1
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Jeffcoate W, Boyko EJ, Game F, Cowled P, Senneville E, Fitridge R. Causes, prevention, and management of diabetes-related foot ulcers. Lancet Diabetes Endocrinol 2024; 12:472-482. [PMID: 38824929 DOI: 10.1016/s2213-8587(24)00110-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 06/04/2024]
Abstract
In this Review, we aim to complement the 2023 update of the guidelines of the International Working Group on the Diabetic Foot. We highlight the complexity of the pathological processes that underlie diabetes-related foot ulceration (DFU) and draw attention to the potential implications for clinical management and outcome. Variation observed in the incidence and outcome of DFUs in different communities might result from differences in study populations and the accessibility of care. Comparing differences in incidence, management, and outcome of DFUs in different communities is an essential component of the quality of disease care. Additionally, these comparisons can also highlight the relationship between DFU incidence, management, and outcome and the structure of local clinical services and the availability of staff with the necessary skills. The clinical outcome is, however, also dependent on the availability of multidisciplinary care and the ability of people with DFUs to gain access to that care.
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Affiliation(s)
| | - Edward J Boyko
- VA Puget Sound Health Care System, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Prue Cowled
- Discipline of Surgery, The University of Adelaide, Adelaide, SA, Australia
| | - Eric Senneville
- Discipline of Infectious Diseases, The University of Lille, Gustave Dron Hospital, Tourcoing, France
| | - Robert Fitridge
- Discipline of Surgery, The University of Adelaide, Adelaide, SA, Australia; Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, SA, Australia.
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2
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Lau J, Huang J, Kassamali Escobar Z. Antipseudomonal Antibiotics in Diabetic Foot Infections: A Practical Perspective From a Community Hospital. Open Forum Infect Dis 2024; 11:ofae258. [PMID: 38933740 PMCID: PMC11200182 DOI: 10.1093/ofid/ofae258] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 05/08/2024] [Indexed: 06/28/2024] Open
Affiliation(s)
- Janice Lau
- Department of Pharmacy, UW Medicine, Valley Medical Center, Renton, Washington, USA
| | - Joanne Huang
- Department of Pharmacy, UW Medicine, Valley Medical Center, Renton, Washington, USA
| | - Zahra Kassamali Escobar
- Department of Pharmacy, UW Medicine, Fred Hutchinson Cancer Center, Seattle, Washington, USA
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3
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Veve MP, Patel N. Reply to Lau et al Re: "Antipseudomonal Antibiotics in Diabetic Foot Infections: A Practical Perspective From a Community Hospital". Open Forum Infect Dis 2024; 11:ofae259. [PMID: 38933741 PMCID: PMC11200184 DOI: 10.1093/ofid/ofae259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 05/02/2024] [Indexed: 06/28/2024] Open
Affiliation(s)
- Michael P Veve
- Department of Pharmacy, Henry Ford Hospital, Detroit, Michigan, USA
- Department of Pharmacy Practice, Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan, USA
| | - Nimish Patel
- Division of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California at San Diego, La Jolla, California, USA
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4
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Villa F, Marchandin H, Lavigne JP, Schuldiner S, Cellier N, Sotto A, Loubet P. Anaerobes in diabetic foot infections: pathophysiology, epidemiology, virulence, and management. Clin Microbiol Rev 2024:e0014323. [PMID: 38819166 DOI: 10.1128/cmr.00143-23] [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: 06/01/2024] Open
Abstract
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.
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Affiliation(s)
- Fanny Villa
- VBIC, INSERM U1047, Univ Montpellier, Service des Maladies Infectieuses et Tropicales, CHU Nîmes, Nîmes, France
| | - Hélène Marchandin
- HydroSciences Montpellier, Univ Montpellier, CNRS, IRD, Service de Microbiologie et Hygiène, Hospitalière, CHU Nîmes, Nîmes, France
| | - Jean-Philippe Lavigne
- VBIC, INSERM U1047, Univ Montpellier, Service de Microbiologie et Hygiène Hospitalière, CHU Nîmes, Nîmes, France
| | - Sophie Schuldiner
- VBIC, INSERM U1047, Univ Montpellier, Service des Maladies Métaboliques et Endocriniennes, CHU Nîmes, Nîmes, France
| | | | - Albert Sotto
- VBIC, INSERM U1047, Univ Montpellier, Service des Maladies Infectieuses et Tropicales, CHU Nîmes, Nîmes, France
| | - Paul Loubet
- VBIC, INSERM U1047, Univ Montpellier, Service des Maladies Infectieuses et Tropicales, CHU Nîmes, Nîmes, France
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5
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Frazee BW. Diabetic Foot Infections in the Emergency Department. Emerg Med Clin North Am 2024; 42:267-285. [PMID: 38641391 DOI: 10.1016/j.emc.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
Diabetic foot infection (DFI) is among the most common diabetic complications requiring hospitalization. Prompt emergency department diagnosis and evidence-based management can prevent eventual amputation and associated disability and mortality. Underlying neuropathy, arterial occlusion, immune dysfunction, and hyperglycemia-associated dehydration and ketoacidosis can all contribute to severity and conspire to make DFI diagnosis and management difficult. Serious complications include osteomyelitis, necrotizing infection, and sepsis. Practice guidelines are designed to assist frontline providers with correct diagnosis, categorization, and treatment decisions. Management generally includes a careful lower extremity examination and plain x-ray, obtaining appropriate tissue cultures, and evidence-based antibiotic selection tailored to severity.
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Affiliation(s)
- Bradley W Frazee
- Department of Emergency Medicine, Alameda Health System, Wilma Chan Highland Hospital, 1411 East 31st Street, Oakland, CA 94602, USA.
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6
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Zhou S, Hu X, Wang Y, Fei W, Sheng Y, Que H. The Global Prevalence of Methicillin-Resistant Staphylococcus Aureus in Patients with Diabetic Foot Ulcers: A Systematic Review and Meta-Analysis. Diabetes Metab Syndr Obes 2024; 17:563-574. [PMID: 38333763 PMCID: PMC10849909 DOI: 10.2147/dmso.s446911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 01/16/2024] [Indexed: 02/10/2024] Open
Abstract
Objective Diabetic foot ulcer (DFU) frequently leads to infections, with infected DFUs being a common cause of amputation. Infection by methicillin-resistant Staphylococcus aureus (MRSA) notably increases the necessity for amputation and surgical debridement in affected individuals. Consequently, determining the prevalence and trends of MRSA in patients with DFU is of critical importance. This study aimed to assess the global prevalence and to identify trends in the occurrence of MRSA in tissue or wound swab samples from DFU patients. Methods We conducted a comprehensive literature search across PubMed, Embase, Scopus, and Ovid, spanning from the inception of these databases to July 2023, imposing no language restrictions. The inclusion criteria required that the studies report on 30 or more patients with DFU. Additionally, we categorized our analysis based on geographic region, publication date, and the economic status of the patient's domicile. Our primary endpoint was to ascertain the prevalence of MRSA in DFUs. This systematic review has been registered at (https://www.crd.york.ac.uk/prospero/), with the identifier CRD 42023444360. Results Our analysis encompassed 40 studies involving 12,924 patients across 20 countries. We found that the overall prevalence of MRSA in DFU was 17% (95% Confidence Interval [CI] 0.14-0.20). Regional prevalence varied significantly: in South America, it was 61% (95% CI 0.46-0.76), in North America 20% (95% CI 0.12-0.27), in Europe 19% (95% CI 0.14-0.25), in Africa 13% (95% CI 0.06-0.20), and in other subgroups 11% (95% CI 0.08-0.15). The prevalence of MRSA in DFUs also differed according to the economic status of the countries: 19% (95% CI 0.15-0.23) in high-income countries, 24% (95% CI 0.1-0.37) in upper-middle-income countries, 11% (95% CI 0.07-0.15) in lower-middle-income countries, and 20% (95% CI 0.13-0.27) in low-income countries. Notably, there has been a decline in MRSA prevalence, from 25% before 2010 to 9% thereafter. Conclusion This meta-analysis reveals a decreasing yet still significant global prevalence of MRSA in DFUs. This trend has important implications for antimicrobial resistance and underscores the need for developing targeted programs focusing on infection prevention and exploring alternative therapeutic strategies.
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Affiliation(s)
- Siyuan Zhou
- Department of Traditional Chinese Surgery, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
- Longhua Clinical Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Xiaojie Hu
- Department of Traditional Chinese Surgery, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
- Longhua Clinical Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Yunfei Wang
- Department of Traditional Chinese Surgery, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
- Longhua Clinical Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Wenting Fei
- Longhua Clinical Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Yuqin Sheng
- Longhua Clinical Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
| | - Huafa Que
- Department of Traditional Chinese Surgery, Longhua Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
- Longhua Clinical Medical College, Shanghai University of Traditional Chinese Medicine, Shanghai, People’s Republic of China
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7
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Huizing E, Schreve MA, Stuart JWC, de Vries JPP, Çağdaş Ü. Treatment of clinically uninfected diabetic foot ulcers, with and without antibiotics. J Wound Care 2024; 33:118-126. [PMID: 38329832 DOI: 10.12968/jowc.2024.33.2.118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2024]
Abstract
OBJECTIVE Current guidelines do not recommend the use of antibiotics to treat clinically uninfected ulcers. However, physicians continue to prescribe antibiotics for clinically uninfected ulcers with the rationale 'better to be safe than sorry'. Yet, antibiotic resistance is increasing, side-effects are common and treatment costs are rising. Evidence is needed to identify whether antibiotic treatment for clinically uninfected ulcers can be justified or we should stop prescribing them. The aim of this study was to evaluate whether antibiotic treatment in cases of clinically uninfected ulcers improved ulcer healing compared to treatment without antibiotics. METHOD Consecutive patients treated in the outpatient clinic for clinically uninfected diabetic foot ulcer both in 2015 and in 2017 were retrospectively analysed. Primary outcome was ulcer healing at one year. Secondary outcomes were limb salvage, freedom from any amputation, amputation-free survival (AFS) and survival. RESULTS A total of 102 ulcers of 91 patients were included for final analyses. The non-antibiotics and antibiotics groups both consisted of 51 ulcers. Ulcer healing at one year was 77.3% in the non-antibiotics group and 74.7% in the antibiotics group (p=0.158). No difference was found for limb salvage (93.8% versus 95.9%, respectively; p=0.661), freedom from any amputation (85.6% versus 85.6%, respectively; p=1.000), AFS (85.4% versus 79.1%, respectively; p=0.460) or survival (89.6% versus 83.7%, respectively; p=0.426). CONCLUSION In this study, no benefits of antibiotic treatment over non-antibiotic treatment for clinically uninfected ulcers were identified. The findings of this study emphasise the recommendation of current guidelines to not treat clinically uninfected ulcer with antibiotics.
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Affiliation(s)
- Eline Huizing
- Department of Surgery, Northwest Clinics, Alkmaar, the Netherlands
| | | | | | - Jean-Paul Pm de Vries
- Department of Surgery, Division of Vascular Surgery, University Medical Centre Groningen, the Netherlands
| | - Ünlü Çağdaş
- Department of Surgery, Northwest Clinics, Alkmaar, the Netherlands
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8
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McNeil S, Waller K, Poy Lorenzo YS, Mateevici OC, Telianidis S, Qi S, Churilov I, MacIsaac RJ, Galligan A. Detection, management, and prevention of diabetes-related foot disease in the Australian context. World J Diabetes 2023; 14:942-957. [PMID: 37547594 PMCID: PMC10401446 DOI: 10.4239/wjd.v14.i7.942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/06/2023] [Accepted: 05/23/2023] [Indexed: 07/12/2023] Open
Abstract
Diabetes-related foot disease (DFD) is a widely feared complication among people who live with diabetes. In Australia and globally, rates of disability, cardio-vascular disease, lower extremity amputation, and mortality are significantly increased in patients with DFD. In order to understand and prevent these outcomes, we analyse the common pathogenetic processes of neuropathy, arterial disease, and infection. The review then summarises important management considerations through the interdisciplinary lens. Using Australian and international guidelines, we offer a stepwise, evidence-based practical approach to the care of patients with DFD.
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Affiliation(s)
- Scott McNeil
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Kate Waller
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Podiatry, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Yves S Poy Lorenzo
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Infectious Diseases Unit, Department of Medicine, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Pharmacy, St Vincent’s Hospital Melbourne, Fitzroy 3065, Australia
- Department of Medicine, St Vincent’s Hospital Melbourne, University of Melbourne, Fitzroy 3065, Victoria, Australia
| | - Olimpia C Mateevici
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Infectious Diseases Unit, Department of Medicine, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Stacey Telianidis
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Vascular Surgery, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Sara Qi
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Vascular Surgery, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Irina Churilov
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Medicine, St Vincent’s Hospital Melbourne, University of Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Rehabilitation Medicine, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
| | - Richard J MacIsaac
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Medicine, St Vincent’s Hospital Melbourne, University of Melbourne, Fitzroy 3065, Victoria, Australia
- the Australian Centre for Accelerating Diabetes Innovations, School of Medicine, University of Melbourne, Parkville 3010, Victoria, Australia
| | - Anna Galligan
- High Risk Foot Service, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
- Department of Endocrinology and Diabetes, St Vincent’s Hospital Melbourne, Fitzroy 3065, Victoria, Australia
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9
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Wright A, Wood S, De Silva J, Bell JS. Systemic Antimicrobial Therapy for Diabetic Foot Infections: An Overview of Systematic Reviews. Antibiotics (Basel) 2023; 12:1041. [PMID: 37370360 DOI: 10.3390/antibiotics12061041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/01/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
Diabetic foot infections (DFIs) are a common complication of diabetes; however, there is clinical uncertainty regarding the optimal antimicrobial selection. The aim of this review was to critically evaluate the recent systematic reviews on the efficacy and safety of systemic (parenteral or oral) antimicrobials for DFI. Medline, Embase, CENTRAL, and CINAHL databases and the PROSPERO register were searched from January 2015 to January 2023. Systematic reviews with or without meta-analyses on systemic antimicrobials for DFI, with outcomes of clinical infection resolution or complications, were included. Of the 413 records identified, 6 systematic reviews of 29 individual studies were included. Heterogeneity of individual studies precluded meta-analysis, except for ertapenem versus piperacillin-tazobactam (RR 1.07, 95% CI [0.96-1.19]) and fluoroquinolones versus piperacillin-tazobactam (RR 1.03, 95% CI [0.89-1.20]) in one review. The application of the AMSTAR-2 tool determined two reviews to be of high quality. There was no statistical difference in the clinical resolution of infections for 24 different antimicrobial regimens (penicillins, cephalosporins, carbapenems, fluoroquinolones, vancomycin, metronidazole, clindamycin, linezolid, daptomycin, and tigecycline). However, tigecycline did not meet non-inferiority against ertapenem ± vancomycin (absolute difference -5.5%, 95% CI [-11.0-0.1]) and was associated with a higher incidence of adverse drug events. There is minimal systematic review evidence to suggest one regimen is superior to another for DFI.
