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Reinert N, Wetzel K, Franzeck F, Morgenstern M, Aschwanden M, Wolff T, Clauss M, Sendi P. What is the agreement between principles and practice of antibiotic stewardship in the management of diabetic foot infection: an in-hospital quality control study. J Bone Jt Infect 2024; 9:183-190. [PMID: 39040989 PMCID: PMC11262018 DOI: 10.5194/jbji-9-183-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2024] [Accepted: 05/21/2024] [Indexed: 07/24/2024] Open
Abstract
Introduction: Standardization of diagnostic and treatment concepts in diabetes-related foot infection (DFI) is challenging. In 2019, specific recommendations regarding diagnostic principles and antibiotic therapy (ABT) for DFI, including the one for osteomyelitis (DFO), were introduced in our institution. In this study, we assessed the adherence to these in-house guidelines 2 years after their implementation. Methods: Adult patients with DFI with and without DFO who underwent surgical intervention between 2019 and 2021 were included. Patients' charts were retrospectively reviewed. Accordance to recommendations regarding biopsy sampling, labeling, requesting microbiological and histopathological examinations, and treatment duration were assessed. Results: A total of 80 patients with 117 hospital episodes and 163 surgical interventions were included; 84.6 % required an amputation. Patients with HbA1c levels of < 6.5 % more often required a revision during the same hospitalization than those with HbA1c levels of ≥ 6.5 % (29.4 % vs. 12.1 %, respectively, p = 0.023 ). Specimens were obtained in 71.8 % of operations and sent for histological examination in 63.2 %. The mean duration of ABT was 9 (interquartile range (IQR) 5-15) d in macroscopically surgically cured episodes and 40.5 (IQR 15-42) d in cases with resection margins in non-healthy bone ( p < 0.0001 ). Treatment duration results were similar when using histological results: 13 (IQR 8-42) d for healthy bone vs. 29 (IQR 13-42) d for resection margins consistent with osteomyelitis ( p = 0.026 ). Conclusion: The adherence to recommendations in terms of biopsy sampling was good, moderate for histopathological analysis and poor for labeling the anatomic location. Adherence to recommendations for ABT duration was good, but further shortening of treatment duration for surgically cured cases is necessary.
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Affiliation(s)
- Noémie Reinert
- Center for Musculoskeletal Infections (ZMSI), Department of Orthopedic and Trauma Surgery, University Hospital Basel, Basel, 4031, Switzerland
| | - Katinka Wetzel
- Center for Musculoskeletal Infections (ZMSI), Department of Orthopedic and Trauma Surgery, University Hospital Basel, Basel, 4031, Switzerland
| | - Fabian Franzeck
- Department of Research and Analytic Services, University Hospital Basel, Basel, 4031, Switzerland
| | - Mario Morgenstern
- Center for Musculoskeletal Infections (ZMSI), Department of Orthopedic and Trauma Surgery, University Hospital Basel, Basel, 4031, Switzerland
| | - Markus Aschwanden
- Department of Angiology, University Hospital Basel, Basel, 4031, Switzerland
| | - Thomas Wolff
- Department of Vascular Surgery, University Hospital Basel, Basel, 4031, Switzerland
| | - Martin Clauss
- Center for Musculoskeletal Infections (ZMSI), Department of Orthopedic and Trauma Surgery, University Hospital Basel, Basel, 4031, Switzerland
| | - Parham Sendi
- Institute for Infectious Diseases, University of Bern, Bern, 3001, Switzerland
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Nguyen N, Chua HC, Drake T, Jo J, Stramel SA, Vuong NN, Gonzales-Luna AJ, Olson K, On Behalf Of The Houston Infectious Diseases Network. Significant Publications on Infectious Diseases Pharmacotherapy in 2021. J Pharm Pract 2024; 37:198-211. [PMID: 36122416 DOI: 10.1177/08971900221128334] [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: 11/16/2022]
Abstract
Purpose: To summarize the most noteworthy infectious diseases (ID) pharmacotherapy articles published in peer-reviewed literature in 2021. Summary: Members of the Houston Infectious Diseases Network (HIDN) nominated articles that were deemed to have significant contributions to ID pharmacotherapy in 2021. These nominations included articles pertaining to both general ID, including coronavirus disease 2019 (COVID-19), and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) pharmacotherapy. A total of 35 articles were nominated by HIDN: 30 articles pertaining to general ID pharmacotherapy and 5 articles with HIV/AIDS focus. To select the most influential articles of 2021, a survey was created and distributed to members of the Society of Infectious Diseases Pharmacists (SIDP). Of the 239 SIDP members who responded to the survey, there were 192 recorded votes for the top 10 general ID pharmacotherapy articles and 47 recorded votes for the top HIV/AIDS article, respectively. The top publications are summarized. Conclusion: Antimicrobial stewardship and the optimal management of infectious disease states continues to be a priority in the midst of the ongoing coronavirus disease 2019 (COVID-19) global pandemic. In light of the sheer volume of ID-related articles published in the past year, this review aims to aid clinicians in remaining up-to-date on key practice-changing ID pharmacotherapy publications from 2021.
