, nor >1 week versus <1 week of intravenous treatment affected recurrence. In stratified analyses for both soft tissue DFIs or osteomyelitis separately, we did not observe associations of antibiotic duration with microbiological or clinical recurrences of DFI. The HRs were 1.0 (95% CI 0.6-1.8) for an antibiotic duration >3 weeks overall and 0.6 (95% CI 0.2-1.3) for osteomyelitis cases only. Plotting of duration of antibiotic therapy failed to identify any optimal threshold for preventing recurrences. CONCLUSIONS Our analysis found no threshold for the optimal duration or route of administration of antibiotic therapy to prevent recurrences of DFI. These limited data might support possibly shorter treatment duration for patients with DFI.
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Affiliation(s)
- Karim Gariani
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Service of Diabetology and Endocrinology, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Dan Lebowitz
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Elodie von Dach
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benjamin Kressmann
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Benjamin A Lipsky
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
- University of Oxford, Oxford, UK
| | - Ilker Uçkay
- Service of Infectious Diseases, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
- Infection Control Program, Geneva University Hospitals and Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Luck J, Rodi T, Geierlehner A, Mosahebi A. Allogeneic Skin Substitutes Versus Human Placental Membrane Products in the Management of Diabetic Foot Ulcers: A Narrative Comparative Evaluation of the Literature. INT J LOW EXTR WOUND 2019; 18:10-22. [DOI: 10.1177/1534734618818301] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Outcomes following standard wound care (SWC) for diabetic foot ulcers (DFUs) remain suboptimal. Supplementing SWC with tissue engineered allogeneic cellular wound therapies represents an emerging treatment strategy. This review aimed to evaluate the efficacy and safety of allogeneic skin substitutes and human placental membrane allografts in the management of DFUs. Ovid MEDLINE and Embase databases were searched from inception to October 2017. Any randomized controlled trial (RCT) with an allogeneic skin substitute or placental membrane allograft intervention group was included. Our primary outcome measure was the proportion of completely healed ulcers. Secondary outcome measures included time to complete wound healing and local adverse event rates. Each study was assessed for risk of bias and the quality of evidence was appraised using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach. Moderate quality evidence from 11 included RCTs demonstrated that both allogeneic cellular approaches improve the proportion of completely healed ulcers at 6 and 12 weeks. One RCT showed that a placental membrane allograft was superior to an allogeneic skin substitute, although this has yet to be repeated in other studies. The addition of allogeneic cellular wound products to SWC improves DFU outcomes. Further studies are required to conclusively establish if placental membrane allografts are superior to allogeneic skin substitutes.
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Affiliation(s)
| | - Timo Rodi
- Royal Free Hospital, Hampstead, London, UK
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Marson BA, Deshmukh SR, Grindlay DJC, Ollivere BJ, Scammell BE. A systematic review of local antibiotic devices used to improve wound healing following the surgical management of foot infections in diabetics. Bone Joint J 2018; 100-B:1409-1415. [PMID: 30418057 DOI: 10.1302/0301-620x.100b11.bjj-2018-0720] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Local antibiotics are used in the surgical management of foot infection in diabetic patients. This systematic review analyzes the available evidence of the use of local antibiotic delivery systems as an adjunct to surgery. MATERIALS AND METHODS Databases were searched to identify eligible studies and 13 were identified for inclusion. RESULTS Overall, the quality of the studies was poor. A single trial suggested that wound healing is quicker when a gentamicin-impregnated collagen sponge was implanted at time of surgery, with no difference in length of stay or rate of amputation. Results from studies with high risk of bias indicated no change in wound healing when a gentamicin-impregnated sponge was implanted during transmetatarsal amputation, but a reduction in the incidence of wound breakdown (8% vs 25%, not statistically significant) was identified. A significant cost reduction was identified when using an antimicrobial gel to deliver antibiotics and anti-biofilm agents (quorum-sensing inhibitors) compared with routine dressings and systemic antibiotics. Analyses of case series identified 485 patients who were treated using local antibiotic delivery devices. The rates of wound healing, re-operation, and mortality were comparable to those that have been previously reported for the routine management of these infections. CONCLUSION There is a lack of good-quality evidence to support the use of local antibiotic delivery devices in the treatment of foot infections in patients with diabetes. Cite this article: Bone Joint J 2018;100-B:1409-15.