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Affiliation(s)
- Angela Wright
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia
- Pharmacy Department, Mackay Base Hospital, Mackay, QLD 4740, Australia
| | - Stephen Wood
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia
| | - Janath De Silva
- Medicine Department, Mackay Base Hospital, Mackay, QLD 4740, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia
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10
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Soldevila-Boixader L, Murillo O, Waibel FWA, Huber T, Schöni M, Lalji R, Uçkay I. The Epidemiology of Antibiotic-Related Adverse Events in the Treatment of Diabetic Foot Infections: A Narrative Review of the Literature. Antibiotics (Basel) 2023; 12:antibiotics12040774. [PMID: 37107136 PMCID: PMC10135215 DOI: 10.3390/antibiotics12040774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 04/16/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
The use of antibiotics for the treatment of diabetic foot infections (DFIs) over an extended period of time has been shown to be associated with adverse events (AEs), whereas interactions with concomitant patient medications must also be considered. The objective of this narrative review was to summarize the most frequent and most severe AEs reported in prospective trials and observational studies at the global level in DFI. Gastrointestinal intolerances were the most frequent AEs, from 5% to 22% among all therapies; this was more common when prolonged antibiotic administration was combined with oral beta-lactam or clindamycin or a higher dose of tetracyclines. The proportion of symptomatic colitis due to Clostridium difficile was variable depending on the antibiotic used (0.5% to 8%). Noteworthy serious AEs included hepatotoxicity due to beta-lactams (5% to 17%) or quinolones (3%); cytopenia's related to linezolid (5%) and beta-lactams (6%); nausea under rifampicin, and renal failure under cotrimoxazole. Skin rash was found to rarely occur and was commonly associated with the use of penicillins or cotrimoxazole. AEs from prolonged antibiotic use in patients with DFI are costly in terms of longer hospitalization or additional monitoring care and can trigger additional investigations. The best way to prevent AEs is to keep the duration of antibiotic treatment short and with the lowest dose clinically necessary.
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Affiliation(s)
- Laura Soldevila-Boixader
- Infectious Diseases Service, IDIBELL-Hospital Universitari Bellvitge, Universitat de Barcelona, Feixa Llarga s/n, Hospitalet de Llobregat, 08907 Barcelona, Spain
- Research Network for Infectious Diseases (CIBERINFEC), ISCIII, 28029 Madrid, Spain
- Infectiology, Unit for Clinical and Applied Research, Balgrist University Hospital, 8008 Zurich, Switzerland
| | - Oscar Murillo
- Infectious Diseases Service, IDIBELL-Hospital Universitari Bellvitge, Universitat de Barcelona, Feixa Llarga s/n, Hospitalet de Llobregat, 08907 Barcelona, Spain
- Research Network for Infectious Diseases (CIBERINFEC), ISCIII, 28029 Madrid, Spain
| | - Felix W A Waibel
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Tanja Huber
- Hospital Pharmacy, Balgrist University Hospital, 8008 Zurich, Switzerland
| | - Madlaina Schöni
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Rahim Lalji
- EBPI-UWZH Musculoskeletal Epidemiology Research Group, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, 8008 Zurich, Switzerland
- University Spine Centre Zurich (UWZH), Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Ilker Uçkay
- Infectiology, Unit for Clinical and Applied Research, Balgrist University Hospital, 8008 Zurich, Switzerland
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
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11
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Matijević T, Talapko J, Meštrović T, Matijević M, Erić S, Erić I, Škrlec I. Understanding the multifaceted etiopathogenesis of foot complications in individuals with diabetes. World J Clin Cases 2023; 11:1669-1683. [PMID: 36970006 PMCID: PMC10037285 DOI: 10.12998/wjcc.v11.i8.1669] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/01/2023] [Accepted: 02/17/2023] [Indexed: 03/07/2023] Open
Abstract
Diabetes mellitus, a chronic disease of metabolism, is characterized by a disordered production or cellular utilization of insulin. Diabetic foot disease, which comprises the spectrum of infection, ulceration, and gangrene, is one of the most severe complications of diabetes and is the most common cause of hospitalization in diabetic patients. The aim of this study is to provide an evidence-based overview of diabetic foot complications. Due to neuropathy, diabetic foot infections can occur in the form of ulcers and minor skin lesions. In patients with diabetic foot ulcers, ischemia and infection are the main causes of non-healing ulcers and amputations. Hyperglycemia compromises the immune system of individuals with diabetes, leading to persistent inflammation and delayed wound healing. In addition, the treatment of diabetic foot infections is challenging due to difficulty in accurate identification of pathogenic microorganisms and the widespread issue of antimicrobial resistance. As a further complicating factor, the warning signs and symptoms of diabetic foot problems can easily be overlooked. Issues associated with diabetic foot complications include peripheral arterial disease and osteomyelitis; accordingly, the risk of these complications in people with diabetes should be assessed annually. Although antimicrobial agents represent the mainstay of treatment for diabetic foot infections, if peripheral arterial disease is present, revascularization should be considered to prevent limb amputation. A multidisciplinary approach to the prevention, diagnosis, and treatment of diabetic patients, including those with foot ulcers, is of the utmost importance to reduce the cost of treatment and avoid major adverse consequences such as amputation.
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Affiliation(s)
- Tatjana Matijević
- Department of Dermatology and Venereology, University Hospital Center Osijek, Osijek 31000, Croatia
| | - Jasminka Talapko
- Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
| | - Tomislav Meštrović
- University Centre Varaždin, University North, Varaždin 42000, Croatia
- Institute for Health Metrics and Evaluation and the Department for Health Metrics Sciences, University of Washington School of Medicine, Seattle, WA 98195, United States
| | - Marijan Matijević
- Department of Surgery, National Memorial Hospital Vukovar, Vukovar 32000, Croatia
| | - Suzana Erić
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
- Department of Radiotherapy and Oncology, Clinical Hospital Center Osijek, Osijek 31000, Croatia
| | - Ivan Erić
- Faculty of Medicine, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
- Department of Surgery, Osijek University Hospital Centre, Osijek 31000, Croatia
| | - Ivana Škrlec
- Faculty of Dental Medicine and Health, Josip Juraj Strossmayer University of Osijek, Osijek 31000, Croatia
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12
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Wang G, Lin Z, Li Y, Chen L, Reddy SK, Hu Z, Garza L. Colonizing microbiota is associated with clinical outcomes in diabetic wound healing. Adv Drug Deliv Rev 2023; 194:114727. [PMID: 36758858 PMCID: PMC10163681 DOI: 10.1016/j.addr.2023.114727] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 02/02/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023]
Abstract
With the development of society and the improvement of life quality, more than 500 million people are affected by diabetes. More than 10 % of people with diabetes will suffer from diabetic wounds, and 80 % of diabetic wounds will reoccur, so the development of new diabetic wound treatments is of great importance. The development of skin microbe research technology has gradually drawn people's attention to the complex relationship between microbes and diabetic wounds. Many studies have shown that skin microbes are associated with the outcome of diabetic wounds and can even be used as one of the indicators of wound prognosis. Skin microbes have also been found to have the potential to treat diabetic wounds. The wound colonization of different bacteria can exert opposing therapeutic effects. It is necessary to fully understand the skin microbes in diabetic wounds, which can provide valuable guidance for clinical diabetic wound treatment.
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Affiliation(s)
- Gaofeng Wang
- Department of Plastic and Aesthetic Surgery, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong Province 510515, China; Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21210, USA.
| | - Zhen Lin
- Department of Plastic and Aesthetic Surgery, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong Province 510515, China
| | - Yue Li
- Department of Plastic and Aesthetic Surgery, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong Province 510515, China
| | - Lu Chen
- Department of Plastic and Aesthetic Surgery, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong Province 510515, China
| | - Sashank K Reddy
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21210, USA; Department of Plastic and Reconstructive Surgery, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA
| | - Zhiqi Hu
- Department of Plastic and Aesthetic Surgery, Nanfang Hospital of Southern Medical University, Guangzhou, Guangdong Province 510515, China
| | - Luis Garza
- Department of Dermatology, Johns Hopkins University School of Medicine, Baltimore, MD 21210, USA; Department of Cell Biology, Johns Hopkins University School of Medicine, Baltimore, MD 21210, USA; Department of Oncology, Johns Hopkins University School of Medicine, Baltimore, MD 21210, USA.
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13
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Barshes NR, Clark NJ, Bidare D, Dudenhoeffer JH, Mindru C, Rodriguez-Barradas MC. Polymicrobial Foot Infection Patterns Are Common and Associated With Treatment Failure. Open Forum Infect Dis 2022; 9:ofac475. [PMID: 36267251 PMCID: PMC9578153 DOI: 10.1093/ofid/ofac475] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 09/13/2022] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND That foot infections are predominately polymicrobial has long been recognized, but it is not clear if the various species co-occur randomly or in patterns. We sought nonrandom species co-occurrence patterns that might help better predict prognosis or guide antimicrobial selection. METHODS We analyzed tissue (bone, skin, and other soft tissue), fluid, and swab specimens collected from initial foot infection episodes during a 10-year period using a hospital registry. Nonrandom co-occurrence of microbial species was identified using simple pairwise co-occurrence rates adjusted for multiple comparisons, Markov and conditional random fields, and factor analysis. A historical cohort was used to validate pattern occurrence and identify clinical significance. RESULTS In total, 156 unique species were identified among the 727 specimens obtained from initial foot infection episodes in 694 patients. Multiple analyses suggested that Staphylococcus aureus is negatively associated with other staphylococci. Another pattern noted was the co-occurrence of alpha-hemolytic Streptococcus, Enterococcus fecalis, Klebsiella, Proteus, Enterobacter, or Escherichia coli, and absence of both Bacteroides and Corynebacterium. Patients in a historical cohort with this latter pattern had significantly higher risk-adjusted rates of treatment failure. CONCLUSIONS Several nonrandom microbial co-occurrence patterns are frequently seen in foot infection specimens. One particular pattern with many Proteobacteria species may denote a higher risk for treatment failure. Staphylococcus aureus rarely co-occurs with other staphylococci.
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Affiliation(s)
- Neal R Barshes
- Correspondence: Neal R. Barshes, MD, MPH, Baylor College of Medicine/Michael E. DeBakey Veterans Affairs Medical Center, 2002 Holcombe Boulevard (OCL 112), Houston, TX 77030 ()
| | - Nicholas J Clark
- School of Veterinary Science, School of Veterinary Science, The University of Queensland, Gatton, Queensland, Australia
| | - Deeksha Bidare
- Baylor College of Medicine, One Baylor Plaza, Houston, Texas, USA
| | - J H Dudenhoeffer
- Department of Biology and Biochemistry, University of Houston, Houston, Texas, USA
| | - Cezarina Mindru
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Infectious Disease Section, Department of Medicine, One Baylor Plaza, Houston, Texas, USA
| | - Maria C Rodriguez-Barradas
- Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
- Infectious Disease Section, Department of Medicine, One Baylor Plaza, Houston, Texas, USA
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14
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Baig MS, Banu A, Zehravi M, Rana R, Burle SS, Khan SL, Islam F, Siddiqui FA, Massoud EES, Rahman MH, Cavalu S. An Overview of Diabetic Foot Ulcers and Associated Problems with Special Emphasis on Treatments with Antimicrobials. LIFE (BASEL, SWITZERLAND) 2022; 12:life12071054. [PMID: 35888142 PMCID: PMC9316721 DOI: 10.3390/life12071054] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/07/2022] [Accepted: 07/12/2022] [Indexed: 12/14/2022]
Abstract
One of the most significant challenges of diabetes health care is diabetic foot ulcers (DFU). DFUs are more challenging to cure, and this is particularly true for people who already have a compromised immune system. Pathogenic bacteria and fungi are becoming more resistant to antibiotics, so they may be unable to fight microbial infections at the wound site with the antibiotics we have now. This article discusses the dressings, topical antibacterial treatment, medications and debridement techniques used for DFU and provides a deep discussion of DFU and its associated problems. English-language publications on DFU were gathered from many different databases, such as Scopus, Web of Science, Science Direct, Springer Nature, and Google Scholar. For the treatment of DFU, a multidisciplinary approach involving the use of diagnostic equipment, skills, and experience is required. Preventing amputations starts with patient education and the implementation of new categorization systems. The microbiota involved in DFU can be better understood using novel diagnostic techniques, such as the 16S-ribosomal DNA sequence in bacteria. This could be achieved by using new biological and molecular treatments that have been shown to help prevent infections, to control local inflammation, and to improve the healing process.