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Affiliation(s)
- Nhi Nguyen
- Department of Pharmacy, The University of Texas Medical Branch, Galveston, TX, USA
| | - Hubert C Chua
- Department of Pharmacy, CHI Baylor St Luke's Medical Center, Houston, TX, USA
| | - Ty Drake
- Department of Pharmacy, Houston Methodist Willowbrook Hospital, Houston, TX, USA
| | - Jinhee Jo
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Stefanie Anne Stramel
- Department of Pharmacy, Memorial Hermann Memorial City Medical Center, Houston, TX, USA
| | - Nancy N Vuong
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Kelsey Olson
- Department of Pharmacy, HCA Houston Healthcare Clear Lake, Webster, TX, USA
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Hung SY, Yeh YM, Chiu CH, Armstrong DG, Lin CW, Yang HM, Huang SY, Huang YY, Huang CH. Microbiome of limb-threatening diabetic foot ulcers indicates the association of fastidious Stenotrophomonas and major amputation. JOURNAL OF MICROBIOLOGY, IMMUNOLOGY, AND INFECTION = WEI MIAN YU GAN RAN ZA ZHI 2024; 57:156-163. [PMID: 37919171 PMCID: PMC11254454 DOI: 10.1016/j.jmii.2023.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 09/05/2023] [Accepted: 10/24/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Proper identification of the polymicrobial microorganisms in patients with limb-threatening diabetic foot ulcers (LTDFUs) using conventional culture is insufficient. This prospective study evaluates the potential value of adjuvant molecular testing assisting in identify fastidious micro-organisms in LTDFUs compared to standard treatment alone. METHODS Ninety patients with LTDFUs received interdisciplinary and standard antibiotic treatment in a referral diabetic foot center. A simultaneous 16S amplicon sequencing (16S AS) specimen along with conventional culture collected at admission was used to retrospectively evaluate the microbiological findings and its association with amputation outcomes. RESULTS The microorganism count revealed by 16S AS overwhelmed that of conventional culturing (17 vs. 3 bacteria/ulcer respectively). The Stenotrophomonas spp. revealed in 29 patients were highly correlated with major (above ankle) amputation (OR: 4.76, 95% CI 1.01-22.56), while only one had been concomitantly identified by conventional culturing. Thus, there were 27 cases without proper antibiotics coverage during treatment. CONCLUSIONS Adjuvant molecular testing assisted identification of fastidious pathogens such as Stenotrophomonas infection and might be associated with major amputation in patients with LTDFUs.
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Affiliation(s)
- Shih-Yuan Hung
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Yuan-Ming Yeh
- Genomic Medicine Core Laboratory, Chang Gung Memorial Hospital, Linkou, Taoyuan 333, Taiwan
| | - Cheng-Hsun Chiu
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery, Keck School of Medicine of University of Southern California (USC), Los Angeles, USA (D.G.A.)
| | - Cheng-Wei Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Hui-Mei Yang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Shu-Yu Huang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan City, Taiwan
| | - Yu-Yao Huang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan City, Taiwan; College of Medicine, Chang Gung University, Taoyuan City, Taiwan
| | - Chung-Huei Huang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan City, Taiwan.