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Affiliation(s)
- B A Marson
- Trauma and Sports Medicine, Division of Rheumatology, Orthopaedics and Dermatology, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - S R Deshmukh
- Nottingham Elective Orthopaedic Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - D J C Grindlay
- Trauma and Sports Medicine, Division of Rheumatology, Orthopaedics and Dermatology, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - B J Ollivere
- Trauma and Sports Medicine, Division of Rheumatology, Orthopaedics and Dermatology, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - B E Scammell
- Academic Orthopaedics, Trauma and Sports Medicine, Division of Rheumatology, Orthopaedics and Dermatology, School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK and Nottingham Elective Orthopaedic Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
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32
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Ali SR, Ozdemir BA, Hinchliffe RJ. Critical Appraisal of the Quality of Evidence Addressing the Diagnosis, Prognosis, and Management of Peripheral Artery Disease in Patients With Diabetic Foot Ulceration. Eur J Vasc Endovasc Surg 2018; 56:401-408. [DOI: 10.1016/j.ejvs.2018.05.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 05/10/2018] [Indexed: 02/08/2023]
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Commons RJ, Raby E, Athan E, Bhally H, Chen S, Guy S, Ingram PR, Lai K, Lemoh C, Lim LL, Manning L, Miyakis S, O'Reilly M, Roberts A, Sehu M, Torda A, Vicaretti M, Lazzarini PA. Managing diabetic foot infections: a survey of Australasian infectious diseases clinicians. J Foot Ankle Res 2018; 11:13. [PMID: 29651304 PMCID: PMC5894166 DOI: 10.1186/s13047-018-0256-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 03/29/2018] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Robert J Commons
- 1Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Tiwi, Casuarina, Northern Territory Australia
| | - Edward Raby
- 2Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Dr, Murdoch, WA Australia
| | - Eugene Athan
- 3Department of Infectious Diseases, Barwon Health, Deakin University, Geelong, VIC Australia
| | - Hasan Bhally
- 4Department of Infectious Diseases, North Shore Hospital, Waitemata District Health Board, Auckland, New Zealand
| | - Sharon Chen
- 5Centre for Infectious Diseases and Microbiology Laboratory Services, ICPMR, Westmead Hospital, The University of Sydney, Westmead, NSW Australia
| | - Stephen Guy
- 6Department of Infectious Diseases, Western Health, 160 Gordon St, Footscray, VIC Australia.,7Department of Medicine, Melbourne Medical School - Western Precint, The University of Melbourne, St Albans, VIC Australia
| | - Paul R Ingram
- 2Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Dr, Murdoch, WA Australia.,8School of Pathology and Laboratory Medicine, University of Western Australia, Crawley, WA Australia
| | - Katy Lai
- 9Department of Infectious Diseases, John Hunter Hospital, Lookout Rd, New Lambton Heights, NSW Australia
| | - Chris Lemoh
- 10Monash Infectious Diseases, Dandenong Hospital, 135 David St, Dandenong, VIC Australia
| | - Lyn-Li Lim
- 11Department of Infectious Diseases, Eastern Health, 8 Arnold St, Box Hill, VIC Australia
| | - Laurens Manning
- 12School of Medicine and Pharmacology, University of Western Australia, Harry Perkins Research Institute, Fiona Stanley Hospital, PO Box 404, Bull Creek, WA Australia
| | - Spiros Miyakis
- 13Department of Infectious Diseases, The Wollongong Hospital, Loftus St, Wollongong, NSW Australia
| | - Mary O'Reilly
- 11Department of Infectious Diseases, Eastern Health, 8 Arnold St, Box Hill, VIC Australia
| | - Adam Roberts
- 14Department of Endocrinology, University Hospital Geelong, Bellerine St, Geelong, VIC Australia
| | - Marjoree Sehu
- 15Infection Management Service, Princess Alexandra Hospital, 199 Ipswich Rd, Woolloongabba, QLD Australia.,16University of Queensland, St Lucia, QLD Australia
| | - Adrienne Torda
- 17Department of Infectious Diseases, Prince of Wales Hospital, Barker St, Randwick, NSW Australia
| | - Mauro Vicaretti
- 18Department of Vascular Surgery, Westmead Hospital, Hawkesbury Rd & Darcy Rd, Westmead, NSW Australia
| | - Peter A Lazzarini
- 19School of Clinical Sciences, Queensland University of Technology, Victoria Park Rd, Kelvin Grove, QLD Australia
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Jeffcoate WJ, Vileikyte L, Boyko EJ, Armstrong DG, Boulton AJM. Current Challenges and Opportunities in the Prevention and Management of Diabetic Foot Ulcers. Diabetes Care 2018; 41:645-652. [PMID: 29559450 DOI: 10.2337/dc17-1836] [Citation(s) in RCA: 224] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 01/04/2018] [Indexed: 02/03/2023]
Abstract
Diabetic foot ulcers remain a major health care problem. They are common, result in considerable suffering, frequently recur, and are associated with high mortality, as well as considerable health care costs. While national and international guidance exists, the evidence base for much of routine clinical care is thin. It follows that many aspects of the structure and delivery of care are susceptible to the beliefs and opinion of individuals. It is probable that this contributes to the geographic variation in outcome that has been documented in a number of countries. This article considers these issues in depth and emphasizes the urgent need to improve the design and conduct of clinical trials in this field, as well as to undertake systematic comparison of the results of routine care in different health economies. There is strong suggestive evidence to indicate that appropriate changes in the relevant care pathways can result in a prompt improvement in clinical outcomes.