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Affiliation(s)
- Mirza Shahed Baig
- Department of Pharmaceutical Chemistry, Y. B. Chavan College of Pharmacy, Aurangabad 431001, India;
| | - Ahmadi Banu
- Department of Pharmacology, Vishnu Institute of Pharmaceutical Education & Research, Narsapur 502313, India;
| | - Mehrukh Zehravi
- Department of Clinical Pharmacy Girls Section, Prince Sattam Bin Abdul Aziz University, Alkharj 11942, Saudi Arabia;
| | - Ritesh Rana
- Department of Pharmaceutics, Adarsh Vijendra Institute of Pharmaceutical Sciences, Shobhit University, Gangoh, Saharanpur 247341, India;
| | - Sushil S. Burle
- Department of Pharmacology, Smt. Kishoritai Bhoyar College of Pharmacy, Kamptee, Nagpur 441002, India;
| | - Sharuk L. Khan
- Department of Pharmaceutical Chemistry, MUP’s College of Pharmacy (B Pharm), Degaon, Risod, Washim 444504, India;
- Correspondence: (S.L.K.); (M.H.R.); (S.C.)
| | - Fahadul Islam
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka 1207, Bangladesh;
| | - Falak A. Siddiqui
- Department of Pharmaceutical Chemistry, MUP’s College of Pharmacy (B Pharm), Degaon, Risod, Washim 444504, India;
| | - Ehab El Sayed Massoud
- Biology Department, Faculty of Science and Arts in Dahran Aljnoub, King Khalid University, Abha 62529, Saudi Arabia;
- Research Center for Advanced Materials Science (RCAMS), King Khalid University, Abha 61413, Saudi Arabia
- Agriculture Research Centre, Soil, Water and Environment Research Institute, Giza 3725004, Egypt
| | - Md. Habibur Rahman
- Department of Global Medical Science, Wonju College of Medicine, Yonsei University, Wonju 26426, Korea
- Correspondence: (S.L.K.); (M.H.R.); (S.C.)
| | - Simona Cavalu
- Faculty of Medicine and Pharmacy, University of Oradea, Pta 1 Decembrie 10, 410087 Oradea, Romania
- Correspondence: (S.L.K.); (M.H.R.); (S.C.)
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15
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Ragothaman KK, Elmarsafi TX, Mobaraki A, Zarick CS, Evans KK, Steinberg JS, Attinger CE, Kim PJ. Evaluation of Polymerase Chain Reaction in the Identification and Quantification of Clinically Relevant Bacterial Species in Lower Extremity Wound Infections. J Foot Ankle Surg 2022; 61:713-718. [PMID: 34895822 DOI: 10.1053/j.jfas.2020.07.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 06/28/2020] [Accepted: 07/02/2020] [Indexed: 02/03/2023]
Abstract
Identification of bacteria by polymerase chain reaction (PCR) is known to be more sensitive than culture, which brings to question the clinical applicability of the results. In this study, we evaluate the ability of PCR to detect clinically relevant bacterial species in lower extremity wound infections requiring operative debridement, as well as the quantitative change in biodiversity and bacterial load reflected by PCR during the course of treatment. Thirty-four infected lower extremity were examined by analysis of 16S ribosomal RNA subunit and by culture. McNemar's test was used to measure the concordance of clinically relevant bacterial species identified by PCR compared to culture during each debridement. Change in wound biodiversity from initial presentation to final closure was evaluated by Wilcoxon signed-rank test. Kaplan-Meier survival curve was used to characterize change in measured bacterial load over the course of operative debridement. A total of 15 and 12 clinically relevant bacterial species were identified by PCR and culture, respectively. The most common bacterial species identified were Coagulase-negative Staphylococcus, Staphylococcus aureus, and Enterococcus spp. PCR was less likely to detect Enterococcus spp. on initial debridement and Coagulase-negative Staphylococcus on closure in this study population. A significant decrease in mean number of clinically relevant species detected from initial debridement to closure was reflected by culture (p = .0188) but not by PCR (p = .1848). Both PCR (p = .0128) and culture (p = .0001) depicted significant reduction in mean bacterial load from initial debridement to closure. PCR is able to identify common clinically relevant bacterial species in lower extremity surgical wound infections. PCR displays increased sensitivity compared to culture with relation to detection of biodiversity, rather than bacterial load. Molecular diagnostics and conventional culture may serve a joint purpose to assist with rendering clinical judgment in complex wound infections.
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Affiliation(s)
- Kevin K Ragothaman
- Foot and Ankle Surgeon, Foot and Ankle Associates, Los Gatos and Cupertino, CA.
| | | | | | - Caitlin S Zarick
- Assistant Professor, Department of Plastic Surgery, Georgetown University School of Medicine, Washington, DC
| | - Karen K Evans
- Professor, Department of Plastic Surgery, Georgetown University School of Medicine, Washington, DC
| | - John S Steinberg
- Assistant Professor, Department of Plastic Surgery, Georgetown University School of Medicine, Washington, DC
| | - Christopher E Attinger
- Professor, Department of Plastic Surgery, Georgetown University School of Medicine, Washington, DC
| | - Paul J Kim
- Professor, Departments of Plastic and Orthopaedic Surgery, University of Texas Southwestern, Dallas, TX
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16
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Diabetic foot ulcer, antimicrobial remedies and emerging strategies for the treatment. Int J Health Sci (Qassim) 2022. [DOI: 10.53730/ijhs.v6ns3.6199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
According to the International Diabetes Federation's 2015 study, diabetes affects over 415 million people globally (5 million of whom die each year), and the incidence of diabetes is expected to climb to over 640 million (1 in 10) by 2040. (IDF 2015). Diabetes foot ulcers (DFU) are one of the most significant diabetic health consequences. Antimicrobial treatments, such as dressings, topical therapies, medicines, drugs, debridement procedures, molecular, cellular, and gene therapies, plant extracts, antimicrobial peptides, growth factors, devices, ozone, and energy-based therapies, would be the focus of this study. Scopus, Web of Science, Bentham Science, Science Direct, and Google Scholar were among the sources used to compile the English-language publications on DFU. DFU treatment requires a multidisciplinary approach that includes the use of proper diagnostic tools, competence, and experience. To prevent amputations, this starts with patient education and the use of new categories to steer treatment. New diagnostic methods, such as the 16S ribosomal DNA sequence in bacteria, should become available to acquire a better knowledge of the microbiota in DFUs.
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17
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Mudrik-Zohar H, Carasso S, Gefen T, Zalmanovich A, Katzir M, Cohen Y, Paitan Y, Geva-Zatorsky N, Chowers M. Microbiome Characterization of Infected Diabetic Foot Ulcers in Association With Clinical Outcomes: Traditional Cultures Versus Molecular Sequencing Methods. Front Cell Infect Microbiol 2022; 12:836699. [PMID: 35402307 PMCID: PMC8987016 DOI: 10.3389/fcimb.2022.836699] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 03/01/2022] [Indexed: 12/19/2022] Open
Abstract
Background Infected diabetic foot ulcers (IDFU) are a major complication of diabetes mellitus. These potentially limb-threatening ulcers are challenging to treat due to impaired wound healing characterizing diabetic patients and the complex microbial environment of these ulcers. Aim To analyze the microbiome of IDFU in association with clinical outcomes. Methods Wound biopsies from IDFU were obtained from hospitalized patients and were analyzed using traditional microbiology cultures, 16S rRNA sequencing and metagenomic sequencing. Patients’ characteristics, culture-based results and sequencing data were analyzed in association with clinical outcomes. Results A total of 31 patients were enrolled. Gram-negative bacteria dominated the IDFU samples (79%, 59% and 54% of metagenomics, 16S rRNA and cultures results, respectively, p<0.001). 16S rRNA and metagenomic sequencing detected significantly more anaerobic bacteria, as compared to conventional cultures (59% and 76%, respectively vs. 26% in cultures, p=0.001). Culture-based results showed that Staphylococcus aureus was more prevalent among patients who were treated conservatively (p=0.048). In metagenomic analysis, the Bacteroides genus was more prevalent among patients who underwent amputation (p<0.001). Analysis of metagenomic-based functional data showed that antibiotic resistance genes and genes related to biofilm production and to bacterial virulent factors were more prevalent in IDFU that resulted in amputation (p<0.001). Conclusion Sequencing tools uncover the complex biodiversity of IDFU and emphasize the high prevalence of anaerobes and Gram-negative bacteria in these ulcers. Furthermore, sequencing results highlight possible associations among certain genera, species, and bacterial functional genes to clinical outcomes.
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Affiliation(s)
- Hadar Mudrik-Zohar
- Department of Internal Medicine A, Meir Medical Center, Kfar Saba, Israel
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- *Correspondence: Naama Geva-Zatorsky, ; Hadar Mudrik-Zohar,
| | - Shaqed Carasso
- Rappaport Technion Integrated Cancer Center (TICC), Department of Cell Biology and Cancer Science, Rappaport Faculty of Medicine, The Technion – Israel Institute of Technology, Haifa, Israel
| | - Tal Gefen
- Rappaport Technion Integrated Cancer Center (TICC), Department of Cell Biology and Cancer Science, Rappaport Faculty of Medicine, The Technion – Israel Institute of Technology, Haifa, Israel
| | - Anat Zalmanovich
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Infectious Diseases Unit, Meir Medical Center, Kfar Saba, Israel
| | - Michal Katzir
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Infectious Diseases Unit, Meir Medical Center, Kfar Saba, Israel
| | - Yael Cohen
- Department of Orthopedics B, Meir Medical Center, Kfar Saba, Israel
| | - Yossi Paitan
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Clinical Microbiology Laboratory, Meir Medical Center, Kfar Saba, Israel
| | - Naama Geva-Zatorsky
- Rappaport Technion Integrated Cancer Center (TICC), Department of Cell Biology and Cancer Science, Rappaport Faculty of Medicine, The Technion – Israel Institute of Technology, Haifa, Israel
- Canadian Institute for Advanced Research (CIFAR), Toronto, ON, Canada
- *Correspondence: Naama Geva-Zatorsky, ; Hadar Mudrik-Zohar,
| | - Michal Chowers
- Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
- Infectious Diseases Unit, Meir Medical Center, Kfar Saba, Israel
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18
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Toale C, Kelly A, Leahy F, Meagher H, Stapleton PJ, Moloney MA, Kavanagh EG. Effect of Pseudomonas colonisation on lower limb venous ulcer healing: a systematic review. J Wound Care 2022; 31:186-192. [PMID: 35148629 DOI: 10.12968/jowc.2022.31.2.186] [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: 11/11/2022]
Abstract
OBJECTIVE Pseudomonas aeruginosa is a Gram-negative bacillus that commonly colonises lower limb venous ulcers. Its effects on venous ulcer healing are widely debated. It produces exotoxins and elastase, as well as forming biofilms in hard-to-heal wounds. It is postulated that these virulence factors lead to slower healing times in patients with lower limb venous ulcers colonised with Pseudomonas. This review aimed to summarise the available evidence pertaining to this topic. METHOD A systematic review was performed in August 2019, where the Pubmed, Cochrane and Embase databases were searched for relevant literature according to PRISMA guidelines. Retrospective and prospective studies examining the effect of Pseudomonas colonisation on any measure of ulcer healing were included. RESULTS Some 282 articles were screened, of which seven studies including 491 patients were ultimately included for analysis. Of these, no study demonstrated a significant association between Pseudomonas colonisation and delayed healing of venous ulcers. In five of the seven studies, the effect of Pseudomonas aeruginosa on initial ulcer size at presentation was recorded. CONCLUSION All the studies demonstrated an association between ulcer size and the presence of Pseudomonas aeruginosa. While Pseudomonas aeruginosa may colonise larger ulcers or those with a worse prognosis, no evidence was found to support the hypothesis that this colonisation had a negative impact on lower limb venous ulcer healing.
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Affiliation(s)
- Conor Toale
- Department of Vascular/Endovascular Surgery, University Hospital Limerick, Ireland
| | - Aisling Kelly
- Department of Vascular/Endovascular Surgery, University Hospital Limerick, Ireland
| | - Fiona Leahy
- Department of Vascular/Endovascular Surgery, University Hospital Limerick, Ireland
| | - Helen Meagher
- Department of Vascular/Endovascular Surgery, University Hospital Limerick, Ireland
| | | | - Michael A Moloney
- Department of Vascular/Endovascular Surgery, University Hospital Limerick, Ireland
| | - Eamon G Kavanagh
- Department of Vascular/Endovascular Surgery, University Hospital Limerick, Ireland.,Department of Microbiology, University Hospital Limerick, Ireland
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19
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Pratama V, Risni HW, Yunir E, Sauriasari R. A Systematic Review of Randomized Controlled Trials of Antibiotic Use in Diabetic Foot Ulcer Infections: Focus on Clinical Cure. Infect Chemother 2022; 54:125-139. [PMID: 35384424 PMCID: PMC8987184 DOI: 10.3947/ic.2021.0144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/19/2022] [Indexed: 11/24/2022] Open
Abstract
Background Materials and Methods Results Conclusion
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Affiliation(s)
- Vincent Pratama
- Faculty of Pharmacy, Universitas Indonesia, Depok, Indonesia
| | | | - Em Yunir
- Division of Endocrinology, Department of Internal Medicine Dr. Cipto Mangunkusumo National Referral Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Rani Sauriasari
- Faculty of Pharmacy, Universitas Indonesia, Depok, Indonesia
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20
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Kim JJ, Littman AJ, Sorkin JD, Roghmann MC. Association Between Foot Surgery Type and Subsequent Healing in Veterans With Moderate-to-Severe Diabetic Foot Infections. Open Forum Infect Dis 2021; 9:ofab650. [PMID: 35111873 PMCID: PMC8802798 DOI: 10.1093/ofid/ofab650] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 12/21/2021] [Indexed: 11/19/2022] Open
Abstract
Background Diabetic foot infections are a common precursor to lower extremity amputations. The treatment of diabetic foot infections involves both medical and surgical management, of which limb-sparing surgeries are increasingly preferred over amputations at or above the ankle to preserve mobility and quality of life. The outcomes following these limb-sparing surgeries are not well described. Methods This was a single-center, retrospective cohort study of 90 Veterans with moderate-to-severe diabetic foot infections between 2017 and 2019 from the Veterans Affairs Maryland Health Care System. The exposure was foot surgery with bone resection (ie, toe amputation, metatarsal resection, transmetatarsal amputation) vs debridement alone. The outcome was healing within 1 year. We used log-binomial regression to assess the association between foot surgery type and healing, stratify by infection location, and evaluate potential confounding variables. Results The cumulative incidence of healing after foot surgery with bone resection was greater than that following debridement (risk ratio [RR], 1.80 [95% confidence interval {CI}, 1.17–2.77]). This association was modified by infection location and greater for toe infections (RR, 4.52 [95% CI, 1.30–15.7]) than other foot infections (RR, 1.19 [95% CI, .69–2.02]). We found no evidence of confounding by comorbidities or infection severity. Conclusions For patients with toe infections, foot surgery with bone resection was associated with better healing than debridement alone. The multiple specialties caring for patients with diabetic foot infections need a stronger common knowledge base—from studies like this and future studies—to better counsel patients about their treatment and prognosis.