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Uçkay I, Bomberg H, Risch M, Müller D, Betz M, Farshad M. Broad-spectrum antibiotic prophylaxis in tumor and infected orthopedic surgery-the prospective-randomized, microbiologist-blinded, stratified, superiority trials: BAPTIST Trials. Trials 2024; 25:69. [PMID: 38243311 PMCID: PMC10799415 DOI: 10.1186/s13063-023-07605-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 08/26/2023] [Indexed: 01/21/2024] Open
Abstract
BACKGROUND The perioperative antibiotic prophylaxis with 1st or 2nd generation cephalosporins is evidence-based in orthopedic surgery. There are, however, situations with a high risk of prophylaxis-resistant surgical site infections (SSI). METHODS We perform a superiority randomized controlled trial with a 10% margin and a power of 90% in favor of the broad-spectrum prophylaxis. We will randomize orthopedic interventions with a high risk for SSI due to selection of resistant pathogens (open fractures, surgery under therapeutic antibiotics, orthopedic tumor surgery, spine surgery with American Society of Anesthesiologists (ASA) score ≥ 3 points) in a prospective-alternating scheme (1:1, standard prophylaxis with cefuroxime versus a broad-spectrum prophylaxis of a combined single-shot of vancomycin 1 g and gentamicin 5 mg/kg parenterally). The primary outcome is "remission" at 6 weeks for most orthopedic surgeries or at 1 year for surgeries with implant. Secondary outcomes are the risk for prophylaxis-resistant SSI pathogens, revision surgery for any reason, change of antibiotic therapy during the treatment of infection, adverse events, and the postoperative healthcare-associated infections other than SSI within 6 weeks (e.g., urine infections or pneumonia). With event-free surgeries to 95% in the broad-spectrum versus 85% in the standard prophylaxis arm, we need 2 × 207 orthopedic surgeries. DISCUSSION In selected patients with a high risk for infections due to selection of prophylaxis-resistant SSI, a broad-spectrum combination with vancomycin and gentamycin might prevent SSIs (and other postoperative infections) better than the prophylaxis with cefuroxime. TRIAL REGISTRATION ClinicalTrial.gov NCT05502380. Registered on 12 August 2022. Protocol version: 2 (3 June 2022).
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Affiliation(s)
- Ilker Uçkay
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
- Unit for Clinical and Applied Research, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
- Infection Control, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland.
| | - Hagen Bomberg
- Department of Anesthesiology, Intensive Care and Pain Medicine, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Markus Risch
- Department of Anesthesiology, Intensive Care and Pain Medicine, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Daniel Müller
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Michael Betz
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
| | - Mazda Farshad
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
- Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zurich, Switzerland
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Ferhaoui N, Tanaka R, Sekizuka T, Kuroda M, Sebaihia M. Whole genome sequencing and pan-genome analysis of Staphylococcus/Mammaliicoccus spp. isolated from diabetic foot ulcers and contralateral healthy skin of Algerian patients. BMC Microbiol 2023; 23:342. [PMID: 37974097 PMCID: PMC10652506 DOI: 10.1186/s12866-023-03087-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 10/24/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Diabetic foot infections (DFIs) are the most common complications of diabetic foot ulcers (DFUs), and a significant cause of lower extremity amputation. In this study we used whole genome sequencing to characterize the clonal composition, virulence and resistance genetic determinants of 58 Staphylococcus/Mammaliicoccus spp. isolates from contralateral healthy skin and DFU from 44 hospitalized patients. RESULTS S. aureus (n = 32) and S. epidermidis (n = 10) isolates were recovered from both DFUs and healthy skin, whereas, S. haemolyticus (n = 8), M. sciuri (n = 1), S. hominis (n = 1) and S. simulans (n = 3) were recovered exclusively from healthy skin. In contrast, S. caprae (n = 2) and S. saprophyticus (n = 1) were recovered only from DFUs. Among S. aureus isolates, MRSA were present with high prevalence (27/32, 84.4%), 18 of which (66.7%) were from DFUs and 9 (33.3%) from healthy skin. In contrast, the coagulase-negative Staphylococcus (CoNS)/Mammaliicoccus isolates (n = 26), in particular S. epidermidis and S. haemolyticus were more prevalent in healthy skin, (10/26, 38.5%) and (8/26, 30.8%), respectively. MLST, spa and SCCmec typing classified the 32 S. aureus isolates into 6 STs, ST672, ST80, ST241, ST1, ST97, ST291 and 4 unknown STs (STNF); 8 spa types, t044, t037, t3841, t1247, t127, t639, t937 and t9432 and 2 SCCmec types, type IV and type III(A). Among CoNS, the S. epidermidis isolates belonged to ST54, ST35 and ST640. S. haemolyticus belonged to ST3, ST25, ST29, ST1 and ST56. The sole M. sciuri isolate was found to carry an SCCmec type III(A). A wide range of virulence genes and antimicrobial resistance genes were found among our isolates, with varying distribution between species or STs. The pan-genome analysis revealed a highly clonal population of Staphylococcus isolates, particularly among S. aureus isolates. Interestingly, the majority of S. aureus isolates including MRSA, recovered from the healthy skin and DFUs of the same patient belonged to the same clone and exhibited similar virulence/resistance genotype. CONCLUSIONS Our study provides clinically relevant information on the population profile, virulence and antibiotic resistance of Staphylococcus/Mammaliicoccus spp. in DFIs, which could serve as a basis for further studies on these as well as other groups of pathogens associated with DFIs.
