Skin and soft tissue infections in hospitalised patients with diabetes: culture isolates and risk factors associated with mortality, length of stay and cost

Improving Empiric Antibiotic Selection for Patients Hospitalized With Skin and Soft Tissue Infection: The INSPIRE 3 Skin and Soft Tissue Randomized Clinical Trial

Importance

Empiric extended-spectrum antibiotics are routinely prescribed for patients hospitalized with skin and soft tissue infections (SSTIs) despite low likelihoods of infection with multidrug-resistant organisms (MDROs).

Objective

To evaluate whether computerized provider order entry (CPOE) prompts presenting patient-specific and pathogen-specific MDRO infection risk estimates could reduce empiric extended-spectrum antibiotics for noncritically ill patients admitted with SSTI.

Design, Setting, and Participants

This cluster randomized clinical trial included 92 hospitals and assessed the effect of an antibiotic stewardship bundle that included CPOE prompts vs routine stewardship on antibiotic selection during the first 3 hospital days (empiric period) in noncritically ill adults hospitalized with SSTI. The trial population included adults 18 years and older treated with empiric antibiotics for SSTI in non-intensive care unit (ICU) settings. Data were collected from January 2019 to December 2023.

Interventions

CPOE prompts recommending standard-spectrum antibiotics in patients prescribed extended-spectrum antibiotics during the empiric period when absolute risk of MDRO SSTI was estimated to be less than 10%, coupled with feedback and education.

Main Outcomes and Measures

The primary outcome was empiric extended-spectrum antibiotic days of therapy (summed number of different extended-spectrum antibiotics targeting Pseudomonas and/or MDR gram-negative bacteria received per patient each calendar day). The secondary outcome was antipseudomonal days of therapy. Safety outcomes included days to ICU transfer and hospital length of stay. Outcomes compared differences between baseline and intervention periods across strategies.

Results

Among 118 562 patients admitted with SSTI at 92 hospitals, 67 033 (56.7%) were male and the mean (SD) age was 58.0 (17.5) years. A total of 57 837 patients were included in the baseline period and 60 725 in the intervention period. Receipt of any empiric extended-spectrum antibiotic during the baseline and intervention periods was 57.0% (16 855 of 29 595) and 56.0% (17 534 of 31 337), respectively, for the routine stewardship group compared with 55.4% (15 650 of 28 242) and 43.0% (12 647 of 29 388), respectively, for the CPOE group. Empiric extended-spectrum days of therapy per 1000 empiric days targeting Pseudomonas and/or MDR gram-negative pathogens was 511.5 during the baseline period and 488.7 during the intervention period in the routine stewardship group and was 496.2 and 359.1, respectively, in the CPOE bundle group (rate ratio, 0.72; 95% CI, 0.67-0.79; P < .001). There was no evidence of inferiority in the CPOE bundle group for mean (SD) hospital length of stay (routine stewardship, 6.5 [3.8] days; CPOE bundle, 6.4 [3.8] days) and days to ICU transfer (routine stewardship, 6.3 [3.2] days; CPOE bundle, 6.3 [3.1] days).

Conclusions and Relevance

In this randomized clinical trial, CPOE prompts recommending standard-spectrum empiric antibiotics for low-risk patients hospitalized with SSTI coupled with education and feedback significantly reduced use of extended-spectrum antibiotics without increasing admissions to ICUs or hospital length of stay.

Trial Registration

ClinicalTrials.gov Identifier: NCT05423756.

Skin repair and infection control in diabetic, obese mice using bioactive laser-activated sealants

Conventional wound approximation devices, including sutures, staples, and glues, are widely used but risk of wound dehiscence, local infection, and scarring can be exacerbated in these approaches, including in diabetic and obese individuals. This study reports the efficacy and quality of tissue repair upon photothermal sealing of full-thickness incisional skin wounds using silk fibroin-based laser-activated sealants (LASEs) containing copper chloride salt (Cu-LASE) or silver nanoprisms (AgNPr-LASE), which absorb and convert near-infrared (NIR) laser energy to heat. LASE application results in rapid and effective skin sealing in healthy, immunodeficient, as well as diabetic and obese mice. Although lower recovery of epidermal structure and function was seen with AgNPr-LASE sealing, likely because of the hyperthermia induced by laser and presence of this material in the wound space, this approach resulted in higher enhancement in recovery of skin biomechanical strength compared to sutures and Cu-LASEs in diabetic, obese mice. Histological and immunohistochemical analyses revealed that AgNPr-LASEs resulted in significantly lower neutrophil migration to the wound compared to Cu-LASEs and sutures, indicating a more muted inflammatory response. Cu-LASEs resulted in local tissue toxicity likely because of effects of copper ions as manifested in the form of a significant epidermal gap and a 'depletion zone', which was a region devoid of viable cells proximal to the wound. Compared to sutures, LASE-mediated sealing, in later stages of healing, resulted in increased angiogenesis and diminished myofibroblast activation, which can be indicative of lower scarring. AgNPr-LASE loaded with vancomycin, an antibiotic drug, significantly lowered methicillin-resistant Staphylococcus aureus (MRSA) load in a pathogen challenge model in diabetic and obese mice and also reduced post-infection inflammation of tissue compared to antibacterial sutures. Taken together, these attributes indicate that AgNPr-LASE demonstrated a more balanced quality of tissue sealing and repair in diabetic and obese mice and can be used for combating local infections, that can result in poor healing in these individuals.

Anaerobes in diabetic foot infections: pathophysiology, epidemiology, virulence, and management

SUMMARYDiabetic foot infections (DFI) are a public health problem worldwide. DFI are polymicrobial, biofilm-associated infections involving complex bacterial communities organized in functional equivalent pathogroups, all including anaerobes. Indeed, multiple pathophysiological factors favor the growth of anaerobes in this context. However, the prevalence, role, and contribution of anaerobes in wound evolution remain poorly characterized due to their challenging detection. Studies based on culture reviewed herein showed a weighted average of 17% of patients with anaerobes. Comparatively, the weighted average of patients with anaerobes identified by 16S rRNA gene sequencing was 83.8%. Culture largely underestimated not only the presence but also the diversity of anaerobes compared with cultivation-independent approaches but both methods showed that anaerobic Gram-negative bacilli and Gram-positive cocci were the most commonly identified in DFI. Anaerobes were more present in deeper lesions, and their detection was associated with fever, malodorous lesions, and ulcer depth and duration. More specifically, initial abundance of Peptoniphilus spp. was associated with ulcer-impaired healing, Fusobacterium spp. detection was significantly correlated with the duration of DFI, and the presence of Bacteroides spp. was significantly associated with amputation. Antimicrobial resistance of anaerobes in DFI remains slightly studied and warrants more consideration in the context of increasing resistance of the most frequently identified anaerobes in DFI. The high rate of patients with DFI-involving anaerobes, the increased knowledge on the species identified, their virulence factors, and their potential role in wound evolution support recommendations combining debridement and antibiotic therapy effective on anaerobes in moderate and severe DFI.

Triple threat: how diabetes results in worsened bacterial infections

Diabetes mellitus, characterized by impaired insulin signaling, is associated with increased incidence and severity of infections. Various diabetes-related complications contribute to exacerbated bacterial infections, including hyperglycemia, innate immune cell dysfunction, and infection with antibiotic-resistant bacterial strains. One defining symptom of diabetes is hyperglycemia, resulting in elevated blood and tissue glucose concentrations. Glucose is the preferred carbon source of several bacterial pathogens, and hyperglycemia escalates bacterial growth and virulence. Hyperglycemia promotes specific mechanisms of bacterial virulence known to contribute to infection chronicity, including tissue adherence and biofilm formation. Foot infections are a significant source of morbidity in individuals with diabetes and consist of biofilm-associated polymicrobial communities. Bacteria perform complex interspecies behaviors conducive to their growth and virulence within biofilms, including metabolic cross-feeding and altered phenotypes more tolerant to antibiotic therapeutics. Moreover, the metabolic dysfunction caused by diabetes compromises immune cell function, resulting in immune suppression. Impaired insulin signaling induces aberrations in phagocytic cells, which are crucial mediators for controlling and resolving bacterial infections. These aberrancies encompass altered cytokine profiles, the migratory and chemotactic mechanisms of neutrophils, and the metabolic reprogramming required for the oxidative burst and subsequent generation of bactericidal free radicals. Furthermore, the immune suppression caused by diabetes and the polymicrobial nature of the diabetic infection microenvironment may promote the emergence of novel strains of multidrug-resistant bacterial pathogens. This review focuses on the "triple threat" linked to worsened bacterial infections in individuals with diabetes: (i) altered nutritional availability in diabetic tissues, (ii) diabetes-associated immune suppression, and (iii) antibiotic treatment failure.