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Affiliation(s)
- Justin J Kim
- Geriatrics Research Education and Clinical Center, Veterans Affairs Maryland Health Care System, Baltimore, Maryland, USA
| | - Alyson J Littman
- Seattle Epidemiologic Research and Information Center, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Seattle–Denver Center of Innovation for Veteran-Centered and Value-Driven Care, Health Services Research and Development, Veterans Affairs Puget Sound Health Care System, Seattle, Washington, USA
- Department of Epidemiology, University of Washington School of Public Health, Seattle, Washington, USA
| | - John D Sorkin
- Geriatrics Research Education and Clinical Center, Veterans Affairs Maryland Health Care System, Baltimore, Maryland, USA
- Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Mary-Claire Roghmann
- Geriatrics Research Education and Clinical Center, Veterans Affairs Maryland Health Care System, Baltimore, Maryland, USA
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, USA
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21
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Hiew J, Whitmore T, McEvoy M, Weatherall D, Ingram PR, Manning L. Subcutaneous ertapenem delivered by an Australian outpatient parenteral antimicrobial therapy service: a retrospective comparative efficacy study. Intern Med J 2021; 51:1717-1721. [PMID: 34664365 DOI: 10.1111/imj.15511] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/15/2021] [Accepted: 04/15/2021] [Indexed: 02/06/2023]
Abstract
Subcutaneous (SC) administration of ertapenem in outpatient parenteral antimicrobial therapy (OPAT) services may be a practical alternative to intravenous delivery for complicated infections. The clinical features and outcomes according to route of administration were compared from a large Australian OPAT service. Chronic renal impairment was more common in the SC group, reflecting an opportunity for route of administration as a vein preservation strategy. Adverse events were uncommon and successful outcomes were not different between the groups.
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Affiliation(s)
- Jonathan Hiew
- Multidisciplinary Diabetic Foot Ulcer Service, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Department of Podiatry, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Timothy Whitmore
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Mahalia McEvoy
- Multidisciplinary Diabetic Foot Ulcer Service, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Department of Podiatry, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Deborah Weatherall
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Silver Chain Home Hospital, Perth, Western Australia, Australia
| | - Paul R Ingram
- Multidisciplinary Diabetic Foot Ulcer Service, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Medical School, University of Western Australia, Harry Perkins Research Institute, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Laurens Manning
- Multidisciplinary Diabetic Foot Ulcer Service, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Medical School, University of Western Australia, Harry Perkins Research Institute, Fiona Stanley Hospital, Perth, Western Australia, Australia
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22
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Ernlund AW, Moffatt LT, Timm CM, Zudock KK, Howser CW, Blount KM, Alkhalil A, Shupp JW, Karig DK. Examining the effect of wound cleansing on the microbiome of venous stasis ulcers. Wound Repair Regen 2021; 29:766-776. [PMID: 33991156 DOI: 10.1111/wrr.12926] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Revised: 03/11/2021] [Accepted: 04/21/2021] [Indexed: 11/30/2022]
Abstract
Common treatment for venous leg wounds includes topical wound dressings with compression. At each dressing change, wounds are debrided and washed; however, the effect of the washing procedure on the wound microbiome has not been studied. We hypothesized that wound washing may alter the wound microbiome. To characterize microbiome changes with respect to wound washing, swabs from 11 patients with chronic wounds were sampled before and after washing, and patient microbiomes were characterized using 16S rRNA sequencing and culturing. Microbiomes across patient samples prior to washing were typically polymicrobial but varied in the number and type of bacterial genera present. Proteus and Pseudomonas were the dominant genera in the study. We found that washing does not consistently change microbiome diversity but does cause consistent changes in microbiome composition. Specifically, washing caused a decrease in the relative abundance of the most highly represented genera in each patient cluster. The finding that venous leg ulcer wound washing, a standard of care therapy, can induce changes in the wound microbiome is novel and could be potentially informative for future guided therapy strategies.
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Affiliation(s)
- Amanda W Ernlund
- Department of Research and Exploratory Development, Johns Hopkins Applied Physics Laboratory, Laurel, Maryland, USA
| | - Lauren T Moffatt
- The Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Hyattsville, Maryland, USA.,Departments of Surgery, Biochemistry and Molecular & Cellular Biology, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Collin M Timm
- Department of Research and Exploratory Development, Johns Hopkins Applied Physics Laboratory, Laurel, Maryland, USA
| | - Kristina K Zudock
- Department of Research and Exploratory Development, Johns Hopkins Applied Physics Laboratory, Laurel, Maryland, USA
| | - Craig W Howser
- Department of Research and Exploratory Development, Johns Hopkins Applied Physics Laboratory, Laurel, Maryland, USA
| | - Kianna M Blount
- Department of Research and Exploratory Development, Johns Hopkins Applied Physics Laboratory, Laurel, Maryland, USA
| | - Abdulnaser Alkhalil
- The Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Hyattsville, Maryland, USA
| | - Jeffrey W Shupp
- The Firefighters' Burn and Surgical Research Laboratory, MedStar Health Research Institute, Hyattsville, Maryland, USA.,Departments of Surgery, Biochemistry and Molecular & Cellular Biology, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - David K Karig
- Department of Research and Exploratory Development, Johns Hopkins Applied Physics Laboratory, Laurel, Maryland, USA.,Department of Bioengineering, Clemson University, 301 Rhodes Research Center, Clemson, South Carolina, USA
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23
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Uçkay I, Holy D, Schöni M, Waibel FWA, Trache T, Burkhard J, Böni T, Lipsky BA, Berli MC. How good are clinicians in predicting the presence of Pseudomonas spp. in diabetic foot infections? A prospective clinical evaluation. Endocrinol Diabetes Metab 2021; 4:e00225. [PMID: 33855224 PMCID: PMC8029573 DOI: 10.1002/edm2.225] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 12/22/2020] [Accepted: 12/26/2020] [Indexed: 12/17/2022] Open
Abstract
Introduction The most frequently prescribed empirical antibiotic agents for mild and moderate diabetic foot infections (DFIs) are amino-penicillins and second-generation cephalosporins that do not cover Pseudomonas spp. Many clinicians believe they can predict the involvement of Pseudomonas in a DFI by visual and/or olfactory clues, but no data support this assertion. Methods In this prospective observational study, we separately asked 13 experienced (median 11 years) healthcare workers whether they thought the Pseudomonas spp. would be implicated in the DFI. Their predictions were compared with the results of cultures of deep/intraoperative specimens and/or the clinical remission of DFI achieved with antibiotic agents that did not cover Pseudomonas. Results Among 221 DFI episodes in 88 individual patients, intraoperative tissue cultures grew Pseudomonas in 22 cases (10%, including six bone samples). The presence of Pseudomonas was correctly predicted with a sensitivity of 0.32, specificity of 0.84, positive predictive value of 0.18 and negative predictive value 0.92. Despite two feedbacks of the interim results and a 2-year period, the clinicians' predictive performance did not improve. Conclusion The combined visual and olfactory performance of experienced clinicians in predicting the presence of Pseudomonas in a DFI was moderate, with better specificity than sensitivity, and did not improve over time. Further investigations are needed to determine whether clinicians should use a negative prediction of the presence of Pseudomonas in a DFI, especially in settings with a high prevalence of pseudomonal DFIs.
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Affiliation(s)
- Ilker Uçkay
- InfectiologyBalgrist University HospitalZurichSwitzerland
- Department of Orthopedic SurgeryBalgrist University HospitalZurichSwitzerland
| | - Dominique Holy
- Internal MedicineBalgrist University HospitalZurichSwitzerland
| | - Madlaina Schöni
- Department of Orthopedic SurgeryBalgrist University HospitalZurichSwitzerland
| | - Felix W. A. Waibel
- Department of Orthopedic SurgeryBalgrist University HospitalZurichSwitzerland
| | - Tudor Trache
- Department of Orthopedic SurgeryBalgrist University HospitalZurichSwitzerland
| | - Jan Burkhard
- Internal MedicineBalgrist University HospitalZurichSwitzerland
| | - Thomas Böni
- Department of Orthopedic SurgeryBalgrist University HospitalZurichSwitzerland
| | | | - Martin C. Berli
- Department of Orthopedic SurgeryBalgrist University HospitalZurichSwitzerland
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Miller M, Knepper B, Young H. Risk Factors Associated with 30-Day Readmission in Patients with Diabetic Foot Infections. J Am Podiatr Med Assoc 2020; 110:449524. [PMID: 33301579 DOI: 10.7547/19-023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND Diabetic foot infections (DFIs) are the most common cause of hospitalization for patients with diabetes. Studies have shown diabetic patients have high readmission rates. It is important to identify variables that contribute to readmission. This study aimed to investigate clinical variables associated with 30-day hospital readmission in patients with DFI. METHODS We conducted a retrospective study of adults admitted to the hospital for DFI between July 1, 2012, and July 1, 2015. We identified patients by International Classification of Diseases, Ninth Revision codes and randomly selected 35% of medical records for review. Patients were excluded if they did not have a DFI by review, were pregnant, or were incarcerated. The primary outcome was 30-day readmission. Data collected included baseline demographics, medical comorbidities, substance abuse, homelessness, tobacco use, and laboratory and surgical pathology data. Univariate and multivariate logistic regression models were used to identify independent predictors. RESULTS Of 140 included patients, 106 (76%) were male. Median age was 55 years and length of stay (LOS) was 7 days. In univariate analysis, 31 patients (22%) were readmitted in the 30 days after the index hospitalization. Factors associated with readmission included treatment failure, elevated C-reactive protein level, and hospital LOS (P < .05). In multivariate analyses, LOS and treatment failure were independent predictors of readmission. CONCLUSIONS The 30-day readmission rate for patients with DFI is high. Treatment failure, C-reactive protein, and LOS are independently associated with readmission. More work is needed to determine reasons for readmission so that appropriate measures can be taken before discharge.
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Hutting KH, aan de Stegge WB, Kruse RR, van Baal JG, Bus SA, van Netten JJ. Infrared thermography for monitoring severity and treatment of diabetic foot infections. VASCULAR BIOLOGY (BRISTOL, ENGLAND) 2020; 2:1-10. [PMID: 32935076 PMCID: PMC7487596 DOI: 10.1530/vb-20-0003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Accepted: 07/21/2020] [Indexed: 12/16/2022]
Abstract
Monitoring of diabetic foot infections is largely based on clinical assessment, which is limited by moderate reliability. We conducted a prospective study to explore monitoring of thermal asymmetry (difference between mean plantar temperature of the affected and unaffected foot) for the assessment of severity of diabetic foot infections. In patients with moderate or severe diabetic foot infections (International Working Group on the Diabetic Foot infection-grades 3 or 4) we measured thermal asymmetry with an advanced infrared thermography setup during the first 4-5 days of in-hospital treatment, in addition to clinical assessments and tests of serum inflammatory markers (white blood cell counts and C-reactive protein levels). We assessed the change in thermal asymmetry from baseline to final assessment, and investigated its association with infection-grades and serum inflammatory markers. In seven included patients, thermal asymmetry decreased from median 1.8°C (range: -0.6 to 8.4) at baseline to 1.5°C (range: -0.1 to 5.1) at final assessment (P = 0.515). In three patients who improved to infection-grade 2, thermal asymmetry at baseline (median 1.6°C (range: -0.6 to 1.6)) and final assessment (1.5°C (range: 0.4 to 5.1)) remained similar (P = 0.302). In four patients who did not improve to infection-grade 2, thermal asymmetry decreased from median 4.3°C (range: 1.8 to 8.4) to 1.9°C (range: -0.1 to 4.4; P = 0.221). No correlations were found between thermal asymmetry and infection-grades (r = -0.347; P = 0.445), CRP-levels (r = 0.321; P = 0.482) or WBC (r = -0.250; P = 0.589) during the first 4-5 days of hospitalization. Based on these explorative findings we suggest that infrared thermography is of no value for monitoring diabetic foot infections during in-hospital treatment.
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Affiliation(s)
- Kor H Hutting
- Department of Surgery, Hospital Group Twente, Almelo/Hengelo, the Netherlands
| | - Wouter B aan de Stegge
- Department of Surgery, Hospital Group Twente, Almelo/Hengelo, the Netherlands
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Rombout R Kruse
- Department of Surgery, Hospital Group Twente, Almelo/Hengelo, the Netherlands
| | - Jeff G van Baal
- Department of Surgery, Hospital Group Twente, Almelo/Hengelo, the Netherlands
- Welsh Wound Innovation Centre, Rhodfa Marics, Ynysmaerdy, Pontyclun, UK
| | - Sicco A Bus
- Department of Surgery, Hospital Group Twente, Almelo/Hengelo, the Netherlands
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
| | - Jaap J van Netten
- Department of Surgery, Hospital Group Twente, Almelo/Hengelo, the Netherlands
- Department of Rehabilitation Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam Movement Sciences, Amsterdam, the Netherlands
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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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Peters EJG, Lipsky BA, Senneville É, Abbas ZG, Aragón-Sánchez J, Diggle M, Embil JM, Kono S, Lavery LA, Malone M, Urbančič-Rovan V, Van Asten SA. Interventions in the management of infection in the foot in diabetes: a systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3282. [PMID: 32176437 DOI: 10.1002/dmrr.3282] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/01/2019] [Accepted: 09/19/2019] [Indexed: 12/11/2022]
Abstract
The optimal approaches to managing diabetic foot infections remain a challenge for clinicians. Despite an exponential rise in publications investigating different treatment strategies, the various agents studied generally produce comparable results, and high-quality data are scarce. In this systematic review, we searched the medical literature using the PubMed and Embase databases for published studies on the treatment of diabetic foot infections as of June 2018. This systematic review is an update of previous reviews, the first of which was undertaken in 2010 and the most recent in 2014, by the infection committee of the International Working Group of the Diabetic Foot. We defined the context of literature by formulating clinical questions of interest, then developing structured clinical questions (PICOs) to address these. We only included data from controlled studies of an intervention to prevent or cure a diabetic foot infection. Two independent reviewers selected articles for inclusion and then assessed their relevant outcomes and the methodological quality. Our literature search identified a total of 15 327 articles, of which we selected 48 for full-text review; we added five more studies discovered by means other than the systematic literature search. Among these selected articles were 11 high-quality studies published in the last 4 years and two Cochrane systematic reviews. Overall, the outcomes in patients treated with the different antibiotic regimens for both skin and soft tissue infection and osteomyelitis of the diabetic foot were broadly equivalent across studies, except that treatment with tigecycline was inferior to ertapenem (±vancomycin). Similar outcomes were also reported in studies comparing primarily surgical and predominantly antibiotic treatment strategies in selected patients with diabetic foot osteomyelitis. There is insufficient high-quality evidence to assess the effect of various adjunctive therapies, such as negative pressure wound therapy, topical ointments or hyperbaric oxygen, on infection related outcomes of the diabetic foot. In general, the quality of more recent trial designs are better in past years, but there is still a great need for further well-designed trials to produce higher quality evidence to underpin our recommendations.