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Affiliation(s)
- Nerdjes Ferhaoui
- Laboratory of Molecular Biology, Genomics and Bioinformatics, Department of Biology, Faculty of Nature and Life Sciences, University Hassiba Benbouali, Chlef, Algeria
| | - Rina Tanaka
- Pathogen Genomics Center, National Institute of Infectious Diseases (NIID), Tokyo, Japan
| | - Tsuyoshi Sekizuka
- Pathogen Genomics Center, National Institute of Infectious Diseases (NIID), Tokyo, Japan
| | - Makoto Kuroda
- Pathogen Genomics Center, National Institute of Infectious Diseases (NIID), Tokyo, Japan
| | - Mohammed Sebaihia
- Laboratory of Molecular Biology, Genomics and Bioinformatics, Department of Biology, Faculty of Nature and Life Sciences, University Hassiba Benbouali, Chlef, Algeria.
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Ali Jassim MM. Immunological profile of diabetic foot ulcers: update review. MUTHANNA MEDICAL JOURNAL 2023. [DOI: 10.52113/1/1/2023-38-43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The most frequent consequence of diabetes mellitus, diabetic foot ulcers frequently do not heal and necessitate lower limb amputation. According to estimates, DFU accounts for 50% to 70% of all lower limb amputations, and 50% of patients with DFU have peripheral artery disease (PAD), which is occasionally brought on by atherosclerosis. Deformity of foot, peripheral artery disease (PAD), loss protective sensation (LOPS), and a history of foot ulcers. Global prevalence for DFUs varies by region. One of the frequent complications of diabetes in poor nations, such as Iraq, is diabetic foot; approximately two-thirds of the patients with diabetes have Diabetic Foot disorder (DFD) in Iraq and this health issue had significant negative social and economic effects. The Saudi Arabia and Bahrain have the highest prevalence rates of DFU; the reported yearly incidence of diabetic foot ulcers ranges from "2.1% to 7.4%". There are three types of diabetic foot ulcers: neuropathic, neuroischaemic, and ischemic. An infected DFU often contains three to five different types of bacteria, including gram-positive aerobes, such as "Staphylococcus sp.", gram-positive anaerobes, gram negative aerobes, gram negative anaerobes, and fungi (Candida spp.). Numerous studies have demonstrated that effective management of DFU can significantly decrease, postpone, or even completely avoid consequences like infection, gangrene, amputation, and death.