Rose Bengal diacetate-mediated antimicrobial photodynamic inactivation: potentiation by potassium iodide and acceleration of wound healing in MRSA-infected diabetic mice

Previous studies have shown that antimicrobial photodynamic inactivation (aPDI) can be strongly potentiated by the addition of the non-toxic inorganic salt, potassium iodide (KI). This approach was shown to apply to many different photosensitizers, including the xanthene dye Rose Bengal (RB) excited by green light (540 nm). Rose Bengal diacetate (RBDA) is a lipophilic RB derivative that is easily taken up by cells and hydrolyzed to produce an active photosensitizer. Because KI is not taken up by microbial cells, it was of interest to see if aPDI mediated by RBDA could also be potentiated by KI. The addition of 100 mM KI strongly potentiated the killing of Gram-positive methicillin-resistant Staphylocccus aureus, Gram-negative Eschericia coli, and fungal yeast Candida albicans when treated with RBDA (up to 15 µM) for 2 hours followed by green light (540 nm, 10 J/cm2). Both RBDA aPDI regimens (400 µM RBDA with or without 400 mM KI followed by 20 J/cm2 green light) accelerated the healing of MRSA-infected excisional wounds in diabetic mice, without damaging the host tissue.

Epidemiology, microbiology, and diagnosis of infection in diabetic ketoacidosis and hyperosmolar hyperglycemic syndrome: A multicenter retrospective observational study

AIMS

We investigated the characteristics of infection and the utility of inflammatory markers in diabetic ketoacidosis (DKA) and hyperosmolar hyperglycemic syndrome (HHS).

METHODS

A multicenter, retrospective observational study in 21 acute-care hospitals was conducted in Japan. This study included adult hospitalized patients with DKA and HHS. We analyzed the diagnostic accuracy of markers including C-reactive protein (CRP) and procalcitonin (PCT) for bacteremia. Multiple regression models were created for estimating bacteremia risk factors.

RESULTS

A total of 771 patients, including 545 patients with DKA and 226 patients with HHS, were analyzed. The mean age was 58.2 (SD, 19.3) years. Of these, 70 tested positive for blood culture. The mortality rates of those with and without bacteremia were 14 % and 3.3 % (P-value < 0.001). The area under the curve (AUC) of CRP and PCT for diagnosis of bacteremia was 0.85 (95 %CI, 0.81-0.89) and 0.76 (95 %CI, 0.60-0.92), respectively. Logistic regression models identified older age, altered level of consciousness, hypotension, and higher CRP as risk factors for bacteremia.

CONCLUSIONS

The mortality rate was higher in patients with bacteremia than patients without it. CRP, rather than PCT, may be valid for diagnosing bacteremia in hyperglycemic emergencies.

TRIAL REGISTRATION

This study is registered in the UMIN clinical trial registration system (UMIN000025393, Registered December 23, 2016).

Hyperglycemia potentiates increased Staphylococcus aureus virulence and resistance to growth inhibition by Pseudomonas aeruginosa

IMPORTANCE

Individuals with diabetes are prone to more frequent and severe infections, with many of these infections being polymicrobial. Polymicrobial infections are frequently observed in skin infections and in individuals with cystic fibrosis, as well as in indwelling device infections. Two bacteria frequently co-isolated from infections are Staphylococcus aureus and Pseudomonas aeruginosa. Several studies have examined the interactions between these microorganisms. The majority of these studies use in vitro model systems that cannot accurately replicate the microenvironment of diabetic infections. We employed a novel murine indwelling device model to examine interactions between S. aureus and P. aeruginosa. Our data show that competition between these bacteria results in reduced growth in a normal infection. In a diabetic infection, we observe increased growth of both microbes and more severe infection as both bacteria invade surrounding tissues. Our results demonstrate that diabetes changes the interaction between bacteria resulting in poor infection outcomes.

Diabetes mellitus promotes the nasal colonization of high virulent Staphylococcus aureus through the regulation of SaeRS two-component system

Diabetic foot infections are a common complication of diabetes. Staphylococcus aureus is frequently isolated from diabetic foot infections and commonly colonizes human nares. According to the study, the nasal microbiome analysis revealed that diabetic patients had a significantly altered nasal microbial composition and diversity. Typically, the fasting blood glucose (FBG) level had an impact on the abundance and sequence type (ST) of S. aureus in diabetic patients. We observed that highly virulent S. aureus ST7 strains were more frequently colonized in diabetic patients, especially those with poorly controlled FBG, while ST59 was dominant in healthy individuals. S. aureus ST7 strains were more resistant to human antimicrobial peptides and formed stronger biofilms than ST59 strains. Critically, S. aureus ST7 strains displayed higher virulence compared to ST59 strains in vivo. The dominance of S. aureus ST7 strains in hyperglycemic environment is due to the higher activity of the SaeRS two-component system (TCS). S. aureus ST7 strains outcompeted ST59 both in vitro, and in nasal colonization model in diabetic mice, which was abolished by the deletion of the SaeRS TCS. Our data indicated that highly virulent S. aureus strains preferentially colonize diabetic patients with poorly controlled FBG through SaeRS TCS. Detection of S. aureus colonization and elimination of colonizing S. aureus are critical in the care of diabetic patients with high FBG.

Diabetes-Related Mortality in a Developing Country: An Exploration of Tertiary Hospital Data

(1) Background: Given the growing global diabetes crisis, this study examined the causes of mortality in diabetic patients at a Mongolian tertiary care hospital. (2) Between 2017 and 2021, data from 100 individuals with diabetes (53% male, mean age 58.5 years, duration of diabetes, 9.6 years, HbA1c level, 9.7%, 11.1% type 1 diabetes) were reviewed. (3) Results: The predominant cause of mortality was sepsis, accounting for 65.0% of cases and emerging as a contributing factor in 75.0% of instances. Renal failure constituted the second leading cause of death, accounting for 19.0% of mortalities. Other contributing factors included chronic liver disease (6.0%) and ARDS (3.0%). Regarding sepsis, the individuals affected were relatively younger (57.5 ± 11.2 vs. 61.7 ± 11.2, p = 0.988), with a slightly higher prevalence among female patients (77.4%) and those with T1DM (81.8%), though these differences were not statistically significant (p > 0.05). Patients with sepsis exhibited lower BMI values (26.7 ± 4.1 vs. 28.5 ± 6.2, p = 0.014) and poorer glycemic control (9.8 ± 3.1 vs. 9.6 ± 5.1, p = 0.008); (4) Conclusions: This hospital-based data analysis in Mongolia highlights sepsis as the primary cause of mortality among diabetes patients in tertiary hospitals regardless of age, gender, or diabetes type while also indicating a potential association between a lower BMI, poor glycemic control, smoking, and the risk of sepsis.

Waterjet in Bacterial Clearance of Diabetic Lower Extremity Contaminated Wounds: A Retrospective Cohort Study

The waterjet debridement is now a standard practice in contaminated or infected diabetic lower extremity wounds. The bacterial clearance of the waterjet debridement remains an important parameter that should be predicted in this application. This study aimed to investigate the waterjet in reducing the diabetic lower extremity wound contaminants. A retrospective cohort study was conducted. Patients' etiology and pathogen diagnosis were established as diabetic lower extremity contaminated wound. The high-power waterjet (Versajet™, Smith-Nephew) was used in the treatment group and conventional surgical methods were used in the control group. The bacteriological swab samples were collected before and after the debridement. The results of bacterial culture were analyzed. A total of 74 patients were included in our study, 40 patients in the treatment group and 34 in the control group. Patient characteristics were well matched. The preoperative bacteriological swab samples of the 2 groups showed no significant difference between each other with a P value of .1022. The culture result of postoperative bacteriological swab samples in the treatment group was significantly lower than control with a P value of .0099. The odds of bacterial clearance were greater in the treatment group than in the control group (odds ratio, 5.139; 95% confidence interval, 1.386-18.41). As demonstrated by this retrospective research, waterjet debridement reduced the bacterial load in the diabetic lower extremity contaminated wounds.

