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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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Above-the-knee amputation versus knee arthrodesis for revision of infected total knee arthroplasty: Recurrent infection rates and functional outcomes of 43 patients at a mean follow-up of 6.7 years. Orthop Traumatol Surg Res 2021; 107:102914. [PMID: 33812091 DOI: 10.1016/j.otsr.2021.102914] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 11/02/2020] [Accepted: 11/12/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION In cases of repeated treatment failure of periprosthetic joint infections (PJI) of the knee, above-the-knee amputation (AKA) or knee arthrodesis can be proposed to reduce the risk of recurrent infection, especially in cases with major bone defects or irreparable damage to the extensor mechanism of the knee. Since AKA versus knee arthrodesis results have been rarely assessed for these indications, we conducted a retrospective case-control study to compare both the rates of recurrent infection and functional outcomes. Hypothesis Patients who underwent AKA had fewer recurrent infections than those who had arthrodesis. MATERIALS AND METHODS Twenty patients who underwent AKA and 23 patients who had knee arthrodesis, between 2003 and 2019, were retrospectively included in this study. These two groups were comparable in age (73.8 versus 77.7 years (p=.31)) and sex (10 women and 10 men versus 16 women and seven men (p=.19)). Each group was analyzed individually and then compared in terms of survival (recurrent infection) and functional outcomes using clinical assessment scores (visual analog scale (VAS), French neuropathic pain questionnaire (DN4), Parker and Palmer mobility score and the 36-item short-form survey (SF-36)). RESULTS The rate of recurrent infection was 10% (two out of 20 patients) for the AKA group and 21.75% (five out of 23 patients) for the arthrodesis group (p=.69). The mean follow-up for the AKA group was 4.18 years (1.2-11.8) and 9.7 years (1.1-14.33) for the arthrodesis group (p=.002). The number of previous revisions (three (1.5-4) for AKA and two (2-3) for arthrodesis) and the time between the primary arthroplasty and surgical procedure were significantly greater in the AKA group (48.0 (12.0-102.0) months) than the arthrodesis group (48.0 (24.0-87.0) months) (p<001). The AKA group had significantly better clinical results for VAS (2.7±2.2 vs. 3.1±3.3), DN4 (1.5±2.1 vs. 2.6±2.9), Parker and Palmer (5.2±1.7 vs. 4.6±1.4), and SF-36 (30.9±15.6 vs. 26.9±17.0) (p<001). CONCLUSION Above-the-knee amputation and knee arthrodesis showed no differences in the rate of recurrent sepsis. However, the comparison of the two groups demonstrated that patients who underwent an AKA had less pain, were more autonomous and had a better quality of life. LEVEL OF EVIDENCE III; retrospective case-control.
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Molines-Barroso RJ, García-Morales E, Sevillano-Fernández D, García-Álvarez Y, Álvaro-Afonso FJ, Lázaro-Martínez JL. Culture Concordance in Different Sections of the Metatarsal Head: Interpretations of Microbiological Results. INT J LOW EXTR WOUND 2021; 22:270-277. [PMID: 33909483 DOI: 10.1177/15347346211003722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Microbiological cultures of per-wound bone biopsies have shown a lack of correlation and a high rate of false-negative results when compared with bone biopsy cultures in diabetic foot osteomyelitis. The selection of samples from the area of active osteomyelitis, which contains a complete census of the microorganisms responsible for the infection, is essential to properly guide antimicrobial treatment. We aimed to comparatively evaluate the quantitative and qualitative cultures taken from different areas, in metatarsal heads resected for osteomyelitis. For this purpose, we consecutively selected 13 metatarsal heads from 12 outpatients with plantar ulcers admitted to our diabetic foot unit. Metatarsal heads were divided transversally into 3 portions: plantar (A), central (B), and dorsal (C), and the 39 resulting samples were cultured. Qualitative and quantitative microbiological analysis was performed, and the isolated species and bacterial load, total and species specific, were compared between the 3 metatarsal bone segments. The primary outcome of the study was the bacterial diversity detected in the different bone sections. Cultures were positive in 12 of the 13 included metatarsal heads (92%). A total of 34 organisms were isolated from all specimens. Ten of the 12 cultures (83%) were polymicrobial. Ten of the 13 metatarsal heads (77%) had identical microbiological results in each of the 3 bone sections. The largest number of microorganisms was found in the central section. The overall concordance between sections was 91%. The predominant microorganisms were coagulase-negative staphylococci (41%). Statistical differences were not found in the bioburden between sections (range 3.25-3.41 log10 colony-forming unit/g for all sections; P = .511). The results of our study suggest that microorganisms exhibit a high tendency to spread along the metatarsal bone and that the degree of progression along the bone is species dependent. The central portions of metatarsal bones tend to accumulate a higher diversity of species. Thus, we recommend this area of bone for targeted biopsy in patients with suspected osteomyelitis.