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Moderate to Severe Soft Tissue Diabetic Foot Infections: A Randomized, Controlled, Pilot Trial of Post-debridement Antibiotic Treatment for 10 versus 20 days. Ann Surg 2022; 276:233-238. [PMID: 35623048 PMCID: PMC9259031 DOI: 10.1097/sla.0000000000005205] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND The optimal duration of antibiotic therapy for soft-tissue infections of the diabetic foot remains unknown. OBJECTIVE We determine if antibiotic therapy after debridement for a short (10 days), compared with a long (20 days), duration for soft-tissue infections of the diabetic foot results in similar rates of clinical remission and adverse events (AE). SUMMARY OF BACKGROUND DATA The optimal duration of systemic antibiotic therapy, after successful debridement, for soft tissue infections of diabetic patients is unknown. Because of the high recurrence risk, overuse is commonplace. METHODS This was a randomized, controlled, non-inferiority pilot trial of cases of diabetic foot infection (excluding osteomyelitis) with the primary outcome of "clinical remission at 2-months follow-up". RESULTS Among 66 enrolled episodes (17% females; median age 71 years), we randomized 35 to the 10-day arm and 31 to the 20-day arm. The median duration of the parenteral antibiotic therapy was 1 day, with the remainder given orally. In the intention-to-treat population, we achieved clinical remission in 27 (77%) patients in the 10-day arm compared to 22 (71%) in the 20-days arm ( P = 0.57). There were a similar proportion in each arm of AE (14/35 versus 11/31; P = 0.71), and remission in the per-protocol population (25/32 vs 18/27; P = 0.32). Overall, 8 soft tissue DFIs in the 10-day arm and 5 cases in the 20-day arm recurred as a new osteomyelitis [8/35 (23%) versus 5/31 (16%); P = 0.53]. Overall, the number of recurrences limited to the soft tissues was 4 (6%). By multivariate analysis, rates of remission (intention-to-treat population, hazard ratio 0.6, 95%CI 0.3-1.1; per-protocol population 0.8, 95%CI 0.4-1.5) and AE were not significantly different with a 10-day compared to 20-day course. CONCLUSIONS In this randomized, controlled pilot trial, post-debridement antibiotic therapy for soft tissue DFI for 10 days gave similar (and non-inferior) rates of remission and AEs to 20 days. A larger confirmatory trial is under way. TRIAL REGISTRATION ClinicalTrials NCT03615807.
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Fletcher J, Porter R, Boulton Z, Brown L, Knight B, Romanczuk L, Aiken S, Delury C, Michell S. In vitro efficacy of antibiotic loaded calcium sulfate beads (Stimulan Rapid Cure) against polymicrobial communities and individual bacterial strains derived from diabetic foot infections. J Med Microbiol 2022; 71. [PMID: 35604937 DOI: 10.1099/jmm.0.001517] [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: 11/18/2022] Open
Abstract
Introduction. Diabetic foot infection (DFI) is the main reason for diabetes-related hospitalisation and is a major cause of diabetes-related amputation. DFIs are often complicated by ischaemia in the affected limb, the presence of polymicrobial biofilms and increasingly the occurrence of antibiotic resistant bacteria.Hypothesis/Gap statement. Antibiotic loaded beads could inhibit the growth of polymicrobial DFI communities with differing compositions in vitro.Aim. This study investigates the in vitro efficacy of antibiotic loaded calcium sulfate beads (Stimulan Rapid Cure, Biocomposites Ltd., UK) against polymicrobial DFI communities and individual bacterial strains derived from DFIs.Methodology. Debrided tissue obtained from the base of infected diabetic foot ulcers was homogenised and spread over the surface of Columbia blood agar (CBA) and fastidious anaerobe agar (FAA) plates. Calcium sulfate beads containing a combination of vancomycin and gentamicin were then placed on the surface of the agar and following incubation, zones of inhibition (ZOI) were measured. For individual bacterial strains isolated from the infected tissue, calcium sulfate beads containing vancomycin, gentamicin, flucloxacillin or rifampicin and beads containing a combination of vancomycin and gentamicin or flucloxacillin and rifampicin were tested for their ability to inhibit growth.Results. Calcium sulfate beads loaded with a combination of vancomycin and gentamicin were able to inhibit bacterial growth from all polymicrobial tissue homogenates tested, with ZOI diameters ranging from 15 to 40 mm. In the case of individual bacterial strains, beads containing combinations of vancomycin and gentamicin or flucloxacillin and rifampicin were able to produce ZOI with Gram-positive facultatitive anaerobic strains such as Staphylococcus aureus and Enterococcus faecalis, Gram-negative facultative anaerobic strains such as Pseudomonas aeruginosa and obligate anaerobic strains such as Finegoldia magna even where acquired resistance to one of the antibiotics in the combination was evidenced.Conclusion. The local use of calcium sulfate beads containing a combination of two antibiotics demonstrated high efficacy against polymicrobial DFI communities and individual DFI bacterial strains in in vitro zone of inhibition tests. These results show promise for clinical application, but further research and clinical studies are required.