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Affiliation(s)
- William J Jeffcoate
- Department of Diabetes and Endocrinology, Nottingham University Hospitals Trust, Nottingham, U.K.
| | - Loretta Vileikyte
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, U.K., and Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL
| | | | - David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA
| | - Andrew J M Boulton
- Division of Diabetes, Endocrinology and Gastroenterology, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, U.K., and Diabetes Research Institute, Miller School of Medicine, University of Miami, Miami, FL
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Vas PRJ, Edmonds M, Kavarthapu V, Rashid H, Ahluwalia R, Pankhurst C, Papanas N. The Diabetic Foot Attack: “’Tis Too Late to Retreat!”. INT J LOW EXTR WOUND 2018; 17:7-13. [DOI: 10.1177/1534734618755582] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
The “diabetic foot attack” is one of the most devastating presentations of diabetic foot disease, typically presenting as an acutely inflamed foot with rapidly progressive skin and tissue necrosis, at times associated with significant systemic symptoms. Without intervention, it may escalate over hours to limb-threatening proportions and poses a high amputation risk. There are only best practice approaches but no international protocols to guide management. Immediate recognition of a typical infected diabetic foot attack, predominated by severe infection, with prompt surgical intervention to debride all infected tissue alongside broad-spectrum antibiotic therapy is vital to ensure both limb and patient survival. Postoperative access to multidisciplinary and advanced wound care therapies is also necessary. More subtle forms exist: these include the ischemic diabetic foot attack and, possibly, in a contemporary categorization, acute Charcot neuroarthropathy. To emphasize the importance of timely action especially in the infected and ischemic diabetic foot attack, we revisit the concept of “time is tissue” and draw parallels with advances in acute myocardial infarction and stroke care. At the moment, international protocols to guide management of severe diabetic foot presentations do not specifically use the term. However, we believe that it may help increase awareness of the urgent actions required in some situations.
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Bello OO, Oyekanmi EO, Kelly BA, Mebude OO, Bello TK. Antibiotic Susceptibility Profiles of Bacteria from Diabetic Foot Infections in Selected Teaching Hospitals in Southwestern Nigeria. ACTA ACUST UNITED AC 2018. [DOI: 10.21467/ias.4.1.1-13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
One of the serious complications associated with diabetes is foot ulcer and this condition affects the quality of life in patients in all classes, races and ages. Chronic wounds are prone to colonization by wide array of microorganisms which could be extremely hazardous to patients if effective and timely therapeutic intervention is not made. This study was conducted to determine the antibiotic susceptibility profiles of bacteria from diabetic foot infections in southwestern Nigeria. Samples were collected from a total of 142 diabetic foot ulcer patients with moistened sterile cotton swabs. Nutrient agar, Mac-Conkey agar, blood agar and mannitol salt agar media were used for the isolation of total viable bacteria, Gram-negative non-spore forming lactose fermenters, fastidious bacteria and staphylococci, respectively. Morphological and biochemical characteristics of pure cultures were determined in accordance with standard laboratory criteria. API 20 E and API 20 NE were used for the confirmation of identity of the bacterial isolates. The disc diffusion technique was employed for the determination of antibiotic susceptibility of bacterial isolates in accordance with standard procedures. The antibiotics investigated included amikacin, amoxicillin, ampicillin, ceftazidime, cefazolin, ceftriaxone, chloramphenicol, ciprofloxacin, clindamycin, gentamicin, imipenem, linezolid, methicillin, netilmicin, ofloxacin, oxacillin, penicillin, piperacilin, sulfamethoxazole, trimethoprim and vancomycin. One hundred and seventy-seven isolates were encountered and these were characterized into eleven bacterial species. These included Staphylococcus aureus (22.03%), Pseudomonas aeruginosa (16.95%), Staphylococcus epidermidis (12.43%), Proteus mirabilis (8.48%), Klebsiella pneumoniae (7.91%), E. coli (7.35%), Staphylococcus saprophyticus (6.78%), Streptococcus pyogenes (5.65%), Morganella morganii (5.09%), Citrobacter freundii (4.52%) and Acinetobacter baumannii (2.83%). Gram-negative bacteria showed 76.99% susceptibility to the antibiotics while 22.85% was resistant. Gram-positive bacteria showed 93.75% susceptibility and 5.01% resistance to the antibiotics. This study revealed that there is no definite aetiologic bacterial agent for diabetic foot infections and many of the associated bacteria are sensitive to certain antibiotics.