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Affiliation(s)
- Edgar J G Peters
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine, Amsterdam Infection and Immunity Institute, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Benjamin A Lipsky
- Department of Medicine, University of Washington, Seattle, Washington
| | | | - Zulfiqarali G Abbas
- Abbas Medical Centre, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Mathew Diggle
- Alberta Public Laboratories, University of Alberta Hospital, Edmonton, Canada
| | - John M Embil
- University of Manitoba, Winnipeg, Manitoba, Alberta, Canada
| | - Shigeo Kono
- WHO-Collaborating Centre for Diabetes, National Hospital Organization Kyoto Medical Centre, Kyoto, Japan
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, Texas
| | - Matthew Malone
- School of Medicine, Infectious Diseases and Microbiology, South West Sydney Local Health District, Western Sydney University, Sydney, Australia
| | - Vilma Urbančič-Rovan
- Faculty of Medicine, University Medical Centre, University of Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Suzanne A Van Asten
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
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Hand R, Manning L, Ritter JC, Norman P, Lamb L, Makepeace A, Sankhesara D, Hamilton E, Ingram P. Antimicrobial stewardship opportunities among inpatients with diabetic foot infections: microbiology results from a tertiary hospital multidisciplinary unit. Intern Med J 2020; 49:533-536. [PMID: 30957374 DOI: 10.1111/imj.14251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2018] [Revised: 08/22/2018] [Accepted: 08/22/2018] [Indexed: 01/01/2023]
Abstract
Among 125 inpatients with diabetic foot infections managed by a multidisciplinary foot ulcer unit, knowledge of methicillin-resistant Staphylococcus aureus colonisation status assisted decision-making to prescribe appropriately or with-hold empiric anti-methicillin-resistant Staphylococcus aureus therapy. Despite adherence to national guidelines, apparent overuse of anti-pseudomonal therapy was frequent, providing potential antimicrobial stewardship opportunities.
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Affiliation(s)
- Robert Hand
- Department of General Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Laurens Manning
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia.,Faculty of Medicine and Health Sciences, University of Western Australia, Harry Perkins Research Institute, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Jens C Ritter
- Department of Vascular Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Paul Norman
- Department of Vascular Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Lydia Lamb
- Department of Endocrinology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Ashley Makepeace
- Department of Endocrinology, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Dipen Sankhesara
- Department of General Medicine, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Emma Hamilton
- Department of Endocrinology, Fiona Stanley Hospital, Perth, Western Australia, Australia.,School of Medicine and Pharmacology, University of Western Australia, Harry Perkins Research Institute, Fiona Stanley Hospital, Perth, Western Australia, Australia
| | - Paul Ingram
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia, Australia.,School of Pathology and Laboratory Medicine, University of Western Australia, Perth, Western Australia, Australia.,Department of Microbiology, PathWest Laboratory Medicine, Perth, Western Australia, Australia
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29
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Manning L, Hamilton EJ, Raby E, Norman PE, Davis W, Wood F, Carville K, Baba M, Hiew J, Ryan E, Ferreira I, Gittings P, Ritter JC. Spray on skin for diabetic foot ulcers: an open label randomised controlled trial. J Foot Ankle Res 2019; 12:52. [PMID: 31788029 PMCID: PMC6858641 DOI: 10.1186/s13047-019-0362-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 10/30/2019] [Indexed: 12/24/2022] Open
Abstract
Background One Australian loses a limb every 3 h as a result of infected diabetic foot ulcers (DFU). This common condition accounts for substantial morbidity and mortality for affected individuals and heavy economic costs for the health sector and the community. There is an urgent need to test interventions that improve wound healing time, prevent amputations and recurrent ulceration in patients presenting with DFU whilst improving quality of life and reducing health care costs. Methods One hundred and fifty eligible participants will be randomised to receive an autologous skin cell suspension, also termed 'spray-on' skin (ReCell®) or standard care interventions for their DFU. The primary outcome is complete wound healing at 6 months, but participants will be followed up for a total of 12 months to enable secondary outcomes including total overall costs, ulcer free days at 12 months and quality of life to be assessed. Discussion Outpatient costs for dressings, home nursing visits and outpatient appointments are key cost drivers for DFU. If spray-on skin is effective, large cost savings to WA Health will be realised immediately through a shortened time to healing, and through a higher proportion of patients achieving complete healing. Shortened healing times may enable participants to return to work earlier. Any economic benefits are likely to be amplified across Australia and other similar demographic settings where aging populations with increased diabetes rates are considered major future challenges. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12618000511235. Registered on 9 April 2018.
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Affiliation(s)
- Laurens Manning
- 1Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, WA 6150 Australia
| | - Emma J Hamilton
- 2Endocrinology Department, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, WA 6150 Australia
| | - Edward Raby
- 1Department of Infectious Diseases, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, WA 6150 Australia
| | - Paul E Norman
- 3Medical School, University of Western Australia, Crawley, WA 6009 Australia.,4Department of Vascular Surgery, Fremantle Hospital, Alma Street, Fremantle, WA 6160 Australia
| | - Wendy Davis
- 3Medical School, University of Western Australia, Crawley, WA 6009 Australia
| | - Fiona Wood
- 5State Burns Unit, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, WA 6150 Australia
| | - Keryln Carville
- 6Silver Chain Group and School of Nursing and Midwifery, Curtin University, Bentley, WA 6102 Australia
| | - Mendel Baba
- 7Podiatry Department, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, WA 6150 Australia
| | - Jonathan Hiew
- 7Podiatry Department, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, WA 6150 Australia
| | - Erica Ryan
- 7Podiatry Department, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, WA 6150 Australia
| | - Ivana Ferreira
- 7Podiatry Department, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, WA 6150 Australia
| | - Paul Gittings
- 8Burns Department, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, WA 6150 Australia
| | - Jens C Ritter
- 9Department of Vascular Surgery, Fiona Stanley Hospital, 11 Robin Warren Drive, Murdoch, WA 6150 Australia
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30
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Bacterial Diversity of Diabetic Foot Ulcers: Current Status and Future Prospectives. J Clin Med 2019; 8:jcm8111935. [PMID: 31717640 PMCID: PMC6912738 DOI: 10.3390/jcm8111935] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 11/06/2019] [Accepted: 11/08/2019] [Indexed: 02/08/2023] Open
Abstract
Diabetic foot ulcers (DFUs) and diabetic foot infections (DFIs) are associated with reduced patient quality of life, lower-extremity amputation, hospitalization, and high morbidity and mortality. Diverse bacterial communities have been identified in DFUs/DFIs, playing a significant role in infection prognosis. However, due to the high heterogeneity of bacterial communities colonized in DFUs/DFIs, culture-based methods may not isolate all of the bacterial population or unexpected microorganisms. Recently, high sensitivity and specificity of DNA (metagenomics) and RNA (metatranscriptomics) technologies have addressed limitations of culture-based methods and have taken a step beyond bacterial identification. As a consequence, new advances obtained from DNA- and RNA-based techniques for bacterial identification can improve therapeutic approaches. This review evaluated the current state of play in aetiology of DFUs/DFIs on culture and molecular approaches, and discussed the impact of metagenomic and metatranscriptomic methods in bacterial identification approaches.
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31
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Diabetic Foot Ulcers: Current Advances in Antimicrobial Therapies and Emerging Treatments. Antibiotics (Basel) 2019; 8:antibiotics8040193. [PMID: 31652990 PMCID: PMC6963879 DOI: 10.3390/antibiotics8040193] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 10/16/2019] [Accepted: 10/17/2019] [Indexed: 12/23/2022] Open
Abstract
Diabetic foot ulcers (DFUs) are very important diabetes-related lesions that can lead to serious physical consequences like amputations of limbs and equally severe social, psychological, and economic outcomes. It is reported that up to 25% of patients with diabetes develop a DFU in their lifetime, and more than half of them become infected. Therefore, it is essential to manage infection and ulcer recovery to prevent negatives outcomes. The available information plays a significant role in keeping both physicians and patients aware of the emerging therapies against DFUs. The purpose of this review is to compile the currently available approaches in the managing and treatment of DFUs, including molecular and regenerative medicine, antimicrobial and energy-based therapies, and the use of plant extracts, antimicrobial peptides, growth factors, ozone, devices, and nano-medicine, to offer an overview of the assessment of this condition.
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Lenhard JR, Smith NM, Quach CD, Nguyen TQ, Doan LH, Chau J. Bacterial brothers in arms: cooperation of Staphylococcus aureus and Pseudomonas aeruginosa during antimicrobial exposure. J Antimicrob Chemother 2019; 74:2657-2665. [DOI: 10.1093/jac/dkz247] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Revised: 05/03/2019] [Accepted: 05/16/2019] [Indexed: 12/23/2022] Open
Abstract
Abstract
Objectives
The optimal selection of antibacterials during polymicrobial infections is poorly defined. The objective of the current investigation was to quantify the pharmacodynamics of relevant antimicrobials during co-culture of Pseudomonas aeruginosa with two separate Staphylococcus aureus phenotypes.
Methods
Time–kill experiments were conducted against co-cultures of the P. aeruginosa strain PA01 paired with either the normal phenotype (NP) MRSA isolate COL or the small colony variant phenotype (SCVP) MRSA isolate Ia48. The killing by levofloxacin, gentamicin, clindamycin, vancomycin and polymyxin B was evaluated to investigate drugs with activity against one or both pathogens. A Hill-type function and a mechanism-based model were used to describe bacterial killing.
Results
P. aeruginosa attenuated the activity of clindamycin against NP MRSA, with a reduction in the Emax (maximal killing) from 3.67 (95% CI 2.79–4.56) in monoculture to 1.86 (95% CI 1.35–2.37) during co-culture, whereas a significant protective effect was not observed for other antibacterials. The reduction in NP MRSA killing by clindamycin was described well by a mechanism-based model that generated a maximal killing rate constant of clindamycin against the susceptible NP MRSA subpopulation of 0.267 h−1 in monoculture and 0.0395 h−1 in the presence of P. aeruginosa. During exposure to gentamicin, P. aeruginosa was the dominant organism in co-culture experiments regardless of the drug concentration or S. aureus phenotype; however, the SCVP MRSA was able to dominate the joint population beginning at a levofloxacin concentration of 1.5 mg/L.
Conclusions
The anti-staphylococcal activity of clindamycin was attenuated by the presence of P. aeruginosa.
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Affiliation(s)
- Justin R Lenhard
- California Northstate University College of Pharmacy, Elk Grove, CA, USA
| | - Nicholas M Smith
- Laboratory for Antimicrobial Dynamics, NYS Center of Excellence in Bioinformatics & Life Sciences, Buffalo, NY, USA
- School of Pharmacy and Pharmaceutical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Christine D Quach
- California Northstate University College of Pharmacy, Elk Grove, CA, USA
| | - Tuan Q Nguyen
- California Northstate University College of Pharmacy, Elk Grove, CA, USA
| | - Linh H Doan
- California Northstate University College of Pharmacy, Elk Grove, CA, USA
| | - Jeanette Chau
- California Northstate University College of Pharmacy, Elk Grove, CA, USA
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Karhade AV, Kwon JY. Trends in Foot and Ankle Studies Published in High-Impact General Medical Journals: A Systematic Review. J Foot Ankle Surg 2019; 58:540-544. [PMID: 30803910 DOI: 10.1053/j.jfas.2018.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Indexed: 02/03/2023]
Abstract
The foot and ankle surgery literature lacks an analysis of studies published in general medical journals. Studies published in general medical journals have high visibility and significant impact on decision making by medical practitioners and health care policy makers. Knowledge of the subject matter and methodologic characteristics of foot and ankle publications being read by general medical practitioners and the lay public is important to the practicing foot and ankle surgeon. A systematic review of foot and ankle studies published from 2000 to 2017 in 5 high-impact general medical journals was undertaken. Data extracted included study topic, study design, study demographics, and methodologic characteristics of randomized controlled trials (RCTs). There were 47 foot and ankle studies published in the selected medical journals examined during the study time period. Most common topics were diabetic foot ulcers (n = 25 [53.2%]), plantar fasciitis (n = 6 [12.8%]), and Achilles tendinopathy (n = 5 [10.6%]). The most common study types were reviews (n = 24 [51.1%]), RCTs (n = 12 [25.4%], and prospective studies (n = 6 [12.8%]). Of the published RCTs, the most common journal of publication was the Journal of the American Medical Association (n = 7 [58.3%]). The median number of citations for RCTs published before 2016 was 242.5. Of the small number of RCTs that compared operative with nonoperative treatment, the majority supported nonoperative management (n = 3 [75%]). Diabetic foot ulcers, plantar fasciitis, and Achilles tendinopathy are the most commonly published foot and ankle topics in general medical journals.