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Affiliation(s)
- Julie Fletcher
- Biosciences, University of Exeter, Stocker Road, Exeter, EX4 4QD, UK
| | - Rob Porter
- Microbiology Department, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Zoe Boulton
- Macleod Diabetes and Endocrine Centre, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Laura Brown
- Macleod Diabetes and Endocrine Centre, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Bridget Knight
- National Institute for Health Research Exeter Clinical Research Facility, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Lidia Romanczuk
- National Institute for Health Research Exeter Clinical Research Facility, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Sean Aiken
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire, ST5 5NL, UK
| | - Craig Delury
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire, ST5 5NL, UK
| | - Stephen Michell
- Biosciences, University of Exeter, Stocker Road, Exeter, EX4 4QD, UK
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Haug F, Waibel FWA, Lisy M, Winkler E, Uçkay I, Schöni M. The impact of the length of total and intravenous systemic antibiotic therapy for the remission of diabetic foot infections. Int J Infect Dis 2022; 120:179-186. [PMID: 35358726 DOI: 10.1016/j.ijid.2022.03.049] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/18/2022] [Accepted: 03/23/2022] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVE We investigated the impact of the total length of systemic antibiotic therapy (ABT) and its initial intravenous (IV) part on clinical failure (CF) and microbiological failure (MF) in diabetic foot infections (DFIs). METHODS In this single-center, retrospective, unmatched case-control study, we included DFI episodes treated with a combined surgical-antibiotic approach. RESULTS We included 721 DFI episodes, 537 with osteomyelitis (DFO). CF occurred in 191 (26.5%) and MF in 42 (5.8%) episodes. Multivariate Cox regression analysis showed that a short ABT of 8-21 days (hazard ratio [HR] 0.4; 95% CI 0.2-0.7) was inversely associated with CF. This was also applicable for IV ABT with relatively short durations of 2-7 days (HR 0.5; 95% CI 0.3-0.8) or 8-14 days (HR 0.6; 95% CI 0.4-0.9). We failed to detect a minimal threshold of total or IV ABT predictive for CF or MF. CONCLUSIONS Compared with total ABT of more than 84 days and IV therapy of more than 14 days, shorter total and IV ABT yielded no enhanced risk of CF or MF. Considering the "bias by indication" that is inherent to retrospective DFI studies, the best study design concerning the duration of ABT would be a stratified, prospective randomized trial, which is currently under way in our medical center.
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Affiliation(s)
- Florian Haug
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Switzerland.
| | - Felix W A Waibel
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Switzerland
| | - Marcus Lisy
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Switzerland
| | - Elin Winkler
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Switzerland
| | - Ilker Uçkay
- Unit for Clinical and Applied Research, Balgrist University Hospital, University of Zurich, Switzerland; Infectiology, Balgrist University Hospital, University of Zurich, Switzerland
| | - Madlaina Schöni
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Switzerland
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10
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Maurer S, Hepp Z, McCallin S, Waibel F, Romero F, Zorman Y, Lipsky B, Uçkay İ. Short and oral antimicrobial therapy for diabetic foot infection: a narrative review of current knowledge. J Bone Jt Infect 2022; 7:61-70. [PMID: 35415069 PMCID: PMC8990364 DOI: 10.5194/jbji-7-61-2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/17/2022] [Indexed: 02/06/2023] Open
Abstract
Diabetic foot infection is a frequent complication in long-standing diabetes mellitus. For antimicrobial therapy of this infection, both the optimal duration and the route of administration are often based more on expert opinion than on published evidence. We reviewed the scientific literature, specifically seeking prospective trials, and aimed at addressing two clinical issues: (1) shortening the currently recommended antibiotic duration and (2) using oral (rather than parenteral) therapy, especially after the patient has undergone debridement and revascularization. We also reviewed some older key articles that are critical to our understanding of the treatment of these infections, particularly with respect to diabetic foot osteomyelitis. Our conclusion is that the maximum duration of antibiotic therapy for osteomyelitis should be no more than to 4-6 weeks and might even be shorter in selected cases. In the future, in addition to conducting randomized trials and propagating national and international guidance, we should also explore innovative strategies, such as intraosseous antibiotic agents and bacteriophages.