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McArdle CD, Lagan KM, McDowell DA. Effects of pH on the Antibiotic Resistance of Bacteria Recovered from Diabetic Foot Ulcer Fluid An In Vitro Study. J Am Podiatr Med Assoc 2018; 108:6-11. [PMID: 29547034 DOI: 10.7547/16-033] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND This study investigated the resistance of bacteria isolated from diabetic foot ulcers (DFUs) to antibiotics frequently used in the management of the diabetic foot infections, at a range of pH values (pH 6.5, 7.5, and 8.5) known to exist in DFU wound fluid. This study aimed to determine whether changes (or atypical stasis) in wound fluid pH modulate the antibiotic resistance of DFU isolates, with potential implications in relation to the suppression/eradication of bacterial infections in DFUs. METHODS Thirty bacterial isolates were recovered from DFU wound fluid, including Staphylococcus spp, Staphylococcus aureus, Escherichia coli, Streptococcus spp, Pseudomonas spp, and Pseudomonas aeruginosa. The resistances of these isolates to a panel of antibiotics currently used in the treatment of infected or potentially infected DFUs, ie, ciprofloxacin, amoxicillin-clavulanate, doxycycline, and piperacillin-tazobactam, at the previously mentioned pH values were determined by a modification of the Kirby-Bauer assay. RESULTS The resistance of DFU isolates to clinically relevant antibiotics was significantly affected by the pH levels in DFU wound fluid. CONCLUSIONS These findings highlight the importance of a more comprehensive understanding of the conditions in DFUs to inform clinical decision making in the selection and application of antibiotics in treating these difficult-to-heal wounds. The scale of the differences in the efficacies of antibiotics at the different pH values examined is likely to be sufficient to suggest reconsideration of the antibiotics of choice in the treatment of DFU infection.
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Affiliation(s)
- Carla D. McArdle
- Queen Margaret University, Health Sciences, Musselburgh, Edinburgh, Scotland
| | - Katie M. Lagan
- Centre for Rehabilitation and Health Sciences, Ulster University, Newtownabbey, County Antrim, Ireland
| | - David A. McDowell
- Centre for Rehabilitation and Health Sciences, Ulster University, Newtownabbey, County Antrim, Ireland
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van Asten SAV, Mithani M, Peters EJG, La Fontaine J, Kim PJ, Lavery LA. Complications during the treatment of diabetic foot osteomyelitis. Diabetes Res Clin Pract 2018; 135:58-64. [PMID: 28951333 DOI: 10.1016/j.diabres.2017.06.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2016] [Revised: 03/05/2017] [Accepted: 06/06/2017] [Indexed: 01/19/2023]
Abstract
AIM To identify complications of medical treatment in patients with diabetic foot osteomyelitis (DFO). METHODS We reviewed 143 records of consecutive patients admitted with DFO, confirmed by bone histopathology or culture. Complications monitored included acute kidney injuries (AKI), development of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE), gastrointestinal complications, and venous catheter related complications during a 12months follow-up period. RESULTS Forty-seven AKI episodes were reported during follow-up; half occurred during the first hospitalization with involvement of antimicrobial therapy in 14 events (29.8%). Patients with AKI were more likely to have recurrent ulcerations (69.2% vs. 45.2%, p=0.02), recurrent infections (38.5% vs. 17.3%, p=0.01), and recurrent hospitalizations (43.6% vs. 28.8%, p=0.02) during follow-up. Only 14 MRSA isolates were found in bone samples at baseline (9.8%). Resistant strains of MRSA and VRE were identified in twenty-one patients (14.7%) during follow-up. Patients re-hospitalized for infection were more likely to have resistant bacterial strains (52.6% vs. 25.8%, p=0.02). CONCLUSIONS In this study, the rates of VRE and MRSA in bone biopsies of patients with DFO were lower than in previous reports. Acute kidney injury occurred frequently in our patient population but might not be associated with antibiotic exposure.