Necrotizing Fasciitis-Severe Complication of Bullous Pemphigoid: A Systematic Review, Risk Factors, and Treatment Challenges

Background and objectives: Bullous pemphigoid (BP), the most common subepidermal autoimmune skin blistering disease (AIBD) has an estimated annual incidence of 2.4 to 42.8 new cases per million in different populations, designating it an orphan disease. Characterized by disruption of the skin barrier combined with therapy-induced immunosuppression, BP could pose a risk for skin and soft tissue infections (SSTI). Necrotizing fasciitis (NF) is a rare necrotizing skin and soft tissue infection, with a prevalence of 0.40 cases per 100,000 to 15.5 cases per 100,000 population, often associated with immunosuppression. Low incidences of NF and BP classify them both as rare diseases, possibly contributing to the false inability of making a significant correlation between the two. Here, we present a systematic review of the existing literature related to the ways these two diseases correlate. Materials and methods: This systematic review was conducted according to the PRISMA guidelines. The literature review was conducted using PubMed (MEDLINE), Google Scholar, and SCOPUS databases. The primary outcome was prevalence of NF in BP patients, while the secondary outcome was prevalence and mortality of SSTI in BP patients. Due to the scarcity of data, case reports were also included. Results: A total of 13 studies were included, six case reports of BP complicated by NF with six retrospective studies and one randomized multicenter trial of SSTIs in BP patients. Conclusions: Loss of skin integrity, immunosuppressive therapy, and comorbidities commonly related to BP patients are risk factors for necrotizing fasciitis. Evidence of their significant correlation is emerging, and further studies are deemed necessary for the development of BP-specific diagnostic and treatment protocols.

A Manganese-independent Aldolase Enables Staphylococcus aureus To Resist Host-imposed Metal Starvation

The preferred carbon source of Staphylococcus aureus and many other pathogens is glucose, and its consumption is critical during infection. However, glucose utilization increases the cellular demand for manganese, a nutrient sequestered by the host as a defense against invading pathogens. Therefore, bacteria must balance glucose metabolism with the increasing demand that metal-dependent processes, such as glycolysis, impose upon the cell. A critical regulator that enables S. aureus to resist nutritional immunity is the ArlRS two-component system. This work revealed that ArlRS regulates the expression of FdaB, a metal-independent fructose 1,6-bisphosphate aldolase. Further investigation revealed that when S. aureus is metal-starved by the host, FdaB functionally replaces the metal-dependent isozyme FbaA, thereby allowing S. aureus to resist host-imposed metal starvation in culture. Although metal-dependent aldolases are canonically zinc-dependent, this work uncovered that FbaA requires manganese for activity and that FdaB protects S. aureus from manganese starvation. Both FbaA and FdaB contribute to the ability of S. aureus to cause invasive disease in wild-type mice. However, the virulence defect of a strain lacking FdaB was reversed in calprotectin-deficient mice, which have defects in manganese sequestration, indicating that this isozyme contributes to the ability of this pathogen to overcome manganese limitation during infection. Cumulatively, these observations suggest that the expression of the metal-independent aldolase FdaB allows S. aureus to alleviate the increased demand for manganese that glucose consumption imposes, and highlights the cofactor flexibility of even established metalloenzyme families. IMPORTANCE Staphylococcus aureus and other pathogens consume glucose during infection. Glucose utilization increases the demand for transition metals, such as manganese, a nutrient that the host limits as a defense mechanism against invading pathogens. Therefore, pathogenic bacteria must balance glucose and manganese requirements during infection. The two-component system ArlRS is an important regulator that allows S. aureus to adapt to both glucose and manganese starvation. Among the genes regulated by ArlRS is the metal-independent fructose 1,6-bisphosphate aldolase fdaB, which functionally substitutes for the metal-dependent isoenzyme FbaA and enables S. aureus to survive host-imposed manganese starvation. Unexpectedly, and differing from most characterized metal-dependent aldolases, FbaA requires manganese for activity. Cumulatively, these findings reveal a new mechanism for overcoming nutritional immunity as well as the cofactor plasticity of even well-characterized metalloenzyme families.

Study of Phenotypic and Genotypic Factors of Staphylococcus aureus Clinical Local Isolates

The isolates of Staphylococcus aureus were isolated from patients with various infections in hospitals, the isolates were identified and accurately diagnosed by phenotypic examination and biochemical tests, as well Vitek-2, and then genetic detection and diagnosis of many of the pathogenic factors associated with Staphylococcus aureus using conventional polymerase chain reaction (PCR) and testing for association by antibiotic resistance and production of some toxins by Staphylococcus aureus. After performing analysis of statistical, it was set up that the correlation coefficient of the PCR technique using virulence genes, sensitivity test to antibiotics and other virulence factors were significant at p < 0.05, but was insignificant with the biofilm production.

Hyperglycemia in Diabetic Skin Infections Promotes Staphylococcus aureus Virulence Factor Aureolysin: Visualization by Molecular Imaging

Bacterial skin infections are common in diabetic patients, with Staphylococcus aureus (S. aureus) being the most commonly isolated, causing comorbidities such as increased mortality and long-term hospitalization. While precise mechanisms remain to be determined, hyperglycemia represents an important pathogenetic factor responsible for the increased risk of S. aureus infection. Herein, we constructed a series of ratiometric fluorescent molecular probes for aureolysin (Aur), a major virulence factor in S. aureus. Using probe 1, we were able to determine specific Aur activity in both cells and tissues. We also observed that elevated glucose levels led to 2-fold higher Aur expression in S. aureus cultures. In a diabetic mouse model, we used molecular imaging to demonstrate that hyperglycemia tripled S. aureus Aur virulence compared to nondiabetic mice, resulting in more severe infections.

Impact of Nares Swabs in the Operative Management of Distal Lower Extremity Infections

Associations between nares surveillance cultures and lower extremity wound cultures remains a topic of discussion in the literature and in clinical practice. Reports are limited due to the questionable accuracy of bedside foot cultures. A retrospective review of our institution's lower extremity wounds requiring surgical management distal to the tibial tuberosity was conducted. Deep intraoperative tissue cultures collected in a sterile operating field were referenced against nares cultures from the same hospitalization. Accuracy, sensitivity, and specificity of nares cultures for predicting methicillin-resistant Staphylococcus aureus (MRSA) infection were determined. Four hundred and forty unique patients with both nares and wound cultures met inclusion criteria. Comorbid diagnoses revealed 66.82%, 30.68%, and 32.27% of patients had diabetes mellitus, chronic kidney disease, and/or peripheral arterial disease, respectively. Sensitivity and specificity were found to be 53.13% and 96.13%, respectively. Prevalence of MRSA in a lower extremity wound was 14.9%, and accuracy of nares culture was 90.04% (CI: 86.91%-92.65%). A review of 30 false negative cases was conducted. Using exclusion criteria of a hospital admission within 60 days of presentation, history of MRSA infection, and/or presentation from a long-term care facility, negative predictive value of MRSA nares colonization was 99.51%. A case of necrotizing fasciitis accounted for one outlier. This data demonstrates that nares surveillance swabs have excellent diagnostic performance in ruling out MRSA infections in foot and ankle wounds. Further analysis is required to determine whether this performance is improved in specialized subgroups or dependent on temporal proximity.

The amputation and mortality of inpatients with diabetic foot ulceration in the COVID-19 pandemic and postpandemic era: A machine learning study

This study aimed to explore the clinical characteristic and outcomes of inpatients with diabetic foot ulceration (DFU) in 2019 (prelockdown) and 2020 (postlockdown) due to the COVID-19 pandemic, at an emergency medical service unit. Prediction models for mortality and amputation were developed to describe the risk factors using a machine learning-based approach. Hospitalized DFU patients (N = 23) were recruited after the lockdown in 2020 and matched with corresponding inpatients (N = 23) before lockdown in 2019. Six widely used machine learning models were built and internally validated using 3-fold cross-validation to predict the risk of amputation and death in DFU inpatients under the COVID-19 pandemic. Previous DF ulcers, prehospital delay, and mortality were significantly higher in 2020 compared to 2019. Diabetic foot patients in 2020 had higher hs-CRP levels (P = .037) but lower hemoglobin levels (P = .017). The extreme gradient boosting (XGBoost) performed best in all models for predicting amputation and mortality with the highest area under the curve (0.86 and 0.94), accuracy (0.80 and 0.90), sensitivity (0.67 and 1.00), and negative predictive value (0.86 and 1.00). A long delay in admission and a higher risk of mortality was observed in patients with DFU who attended the emergency center during the COVID-19 post lockdown. The XGBoost model can provide evidence-based risk information for patients with DFU regarding their amputation and mortality. The prediction models would benefit DFU patients during the COVID-19 pandemic.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Worsening Glycemia Increases the Odds of Intermittent but Not Persistent Staphylococcus aureus Nasal Carriage in Two Cohorts of Mexican American Adults