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Affiliation(s)
- Steven M. Maurer
- Orthopedic Surgery, Balgrist University Hospital, University of
Zurich, Zurich, Switzerland
| | - Zehra S. Hepp
- Orthopedic Surgery, Balgrist University Hospital, University of
Zurich, Zurich, Switzerland
- Internal Medicine, Balgrist University Hospital, University of
Zurich, Zurich, Switzerland
| | - Shawna McCallin
- Clinical and Phage Research, Balgrist University Hospital, University
of Zurich, Zurich, Switzerland
| | - Felix W. A. Waibel
- Orthopedic Surgery, Balgrist University Hospital, University of
Zurich, Zurich, Switzerland
| | - Federico C. Romero
- Department of Infectious Diseases, Sanatorio
Allende Hospital, Córdoba, Argentina
| | - Yılmaz Zorman
- Cardiovascular Surgery Department, Koç University Hospital,
Istanbul, Turkey
| | | | - İlker Uçkay
- Infectiology, Balgrist University Hospital, University of Zurich, Zurich,
Switzerland
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Uçkay I, Yogarasa V, Waibel FWA, Seiler-Bänziger A, Kuhn M, Sahli M, Berli MC, Lipsky BA, Schöni M. Nutritional Interventions May Improve Outcomes of Patients Operated on for Diabetic Foot Infections: A Single-Center Case-Control Study. J Diabetes Res 2022; 2022:9546144. [PMID: 36034588 PMCID: PMC9410992 DOI: 10.1155/2022/9546144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 07/30/2022] [Indexed: 11/18/2022] Open
Abstract
AIM While a patient's nutritional status is known to generally have a role in postoperative wound healing, there is little information on its role as therapy in the multifaceted problem of diabetic foot infections (DFIs). METHODS We assessed this issue by conducting a retrospective case-control cohort study using a multivariate Cox regression model. The nutrition status of the DFI patients was assessed by professional nutritionists, who also orchestrated the nutritional intervention (counselling, composition of the intrahospital food) during hospitalization. RESULTS Among 1,013 DFI episodes in 586 patients (median age 67 years; 882 with osteomyelitis), 191 (19%) received a professional assessment of their nutrition accompanied by between 1 and 6 nutritional interventions. DFI cases who had professional nutritionists' interventions had a significantly shorter hospital stay, had shorter antibiotic therapies, and tended to fewer surgical debridements. By multivariate analysis, episodes with low Nutritional Risk Status- (NRS-) Scores 1-3 were associated with significantly lower failure rates after therapy for DFI (Cox regression analysis; hazard ratio 0.2, 95% confidence interval 0.1-0.7). CONCLUSIONS In this retrospective cohort study, DFI episodes with low NRS-Score were associated with lower rates of clinical failure after DFI treatment, while nutritional interventions improved the outcome of DFI. We need prospective interventional trials for this treatment, and these are underway.
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Affiliation(s)
- Ilker Uçkay
- Infectiology, Balgrist University Hospital, University of Zurich, Switzerland
- Diabetic Foot Unit, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Switzerland
| | - Vinoth Yogarasa
- Infectiology, Balgrist University Hospital, University of Zurich, Switzerland
- Diabetic Foot Unit, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Switzerland
| | - Felix W. A. Waibel
- Diabetic Foot Unit, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Switzerland
| | | | - Maja Kuhn
- Nutritionist Service, Balgrist University Hospital, University of Zurich, Switzerland
| | - Margrit Sahli
- Nutritionist Service, Balgrist University Hospital, University of Zurich, Switzerland
| | - Martin C. Berli
- Diabetic Foot Unit, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Switzerland
| | | | - Madlaina Schöni
- Diabetic Foot Unit, Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Switzerland
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Lipsky BA, Uçkay İ. Treating Diabetic Foot Osteomyelitis: A Practical State-of-the-Art Update. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:339. [PMID: 33916055 PMCID: PMC8066570 DOI: 10.3390/medicina57040339] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 12/17/2022]
Abstract
Background and Objectives: Diabetic foot osteomyelitis (DFO) can be difficult to treat and securing optimal clinical outcomes requires a multidisciplinary approach involving a wide variety of medical, surgical and other health care professionals, as well as the patient. Results of studies conducted in the past few years have allowed experts to formulate guidelines that can improve clinical outcomes. Material and Methods: We conducted a narrative review of the literature on treat- ment of DFO, with an emphasis on studies published in the last two years, especially regarding antimicrobial therapies and surgical approached to treatment of DFO, supplemented by our own extensive clinical and research experience in this field. Results: Major amputations were once com- mon for DFO but, with improved diagnostic and surgical techniques, "conservative" surgery (foot- sparing, resecting only the infected and necrotic bone) is becoming commonplace, especially for forefoot infections. Traditional antibiotic therapy, which has been administered predominantly in- travenously and frequently for several months, can often be replaced by appropriately selected oral antibiotic regimens following only a brief (or even no) parenteral therapy, and given for no more than 6 weeks. Based on ongoing studies, the recommended duration of treatment may soon be even shorter, especially for cases in which a substantial portion of the infected bone has been resected. Using the results of cultures (preferably of bone specimens) and antimicrobial stewardship princi- ples allows clinicians to select evidence-based antibiotic regimens, often of a limited pathogen spec- trum. Intra-osseous antimicrobial and surgical approaches to treatment are also evolving in light of ongoing research. Conclusions: In this narrative, evidenced-based review, taking consideration of principles of antimicrobial stewardship and good surgical practice, we have highlighted the recent literature and offered practical, state-of-the-art advice on the antibiotic and surgical management of DFO.