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Affiliation(s)
- Suzanne A V van Asten
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Department of Internal Medicine, VU Medical Center, Amsterdam, The Netherlands.
| | - Moez Mithani
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Edgar J G Peters
- Department of Internal Medicine, VU Medical Center, Amsterdam, The Netherlands
| | - Javier La Fontaine
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Paul J Kim
- Department of Plastic Surgery, Georgetown University Medical Center, WA, USA
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Graz H, D'Souza VK, Alderson DEC, Graz M. Diabetes-related amputations create considerable public health burden in the UK. Diabetes Res Clin Pract 2018; 135:158-165. [PMID: 29133201 DOI: 10.1016/j.diabres.2017.10.030] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 10/26/2017] [Indexed: 11/30/2022]
Abstract
AIMS The main aim of this study was to assess the cost of diabetic amputation (both direct and indirect) to the National Health Service from the point of amputation onwards. METHODS This systematic review involved searches of published literature between January 2007 and March 2017 mainly using the bibliographic databases, the Cochrane Library, EMBASE via Ovid®, MEDLINE via Ovid®, as well as grey literature, both in print and in electronic formats published through non-commercial publications, which reported the cost of amputation due to diabetic foot ulcers. RESULTS The studies included in this review varied considerably in estimating the cost including cost elements and how those costs were categorised. The cost estimates for inpatient care associated with amputation involving admissions or procedures on amputation stumps in people with diabetes was £43.8 million. The annual expenditure for post-amputation care involving prosthetic care, physiotherapy, transport and wheelchair use was £20.8 million. CONCLUSIONS There is a considerable public health and economic burden caused by diabetes-related amputations in England. More focussed research is needed with improved methods of estimating costs that would account for direct and indirect costs associated with diabetic amputation.
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Affiliation(s)
- Heather Graz
- Neem Biotech Ltd., Units G and H, Roseheyworth Business Park, Roseheyworth, Abertillery, Blaenau Gwent NP13 1SX, Wales, UK
| | - Vijay K D'Souza
- Cogentia Healthcare Consulting Ltd., Richmond House, 16-20 Regent Street, Cambridge CB2 1DB, UK.
| | - David E C Alderson
- Cogentia Healthcare Consulting Ltd., Richmond House, 16-20 Regent Street, Cambridge CB2 1DB, UK
| | - Michael Graz
- Neem Biotech Ltd., Units G and H, Roseheyworth Business Park, Roseheyworth, Abertillery, Blaenau Gwent NP13 1SX, Wales, UK
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O'Connor T, Moore Z, Patton D, Wilson P, Gillen C, Hughes M, Reilly A. Combined use of modulated ultrasound and electric current stimulation for diabetic foot ulcers: a case series. J Wound Care 2017; 26:632-640. [PMID: 29131756 DOI: 10.12968/jowc.2017.26.11.632] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Diabetic foot ulcers (DFUs) are a significant challenge in wound care practice. Our aim was to evaluate the combined use of of two therapies, ultrasound and electrostimulation, in the treatment of DFUs. METHOD This study employed a prospective, non-comparative, case series design, undertaken in a podiatry-led diabetic foot clinic, in an acute hospital setting, in an urban location in Ireland. We recruited patinets with hard-to-heal DFUs who were treated twice a week with combined modulated ultrasound and electric current stimulation. RESULTS We recruited seven patients with eight chronic DFUs. A mean wound size reduction of 71% was achieved and there were no adverse reactions to the therapy. CONCLUSION The results of this small case series indicate that combined modulated ultrasound and electric current stimulation offers promise as an adjunct therapy for DFUs. Further large scale trials are now warranted.
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Affiliation(s)
- T O'Connor
- Senior Lecturer, School of Nursing & Midwifery, Royal College of Surgeons in Ireland
| | - Z Moore
- Professor & Head of the School of Nursing & Midwifery, School of Nursing & Midwifery, Royal College of Surgeons in Ireland
| | - D Patton
- Senior Lecturer, School of Nursing & Midwifery, Royal College of Surgeons in Ireland
| | - P Wilson
- Podiatrist, St James's Hospital, Dublin
| | - C Gillen
- Podiatrist, St James's Hospital, Dublin
| | - M Hughes
- Podiatrist, St James's Hospital, Dublin
| | - A Reilly
- Research Assistant, School of Nursing & Midwifery, Royal College of Surgeons in Ireland
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Mandell JC, Khurana B, Smith JT, Czuczman GJ, Ghazikhanian V, Smith SE. Osteomyelitis of the lower extremity: pathophysiology, imaging, and classification, with an emphasis on diabetic foot infection. Emerg Radiol 2017; 25:175-188. [DOI: 10.1007/s10140-017-1564-9] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2017] [Accepted: 10/11/2017] [Indexed: 12/26/2022]
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Dumville JC, Lipsky BA, Hoey C, Cruciani M, Fiscon M, Xia J. Topical antimicrobial agents for treating foot ulcers in people with diabetes. Cochrane Database Syst Rev 2017; 6:CD011038. [PMID: 28613416 PMCID: PMC6481886 DOI: 10.1002/14651858.cd011038.pub2] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND People with diabetes are at high risk for developing foot ulcers, which often become infected. These wounds, especially when infected, cause substantial morbidity. Wound treatments should aim to alleviate symptoms, promote healing, and avoid adverse outcomes, especially lower extremity amputation. Topical antimicrobial therapy has been used on diabetic foot ulcers, either as a treatment for clinically infected wounds, or to prevent infection in clinically uninfected wounds. OBJECTIVES To evaluate the effects of treatment with topical antimicrobial agents on: the resolution of signs and symptoms of infection; the healing of infected