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Bader MS, Hawboldt J, Vincent Y, Irfan N, Mertz D, Farrell A, Brooks A. Distant metastatic foci of infection in adult patients with diabetic foot - not as rare as we think?: case series and review of the literature. Infect Dis (Lond) 2021; 53:255-273. [PMID: 33423592 DOI: 10.1080/23744235.2020.1868569] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Diabetic foot is one of the common complications of diabetes mellitus. We report clinical and microbiological characteristics and outcomes of cases with distant metastatic foci of infection arising from diabetic foot. METHODS Retrospective review of adult patients with diabetic foot infection or diabetic foot ulcer who demonstrated distant metastatic foci of infection between August 2017 and December 2019. We performed a literature search of similar cases published until June 2020. RESULTS Twelve patients with diabetic foot infection or diabetic foot ulcer with distant metastatic foci of infection were identified. The median age of patients was 67.5 years (range 60.5-73.5 years) and 11 males. The most common distant metastatic foci of infection included endocarditis (n = 7) followed by septic arthritis (n = 3) and spine infections (n = 2). Five patients had multiple site and organ involvement. Staphylococcus aureus was the only organism isolated from blood (n = 11), diabetic foot (n = 7), and metastatic foci (n = 8) sources. Three patients died and three had a relapse of distant metastatic foci of infection. Thirty-eight cases were identified in the literature with similar characteristics. CONCLUSIONS Prevalence of distant metastatic foci of infection in adult patients with diabetic foot and burden of illness, in terms of mortality, morbidity, and length of hospital stay, appears to be underreported in the literature. A large prospective study is needed to assess the true prevalence of complications, associated risk factors, outcomes and prognostic factors.
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Affiliation(s)
- Mazen S Bader
- Division of Infectious Diseases, Department of Medicine, Faculty of Health Sciences, Juravinski Hospital and Cancer Centre, McMaster University, Hamilton, Canada
| | - John Hawboldt
- School of Pharmacy, Memorial University of Newfoundland, St Johns, Canada
| | - Yasmeen Vincent
- Departments of Pathology and Molecular Medicine, McMaster University, Hamilton, Canada
| | - Neal Irfan
- Department of Pharmacy, Hamilton Health Sciences, Hamilton General Hospital, Hamilton, Canada
| | - Dominik Mertz
- Departments of Medicine, Pathology and Molecular Medicine and Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Alison Farrell
- Public Services Librarian HSL, Memorial University of Newfoundland, St Johns, Canada
| | - Annie Brooks
- Department of Pharmacy, Hamilton Health Sciences, Juravinski Hospital and Cancer Centre, Hamilton, Canada
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Chen SY, Giurini JM, Karchmer AW. Invasive Systemic Infection After Hospital Treatment for Diabetic Foot Ulcer: Risk of Occurrence and Effect on Survival. Clin Infect Dis 2016; 64:326-334. [PMID: 28013263 DOI: 10.1093/cid/ciw736] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 11/07/2016] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Diabetic foot ulcers (DFUs) threaten limbs and prompt hospitalization. After hospitalization, remote-site invasive systemic infection related to DFU (DFU-ISI) may occur. The characteristics of DFU-ISIs and their effect on mortality risk have not been defined. METHODS We conducted a retrospective cohort study of 819 diabetic patients hospitalized for treatment of 1212 unique DFUs during a 9-year period. We defined the index ulcer as that present at the first (index) DFU admission to our hospital. We defined DFU-ISI as a nonfoot infection that occurred after the index hospitalization and was caused by a microorganism concomitantly or previously cultured from the index ulcer. We determined the frequency, risk factors, and mortality risk associated with DFU-ISIs. RESULTS After 1212 index DFU hospitalizations, 141 patients had 172 DFU-ISIs. Of the initial 141 DFU-ISIs, 64% were bacteremia, 13% deep abscesses, 10% pneumonia, 7% endocarditis, and 6% skeletal infections. Methicillin-resistant Staphylococcus aureus (MRSA) caused 57% of the ISIs. Patients with initial DFU cultures yielding MRSA and protracted open ulcers had a high 24-month cumulative probability of DFU-ISI (31%) and all-cause mortality rate (13%). Analysis with Cox regression modeling showed that complicated ulcer healing (hazard ratio, 3.812; 95% confidence interval, 2.434-5.971) and initial DFU culture yielding MRSA (2.030; 1.452-2.838) predicted DFU-ISIs and that DFU-ISIs were associated with increased mortality risk (1.987; 1.106-3.568). CONCLUSIONS DFU-ISIs are important late complications of DFUs. Prevention of DFU-ISIs should be studied prospectively. Meanwhile, clinicians should aggressively incorporate treatment to accelerate ulcer healing and address MRSA into the care of diabetic patients with foot ulcers.