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Affiliation(s)
- Benjamin A. Lipsky
- Department of Medicine, University of Washington, Seattle, WA 98116, USA
| | - İlker Uçkay
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland;
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Gariani K, Pham TT, Kressmann B, Jornayvaz FR, Gastaldi G, Stafylakis D, Philippe J, Lipsky BA, Uçkay İ. Three versus six weeks of antibiotic therapy for diabetic foot osteomyelitis: A prospective, randomized, non-inferiority pilot trial. Clin Infect Dis 2020; 73:e1539-e1545. [PMID: 33242083 DOI: 10.1093/cid/ciaa1758] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In patients with diabetic foot osteomyelitis (DFO) who underwent surgical debridement, we investigated whether a short (3 weeks), compared with a long (6 weeks) duration of systemic antibiotic treatment is associated with non-inferior results for clinical remission and adverse events (AE). METHODS In this prospective, randomized, non-inferiority, pilot trial, we randomized (allocation 1:1), patients with DFO after surgical debridement to either a 3-week or a 6-week course of antibiotic therapy. The minimal duration of follow-up after end of therapy was two months. We compared outcomes using Cox regression and non-inferiority analyses (25% margin, power 80%). RESULTS Among 93 enrolled patients (18% females; median age 65 years), 44 were randomized to the 3-week arm and 49 to the 6-week arm. The median number of surgical debridement was 1 (range, 0-2 interventions). In the intention-to-treat (ITT) population, remission occurred in 37 (84%) of the patients in the 3-week arm compared to 36 (73%) in the 6-week arm (p=0.21). The number of AE was similar in the two study arms (17/44 vs. 16/49; p=0.51), as were the remission incidences in the per-protocol (PP) population (33/39 vs. 32/43; p=0.26). In multivariate analysis, treatment with the shorter antibiotic course was not significantly associated with remission (for the ITT population, hazard ratio 1.1, 95%CI 0.6-1.7; for the PP population hazard ratio 0.8, 95%CI 0.5-1.4). CONCLUSIONS In this randomized, controlled pilot trial, a post-debridement systemic antibiotic therapy course for DFO of 3-weeks gave similar (and statistically non-inferior) incidences of remission and AE to a course of 6 weeks.
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Affiliation(s)
- Karim Gariani
- Service of Endocrinology, Diabetes, Hypertension and Nutrition, Geneva University Hospitals, Geneva, Switzerland
| | - Truong-Thanh Pham
- Service of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland.,Orthopedic Surgery Service, Geneva University Hospitals, Geneva, Switzerland
| | - Benjamin Kressmann
- Service of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland.,Orthopedic Surgery Service, Geneva University Hospitals, Geneva, Switzerland
| | - François R Jornayvaz
- Service of Endocrinology, Diabetes, Hypertension and Nutrition, Geneva University Hospitals, Geneva, Switzerland
| | - Giacomo Gastaldi
- Service of Endocrinology, Diabetes, Hypertension and Nutrition, Geneva University Hospitals, Geneva, Switzerland
| | | | - Jacques Philippe
- Service of Endocrinology, Diabetes, Hypertension and Nutrition, Geneva University Hospitals, Geneva, Switzerland
| | - Benjamin A Lipsky
- Service of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - İlker Uçkay
- Service of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland.,Orthopedic Surgery Service, Geneva University Hospitals, Geneva, Switzerland.,Infectiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,Unit for Clinical and Applied Research, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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