diabetic foot ulcers; and preventing infection and improving healing in clinically uninfected diabetic foot ulcers. SEARCH METHODS We searched the Cochrane Wounds Specialised Register, CENTRAL, Ovid MEDLINE, Ovid MEDLINE (In-Process & Other Non-Indexed Citations), Ovid Embase, and EBSCO CINAHL Plus in August 2016. We also searched clinical trials registries for ongoing and unpublished studies, and checked reference lists to identify additional studies. We used no restrictions with respect to language, date of publication, or study setting. SELECTION CRITERIA We included randomised controlled trials conducted in any setting (inpatient or outpatient) that evaluated topical treatment with any type of solid or liquid (e.g., cream, gel, ointment) antimicrobial agent, including antiseptics, antibiotics, and antimicrobial dressings, in people with diabetes mellitus who were diagnosed with an ulcer or open wound of the foot, whether clinically infected or uninfected. DATA COLLECTION AND ANALYSIS Two review authors independently performed study selection, 'Risk of bias' assessment, and data extraction. Initial disagreements were resolved by discussion, or by including a third review author when necessary. MAIN RESULTS We found 22 trials that met our inclusion criteria with a total of over 2310 participants (one study did not report number of participants). The included studies mostly had small numbers of participants (from 4 to 317) and relatively short follow-up periods (4 to 24 weeks). At baseline, six trials included only people with ulcers that were clinically infected; one trial included people with both infected and uninfected ulcers; two trials included people with non-infected ulcers; and the remaining 13 studies did not report infection status.Included studies employed various topical antimicrobial treatments, including antimicrobial dressings (e.g. silver, iodides), super-oxidised aqueous solutions, zinc hyaluronate, silver sulphadiazine, tretinoin, pexiganan cream, and chloramine. We performed the following five comparisons based on the included studies: Antimicrobial dressings compared with non-antimicrobial dressings: Pooled data from five trials with a total of 945 participants suggest (based on the average treatment effect from a random-effects model) that more wounds may heal when treated with an antimicrobial dressing than with a non-antimicrobial dressing: risk ratio (RR) 1.28, 95% confidence interval (CI) 1.12 to 1.45. These results correspond to an additional 119 healing events in the antimicrobial-dressing arm per 1000 participants (95% CI 51 to 191 more). We consider this low-certainty evidence (downgraded twice due to risk of bias). The evidence on adverse events or other outcomes was uncertain (very low-certainty evidence, frequently downgraded due to risk of bias and imprecision). Antimicrobial topical treatments (non dressings) compared with non-antimicrobial topical treatments (non dressings): There were four trials with a total of 132 participants in this comparison that contributed variously to the estimates of outcome data. Evidence was generally of low or very low certainty, and the 95% CIs spanned benefit and harm: proportion of wounds healed RR 2.82 (95% CI 0.56 to 14.23; 112 participants; 3 trials; very low-certainty evidence); achieving resolution of infection RR 1.16 (95% CI 0.54 to 2.51; 40 participants; 1 trial; low-certainty evidence); undergoing surgical resection RR 1.67 (95% CI 0.47 to 5.90; 40 participants; 1 trial; low-certainty evidence); and sustaining an adverse event (no events in either arm; 81 participants; 2 trials; very low-certainty evidence). Comparison of different topical antimicrobial treatments: We included eight studies with a total of 250 participants, but all of the comparisons were different and no data could be appropriately pooled. Reported outcome data were limited and we are uncertain about the relative effects of antimicrobial topical agents for each of our review outcomes for this comparison, that is wound healing, resolution of infection, surgical resection, and adverse events (all very low-certainty evidence). Topical antimicrobials compared with systemic antibiotics : We included four studies with a total of 937 participants. These studies reported no wound-healing data, and the evidence was uncertain for the relative effects on resolution of infection in infected ulcers and surgical resection (very low certainty). On average, there is probably little difference in the risk of adverse events between the compared topical antimicrobial and systemic antibiotics treatments: RR 0.91 (95% CI 0.78 to 1.06; moderate-certainty evidence - downgraded once for inconsistency). Topical antimicrobial agents compared with growth factor: We included one study with 40 participants. The only review-relevant outcome reported was number of ulcers healed, and these data were uncertain (very low-certainty evidence). AUTHORS' CONCLUSIONS The randomised controlled trial data on the effectiveness and safety of topical antimicrobial treatments for diabetic foot ulcers is limited by the availability of relatively few, mostly small, and often poorly designed trials. Based on our systematic review and analysis of the literature, we suggest that: 1) use of an antimicrobial dressing instead of a non-antimicrobial dressing may increase the number of diabetic foot ulcers healed over a medium-term follow-up period (low-certainty evidence); and 2) there is probably little difference in the risk of adverse events related to treatment between systemic antibiotics and topical antimicrobial treatments based on the available studies (moderate-certainty evidence). For each of the other outcomes we examined there were either no reported data or the available data left us uncertain as to whether or not there were any differences between the compared treatments. Given the high, and increasing, frequency of diabetic foot wounds, we encourage investigators to undertake properly designed randomised controlled trials in this area to evaluate the effects of topical antimicrobial treatments for both the prevention and the treatment of infection in these wounds and ultimately the effects on wound healing.