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Affiliation(s)
- Shey-Ying Chen
- Division of Infectious Diseases, Department of Medicine, and
- Department of Emergency Medicine, National Taiwan University Hospital, College of Medicine, Taipei
| | - John M Giurini
- Division of Podiatry, Department of Surgery, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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Mantovani A, Trombetta M, Imbriaco C, Rigolon R, Mingolla L, Zamboni F, Dal Molin F, Cioccoloni D, Sanga V, Bruti M, Brocco E, Conti M, Ravenna G, Perrone F, Stoico V, Bonora E. Diabetic foot complicated by vertebral osteomyelitis and epidural abscess. Endocrinol Diabetes Metab Case Rep 2016; 2016:150132. [PMID: 27252859 PMCID: PMC4872002 DOI: 10.1530/edm-15-0132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 04/21/2016] [Indexed: 12/18/2022] Open
Abstract
UNLABELLED Vertebral osteomyelitis (or spondylodiscitis) is steadily increasing in Western countries and often results from hematogenous seeding, direct inoculation during spinal surgery, or contiguous spread from an infection in the adjacent soft tissue. We present the case of a 67-year-old white patient with type 2 diabetes who went to Hospital for high fever, back pain, and worsening of known infected ulcers in the left foot. Despite intravenous antibiotic treatment and surgical debridement of the foot infection, high fever and lower back pain continued. Bone biopsy and two consecutive blood cultures were positive for Staphylococcus aureus. A spinal magnetic resonance imaging (MRI) was performed, revealing serious osteomyelitis in L4 and L5 complicated by an epidural abscess. Contiguous or other distant focuses of infection were not identified. In this case, diabetic foot could be considered as a primary distant focus for vertebral osteomyelitis. Clinicians should consider vertebral osteomyelitis as a 'possible' diagnosis in patients with type 2 diabetes complicated by foot infection that is associated with fever and lower back pain. LEARNING POINTS Vertebral osteomyelitis is increasing in Western countries, especially in patients with type 2 diabetes.The primary focus of infection is the genitourinary tract followed by skin, soft tissue, endocarditis, bursitis, septic arthritis, and intravascular access.Diabetic foot could be a rare primary focus of infection for vertebral osteomyelitis, and, however, vertebral osteomyelitis could be a serious, albeit rare, complication of diabetic foot.Clinicians should keep in mind the many potential complications of diabetic foot ulcerations and consider vertebral osteomyelitis as a "possible" diagnosis in patients with type 2 diabetes and foot ulcers associated with nonspecific symptoms such as lower back pain.Early diagnosis and correct management of vertebral osteomyelitis are crucial to improve clinical outcomes.
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Affiliation(s)
- Alessandro Mantovani
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Maddalena Trombetta
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Chiara Imbriaco
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Riccardo Rigolon
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Lucia Mingolla
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Federica Zamboni
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Francesca Dal Molin
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Dario Cioccoloni
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Viola Sanga
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Massimiliano Bruti
- Division of Plastic Surgery, Department of Surgery, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Enrico Brocco
- Regional Referral Center for the Treatment of Diabetic Foot , Policlinico Abano Terme, Padova , Italy
| | - Michela Conti
- Division of Infectious Disease, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Giorgio Ravenna
- Division of Neurosurgery, Department of Surgery, University and Azienda Ospedaliera Universitaria Integrataof Verona , Verona , Italy
| | - Fabrizia Perrone
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Vincenzo Stoico
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
| | - Enzo Bonora
- Division of Endocrinology, Diabetes and Metabolism, Department of Medicine, University and Azienda Ospedaliera Universitaria Integrata of Verona , Verona , Italy
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Epstein NE. Timing and prognosis of surgery for spinal epidural abscess: A review. Surg Neurol Int 2015; 6:S475-86. [PMID: 26605109 PMCID: PMC4617026 DOI: 10.4103/2152-7806.166887] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 08/10/2015] [Indexed: 12/12/2022] Open
Abstract
Background: The nonsurgical versus surgical management of spinal epidural abscesses (SEAs) remains controversial. Even with the best preoperative screening for multiple risk factors, high nonoperative failure rates are attended by considerable morbidity (e.g., irreversible paralysis) and mortality. Therefore, the focus remains on early surgery. Methods: Most papers promote early recognition of the clinical triad (e.g., fever [50%], spinal pain [92–100%], and neurological deficits [47%]) for SEA. They also identify SEA-related risk factors for choosing nonsurgical versus surgical approaches; advanced age (>65 or 80), diabetes (15–30%), cancer, intravenous drug abuse (25%), smoking (23%), elevated white blood cell count (>12.5), high C-reactive protein >115, positive blood cultures, magnetic resonance imaging/computed tomographic documented cord compression, and significant neurological deficits (e.g., 19–45%). Results: Surgical options include: decompressions, open versus minimally invasive biopsy/culture/irrigation, or fusions. Up to 75% of SEA involve the thoracolumbar spine, and 50% are located ventrally. Wound cultures are positive in up to 78.8% of cases and are often (60%) correlated with positive blood cultures. The most typical offending organism is methicillin resistant Staphylococcus aureus, followed by methicillin sensitive S. aureus. Unfortunately, the failure rates for nonoperative treatment of SEA remain high (e.g., 41–42.5%), contributing to significant morbidity (22% risk of permanent paralysis), and mortality (3–25%). Conclusion: The vast majority of studies advocated early surgery to achieve better outcomes for treating SEA; this avoids high failure rates (41–42.5%) for nonoperative therapy, and limits morbidity/mortality rates.
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Affiliation(s)
- Nancy E Epstein
- Department of NeuroScience/Neurosurgery, Winthrop University Hospital, Mineola, New York 11501, USA
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