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Affiliation(s)
- Aditya V Karhade
- Medical Student, Orthopaedic Foot & Ankle Service, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - John Y Kwon
- Assistant Professor and Chief, Orthopaedic Foot & Ankle Service, Department of Orthopaedic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA.
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Neves JM, Duarte B, Pinto M, Formiga A, Neves J. Diabetic Foot Infection: Causative Pathogens and Empiric Antibiotherapy Considerations—The Experience of a Tertiary Center. INT J LOW EXTR WOUND 2019; 18:122-128. [DOI: 10.1177/1534734619839815] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Most moderate-to-severe diabetic foot infections (DFIs) require hospitalization with urgent surgical approach and administration of empiric antibiotherapy. To ensure optimal antibiotic coverage, regular microbiological background updates are imperative. The purpose is to characterize the microbiological profile and the antibiotic sensitivity pattern of the DFI causative pathogens isolated within a specialized DFI unit of a tertiary hospital, in order to establish evidence-based policies regarding empirical antibiotic use. A cross-sectional study was conducted. Microbiological cultures and corresponding antibiotic sensitivity tests collected from moderate-to-severe DFIs as a first approach to the hospitalized patient were retrieved and analyzed during a 12-month period. Two groups were analyzed: inpatients that had been previously followed at the diabetic foot clinic of the hospital and inpatients without a previous contact with the hospital services. A total of 125 isolates obtained from 87 patients were deemed for analysis. Globally, a predominance of Gram-positive bacteria was observed (60%). Staphylococcus aureus was the most common pathogen. The global ratio of methicillin-sensitive S aureus to methicillin-resistant S aureus (MRSA) was 1.3:1, with similar findings in both groups. According to the antibiotic sensitivity test results, and within the recommended empiric antibiotic regimens for DFI, piperacillin/tazobactam seems to be the most suitable option. Gram-positive bacteria prevail as the main isolates in DFIs. Screening for MRSA-specific risk factors is mandatory. When going for a first empiric therapy, piperacillin/tazobactam is recommended in this institution, and an anti-MRSA agent should be added early, if necessary. We encourage continuous monitoring for the bacterial prevalence in Portuguese diabetic foot centers as it is paramount for the decision making regarding DFI protocols.
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Affiliation(s)
- José Miguel Neves
- Department of Dermatology and Venereology, Centro Hospitalar Universitário de Lisboa Central
| | - Bruno Duarte
- Department of Dermatology and Venereology, Centro Hospitalar Universitário de Lisboa Central
| | - Margarida Pinto
- Microbiology Department, Centro Hospitalar Universitário de Lisboa Central
| | - Ana Formiga
- Diabetic Foot Unit, General Surgery Department, Centro Hospitalar Universitário de Lisboa Central
| | - José Neves
- Diabetic Foot Unit, General Surgery Department, Centro Hospitalar Universitário de Lisboa Central
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Schmidt BM, McHugh JB, Patel RM, Wrobel JS. Prospective Analysis of Surgical Bone Margins After Partial Foot Amputation in Diabetic Patients Admitted With Moderate to Severe Foot Infections. Foot Ankle Spec 2019; 12:131-137. [PMID: 29644884 PMCID: PMC7185086 DOI: 10.1177/1938640018770285] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Osteomyelitis is common in diabetic foot infections and medical management can lead to poor outcomes. Surgical management involves sending histopathologic and microbiologic specimens which guides future intervention. We examined the effect of obtainment of surgical margins in patients undergoing forefoot amputations to identify patient characteristics associated with outcomes. Secondary aims included evaluating interobserver reliability of histopathologic data at both the distal-to and proximal-to surgical bone margin. METHODS Data were prospectively collected on 72 individuals and was pooled for analysis. Standardized method to retrieve intraoperative bone margins was established. A univariate analysis was performed. Negative outcomes, including major lower extremity amputation, wound dehiscence, reulceration, reamputation, or death were recorded. RESULTS Viable proximal margins were obtained in 63 out of 72 cases (87.5%). Strong interobserver reliability of histopathology was recorded. Univariate analysis demonstrated preoperative platelets, albumin, probe-to-bone testing, absolute toe pressures, smaller wound surface area were associated with obtaining viable margins. Residual osteomyelitis resulted in readmission 2.6 times more often and more postoperative complications. CONCLUSIONS Certain patients were significantly different in the viable margin group versus dirty margin group. High interobserver reliability was demonstrated. Obtainment of viable margins resulted in reduced rates of readmission and negative outcomes. LEVELS OF EVIDENCE Prognostic, Level I: Prospective.
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Affiliation(s)
- Brian M. Schmidt
- Division of Metabolism, Endrocrinology, and Diabetes, Department of Internal Medicine
| | | | - Rajiv M. Patel
- Department of Pathology, Michigan Medicine, Ann Arbor, Michigan
| | - James S. Wrobel
- Division of Metabolism, Endrocrinology, and Diabetes, Department of Internal Medicine
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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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Chambers J, Page-Sharp M, Salman S, Dyer J, Davis TME, Batty KT, Manning L. Ertapenem for osteoarticular infections in obese patients: a pharmacokinetic study of plasma and bone concentrations. Eur J Clin Pharmacol 2018; 75:511-517. [PMID: 30511329 DOI: 10.1007/s00228-018-2597-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 11/04/2018] [Indexed: 11/25/2022]
Abstract
PURPOSE Ertapenem is used off-label to treat osteoarticular infections but there are few pharmacokinetic (PK) data to guide optimal dosing strategies in patients who may be obese with multiple co-morbidities including diabetes and peripheral vascular disease. METHODS Participants undergoing lower limb amputation or elective joint arthroplasty received a dose of intravenous ertapenem prior to surgery. Eight plasma samples were collected over 24 h, together with at least one bone sample per patient. Ertapenem concentrations in plasma and bone were measured using liquid-chromatography/mass-spectroscopy and analysed using non-linear mixed effects PK modelling. RESULTS Plasma and bone concentrations were obtained from 10 participants. The final population PK model showed that a fat free body mass was the most appropriate body size adjustment. Ertapenem diffused rapidly into bone but concentrations throughout the 24 h dosing period were on average 40-fold higher in plasma, corresponding to a bone to plasma ratio of 0.025, and highly variable between individuals. Simulations demonstrated a high probability of target attainment (PTA) for free plasma concentrations when the minimum inhibitory concentrations (MIC) were ≤ 0.25 mg/L. By contrast, at MICs of 0.5 mg/L and ≥ 1 mg/L, the fractions of patients attaining this target was ~ 80% and 40%, respectively. In bone, the PTA was ≤ 45% when the MIC was ≥ 0.25 mg/L. CONCLUSION Local bone and free plasma concentrations appear adequate for osteoarticular infections where Enterobacteriaceae are the main causative pathogens, but for Staphylococcus aureus and other bacteria, conventional dosing may lead to inadequate PTA.
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Affiliation(s)
- Jonathan Chambers
- Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Madhu Page-Sharp
- School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, Western Australia, Australia
| | - Sam Salman
- Faculty of Health and Medical Sciences, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - John Dyer
- Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Timothy M E Davis
- Faculty of Health and Medical Sciences, University of Western Australia, Fremantle Hospital, Fremantle, Western Australia, Australia
| | - Kevin T Batty
- School of Pharmacy and Biomedical Sciences, Curtin University, Bentley, Western Australia, Australia
| | - Laurens Manning
- Faculty of Health and Medical Sciences, Harry Perkins Research Institute, Fiona Stanley Hospital, University of Western Australia, PO Box 404, Bull Creek 6149, Murdoch, Western Australia, Australia.
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Tchero H, Kangambega P, Noubou L, Becsangele B, Fluieraru S, Teot L. Antibiotic therapy of diabetic foot infections: A systematic review of randomized controlled trials. Wound Repair Regen 2018; 26:381-391. [PMID: 30099812 DOI: 10.1111/wrr.12649] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 06/05/2018] [Indexed: 12/22/2022]
Abstract
Diabetic foot infection is a common diabetic complication that may end in lower limb amputation if not treated properly. We performed this systematic review to assess the clinical efficacy of different antibiotic regimens, whether systemic or topical, in the treatment of moderate to severe diabetic foot infections. We searched Medline, Web of Science, SCOPUS, Cochrane CENTRAL, and ScienceDirect for randomized controlled trials that evaluated the efficacy of antibiotic regimens in moderate to severe diabetic foot infections. The primary outcome of interest was the clinical efficacy (cure/improvement rates) of the regimens. We included 16 trials (4,158 patients) in this review, from which we extracted 10 comparisons: some trials compared systemic antibiotics to each other, others compared systemic to topical agents, while one study compared the combined topical and systemic agents to systemic antibiotics alone. Qualitative analysis of the findings of these studies showed that: (1) pipracillin/tazobactam was superior to ertapenem in severe infections (clinical resolution rate: 91.5% compared with PIP/TAZ 97.2%, p ≤ 0.04), but had similar efficacy in moderate infections, (2) ertapenem was more effective than tigecycline in moderate to severe infections (absolute difference -5.5, [95% CI -11.0, 0.1]), (3) the adjuvant use of topical agents with systemic antibiotics improved the outcomes, compared with systemic antibiotics alone (p = 0.024), (4) the rates of recurrence and re-ulceration were significantly lower in patients using the amino-penicillin regimen, compared with those using oral/intravenous ofloxacin, and (5) lower rates of complications accompanied the imipenem/cilastatin regimen, compared with the pipracillin/tazobactam regimen (p = 0.13). In conclusion, data from the included studies showed better results for ertapenem when compared with tigecycline; however, it was inferior to pipracillin/tazobactam in severe infections. The adjuvant use of topical agents improves the efficacy of systemic antibiotics in diabetic foot infection.
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Affiliation(s)
- Huidi Tchero
- Department of Trauma and Orthopedics Surgery and Wound Healing Unit, Saint Martin Hospital Center BP 381, CH Saint Martin, Guadeloupe
| | - Pauline Kangambega
- Division of Diabetes, Endocrinology and Metabolism, Pointe-A-Pitre CHRU, Pointe-A-Pitre
| | - Lazarre Noubou
- Department of Trauma and Orthopedics Surgery and Wound Healing Unit, Saint Martin Hospital Center BP 381, CH Saint Martin, Guadeloupe
| | - Beatrice Becsangele
- Wound Healing Unit, Saint Martin Hospital Center, BP 381, CH Saint Martin, Guadeloupe
| | - Sergiu Fluieraru
- Department of Reconstructive and Plastic Surgery, and Wound Healing Unit, University Hospital, Montpellier, France
| | - Luc Teot
- Department of Reconstructive and Plastic Surgery, and Wound Healing Unit, University Hospital, Montpellier, France
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Sato T, Abe T, Ichioka S. Factors impairing cell proliferation in the granulation tissue of pressure ulcers: Impact of bacterial burden. Wound Repair Regen 2018; 26:284-292. [PMID: 30265416 DOI: 10.1111/wrr.12675] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 07/24/2018] [Accepted: 09/05/2018] [Indexed: 11/30/2022]
Abstract
The authors aimed to assess the factors that impair cell proliferation in the granulation tissue of pressure ulcers using immunohistochemistry for the cell proliferation marker Ki-67. This was a single center, cross-sectional study. The study included 86 patients with stage III or IV pressure ulcers. Two granulation tissue biopsy specimens were obtained from 86 patients. The specimens were used for histological examination, Ki-67 immunohistochemistry, and bacterial count assessment. The % of Ki-67-stained cells was considered as the Ki-67 index. Pearson's product-moment correlation coefficient (r) was used to assess the relationship between the Ki-67 index and other quantitative variables, including age, body mass index, bacterial count (Log10 CFU/g), serum albumin level, hemoglobin level, white blood cell count, and C-reactive protein level. The Mann-Whitney U test was used to compare the mean Ki-67 index according to gender, diabetes, smoking status, and wound culture. Univariate and multivariate linear regression analyses were used to assess the association between the Ki-67 index and other parameters. The Mann-Whitney U test revealed that the bacteria-positive group had a lower Ki-67 index (p = 0.045). Bacterial count demonstrated a significant negative correlation with the Ki-67 index (r = -0.325, p = 0.002). Multivariate linear regression analysis showed that bacterial count was a significant predictor of the Ki-67 index. The adjusted β-coefficient was -1.34 (95% confidence interval, -2.01 to -0.66, p < 0.001). Among the isolated bacteria, Corynebacterium spp. and Staphylococcus aureus were significantly associated with a low Ki-67 index, but Pseudomonas aeruginosa was not. These results suggest a negative relationship between bacterial count and cell proliferation in pressure ulcer granulation tissue, as indicated by the Ki-67 index. Granulation tissue formation in pressure ulcers may be accelerated if high bacterial load is treated appropriately.
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Affiliation(s)
- Tomoya Sato
- Department of Plastic and Reconstructive Surgery, Saitama Medical University, Saitama, Japan
| | - Takahiro Abe
- Department of Oral and Maxillofacial Surgery, The University of Tokyo, Tokyo, Japan
| | - Shigeru Ichioka
- Department of Plastic and Reconstructive Surgery, Saitama Medical University, Saitama, Japan
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Henig O, Pogue JM, Cha R, Kilgore PE, Hayat U, Ja'ara M, Ali RM, Mahboob S, Pansare R, Deeds K, Joarder B, Kandala H, Dhar S, Kaye KS. Epidemiology of Diabetic Foot Infection in the Metro-Detroit Area With a Focus on Independent Predictors for Pathogens Resistant to Recommended Empiric Antimicrobial Therapy. Open Forum Infect Dis 2018; 5:ofy245. [PMID: 30402532 PMCID: PMC6215454 DOI: 10.1093/ofid/ofy245] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 09/25/2018] [Indexed: 11/13/2022] Open
Abstract
Background The polymicrobial nature of diabetic foot infection (DFI) and the emergence of antimicrobial resistance have complicated DFI treatment. Current treatment guidelines for deep DFI recommend coverage of methicillin-resistant Staphylococcus aureus (MRSA) and susceptible Enterobacteriaceae. This study aimed to describe the epidemiology of DFI and to identify predictors for DFI associated with multidrug-resistant organisms (MDROs) and pathogens resistant to recommended treatment (PRRT). Methods Adult patients admitted to Detroit Medical Center from January 2012 to December 2015 with DFI and positive cultures were included. Demographics, comorbidities, microbiological history, sepsis severity, and antimicrobial use within 3 months before DFI were obtained retrospectively. DFI-PRRT was defined as a DFI associated with a pathogen resistant to both vancomycin and ceftriaxone. DFI-MDRO pathogens included MRSA in addition to PRRT. Results Six-hundred forty-eight unique patients were included, with a mean age of 58.4 ± 13.7 years. DFI-MDRO accounted for 364 (56%) of the cohort, and 194 (30%) patients had DFI-PRRT. Independent predictors for DFI-PRRT included history of PRRT in a diabetic foot ulcer, antimicrobial exposure in the prior 90 days, peripheral vascular disease, and chronic kidney disease. Long-term care facility residence was independently associated with DFI due to ceftriaxone-resistant Enterobacteriaceae, and recent hospitalization was an independent predictor of DFI due to vancomycin-resistant Enterococcus. Conclusions An unexpectedly high prevalence of DFI-PRRT pathogens was identified. History of the same pathogen in a prior diabetic foot ulcer and recent antimicrobial exposure were independent predictors of DFI-PRRT and should be considered when selecting empiric DFI therapy.