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Affiliation(s)
- Jo C Dumville
- University of Manchester, Manchester Academic Health Science CentreDivision of Nursing, Midwifery & Social Work, School of Health Sciences, Faculty of Biology, Medicine & HealthManchesterUKM13 9PL
| | - Benjamin A Lipsky
- Green Templeton College, University of OxfordDivision of Medical Sciences79 Stone MeadowOxfordUKOX2 6TD
| | - Christopher Hoey
- VA Puget Sound Health Care System Medical CenterPharmacy and Nutritional CareS‐Pharm‐1191660 S. Columbian WaySeattleWAUSA98108‐1597
| | - Mario Cruciani
- Azienda ULSS9 ScaligeraAntibiotic Stewardship ProgrammeVeronaItaly37135
| | - Marta Fiscon
- University of VeronaCentro Malattie DiffusiveULSS20VeronaItaly
| | - Jun Xia
- The Ingenuity Centre, The University of NottinghamSystematic Review Solutions LtdTriumph RoadNottinghamUKNG7 2TU
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Update on the Role of Infection and Biofilms in Wound Healing: Pathophysiology and Treatment. Plast Reconstr Surg 2017; 138:61S-70S. [PMID: 27556776 DOI: 10.1097/prs.0000000000002679] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Chronic wounds, and among these infected diabetic foot ulcers, are a worldwide problem. The poor treatment outcomes result in high healthcare costs, amputations, a decreased quality of life, and an increased mortality. These outcomes are influenced by several factors, including biofilm formation. A biofilm consists of pathogenic bacteria that are encased in an exopolysaccharide layer and communicate through secretion of signaling molecules. Bacteria that live in a biofilm are refractory to host responses and treatment. METHODS We performed a nonsystematic review of the currently published to-date medical biofilm literature. The review summarizes the evidence of biofilm in chronic wounds, the role of biofilm in wound healing, detection of biofilm, and available antibiofilm treatments. Articles containing basic science and clinical research, as well as systematic reviews, are described and evaluated. The articles have variable levels of evidence. All articles have been peer reviewed and meet the standards of evidence-based medicine. RESULTS Both animal and human studies have identified biofilm in chronic wounds and have suggested that healing might be influenced by its presence. A promising development in biofilm detection is rapid molecular diagnostics combined with direct microscopy. This technique, rather than classic culture, might support individualized treatment in the near future. A wide range of treatments for chronic wounds also influence biofilm formation. Several agents that specifically target biofilm are currently being researched. CONCLUSIONS Biofilm formation has a substantial role in chronic wounds. Several diagnostic and therapeutic methods against biofilm are currently being developed.
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Clokie M, Greenway AL, Harding K, Jones NJ, Vedhara K, Game F, Dhatariya KK. New horizons in the understanding of the causes and management of diabetic foot disease: report from the 2017 Diabetes UK Annual Professional Conference Symposium. Diabet Med 2017; 34:305-315. [PMID: 28029181 DOI: 10.1111/dme.13313] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/22/2016] [Indexed: 01/24/2023]
Abstract
Diabetes-related foot disease remains a common problem. For wounds, classic teaching recommends the treatment of any infection, offloading the wound and ensuring a good blood supply, as well as ensuring that the other modifiable risk factors are addressed and optimized. There remain, however, several questions about these and other aspects of the care of diabetes-related foot disease. Some of these questions are addressed in the present report; in particular, the impact of newer technologies in the identification of any organisms present in a wound, as well as the use of novel approaches to treat infections. The use of new remote sensing technology to identify people at risk of developing foot ulceration is also considered, in an attempt to allow early intervention and prevention of foot ulcers. The psychological impact of foot disease is often overlooked, but with an increasing number of publications on the subject, the cause-and-effect role that psychology plays in foot disease, such as ulcers and Charcot neuroarthropathy, is considered. Finally, because of heterogeneity in diabetic foot studies, comparing results is difficult. A recently published document focusing on ensuring a standardized way of reporting foot disease trials is discussed.