Numerous host and environmental factors contribute to persistent and intermittent nasal Staphylococcus aureus carriage in humans. The effects of worsening glycemia on the odds of S. aureus intermittent and persistent nasal carriage was established in two cohorts from an adult Mexican American population living in Starr County, Texas. The anterior nares were sampled at two time points and the presence of S. aureus determined by laboratory culture and spa-typing. Persistent carriers were defined by the presence of S. aureus of the same spa-type at both time points, intermittent carriers were S. aureus-positive for 1 of 2 swabs, and noncarriers were negative for S. aureus at both time points. Diabetes status was obtained through personal interview and physical examination that included a blood draw for the determination of percent glycated hemoglobin A1c (%HbA1c), fasting plasma glucose, and other blood chemistry values. Using logistic regression and general estimating equations, the odds of persistent and intermittent nasal carriage compared to noncarriers across the glycemic spectrum was determined controlling for covariates. Increasing fasting plasma glucose and %HbA1c in the primary and replication cohort, respectively, were significantly associated with increasing odds of S. aureus intermittent, but not persistent nasal carriage. These data suggest that increasing dysglycemia is a risk factor for intermittent S. aureus nasal carriage potentially placing those with poorly controlled diabetes at an increased risk of acquiring an S. aureus infection. IMPORTANCE Factors affecting nasal S. aureus colonization have been studied primarily in the context of persistent carriage. In contrast, few studies have examined factors affecting intermittent nasal carriage with this pathogen. This study demonstrates that the odds of intermittent but not persistent nasal carriage of S. aureus significantly increases with worsening measures of dysglycemia. This is important in the context of poorly controlled diabetes since the risk of becoming colonized with one of the primary organisms associated with diabetic foot infections can lead to increased morbidity and mortality.

Efficient photocatalytic degradation of industrial contaminants by Piper longum mediated ZnO nanoparticles

Piper longum extract as a reducing agent in green synthesis method is used to synthesize ZnO nanoparticles (ZnO-NPs). The impact of the reductant on the structural, optical and surface morphological properties of ZnO-NPs can be analyzed. Piper longum extract has delicately tuned the band gap of ZnO-NPs. Increase in energy band gap indicates an increase in the number of capping molecules in the prepared ZnO nanoparticles. The carbohydrates and proteins not only play a fundamental role in ZnO capping, which is important for its stability, determination and biocompatibility. Thus obtained nanosized ZnO particles are confirmed by the surface morphological studies. Because of various surface interface properties might have different physical-chemical, desorption-adsorption abilities in the direction towards microbes, create different antibacterial performances. S.aureus has maximum inhibition zone of 23 mm and Escherichia coli has minimum inhibition zone of 7 mm. To assess the photocatalytic activity of the prepared ZnO-NPs under UV light irradiation, methyl orange, malachite green and methylene blue dyes were utilized as model contaminants. The degradation efficiency of MG, MB and MO dyes solution is found that 96%, 69% and 48% of degradation efficiency respectively under ultraviolet light irradiation. The properties of synthetic nanopowders suggest that they have important potential for a variety of biochemical and environmental applications.

Comparative Clinical Outcomes of Patients with Diabetic Foot Infection Caused by Methicillin-Resistant Staphylococcus Aureus (MRSA) or Methicillin-Sensitive Staphylococcus Aureus (MSSA)

Few studies have addressed the interaction of specific pathogens with clinical outcomes in patients with diabetic foot infection (DFI). Our study aim was to compare the clinical outcomes among patients with DFI caused by methicillin-resistant Staphylococcus aureus (MRSA) with cases caused by methicillin-sensitive Staphylococcus aureus (MSSA). We gathered the data of 75 consecutive patients admitted at specialized outpatients diabetic with mild or moderate DFI in which S. aureus was isolated from bone or soft tissue specimens in pure or as a part of the polymicrobial culture. Patients were divided into two groups: those with MRSA infection and those with MSSA infection. Patients with MRSA diabetic foot infections were significantly associated with male gender (86% vs. 64%, P = .029), higher SINBAD Classification Score (3.6 ± 0.99 points vs. 2.8 ± 1.06 points, P = .001), longer mean wound evolution [17.8 (3;29.5) weeks versus 9.1 (1;12) weeks, P = .008], bone involvement [18 (50%) versus 9 (23.1%), P = .015] and longer mean healing time [18.2(8;28) weeks versus 9.1 (1;12) weeks, P = .008]. In addition, male gender (OR 8.81, 95% CI 2.00-38.84) and SINBAD Classification Score (OR 2.70, 1.46-5.00) were identified as independent risk factors for MRSA DFI. Significant differences in the number of surgical procedures to resolve infection [15 (41.7%) versus 13 (33.3%), P = .456] or in the mean healing time after surgical treatment [10.5 weeks (6.7;16.5) versus 6.1 weeks (3;8.7), P = .068] were not observed among groups, suggesting that when treatment is based on early and surgical debridement, MRSA infections are not associated with worse prognosis. In conclusion MRSA DFI has importance in clinical outcomes such as time to healing. We propose that recent lines of research regarding the genetic virulence of strains of S. aureus could provide new insights into our results.

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

Background

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

Methods

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

Results

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

Conclusion

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

Optimization of Antibiotic Selection in the Emergency Department for Adult Skin and Soft Tissue Infections

Objectives: Emergency department (ED) order sets that include skin and soft tissue infections (SSTI) stratification and antimicrobial selection criteria may improve clinical outcomes and appropriateness of initial antibiotic selection. The purpose of this study was to optimize and evaluate antimicrobial prescribing for SSTI in the ED by implementing an institution specific Infectious Diseases Society of America (IDSA) guideline directed computerized provider order entry (CPOE) order set. The primary outcome was the rate of appropriate antibiotic prescribing for SSTI in the ED before and after order set revision. Secondary outcomes were length of hospital stay, rate of continuity of antibiotics from the ED to hospital admission orders, and frequency of order set utilization. Methods: This was a single-centered, retrospective, cohort study. The ED SSTI order set revision reflected current IDSA guidelines, institution formulary, and institution antibiogram. Results: A total of 180 patients were included in the study. The rate of appropriate antibiotic prescribing was 74.4% and 78.9% (P = .60) in the pre-revision and post-revision groups, respectively. Length of hospital stay of admitted patients was 4.93 and 4.32 days (P = .61). Rate of antibiotics continued from the ED to admission was 62.1% and 59.4% (P = .99). Order set utilization was 17.8% and 24.4% (P = .36). A subgroup analysis found appropriateness increased with order set use in admitted patients (50% vs 88.2%; P = .0382) and total patients (50% vs 81.8%; P = .037). Conclusion: An order set reflective of current IDSA guidelines and institution specific antibiogram showed a similar rate of appropriate antibiotic selection compared to provider's clinical judgment. Provider awareness of SSTI management could have been a limitation to the study.

Pseudomonas aeruginosa Pneumonia: Evolution of Antimicrobial Resistance and Implications for Therapy

Pseudomonas aeruginosa (PA), a non-lactose-fermenting gram-negative bacillus, is a common cause of nosocomial infections in critically ill or debilitated patients, particularly ventilator-associated pneumonia (VAP), and infections of urinary tract, intra-abdominal, wounds, skin/soft tissue, and bloodstream. PA rarely affects healthy individuals, but may cause serious infections in patients with chronic structural lung disease, comorbidities, advanced age, impaired immune defenses, or with medical devices (e.g., urinary or intravascular catheters, foreign bodies). Treatment of pseudomonal infections is difficult, as PA is intrinsically resistant to multiple antimicrobials, and may acquire new resistance determinants even while on antimicrobial therapy. Mortality associated with pseudomonal VAP or bacteremias is high (> 35%) and optimal therapy is controversial. Over the past three decades, antimicrobial resistance (AMR) among PA has escalated globally, via dissemination of several international multidrug resistant "epidemic" clones. We discuss the importance of PA as a cause of pneumonia including health care-associated pneumonia, hospital-acquired pneumonia, VAP, the emergence of AMR to this pathogen, and approaches to therapy (both empirical and definitive).

Update on the epidemiology of healthcare-acquired bacterial infections: focus on complicated skin and skin structure infections

Healthcare-associated infections (HCAIs) are a threat to patient safety and cause substantial medical and economic burden in acute care and long-term care facilities. Risk factors for HCAIs include patient characteristics, the type of care and the setting. Local surveillance data and microbiological characterization are crucial tools for guiding antimicrobial treatment and informing efforts to reduce the incidence of HCAI. Skin and soft tissue infections, including superficial and deep incisional surgical site infections, are among the most frequent HCAIs. Other skin and soft tissue infections associated with healthcare settings include vascular access site infections, infected burns and traumas, and decubitus ulcer infections.