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Affiliation(s)
- Raul Juan Molines-Barroso
- 16734Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Esther García-Morales
- 16734Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - David Sevillano-Fernández
- 16734Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Yolanda García-Álvarez
- 16734Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Francisco J Álvaro-Afonso
- 16734Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - José Luis Lázaro-Martínez
- 16734Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
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Senneville E, Joulie D, Blondiaux N, Robineau O. Surgical techniques for Bone Biopsy in Diabetic Foot Infection, and association between results and treatment duration. J Bone Jt Infect 2020; 5:198-204. [PMID: 32670774 PMCID: PMC7358966 DOI: 10.7150/jbji.45338] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 04/27/2020] [Indexed: 02/06/2023] Open
Abstract
Surgery is an important part of the management of patients diagnosed with DFO. It consists in some selected patients, to remove all or part of the infected bone(s) or even to amputate all or part of the foot. Despite the use of sophisticated imaging techniques, it is however difficult to remove all the infected tissue while respecting the principles of an economical surgery. Bone biopsy performed at the margins of the resection permits to identify residual osteomyelitis and to adjust the post-surgical antibiotic treatment. Some recent studies have reported the way to perform bone margin biopsies and have assessed the impact of the bone results on the patient's outcome. However, the real impact of a residual osteomyelitis on the risk of recurrent DFO is still debated and questions regarding the interpretation of the results remain to be solved. Similarly, the consequences in terms of choice and duration of the antimicrobial treatment to use in case of positive bone margin are not clearly established.
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Affiliation(s)
- Eric Senneville
- Infectious Diseases Department Gustave Dron Hospital F-59200 Tourcoing, and Lille University F-59000, Lille, France
- Northern-West French National Referent Centre for Complex Bone and Joint Infections (CRIOAC Lille-Tourcoing)
| | - Donatienne Joulie
- Northern-West French National Referent Centre for Complex Bone and Joint Infections (CRIOAC Lille-Tourcoing)
- Orthopaedic Surgery Department G. Dron Hospital Tourcoing F-59200 Tourcoing France
| | - Nicolas Blondiaux
- Northern-West French National Referent Centre for Complex Bone and Joint Infections (CRIOAC Lille-Tourcoing)
- Microbiology Laboratory G. Dron Hospital Tourcoing F-59200 Tourcoing France
| | - Olivier Robineau
- Infectious Diseases Department Gustave Dron Hospital F-59200 Tourcoing, and Lille University F-59000, Lille, France
- Northern-West French National Referent Centre for Complex Bone and Joint Infections (CRIOAC Lille-Tourcoing)
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Julien G, Francois M, Vernet-Garnier V, Bajolet O, Lebrun D, Hentzien M, Ohl X, Diallo S, Bani-Sadr F. Short duration of post-amputation antibiotic therapy in diabetic foot patients with total resection of osteomyelitis. Med Mal Infect 2020; 50:433-435. [PMID: 32360115 DOI: 10.1016/j.medmal.2020.04.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/07/2020] [Accepted: 04/17/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Short duration of post-amputation antibiotic therapy (2-5 days) is recommended in patients with diabetic foot osteomyelitis after total resection of infected bone tissue. OBJECTIVE To evaluate the long-term effectiveness of short-duration post-amputation antibiotic therapy in diabetic patients with total resection of osteomyelitis assessed by sterile bone bacteriological samples obtained from the resection margin. METHODS The endpoint was the absence of osteomyelitis relapse at 6 months, defined as recurrence of osteomyelitis with the need for surgical revision and/or new bone antibiotic therapy. RESULTS Among 15 patients included, 12 (80%) were cured without recurrence of osteomyelitis at 6 months, with a mean duration of antibiotic therapy of 8.3±5.9 days post surgery. This result is comparable to literature data, while all of them reported longer duration of antibiotic therapy and/or shorter follow-up. CONCLUSION Short duration of post-amputation antibiotic therapy in diabetic patients with sterile bacteriological samples obtained from resection margin seems effective.