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Affiliation(s)
- M Clokie
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, Rhondda Cynon Taf
| | - A L Greenway
- Department of Infection, Immunity and Inflammation, University of Leicester, Leicester, Rhondda Cynon Taf
| | - K Harding
- Medical School, Cardiff University, Heath Park, Cardiff, Rhondda Cynon Taf
| | - N J Jones
- Welsh Wound Innovation Centre, Rhodfa Marics, Ynysmaerdy, Rhondda Cynon Taf
| | - K Vedhara
- Department of Health Psychology, Division of Primary Care, Nottingham University, Nottingham, UK
| | - F Game
- Department of Diabetes, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| | - K K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
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Peters EJ, Lipsky BA. Management of Infected Diabetic Foot Ulcers. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00196-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Wukich DK, Hobizal KB, Sambenedetto TL, Kirby K, Rosario BL. Outcomes of Osteomyelitis in Patients Hospitalized With Diabetic Foot Infections. Foot Ankle Int 2016; 37:1285-1291. [PMID: 27553085 PMCID: PMC5672907 DOI: 10.1177/1071100716664364] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND This study was conducted to evaluate the outcomes of patients with diabetic foot osteomyelitis (DFO) compared to diabetic foot soft tissue infections (STIs). METHODS 229 patients who were hospitalized with foot infections were retrospectively reviewed, identifying 155 patients with DFO and 74 patients with STI. Primary outcomes evaluated were the rates of amputations and length of hospital stay. DFO was confirmed by the presence of positive bone culture and/or histopathology. RESULTS Patients with DFO had a 5.6 times higher likelihood of overall amputation (P < .0001), a 3.4 times higher likelihood of major amputation (P = .027) and a 4.2 times higher likelihood of minor amputation (P < .0001) compared to patients without DFO. Major amputation was performed in 16.7% patients diagnosed with DFO and 5.3% of patients diagnosed with STI. Patients with DFO complicated by Charcot neuroarthropathy had a 7 times higher likelihood of undergoing major amputation (odds ratio 6.78, 95% confidence interval 2.70-17.01, P < .0001). The mean hospital stay was 7 days in DFO and 6 days in patients with DFI (P = .0082). Patients with DFO had a higher erythrocyte sedimentation rate (85 vs 71, P = .02) than patients with STI, however the differences in C-reactive protein (13.4 vs 11.8, P = .29) were not significantly different. CONCLUSION In this study of moderate and severe DFIs, the presence of osteomyelitis resulted in a higher likelihood of amputation and longer hospital stay. Readers should recognize that the findings of this study may not be applicable to less severe cases of DFO that can be effectively managed in an outpatient setting. LEVEL OF EVIDENCE Level III, retrospective comparative case series.
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Affiliation(s)
- Dane K Wukich
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC Mercy Amputation Prevention Center, Pittsburgh, PA, USA
| | | | - Tresa L Sambenedetto
- Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC Mercy Amputation Prevention Center, Pittsburgh, PA, USA
| | | | - Bedda L Rosario
- University of Pittsburgh Graduate School of Public Health, Department of Epidemiology, Pittsburgh, PA, USA
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Affiliation(s)
- Mesut Mutluoglu
- Department of Underwater and Hyperbaric Medicine, (Mutluoglu) GATA Haydarpasa Teaching Hospital, Istanbul, Turkey; Division of Medical Sciences (Lipsky), Green Templeton College, University of Oxford, Oxford, UK
| | - Benjamin A Lipsky
- Department of Underwater and Hyperbaric Medicine, (Mutluoglu) GATA Haydarpasa Teaching Hospital, Istanbul, Turkey; Division of Medical Sciences (Lipsky), Green Templeton College, University of Oxford, Oxford, UK
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Diabetic Foot Infections: Antibiotic Susceptibility Patterns and Determination of Antibiotic Cross-Resistance in Clinical Isolates of Enterococcus Species During 2012 - 2014 in Shiraz, Iran. ARCHIVES OF PEDIATRIC INFECTIOUS DISEASES 2016. [DOI: 10.5812/pedinfect.37680] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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