The Sensor Histidine Kinase ArlS Is Necessary for Staphylococcus aureus To Activate ArlR in Response to Nutrient Availability

Staphylococcus aureus is a versatile opportunistic pathogen whose success is driven by its ability to adapt to diverse environments and host-imposed stresses. Two-component signal transduction systems, such as ArlRS, often mediate these adaptations. Loss of ArlRS or the response regulator ArlR alone impairs the ability of S. aureus to respond to host-imposed manganese starvation and glucose limitation. As sensor histidine kinases and response regulators frequently work as pairs, it has been assumed that ArlS senses and activates ArlR in response to these stimuli. However, recent work suggests that the sensor histidine kinase GraS can also activate ArlR, calling the contribution of ArlS in responding to manganese and glucose availability into question. The results of current studies reveal that ArlS is necessary to activate ArlR in response to manganese sequestration by the host immune effector calprotectin and glucose limitation. Although the loss of ArlS does not completely eliminate ArlR activity, this response regulator is no longer responsive to manganese or glucose availability in the absence of its cognate histidine kinase. Despite the residual activity of ArlR in the absence of ArlS, ArlR phosphorylation by ArlS is required for S. aureus to resist calprotectin-imposed metal starvation. Cumulatively, these findings contribute to the understanding of S. aureus signal transduction in response to nutritional immunity and support the previous observation indicating that ArlRS is activated by a common signal derived from host-imposed manganese and glucose limitation. IMPORTANCE The ability of pathogens, including Staphylococcus aureus, to sense and adapt to diverse environments partially relies on two-component systems, such as ArlRS. Recent work revealed that the response regulator ArlR can be cross-activated by the sensor histidine kinase GraS, rendering the role of its cognate partner, ArlS, in response to manganese and glucose limitation uncertain. The results of this study reveal that ArlS is necessary for the activation of ArlR in response to calprotectin and glucose limitation. Although a low level of ArlR activity remains in the absence of ArlS, ArlS phosphotransfer to ArlR is required for S. aureus to overcome calprotectin-induced nutritional stress. Collectively, this study provides fundamental information to understand how ArlRS mediates staphylococcal adaptation during infection.

A Bittersweet Response to Infection in Diabetes; Targeting Neutrophils to Modify Inflammation and Improve Host Immunity

Chronic and recurrent infections occur commonly in both type 1 and type 2 diabetes (T1D, T2D) and increase patient morbidity and mortality. Neutrophils are professional phagocytes of the innate immune system that are critical in pathogen handling. Neutrophil responses to infection are dysregulated in diabetes, predominantly mediated by persistent hyperglycaemia; the chief biochemical abnormality in T1D and T2D. Therapeutically enhancing host immunity in diabetes to improve infection resolution is an expanding area of research. Individuals with diabetes are also at an increased risk of severe coronavirus disease 2019 (COVID-19), highlighting the need for re-invigorated and urgent focus on this field. The aim of this review is to explore the breadth of previous literature investigating neutrophil function in both T1D and T2D, in order to understand the complex neutrophil phenotype present in this disease and also to focus on the development of new therapies to improve aberrant neutrophil function in diabetes. Existing literature illustrates a dual neutrophil dysfunction in diabetes. Key pathogen handling mechanisms of neutrophil recruitment, chemotaxis, phagocytosis and intracellular reactive oxygen species (ROS) production are decreased in diabetes, weakening the immune response to infection. However, pro-inflammatory neutrophil pathways, mainly neutrophil extracellular trap (NET) formation, extracellular ROS generation and pro-inflammatory cytokine generation, are significantly upregulated, causing damage to the host and perpetuating inflammation. Reducing these proinflammatory outputs therapeutically is emerging as a credible strategy to improve infection resolution in diabetes, and also more recently COVID-19. Future research needs to drive forward the exploration of novel treatments to improve infection resolution in T1D and T2D to improve patient morbidity and mortality.

Diabetes and acute bacterial skin and skin structure infections

Acute bacterial skin and skin structures infections (ABSSSIs) are associated with high morbidity, costs and mortality in patients with diabetes mellitus. Their appropriate management should include several figures and a well-organized approach. This review aims to highlight the interplay between diabetes and ABSSSIs and bring out the unmet clinical needs in this area. Pathogenetic mechanisms underlying the increased risk of ABSSSIs in diabetes mellitus are multifactorial: high glucose levels play a crucial pathogenetic role in the tissue damage and delayed clinical cure. Moreover, the presence of diabetes complications (neuropathy, vasculopathy) further complicates the management of ABSSSIs in patients with diabetes. Multidrug resistance organisms should be considered in this population based on patient risk factors and local epidemiology and etiological diagnosis should be obtained whenever possible. Moreover, drug-drug interactions and drug-related adverse events (such as nephrotoxicity) should be considered in the choice of antibiotic therapy. Reducing unnecessary hospitalizations and prolonged length of hospital stay is of primary importance now, more than ever. To achieve these objectives, a better knowledge of the interplay between acute and chronic hyperglycemia, multidrug resistant etiology, and short and long-term outcome is needed. Of importance, a multidisciplinary approach is crucial to achieve full recovery of these patients.

Susceptibility for Some Infectious Diseases in Patients With Diabetes: The Key Role of Glycemia

Uncontrolled diabetes results in several metabolic alterations including hyperglycemia. Indeed, several preclinical and clinical studies have suggested that this condition may induce susceptibility and the development of more aggressive infectious diseases, especially those caused by some bacteria (including Chlamydophila pneumoniae, Haemophilus influenzae, and Streptococcus pneumoniae, among others) and viruses [such as coronavirus 2 (CoV2), Influenza A virus, Hepatitis B, etc.]. Although the precise mechanisms that link glycemia to the exacerbated infections remain elusive, hyperglycemia is known to induce a wide array of changes in the immune system activity, including alterations in: (i) the microenvironment of immune cells (e.g., pH, blood viscosity and other biochemical parameters); (ii) the supply of energy to infectious bacteria; (iii) the inflammatory response; and (iv) oxidative stress as a result of bacterial proliferative metabolism. Consistent with this evidence, some bacterial infections are typical (and/or have a worse prognosis) in patients with hypercaloric diets and a stressful lifestyle (conditions that promote hyperglycemic episodes). On this basis, the present review is particularly focused on: (i) the role of diabetes in the development of some bacterial and viral infections by analyzing preclinical and clinical findings; (ii) discussing the possible mechanisms by which hyperglycemia may increase the susceptibility for developing infections; and (iii) further understanding the impact of hyperglycemia on the immune system.

Crosstalk Between Staphylococcus aureus and Innate Immunity: Focus on Immunometabolism

Staphylococcus aureus is a leading cause of bacterial infections globally in both healthcare and community settings. The success of this bacterium is the product of an expansive repertoire of virulence factors in combination with acquired antibiotic resistance and propensity for biofilm formation. S. aureus leverages these factors to adapt to and subvert the host immune response. With the burgeoning field of immunometabolism, it has become clear that the metabolic program of leukocytes dictates their inflammatory status and overall effectiveness in clearing an infection. The metabolic flexibility of S. aureus offers an inherent means by which the pathogen could manipulate the infection milieu to promote its survival. The exact metabolic pathways that S. aureus influences in leukocytes are not entirely understood, and more work is needed to understand how S. aureus co-opts leukocyte metabolism to gain an advantage. In this review, we discuss the current knowledge concerning how metabolic biases dictate the pro- vs. anti-inflammatory attributes of various innate immune populations, how S. aureus metabolism influences leukocyte activation, and compare this with other bacterial pathogens. A better understanding of the metabolic crosstalk between S. aureus and leukocytes may unveil novel therapeutic strategies to combat these devastating infections.

Cost-consequence analysis of single-dose dalbavancin versus standard of care for the treatment of acute bacterial skin and skin structure infections in a multi-site healthcare system

BACKGROUND

Acute bacterial skin and skin structure infections (ABSSSI) are common infectious diseases that cause a significant economic burden on the healthcare system. This study aimed to compare the cost-effectiveness of dalbavancin versus standard of care (SoC) in the treatment of ABSSSI in a community-based healthcare system.

METHODS

This was a retrospective study of adult patients with ABSSSI treated with dalbavancin or SoC during a 27-month period. Patients were matched based on age and body mass index. The primary outcome was average net cost of care to the healthcare system per patient, calculated as the difference between reimbursement payments and the total cost to provide care to the patient. The secondary outcome was proportion of cases successfully treated, defined as no ABSSSI-related readmission within 30-days after the initiation of treatment.