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Affiliation(s)
- G Julien
- Department of internal medicine and infectious diseases, Reims teaching hospitals, Reims, France
| | - M Francois
- Department of endocrinology-diabetology, Reims teaching hospitals, Reims, France
| | - V Vernet-Garnier
- Department of bacteriology, Reims teaching hospitals, Reims, France
| | - O Bajolet
- Department of hygiene, Reims teaching hospitals, Reims, France
| | - D Lebrun
- Department of internal medicine and infectious diseases, Manchester hospital, Charleville-Mezieres, France
| | - M Hentzien
- Department of internal medicine and infectious diseases, Reims teaching hospitals, Reims, France
| | - X Ohl
- Department of orthopedic surgery, Reims teaching hospitals, Reims, France
| | - S Diallo
- Department of orthopedic surgery, Reims teaching hospitals, Reims, France
| | - F Bani-Sadr
- Department of internal medicine and infectious diseases, Reims teaching hospitals, Reims, France.
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Rossel A, Lebowitz D, Gariani K, Abbas M, Kressmann B, Assal M, Tscholl P, Stafylakis D, Uçkay I. Stopping antibiotics after surgical amputation in diabetic foot and ankle infections-A daily practice cohort. Endocrinol Diabetes Metab 2019; 2:e00059. [PMID: 31008367 PMCID: PMC6458464 DOI: 10.1002/edm2.59] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 12/28/2018] [Accepted: 12/30/2018] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE The appropriate duration of antibiotic therapy for diabetic foot infections (DFI) after surgical amputations in toto is debated. There are discrepancies worldwide. METHODS Using a clinical pathway for adult DFI patients (retrospective cohort analysis), we conducted a cluster-controlled Cox regression analysis. Minimum follow-up was 2 months. RESULTS We followed 482 amputated DFI episodes for a median of 2.1 years after the index episode. The DFIs predominately affected the forefoot (n = 433; 90%). We diagnosed osteomyelitis in 239 cases (239/482; 50%). In total, 47 cases (10%) were complicated by bacteremia, 86 (18%) by abscesses and 139 (29%) presented with cellulitis. Surgical amputation involved the toes (n = 155), midfoot (280) and hindfoot (47). Overall, 178 cases (37%) required revascularization. After amputation, the median duration of antibiotic administration was 7 days (interquartile range, 1-16 days). In 109 cases (25%), antibiotics were discontinued immediately after surgery. Overall, clinical failure occurred in 90 DFIs (17%), due to the same pathogens in only 38 cases. In multivariate analysis, neither duration of total postsurgical antibiotic administration (HR 1.0, 95% CI 0.99-1.01) nor immediate postoperative discontinuation altered failure rate (HR 0.9, 0.5-1.5). CONCLUSION According to our clinical pathway, we found no benefit in continuing postsurgical antibiotic administration in routine amputation for DFI. In the absence of residual infection (ie, resection at clear margins), antibiotics should be discontinued.