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Affiliation(s)
- Oryan Henig
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Jason M Pogue
- School of Medicine, Wayne State University, Detroit, Michigan.,Department of Pharmacy Services, Detroit Medical Center, Sinai-Grace Hospital, Detroit, Michigan
| | - Raymond Cha
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan
| | - Paul E Kilgore
- Eugene Applebaum College of Pharmacy and Health Sciences, Wayne State University, Detroit, Michigan
| | - Umar Hayat
- Department of Internal Medicine, Detroit Medical Center, Detroit, Michigan
| | - Mahmoud Ja'ara
- Department of Internal Medicine, Detroit Medical Center, Detroit, Michigan
| | - Raza Muhamad Ali
- Allama Iqbal Medical College, Jinnah Hospital Lahore, Lahore, Pakistan
| | - Salman Mahboob
- Karmanos Cancer Institute, Wayne State University, Detroit, Michigan
| | - Rahul Pansare
- Department of Internal Medicine, St Mary Mercy Hospital, Livonia, Michigan
| | - Kathryn Deeds
- School of Medicine, Wayne State University, Detroit, Michigan
| | - Bushra Joarder
- School of Medicine, Wayne State University, Detroit, Michigan
| | - Hyndavi Kandala
- Department of Internal Medicine, Nassau University Medical Center, East Meadow, New York
| | - Sorabh Dhar
- School of Medicine, Wayne State University, Detroit, Michigan.,Department of Internal Medicine, Detroit Medical Center, Detroit, Michigan
| | - Keith S Kaye
- Division of Infectious Diseases, Department of Internal Medicine, University of Michigan Medical School, Ann Arbor, Michigan
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Jneid J, Cassir N, Schuldiner S, Jourdan N, Sotto A, Lavigne JP, La Scola B. Exploring the Microbiota of Diabetic Foot Infections With Culturomics. Front Cell Infect Microbiol 2018; 8:282. [PMID: 30155447 PMCID: PMC6102383 DOI: 10.3389/fcimb.2018.00282] [Citation(s) in RCA: 57] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 07/25/2018] [Indexed: 12/22/2022] Open
Abstract
The purpose of this prospective observational study was to evaluate the richness and diversity of bacteria in samples from diabetic foot infections using a culturomics approach. Bacterial culture findings from wound samples were analyzed together with clinical characteristics and treatment outcomes. We included 43 patients admitted to a French referral center with a moderate to severe diabetic foot infection. The 30,000 colonies identified yielded 53 different bacterial species. The global α-Shannon diversity was 3.34 and the bacterial richness per patient was 4 ± 2. Of all the identified bacterial species, 19 (35.8%) had never been previously cultured or identified by molecular methods from diabetic foot ulcers. Most of the samples were polymicrobial (N = 38; 88.3%). Of all the isolated species, the most prevalent were Staphylococcus aureus (N = 28; 52.8%), Enterococcus faecalis (N = 24; 45.2%), Enterobacter cloacae (N = 12; 22.6%), Staphylococcus lugdunensis (N = 10; 18.7%), Staphylococcus epidermidis (N = 6; 11.3%), Proteus mirabilis (N = 6; 11.3%), and Finegoldia magna (N = 5; 9.4%). The only factor associated with wound improvement after a 1-month follow-up was the presence of E. faecalis (p = 0.012) when compared with patients without wound improvement. This study confirms the complementary role of culturomics in the exploration of complex microbiota. Further studies on a larger scale are needed to fully understand the clinical importance of the microbiota of diabetic foot infections.
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Affiliation(s)
- Joanne Jneid
- MEPHI, APHM, IRD, Aix Marseille University, IHU-Méditerranée Infection, Marseille, France
| | - Nadim Cassir
- MEPHI, APHM, IRD, Aix Marseille University, IHU-Méditerranée Infection, Marseille, France
| | - Sophie Schuldiner
- Service des Maladies Métaboliques et Endocriniennes, Centre Hospitalo-Universitaire de Nîmes, Nîmes, France
| | - Nathalie Jourdan
- Service des Maladies Métaboliques et Endocriniennes, Centre Hospitalo-Universitaire Carémeau, Nîmes, France
| | - Albert Sotto
- Service des Maladies Infectieuses et Tropicales, Centre Hospitalo-Universitaire Carémeau, Nîmes, France.,INSERM, Université de Montpellier, Nîmes, France
| | - Jean-Philippe Lavigne
- INSERM, Université de Montpellier, Nîmes, France.,Service de Microbiologie, Centre Hospitalo-Universitaire Carémeau, Nîmes, France
| | - Bernard La Scola
- MEPHI, APHM, IRD, Aix Marseille University, IHU-Méditerranée Infection, Marseille, France
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Kaimkhani GM, Siddiqui AA, Rasheed N, Rajput MI, Kumar J, Khan MH, Nisar S, Mustafa S, Yaqoob U. Pattern of Infecting Microorganisms and Their Susceptibility to Antimicrobial Drugs in Patients with Diabetic Foot Infections in a Tertiary Care Hospital in Karachi, Pakistan. Cureus 2018; 10:e2872. [PMID: 30155375 PMCID: PMC6110415 DOI: 10.7759/cureus.2872] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Diabetes mellitus is a universal health problem, with its prevalence in Pakistan making it among the top 10 countries in the world. Approximately 13.9 million people in Pakistan will have developed diabetes by 2030. Diabetic foot ulcer (DFU) is one of the more serious complications of diabetes. If not treated properly, patients may develop diabetic foot osteomyelitis leading to gangrene and amputation. These infections are usually polymicrobial, with Staphylococcus aureus (S. aureus), Proteus, Pseudomonas, and Escherichia coli (E. coli) being among the more common organisms isolated from DFU. This survey of patients with DFU in a tertiary hospital in Karachi, Pakistan found 68.5% of patients had peripheral neuropathy, 57% had chronic osteomyelitis, and 37% and 49% had Wagner grades 2 and 3, respectively. Infections were polymicrobial in 83% of patients, E. coli was isolated from 63%, and S. aureus from 58%. Of the isolated organisms, 95% were sensitive to meropenem and 81% to linezolid.
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Affiliation(s)
| | - Adeel A Siddiqui
- Orthopedic Surgery, Dow University of Health Sciences, Karachi, PAK
| | - Nusrat Rasheed
- Orthopaedic Surgery, Dow University of Health Sciences, Karachi, PAK
| | | | - Jagdesh Kumar
- Orthopaedic Surgery, Dow University of Health Sciences, Karachi, PAK
| | | | - Shahzadi Nisar
- Orthopaedic Surgery, Dow University of Health Sciences, Karachi, PAK
| | - Sheema Mustafa
- Orthopaedic Surgery, Dow University of Health Sciences, Karachi , PAK
| | - Uzair Yaqoob
- Surgery, Jinnah Postgraduate Medical Centre, Karachi, PAK
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Almarzoky Abuhussain SS, Goodlet KJ, Nailor MD, Nicolau DP. Optimizing skin and skin structure infection outcomes: considerations of cost of care. Expert Rev Pharmacoecon Outcomes Res 2018. [PMID: 29521147 DOI: 10.1080/14737167.2018.1450142] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Skin and skin structure infections (SSSIs) refer to a collection of clinical infectious syndromes involving layers of skin and associated soft tissues. Although associated with less morbidity and mortality than other common skin infections, SSSIs represent a significant increasing source of healthcare expense, with a prevalence of 500 episodes per 10,000 patient-years in the United States resulting in burdening health care systems, of approximately $6 billion annually. AREAS COVERED Opportunities to reduce costs of care associated with SSSI are highlighted, including transitions of care and avoiding unnecessary hospital admissions. Moreover, we reviewed new antibiotics (e.g. single dose glycopeptides), and the impact of consulting specialists in the emergency department on SSSI treatment outcomes. EXPERT COMMENTARY New healthcare models and payment strategies combined with new therapeutics are challenging norms of care. Newer drugs to treat skin infections can move a substantive percent of patients previously admitted to hospital care to the outpatient setting. Additionally, patients can be managed with oral or one time intravenous regimens, improving the likelihood of patient adherence and satisfaction. These variables need to be weighed against added acquisition costs and the development of thoughtful algorithms is needed to direct care and optimize treatment, cost, and patient satisfaction.
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Affiliation(s)
- S S Almarzoky Abuhussain
- a Ctr. for Anti-Infective Res. & Dev. , Hartford Hospital , Hartford , CT , USA.,b Umm Al-Qura University, Collage of Pharmacy, Clinical Pharmacy Department , Makkah , Saudi Arabia
| | - K J Goodlet
- c Midwestern University, College of Pharmacy, Department of Pharmacy Practice , Glendale , AZ , USA
| | - M D Nailor
- d St. Joseph's Hospital and Medical Center, Department of Pharmacy Services , Phoenix , AZ , USA
| | - D P Nicolau
- a Ctr. for Anti-Infective Res. & Dev. , Hartford Hospital , Hartford , CT , USA
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Fry W, McCafferty S, Gooday C, Nunney I, Dhatariya KK. Assessing the Effect of Piperacillin/Tazobactam on Hematological Parameters in Patients Admitted with Moderate or Severe Foot Infections. Diabetes Ther 2018; 9:219-228. [PMID: 29302933 PMCID: PMC5801243 DOI: 10.1007/s13300-017-0357-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Piperacillin/tazobactam is a commonly used antibiotic for the empirical treatment of severe diabetic foot infections. One of the most feared complications of this drug is the development of pancytopenia. The aim of this study was to determine whether the use of piperacillin/tazobactam caused any hematological changes in patients admitted with severe diabetes-related foot infections from a specialist multidisciplinary foot clinic. Specifically, looking at whether it caused anemia, leukopenia, neutropenia, or thrombocytopenia. METHODS A 1-year retrospective analysis of patients admitted to a tertiary care center for treatment of diabetes-related foot infection using piperacillin/tazobactam. Hematological indices, urea and electrolytes, and C-reactive protein (CRP) were recorded pretreatment, during treatment, and posttreatment. HbA1c, vitamin B12, folate, thyroid-stimulating hormone, and free thyroxin were also analyzed to exclude any potential confounders as a cause of pancytopenia. RESULTS A total of 154 patients were admitted between 1 January 2016 and 31 December 2016 who received piperacillin/tazobactam for severe diabetes-related foot infection. On admission, white cell count and CRP were raised and fell significantly within the first 48 h. Other hematological factors did not change. Five patients developed a mild pancytopenia, of which three were unexplained. CONCLUSION In this relatively small cohort, pancytopenia did not occur. As such, piperacillin/tazobactam appeared to have a low risk of adverse hematological outcomes and remains the treatment of choice for severe diabetes-related foot infections.
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Affiliation(s)
- Will Fry
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
| | - Sean McCafferty
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
| | - Catherine Gooday
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, NR4 7UY, UK
| | - Ian Nunney
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
| | - Ketan K Dhatariya
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK.
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, NR4 7UY, UK.
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Takimoto K, Wang Q, Suzuki D, Katayama M, Hayashi Y. Clinical efficacy of piperacillin/tazobactam in the treatment of complicated skin and soft tissue infections. Expert Opin Pharmacother 2017. [PMID: 28627952 DOI: 10.1080/14656566.2017.1341491] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Complicated skin and soft tissue infections (cSSTIs) are skin and soft tissue infections (SSTIs) that involve deep soft tissue. cSSTIs often require surgical intervention and/or hospitalization. cSSTIs are associated with significant mortality and morbidity, and carry a significant burden on health care systems. Piperacillin/tazobactam has been regarded as a standard treatment for cSSTIs because of its antibiotic spectrum, safety and clinical efficacy. Several antibiotics, as compared to piperacillin/tazobactam, have been evaluated in the treatment of cSSTIs. Areas covered: This review summarizes randomized controlled trials (RCTs) evaluating the clinical efficacy of piperacillin/tazobactam for the treatment of cSSTIs. Expert opinion: Piperacillin/tazobactam, which covers most causative organisms in cSSTIs, is the drug of choice for the treatment of cSSTIs. Other options such as ertapenem and moxifloxacin may be reasonable where multiple daily dosing or intravenous administration is inappropriate. But in general, they should be avoided as an empirical treatment because of their highly association with resistant bacteria, which are becoming a global threat. Therefore, piperacilin/tazobactam is appropriate as an empirical therapy for the treatment of SSTIs and should be de-escalated as soon as causative organisms are identified, their drug-sensitivity results are available, and clinical condition becomes stable.