RESULTS

Of the 418 matched patients, 209 received SoC and 209 received dalbavancin. The average total cost of care per patient was greater with dalbavancin versus SoC ($ 4770 vs $ 2709, p < 0.0001). The average reimbursement per patient was $3084 with dalbavancin versus $2633 SoC (p = 0.527). The net cost, calculated as revenue minus total cost, was $1685 with dalbavancin versus $75 with SoC (p = 0.013). The overall treatment success rate was 74% with dalbavancin versus 85% with SoC (P = 0.004).

CONCLUSION

Dalbavancin was more costly than SoC for the treatment of ABSSSI, with a higher 30-days readmission rate. Dalbavancin does not offer an economic or efficacy advantage.

Lack of nutritional immunity in diabetic skin infections promotes Staphylococcus aureus virulence

Elevated blood/tissue glucose is a hallmark feature of advanced diabetes, and people with diabetes are prone to more frequent and invasive infections with Staphylococcus aureus. Phagocytes must markedly increase glucose consumption during infection to generate and oxidative burst and kill invading bacteria. Similarly, glucose is essential for S. aureus survival in an infection and competition with the host, for this limited resource is reminiscent of nutritional immunity. Here, we show that infiltrating phagocytes do not express their high-efficiency glucose transporters in modeled diabetic infections, resulting in a diminished respiratory burst and increased glucose availability for S. aureus We show that excess glucose in these hyperglycemic abscesses significantly enhances S. aureus virulence potential, resulting in worse infection outcomes. Last, we show that two glucose transporters recently acquired by S. aureus are essential for excess virulence factor production and the concomitant increase in disease severity in hyperglycemic infections.

Codelivery of Sustainable Antimicrobial Agents and Platelet-Derived Growth Factor via Biodegradable Nanofibers for Repair of Diabetic Infectious Wounds

More than half of diabetic wounds demonstrate clinical signs of infection at presentation and lead to poor outcomes. This work develops coaxial sheath-core nanofibrous poly(lactide-co-glycolide) (PLGA) scaffolds that are loaded with bioactive antibiotics and platelet-derived growth factor (PDGF) for the repair of diabetic infectious wounds. PDGF and PLGA/antibiotic solutions were pumped, respectively, into two independent capillary tubings for coaxial electrospinning to prepare biodegradable sheath-core nanofibers. Spun nanofibrous scaffolds sustainably released PDGF, vancomycin, and gentamicin for 3 weeks. The scaffolds also reduced the phosphatase and tensin homologue content, enhanced the amount of angiogenesis marker (CD31) around the wound area, and accelerated healing in the early stage of infected diabetic wound repair. Antibiotic/biomolecule-loaded PLGA nanofibers may provide a very effective way to aid tissue regeneration at the sites of infected diabetic wounds.

Epigenetic regulation of the PGE2 pathway modulates macrophage phenotype in normal and pathologic wound repair

Macrophages are a primary immune cell involved in inflammation, and their cell plasticity allows for transition from an inflammatory to a reparative phenotype and is critical for normal tissue repair following injury. Evidence suggests that epigenetic alterations play a critical role in establishing macrophage phenotype and function during normal and pathologic wound repair. Here, we find in human and murine wound macrophages that cyclooxygenase 2/prostaglandin E2 (COX-2/PGE2) is elevated in diabetes and regulates downstream macrophage-mediated inflammation and host defense. Using single-cell RNA sequencing of human wound tissue, we identify increased NF-κB-mediated inflammation in diabetic wounds and show increased COX-2/PGE2 in diabetic macrophages. Further, we identify that COX-2/PGE2 production in wound macrophages requires epigenetic regulation of 2 key enzymes in the cytosolic phospholipase A2/COX-2/PGE2 (cPLA2/COX-2/PGE2) pathway. We demonstrate that TGF-β-induced miRNA29b increases COX-2/PGE2 production via inhibition of DNA methyltransferase 3b-mediated hypermethylation of the Cox-2 promoter. Further, we find mixed-lineage leukemia 1 (MLL1) upregulates cPLA2 expression and drives COX-2/PGE2. Inhibition of the COX-2/PGE2 pathway genetically (Cox2fl/fl Lyz2Cre+) or with a macrophage-specific nanotherapy targeting COX-2 in tissue macrophages reverses the inflammatory macrophage phenotype and improves diabetic tissue repair. Our results indicate the epigenetically regulated PGE2 pathway controls wound macrophage function, and cell-targeted manipulation of this pathway is feasible to improve diabetic wound repair.

Risk factors for mortality in patients with diabetic foot infections: a prospective cohort study

BACKGROUND

An increasing prevalence of diabetes mellitus has led to a high risk of diabetic foot infections (DFI) and associated morbidity. However, little is known about the relationship between DFI and mortality.

AIM

To investigate the risk of mortality and associated factors in patients with DFI in an Australian context.

METHODS

A prospective cohort study of inpatients with DFI between May 2012 and October 2016 was done at Royal Darwin Hospital, a tertiary referral hospital for the Top End of the Northern Territory. Primary outcome was 1-year mortality with Cox regression analysis undertaken to assess risk factors for mortality.

RESULTS

Four hundred and thirteen consecutive adult diabetic patients with 737 admissions were referred to the High-Risk Foot Service for DFI. Cumulative risk of mortality at 1 year was 8.9% (95% confidence interval (CI) 6.4-12.2). On univariable analysis, mortality was associated with older age (hazard ratio (HR) per year increase 1.08, 95% CI 1.06-1.11, P = 0.001), haemodialysis (HR 3.64, 1.74-7.62, P < 0.001), isolation of Pseudomonas aeruginosa (HR 2.32, 1.05-5.12, P = 0.04) and ischaemic heart disease (HR 2.05, 1.04-4.07, P = 0.04), while indigenous status (HR 0.48, 0.25-0.95, P = 0.04) and HbA1c > 7% (HR 0.45, 0.20-0.99, P < 0.05) were protective. After adjusting for confounders, independent risk factors for mortality were haemodialysis (adjusted HR 5.76, 95% CI 2.28-14.59, P < 0.001) and older age (adjusted HR 1.09, 1.06-1.13, P < 0.001). Patients on haemodialysis had a cumulative risk of mortality of 24.5% (95% CI 14.0-40.8) at 1 year.

CONCLUSION

There is a high risk of mortality associated with DFI, substantially increased in patients undergoing haemodialysis, highlighting the importance of early and dedicated interventions targeted at this high-risk group.

Bioactive Glass in a Rare Case of Osteomyelitis of the Heel in a Guillain-Barré Syndrome: A Case Report

Guillain-Barré syndrome (GBS) represents an acute inflammatory immune-mediated demyelinating polyradiculoneuropathy with an incidence of 0.6 per 100 000 people. In this article, we report the case of a 19-year-old girl affected by GBS since the age of 2 who presented at our clinic complaining for a chronic plantar hindfoot–infected ulceration. Serology showed increase of inflammatory markers and leukocytosis, and magnetic resonance imaging revealed osteomyelitis of calcaneum and soft tissue alterations with air bubbles. The patient was treated in our clinic by an integrated multidisciplinary approach consisting of immediate admission, soft tissue and bone debridement, and administration of antibiotics under the close control of infectious disease specialist. After the control of acute condition, the patient underwent negative pressure therapy associated with instillation of antiseptic solution until the restoration of bone and soft tissue loss of substance and, eventually, to the application of bioactive glass substitute until the achievement of complete wound healing.

Correlation between superficial and intra-operative specimens in diabetic foot infections: results of a cross-sectional Tunisian study

Objective

To determine the correlation between superficial, and intra-operative specimens in diabetic foot infections (DFIs).

Methods

We conducted a cross-sectional study in patients with DFIs hospitalized in a Tunisian teaching hospital. Superficial specimens were collected for all patients, and intra-operative specimens were collected in operated patients. The specimens were processed using standard microbiology techniques. Antimicrobial susceptibility testing was carried out according to the protocol established by the European Committee on Anti-microbial Susceptibility Testing. Intra-operative and superficial specimens were considered correlated if they isolated the same microorganism(s), or if they were both negative.

Results

One hundred twelve patients, 81 males and 31 females, mean age 56 years, were included. Superficial samples were positive in 77% of cases, and isolated 126 microorganisms. Among the positive samples, 71% were monomicrobial. The most frequently isolated microorganisms were Enterobacteriaceae (53%), followed by streptococci (21%) and Staphylococcus aureus (17%). Nine microorganisms (7%) were multi-drug resistant. Intra-operative samples were positive in 93% of cases. Superficial specimens were correlated to intra-operative specimens in 67% of cases. Initial antibiotic therapy was appropriate in 70% of cases. The lower-extremity amputation and the mortality rates were 41% and 1%, respectively.