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Affiliation(s)
- Anne Rossel
- Department of Internal MedicineGeneva University HospitalsGenevaSwitzerland
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
| | - Dan Lebowitz
- Department of Internal MedicineGeneva University HospitalsGenevaSwitzerland
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
| | - Karim Gariani
- Department of Internal MedicineGeneva University HospitalsGenevaSwitzerland
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Service of Diabetology and EndocrinologyGeneva University HospitalsGenevaSwitzerland
| | - Mohamed Abbas
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Infection Control ProgramGeneva University HospitalsGenevaSwitzerland
| | - Benjamin Kressmann
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
| | - Mathieu Assal
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- La Colline Hirslanden ClinicGenevaSwitzerland
| | - Philippe Tscholl
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
- Balgrist University HospitalZurichSwitzerland
| | - Dimitrios Stafylakis
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
| | - Ilker Uçkay
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Infection Control ProgramGeneva University HospitalsGenevaSwitzerland
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
- Balgrist University HospitalZurichSwitzerland
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Vaznaisiene D, Sulcaite R, Vitkauskiene A, Spucis A, Reingardas A, Kymantas V, Balanaska K, Sleivys R, Velicka L, Belickas J, Rysevaite-Kyguoliene K, Pauza DH, Mickiene A, Senneville E. Section's osseous slice biopsy during major amputation of lower extremity: preliminary results of prospective cohort study. BMC Infect Dis 2015; 15:247. [PMID: 26123296 PMCID: PMC4485639 DOI: 10.1186/s12879-015-0993-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Accepted: 06/22/2015] [Indexed: 11/12/2022] Open
Abstract
Background The purpose of this cohort study was to assess the incidence of positive cultures in section’s osseous slice biopsy (SOB) taken at the level of major limb amputation. In case of positive cultures we sought whether the microorganisms present in SOB could take origin from the primary infection site necessitating the amputation. The impact of diabetes on culture results was also investigated. Methods This prospective cohort study, which aimed to confirm the results of the pilot study, analysed patients who underwent major limb amputation between 2012 and 2013 in three Lithuanian hospitals. SOBs at the amputation site (surgical bone biopsies) and percutaneous bone biopsies of the distal site were performed simultaneously during limb amputation. Tissue cultures were analysed by microbiologists, and species along with antibiograms were reported. Histopathological assessment and bacterial typing were also evaluated. A positive culture was defined as the identification of at least 1 bacteria not belonging to the skin flora, at least 2 bacteria belonging to the skin flora with the same antibiotic susceptibility profiles or the same bacteria belonging to the skin flora in two different sites. Fisher’s exact test and Student’s test were used to compare the populations and the microbiological results. The statistical significance level was set at P < 0.05. Results Sixty-nine patients (35 males/34 females), mean age 68.7 (S = 13.6) years, including 21 (30.4 %) with diabetes underwent the major limb amputation. Forty-five amputations (65.2 %) were done above the knee. In total, 207 SOBs and 207 percutaneous distal site biopsies were studied. SOB cultures were positive in 11 (15.9 %) cases. In 5 (45.5 %) cases the same microorganisms were identified in both SOB and distal biopsy cultures. No association between culture results and presence of diabetes was identified. Conclusions Our results suggest that, independently of the diabetes status, foot infection may silently spread along the bone and can achieve the site of major limb amputation. Additional investigations aiming to confirm this hypothesis and to evaluate a prognostic value are in progress.
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Affiliation(s)
- Danguole Vaznaisiene
- Department of Infectious Diseases, Lithuanian University of Health Sciences, Kaunas, Lithuania.
| | - Rita Sulcaite
- Institute of Endocrinology, Lithuanian University of Health Sciences, Kaunas, Lithuania.
| | - Astra Vitkauskiene
- Department of Laboratory Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania.
| | - Arturas Spucis
- Department of Surgical Infection, Republican Hospital of Kaunas, Kaunas, Lithuania.
| | | | - Vytautas Kymantas
- Department of Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania.
| | | | - Rolandas Sleivys
- Department of Surgery, Kaunas Clinical Hospital, Kaunas, Lithuania.
| | - Linas Velicka
- Department of Cardiothoracic and Vascular Surgery, Lithuanian University of Health Sciences, Kaunas, Lithuania.
| | - Juozas Belickas
- Department of Orthopedics and Traumatology, Lithuanian University of Health Sciences, Kaunas, Lithuania.
| | | | - Dainius H Pauza
- Institute of Anatomy, Lithuanian University of Health Sciences, Kaunas, Lithuania.
| | - Aukse Mickiene
- Department of Infectious Diseases, Lithuanian University of Health Sciences, Kaunas, Lithuania.
| | - Eric Senneville
- Infectious Diseases Department, Dron Hospital, Tourcoing, France.
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