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Affiliation(s)
- Kohei Takimoto
- a Department of Intensive Care Medicine , Kameda Medical Center , Kamogawa , Japan
| | - Qianzhi Wang
- b Postgraduate Education Center , Kameda Medical Center , Kamogawa , Japan
| | - Daisuke Suzuki
- c Department of Infectious Diseases , Kameda Medical Center , Kamogawa , Japan
| | - Mitsuya Katayama
- d Department of General Internal Medicine , Kameda Medical Center , Kamogawa , Japan
| | - Yoshiro Hayashi
- a Department of Intensive Care Medicine , Kameda Medical Center , Kamogawa , Japan
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Reveles KR, Duhon BM, Moore RJ, Hand EO, Howell CK. Epidemiology of Methicillin-Resistant Staphylococcus aureus Diabetic Foot Infections in a Large Academic Hospital: Implications for Antimicrobial Stewardship. PLoS One 2016; 11:e0161658. [PMID: 27556897 PMCID: PMC4996514 DOI: 10.1371/journal.pone.0161658] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 08/09/2016] [Indexed: 12/15/2022] Open
Abstract
Introduction Diabetic foot infections (DFIs) are the leading cause of non-traumatic lower extremity amputations in the United States. Antimicrobials active against methicillin-resistant Staphylococcus aureus (MRSA) are recommended in patients with associated risk factors; however, limited data exist to support these recommendations. Due to the changing epidemiology of MRSA, and the consequences of unnecessary antibiotic therapy, guidance regarding the necessity of empirical MRSA coverage in DFIs is needed. We sought to 1) describe the prevalence of MRSA DFIs at our institution and compare to the proportion of patients who receive MRSA antibiotic coverage and 2) identify risk factors for MRSA DFI. Methods This was a retrospective cohort study of all adult, culture-positive DFI patients managed at University Hospital, San Antonio, TX between January 1, 2010 and September 1, 2014. Patient eligibility included a principal ICD-9-CM discharge diagnosis code for foot infection and a secondary diagnosis of diabetes. The primary outcome was MRSA identified in the wound culture. Independent variables assessed included patient demographics, comorbidities, prior hospitalization, DFI therapies, prior antibiotics, prior MRSA infection, and laboratory values. Multivariable logistic regression was used to identify risk factors for MRSA DFI. Results Overall, 318 patients met inclusion criteria. Patients were predominantly Hispanic (79%) and male (69%). Common comorbidities included hypertension (76%), dyslipidemia (52%), and obesity (49%). S. aureus was present in 46% of culture-positive DFIs (MRSA, 15%). A total of 273 patients (86%) received MRSA antibiotic coverage, resulting in 71% unnecessary use. Male gender (OR 3.09, 95% CI 1.37–7.99) and bone involvement (OR 1.93, 1.00–3.78) were found to be independent risk factors for MRSA DFI. Conclusions Although MRSA was the causative pathogen in a small number of DFI, antibiotic coverage targeted against MRSA was unnecessarily high.
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Affiliation(s)
- Kelly R. Reveles
- College of Pharmacy, The University of Texas at Austin, Austin, Texas, United States of America
- Pharmacotherapy Education & Research Center, University of Texas Health Science Center San Antonio, San Antonio, Texas, United States of America
- * E-mail:
| | - Bryson M. Duhon
- College of Pharmacy, The University of Texas at Austin, Austin, Texas, United States of America
- Pharmacotherapy Education & Research Center, University of Texas Health Science Center San Antonio, San Antonio, Texas, United States of America
- University Health System, San Antonio, Texas, United States of America
| | - Robert J. Moore
- College of Pharmacy, The University of Texas at Austin, Austin, Texas, United States of America
- Pharmacotherapy Education & Research Center, University of Texas Health Science Center San Antonio, San Antonio, Texas, United States of America
| | - Elizabeth O. Hand
- College of Pharmacy, The University of Texas at Austin, Austin, Texas, United States of America
- Pharmacotherapy Education & Research Center, University of Texas Health Science Center San Antonio, San Antonio, Texas, United States of America
- University Health System, San Antonio, Texas, United States of America
| | - Crystal K. Howell
- College of Pharmacy, The University of Texas at Austin, Austin, Texas, United States of America
- Pharmacotherapy Education & Research Center, University of Texas Health Science Center San Antonio, San Antonio, Texas, United States of America
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Robineau O, Nguyen S, Senneville E. Optimising the quality and outcomes of treatments for diabetic foot infections. Expert Rev Anti Infect Ther 2016; 14:817-27. [PMID: 27448992 DOI: 10.1080/14787210.2016.1214072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Infection is the commonest foot complication that arises in people with diabetes and may lead to amputation and even death. The emergence of multidrug resistant bacteria, especially in Gram negative rods, may have a negative impact on the chances of cure in these patients. AREAS COVERED We searched the Medline and Pubmed databases for studies using the keywords 'diabetic foot infection' and 'diabetic foot osteomyelits' from 1980 to 2016. Expert commentary: Much has been done in the field of diabetic foot infection regarding pathophysiology, diagnosis and treatment. The construction of multidisciplinary teams is probably the most efficient way to improve the patients' outcome. The rational use of antibiotics and surgical skills are essential in these potentially severe infections. Each case of diabetic infection deserves to be discussed in the light of the current guidelines and the local resources. Because of the overal poor outcome of these infections, prevention remains a priority.
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Affiliation(s)
- O Robineau
- a University Department of Infectious Diseases , Faculty of Medicine of Lille University II, Gustave Dron Hospital , Tourcoing , France
| | - S Nguyen
- a University Department of Infectious Diseases , Faculty of Medicine of Lille University II, Gustave Dron Hospital , Tourcoing , France
| | - E Senneville
- a University Department of Infectious Diseases , Faculty of Medicine of Lille University II, Gustave Dron Hospital , Tourcoing , France
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Isei T, Abe M, Nakanishi T, Matsuo K, Yamasaki O, Asano Y, Ishii T, Ito T, Inoue Y, Imafuku S, Irisawa R, Ohtsuka M, Ohtsuka M, Ogawa F, Kadono T, Kodera M, Kawakami T, Kawaguchi M, Kukino R, Kono T, Sakai K, Takahara M, Tanioka M, Nakamura Y, Hashimoto A, Hasegawa M, Hayashi M, Fujimoto M, Fujiwara H, Maekawa T, Madokoro N, Yoshino Y, Le Pavoux A, Tachibana T, Ihn H. The wound/burn guidelines - 3: Guidelines for the diagnosis and treatment for diabetic ulcer/gangrene. J Dermatol 2016; 43:591-619. [DOI: 10.1111/1346-8138.13285] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 12/02/2015] [Indexed: 12/16/2022]
Affiliation(s)
- Taiki Isei
- Department of Dermatology; Kansai Medical University; Osaka Japan
| | - Masatoshi Abe
- Department of Dermatology; Gunma University Graduate School of Medicine; Gunma Japan
| | - Takeshi Nakanishi
- Department of Dermatology; Osaka City University Graduate School of Medicine; Osaka Japan
| | - Koma Matsuo
- Department of Dermatology; The Jikei University School of Medicine; Tokyo Japan
| | - Osamu Yamasaki
- Department of Dermatology; Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences; Okayama Japan
| | - Yoshihide Asano
- Department of Dermatology; Faculty of Medicine; University of Tokyo; Tokyo Japan
| | - Takayuki Ishii
- Department of Dermatology; Faculty of Medicine; Institute of Medical, Pharmaceutical and Health Sciences; Kanazawa University; Ishikawa Japan
| | - Takaaki Ito
- Department of Dermatology; Hyogo College of Medicine; Hyogo Japan
| | - Yuji Inoue
- Department of Dermatology and Plastic Surgery; Faculty of Life Sciences; Kumamoto University; Kumamoto Japan
| | - Shinichi Imafuku
- Department of Dermatology; Faculty of Medicine; Fukuoka University; Fukuoka Japan
| | - Ryokichi Irisawa
- Department of Dermatology; Tokyo Medical University; Tokyo Japan
| | - Masaki Ohtsuka
- Department of Dermatology; Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences; Okayama Japan
| | - Mikio Ohtsuka
- Department of Dermatology; Fukushima Medical University; Fukushima Japan
| | - Fumihide Ogawa
- Department of Dermatology; Nagasaki University Graduate School of Biomedical Sciences; Nagasaki Japan
| | - Takafumi Kadono
- Department of Dermatology; Faculty of Medicine; University of Tokyo; Tokyo Japan
| | - Masanari Kodera
- Department of Dermatology; Japan Community Health Care Organization Chukyo Hospital; Aichi Japan
| | - Tamihiro Kawakami
- Department of Dermatology; St. Marianna University School of Medicine; Kanagawa Japan
| | - Masakazu Kawaguchi
- Department of Dermatology; Yamagata University Faculty of Medicine; Yamagata Japan
| | - Ryuichi Kukino
- Department of Dermatology; NTT Medical Center; Tokyo Japan
| | - Takeshi Kono
- Department of Dermatology; Nippon Medical School; Tokyo Japan
| | - Keisuke Sakai
- Intensive Care Unit; Kumamoto University Hospital; Kumamoto Japan
| | - Masakazu Takahara
- Department of Dermatology; Graduate School of Medical Sciences; Kyushu University; Fukuoka Japan
| | - Miki Tanioka
- Department of Dermatology; Kyoto University Graduate School of Medicine; Kyoto Japan
| | | | - Akira Hashimoto
- Department of Dermatology; Tohoku University Graduate School of Medicine; Miyagi Japan
| | - Minoru Hasegawa
- Department of Dermatology; Faculty of Medicine; Institute of Medical, Pharmaceutical and Health Sciences; Kanazawa University; Ishikawa Japan
| | - Masahiro Hayashi
- Department of Dermatology; Yamagata University Faculty of Medicine; Yamagata Japan
| | - Manabu Fujimoto
- Department of Dermatology; Faculty of Medicine; Institute of Medical, Pharmaceutical and Health Sciences; Kanazawa University; Ishikawa Japan
| | - Hiroshi Fujiwara
- Department of Dermatology; Niigata University Graduate School of Medical and Dental Sciences; Niigata Japan
| | - Takeo Maekawa
- Department of Dermatology; Jichi Medical University; Tochigi Japan
| | - Naoki Madokoro
- Department of Dermatology; Mazda Hospital; Hiroshima Japan
| | - Yuichiro Yoshino
- Department of Dermatology; Japanese Red Cross Kumamoto Hospital; Kumamoto Japan
| | | | - Takao Tachibana
- Department of Dermatology; Osaka Red Cross Hospital; Osaka Japan
| | - Hironobu Ihn
- Department of Dermatology and Plastic Surgery; Faculty of Life Sciences; Kumamoto University; Kumamoto Japan
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Xu ZR, Ran XW, Xian Y, Yan XD, Yuan GY, Mu SM, Shen JF, Zhang BS, Gan WJ, Wang J. Ertapenem versus piperacillin/tazobactam for diabetic foot infections in China: a Phase 3, multicentre, randomized, double-blind, active-controlled, non-inferiority trial. J Antimicrob Chemother 2016; 71:1688-96. [PMID: 26888908 DOI: 10.1093/jac/dkw004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 01/04/2016] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Few randomized controlled studies have compared antibiotic regimens against diabetic foot infections (DFIs) in Chinese patients. We evaluated the efficacy and safety of ertapenem versus piperacillin/tazobactam for the treatment of DFIs in Chinese patients. METHODS Patients with moderate to severe DFIs requiring parenteral antibiotics were randomized in a 1 : 1 ratio to receive ertapenem (1.0 g once daily) or piperacillin/tazobactam (4.5 g every 8 h) by 30 min intravenous (iv) infusions for ≥5 days. The primary outcome was favourable clinical response at discontinuation of iv therapy (DCIV). An evaluable-patient population was identified for primary analysis of non-inferiority at -15%. Safety was assessed. ClinicalTrials.gov: NCT01370616. RESULTS Of 565 patients randomized, 443 patients (ertapenem = 219 and piperacillin/tazobactam = 224) were clinically evaluable for primary analysis. In the clinically evaluable population, the proportions of patients with favourable clinical response at DCIV were 93.6% (205/219) and 97.3% (218/224) in the ertapenem and piperacillin/tazobactam groups, respectively (difference: -3.8%, 95% CI: -8.3%, 0.0%). Ertapenem had a significantly lower favourable clinical response rate (91.5% versus 97.2%, 95% CI for difference: -12.1%, -0.3%) at DCIV in severe DFI patients. In the modified ITT population, 88.8% (237/267) and 90.6% (241/266) of patients in the ertapenem and piperacillin/tazobactam groups, respectively, had favourable clinical responses at DCIV (difference: -1.9%, 95% CI: -7.3%, 3.3%). Microbiological eradications of causative pathogens and adverse events were similar between treatment groups. CONCLUSIONS Treatment with ertapenem was non-inferior to piperacillin/tazobactam in Chinese patients with DFIs. Ertapenem treatment resulted in a markedly lower rate of clinical resolution in severe DFIs.
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Affiliation(s)
| | - Xing-Wu Ran
- West China Hospital, Sichuan University, Chengdu, China
| | - Yang Xian
- Sichuan Academy of Medical Sciences, Sichuan Provincial People's Hospital, Chengdu, China
| | - Xiao-Dong Yan
- The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Guo-Yue Yuan
- Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | | | | | | | - Wei-Jin Gan
- Biostatistics, PAREXEL International, Shanghai, China
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Lipsky BA, Aragón-Sánchez J, Diggle M, Embil J, Kono S, Lavery L, Senneville É, Urbančič-Rovan V, Van Asten S, Peters EJG. IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes. Diabetes Metab Res Rev 2016; 32 Suppl 1:45-74. [PMID: 26386266 DOI: 10.1002/dmrr.2699] [Citation(s) in RCA: 334] [Impact Index Per Article: 41.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
- Benjamin A Lipsky
- Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- University of Oxford, Oxford, UK
| | | | - Mathew Diggle
- Nottingham University Hospitals Trust, Nottingham, UK
| | - John Embil
- University of Manitoba, Winnipeg, MB, Canada
| | - Shigeo Kono
- WHO-collaborating Centre for Diabetes, National Hospital Organization, Kyoto Medical Center, Kyoto, Japan
| | - Lawrence Lavery
- University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, TX, USA
| | | | | | - Suzanne Van Asten
- University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, TX, USA
- VU University Medical Centre, Amsterdam, The Netherlands
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