Conclusion

In our study, DFIs were most frequently caused by Enterobacteriaceae and superficial specimens were correlated to intra-operative specimens in only two thirds of cases. Clinicians should emphasize on the systematic practice of intraoperative specimens in all patients with DFIs treated surgically, while well-performed superficial specimens could be useful for prescribing appropriate antibiotic therapy in other patients.

The prevalence of methicillin-resistant Staphylococcus aureus among diabetic patients: a meta-analysis

AIMS

Diabetic patients have multiple risk factors for colonisation with methicillin-resistant Staphylococcus aureus (MRSA), a nosocomial pathogen associated with significant morbidity and mortality. This meta-analysis was conducted to estimate the prevalence of MRSA among diabetic patients.

METHODS

The MEDLINE, Embase, BIOSIS, and Web of Science databases were searched for studies published up to May 2018 that reported primary data on the prevalence of MRSA in 10 or more diabetic patients. Two authors independently assessed study eligibility and extracted the data. The main outcomes were the pooled prevalence rates of MRSA colonisation and infection among diabetic populations.

RESULTS

Eligible data sets were divided into three groups containing data about the prevalence of MRSA colonisation or in diabetic foot or other infections. From 23 data sets, the prevalence of MRSA colonisation among 11577 diabetics was 9.20% (95% CI, 6.26-12.63%). Comparison of data from 14 studies that examined diabetic and non-diabetic patients found that diabetics had a 4.75% greater colonisation rate (P < 0.0001). From 41 data sets, the prevalence of MRSA in 10994 diabetic foot infection patients was 16.78% (95% CI, 13.21-20.68%). Among 2147 non-foot skin and soft-tissue infections, the MRSA prevalence rate was 18.03% (95% CI, 6.64-33.41).

CONCLUSIONS

The prevalence of MRSA colonisation among diabetic patients is often higher than among non-diabetics; this may make targeted screening attractive. In the UK, many diabetic patients may already be covered by the current screening policies. The prevalence and impact of MRSA among diabetic healthcare workers requires further research. The high prevalence of MRSA among diabetic foot infections may have implications for antimicrobial resistance, and should encourage strategies aimed at infection prevention or alternative therapies.

Metal-independent variants of phosphoglycerate mutase promote resistance to nutritional immunity and retention of glycolysis during infection

The ability of Staphylococcus aureus and other pathogens to consume glucose is critical during infection. However, glucose consumption increases the cellular demand for manganese sensitizing S. aureus to host-imposed manganese starvation. The current investigations were undertaken to elucidate how S. aureus copes with the need to consume glucose when metal-limited by the host. A critical component of host defense is production of the manganese binding protein calprotectin. S. aureus has two variants of phosphoglycerate mutase, one of which is manganese-dependent, GpmI, and another that is manganese-independent, GpmA. Leveraging the ability to impose metal starvation in culture utilizing calprotectin revealed that the loss of GpmA, but not GpmI, sensitized S. aureus to manganese starvation. Metabolite feeding experiments revealed that the growth defect of GpmA when manganese-starved was due to a defect in glycolysis and not gluconeogenesis. Loss of GpmA reduces the ability of S. aureus to cause invasive disease in wild type mice. However, GpmA was dispensable in calprotectin-deficient mice, which have defects in manganese sequestration, indicating that this isozyme contributes to the ability of S. aureus to overcome manganese limitation during infection. Cumulatively, these observations suggest that expressing a metal-independent variant enables S. aureus to consume glucose while mitigating the negative impact that glycolysis has on the cellular demand for manganese. S. aureus is not the only bacterium that expresses manganese-dependent and -independent variants of phosphoglycerate mutase. Similar results were also observed in culture with Salmonella enterica serovar Typhimurium mutants lacking the metal-independent isozyme. These similar observations in both Gram-positive and Gram-negative pathogens suggest that expression of metal-independent glycolytic isozymes is a common strategy employed by bacteria to survive in metal-limited environments, such as the host.

Pathogens, such as Staphylococcus aureus and Salmonella species, must be able to consume glucose in order to cause infection. However, glycolysis can increase the need for manganese and sensitize invaders to the manganese-withholding defense of the host, known as nutritional immunity. How pathogens manage these conflicting pressures is currently unknown. The current investigations revealed that a second metal-independent variant of phosphoglycerate mutase possessed by both S. aureus and Salmonella enables them to grow and consume glycolytic substrates in the presence of the manganese-binding immune effector calprotectin. Infection experiments revealed that the manganese-independent isozyme critically contributes to the ability of S. aureus to overcome manganese starvation during infection. Together, these results suggest that using metal-independent isozymes to enable the consumption of sugars within the host or other metal-limited environments is a common strategy employed by diverse bacteria.

Determining frequency and pattern of infections associated with diabetes based educational hospitals in Ahvaz city; Iran

BACKGROUND

Diabetes mellitus is a metabolic disease known as one of the most common illness in the world. It is believed that diabetic patients are at high risk of varied infections than non-diabetics. The aim of this study was to determine the frequency and pattern of infections in diabetic patients admitted to the internal wards of educational hospitals of Ahvaz Jundishapur University of Medical Sciences.

METHODS

This descriptive cross-sectional study was performed on 700 diabetic patients from January 2014 to December 2015 in internal wards (general, endocrine, gastroenterology, lung, nephrology, cardiology, neurology and infectious diseases) of educational hospitals affiliated to Ahvaz JundishapurUniversity of Medical Sciences. Data includeddemographic information, type of diabetes treatment, duration of diabetes mellitus, final diagnosis, and blood sugar on admission that were analyzed statistically.

RESULTS

Out of 700 patients, 374 (53.4%) women and 326 (46.6%) men were entered into this study. The number of non-infectious and infectious patients were 506 (72.3%) and 194 (27.7%). The mean of age,duration of diabetes, and glucose were 62.34 ± 14.38 years, 11.11 ± 7.18 years, and 271.98 ± 90 (mg/dl) in patients with infectious diseases respectively. The most common infectious illnesses were diabetic foot infections (32.5%), pneumonia (18%), soft tissue abscess(13.9%), and urinary tract infections (11.3%).

CONCLUSION

Infectious diseases are one of the most common factorsto hospitalize diabetic patients (27.7%), most of whom had diabetic foot infections, pneumonia, and soft tissue abscess.

Synergy between Nutritional Immunity and Independent Host Defenses Contributes to the Importance of the MntABC Manganese Transporter during Staphylococcus aureus Infection

During infection, the host utilizes a diverse array of processes to combat invaders, including the restriction of availability of essential nutrients such as manganese. Similarly to many other pathogens, Staphylococcus aureus possesses two manganese importers, MntH and MntABC. Several infection models have revealed a critical role for MntABC during staphylococcal infection. However, culture-based studies have suggested parity between the two transporters when cells are resisting manganese starvation imposed by the manganese binding immune effector calprotectin. In this investigation, initial elemental analysis revealed that MntABC is the primary transporter responsible for obtaining manganese in culture in the presence of calprotectin. MntABC was also necessary to maintain wild-type levels of manganese-dependent superoxide dismutase activity in the presence of calprotectin. Building on this framework, we investigated if MntABC enabled S. aureus to resist the synergistic actions of nutritional immunity and other host defenses. This analysis revealed that MntABC critically contributes to staphylococcal growth when S. aureus is subjected to manganese limitations and exposed to oxidative stress. This transporter was also important for growth in manganese-limited environments when S. aureus was forced to consume glucose as an energy source, which occurs when it encounters nitric oxide. MntABC also expanded the pH range conducive for S. aureus growth under conditions of manganese scarcity. Collectively, the data presented in this work provide a robust molecular basis for the crucial role of MntABC in staphylococcal virulence. Further, this work highlights the importance of synergy between host defenses and the necessity of evaluating the contribution of virulence factors to pathogenesis in the presence of multiple stressors.

[Prevention and treatment of infectious diseases in diabetic patients]

The bidirectional relationship between infectious diseases and diabetes is well-known. On the one hand, diabetes patients are at a higher risk of presenting with infectious diseases, possibly with more severity, and on the other hand, infectious diseases impair metabolic control in patients with diabetes. Population ageing arises partly due to an increased survival rate in chronic diseases, of which diabetes is amongst them. Improving infectious disease prevention could reduce complications arising from the former diseases, consequences of decompensated diabetes condition (morbidity, incapacity, hospital admissions, healthcare costs, and mortality rates) and result in improved quality of life in patients with diabetes. The current review presents the treatment of infectious diseases in patients with diabetes and the dealing with immuno-preventable diseases with the currently advised vaccinations.

Management of complicated skin and soft tissue infections with a special focus on the role of newer antibiotics

Complicated skin and soft tissue infections (cSSTIs) represent the severe form of infectious disease that involves deeper soft tissues. Involvement of methicillin-resistant Staphylococcus aureus (MRSA) further complicates cSSTI with increased hospitalization, health care costs, and overall mortality. Various international guidelines provide recommendations on the management of cSSTIs, with the inclusion of newer antibiotics. This literature-based review discusses the overall management of cSSTI, including appropriate use of antibiotics in clinical practice. Successful treatment of cSSTIs starts with early and precise diagnosis, including identification of causative pathogen and its load, determination of infection severity, associated complications, and risk factors. The current standard-of-care for cSSTIs involves incision, drainage, surgical debridement, broad-spectrum antibiotic therapy, and supportive care. In recent years, the emergence of newer antibiotics (eg, ceftaroline, tigecycline, daptomycin, linezolid, etc) has provided clinicians wider options of antimicrobial therapy. Selection of antibiotics should be based on the drug characteristics, effectiveness, safety, and treatment costs, alongside other aspects such as host factors and local multidrug resistance rates. However, larger studies on newer antibiotics are warranted to refine the decision making on the appropriate antimicrobial therapy. Local Antimicrobial Stewardship Program strategies in health care settings could guide clinicians for early initiation of specific treatments to combat region-specific antimicrobial resistance, minimize adverse effects, and to improve outcomes such as reduction in Clostridium difficile infections. These strategies involving iv-to-oral switch, de-escalation to narrow-spectrum antibiotics, and dose optimization have an impact on the overall improvement of cSSTI therapy outcomes, especially in countries like Singapore that has a high disease burden.

Antimicrobial peptide modification enhances the gene delivery and bactericidal efficiency of gold nanoparticles for accelerating diabetic wound healing

Impaired angiogenesis and bacterial infection have increasingly been implicated as the major causes of delayed diabetic wound healing. However, there is currently no effective therapy. Here, we optimized a novel gene delivery system based on antimicrobial peptide (LL37) grafted ultra-small gold nanoparticles (AuNPs@LL37, ∼7 nm) for the topical treatment of diabetic wounds with or without bacterial infection. AuNPs@LL37 combines the advantages of cationic AuNPs that condense DNA with those of antibacterial peptides, which are both highly antibacterial and essential for enhancing cellular and nucleus entry to achieve high gene delivery efficiency. AuNPs@LL37 combined with pro-angiogenic (VEGF) plasmids (AuNPs@LL37/pDNAs) significantly improved the gene transfection efficiency in keratinocytes compared with pristine AuNPs/pDNAs, and showed similar expression to Lipo2000/pDNAs (a well-known highly efficient gene transfection agent). Moreover, our therapeutic depot showed higher antibacterial ability than the free antimicrobial peptides and the cationic AuNPs alone in vitro and in vivo due to synergistic effects. Furthermore, the combined system promoted angiogenesis and inhibited bacterial infection in diabetic wounds, resulting in accelerated wound closure rates, faster re-epithelization, improved granulation tissue formation and high VEGF expression. Finally, our therapeutic depot was highly biocompatible in vitro and in vivo, suggesting its potential as a feasible way to treat chronic diabetic wounds.

Outcomes of hyperglycemia in patients with and without diabetes hospitalized for infectious diseases

OBJECTIVE

To examine the prognostic implications of diabetes mellitus (DM) and the importance of glycemic control during hospitalization for infectious diseases.

METHODS

Historical prospectively collected data of patients hospitalized between 2011 and 2013. Infection-related hospitalizations were classified according to site of infection. Median follow-up was 4.5 years. Outcome measures included in-hospital and end-of-follow-up mortality.

RESULTS

The cohort included 8051 patients (50% female, mean age ± SD, 68 ± 20 years) with a primary diagnosis of an infectious disease. Of these, 2363 patients (29%) had type 2 DM. The most common infectious sites included respiratory tract (n = 3285), genitourinary tract (n = 1804), skin and soft tissue (n = 934) and gastrointestinal tract (n = 571). There was no difference in admission rates of patients with and without DM according to the site of infection, except for skin and soft tissue infection which were more common among patients with DM (16% vs 10%). In-hospital mortality risk was greater in patients with DM (aOR = 1.3, 95% CI = 1.1-1.7). In the entire cohort, adjusted mortality risk (aHR, 95% CI) at the end-of-follow-up was greater among patients with DM (1.2, 1.1-1.4), with increased mortality risk following hospitalization for respiratory (1.1, 1.0-1.4) and skin and soft tissue infections (1.7, 1.3-2.3). In-hospital and end-of-follow-up mortality risk were highest among patients with and without DM with median glucose >180 mg/dL during hospitalization.

CONCLUSIONS

In patients hospitalized for infectious diseases, DM is associated with increased long-term mortality risk, specifically following hospitalization for respiratory and skin and soft tissue infections. Poor glycemic control during hospitalization is associated with increased long-term mortality.

S-Nitrosoglutathione loaded poly(lactic-co-glycolic acid) microparticles for prolonged nitric oxide release and enhanced healing of methicillin-resistant Staphylococcus aureus-infected wounds

Methicillin-resistant Staphylococcus aureus (MRSA)-infected wounds have become a significant clinical issue worldwide. Recently, nitric oxide (NO) has emerged as a potent antibacterial agent against MRSA infections and a wound-healing enhancer. Nevertheless, clinical applications of NO have been largely restricted by its gaseous state and short half-life. In this study, our aim was to develop S-nitrosoglutathione (GSNO, an endogenous NO donor)-loaded poly(lactic-co-glycolic acid) [PLGA] microparticles (GSNO-MPs) that release NO over a prolonged period, to accelerate the healing of MRSA-infected wounds with less frequent dosing. GSNO was successfully encapsulated into PLGA microparticles by a solid-in-oil-in-water emulsion solvent evaporation method. Scanning electron microscopy and X-ray diffraction analyses confirmed the successful fabrication of GSNO-MPs. The latter released NO in a prolonged manner over 7 days and exerted a remarkable antibacterial activity against MRSA in a concentration- and time-dependent manner. Moreover, GSNO-MPs had good antibacterial efficacy and were found to accelerate wound healing in a mouse model of MRSA-infected wounds. Therefore, NO-releasing MPs devised in this study may be a promising option for the treatment of cutaneous wounds infected by drug-resistant bacteria such as MRSA.

Excessive localized leukotriene B4 levels dictate poor skin host defense in diabetic mice

Poorly controlled diabetes leads to comorbidities and enhanced susceptibility to infections. While the immune components involved in wound healing in diabetes have been studied, the components involved in susceptibility to skin infections remain unclear. Here, we examined the effects of the inflammatory lipid mediator leukotriene B4 (LTB4) signaling through its receptor B leukotriene receptor 1 (BLT1) in the progression of methicillin-resistant Staphylococcus aureus (MRSA) skin infection in 2 models of diabetes. Diabetic mice produced higher levels of LTB4 in the skin, which correlated with larger nonhealing lesion areas and increased bacterial loads compared with nondiabetic mice. High LTB4 levels were also associated with dysregulated cytokine and chemokine production, excessive neutrophil migration but impaired abscess formation, and uncontrolled collagen deposition. Both genetic deletion and topical pharmacological BLT1 antagonism restored inflammatory response and abscess formation, followed by a reduction in the bacterial load and lesion area in the diabetic mice. Macrophage depletion in diabetic mice limited LTB4 production and improved abscess architecture and skin host defense. These data demonstrate that exaggerated LTB4/BLT1 responses mediate a derailed inflammatory milieu that underlies poor host defense in diabetes. Prevention of LTB4 production/actions could provide a new therapeutic strategy to restore host defense in diabetes.

Too much of a good thing: How modulating LTB4 actions restore host defense in homeostasis or disease

The ability to regulate inflammatory pathways and host defense mechanisms is critical for maintaining homeostasis and responding to infections and tissue injury. While unbalanced inflammation is detrimental to the host; inadequate inflammation might not provide effective signals required to eliminate pathogens. On the other hand, aberrant inflammation could result in organ damage and impair host defense. The lipid mediator leukotriene B₄ (LTB₄) is a potent neutrophil chemoattractant and recently, its role as a dominant molecule that amplifies many arms of phagocyte antimicrobial effector function has been unveiled. However, excessive LTB₄ production contributes to disease severity in chronic inflammatory diseases such as diabetes and arthritis, which could potentially be involved in poor host defense in these groups of patients. In this review we discuss the cellular and molecular programs elicited during LTB₄ production and actions on innate immunity host defense mechanisms as well as potential therapeutic strategies to improve host defense.