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Motaganahalli S, Reynolds G, Haikerwal S, Richards T, Peel TN, Trubiano JA. Evaluating diagnostic tools, outcome measures and antibiotic approach in diabetic foot osteomyelitis: a scoping review and narrative synthesis. Expert Rev Anti Infect Ther 2024:1-9. [PMID: 39254257 DOI: 10.1080/14787210.2024.2403145] [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: 07/07/2024] [Accepted: 09/08/2024] [Indexed: 09/11/2024]
Abstract
INTRODUCTION Diabetic foot osteomyelitis (DFO) is a significant complication of diabetic foot disease; however, diagnosis remains challenging and treatment success is difficult to ascertain. Literature in this space that has utilized varying diagnostic criteria and ideal outcome measures for success is unclear. AREAS COVERED This scoping review assesses methods of diagnosis of DFO and definitions of treatment outcomes in the literature assessing antibiotic therapy for treatment of DFO. EXPERT OPINION There is a lack of consensus in the design of diabetic foot trials, resulting in difficulty for clinicians to assess and manage serious conditions such as DFO. The cure for DFO is challenging to ascertain and treatment failure may be a better approach to assess outcomes in research assessing the efficacy of antibiotic therapy. In the absence of gold-standard diagnostic tools, practical approaches to outcome assessment may allow for greater clinical applicability of available data.
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Affiliation(s)
- Satwik Motaganahalli
- Department of Infectious Diseases and Immunology, Austin Health, Heidelberg, Victoria, Australia
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
| | - Gemma Reynolds
- Department of Infectious Diseases and Immunology, Austin Health, Heidelberg, Victoria, Australia
- National Centre for Infections in Cancer, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Suresh Haikerwal
- Department of Infectious Diseases and Immunology, Austin Health, Heidelberg, Victoria, Australia
| | - Toby Richards
- Division of Surgery, University College London, London, UK
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
| | - Trisha N Peel
- Department of Infectious Diseases, The Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Jason A Trubiano
- Department of Infectious Diseases and Immunology, Austin Health, Heidelberg, Victoria, Australia
- Department of Infectious Diseases, The Peter Doherty Institute for Infection and Immunity, The University of Melbourne, Melbourne, Victoria, Australia
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Uddin A, Russell DA, Game F, Santos D, Siddle HJ. Variation in Systemic Antibiotic Treatment for Diabetic Foot Osteomyelitis in England and Wales: A Multi-Centre Case Review. J Clin Med 2024; 13:3083. [PMID: 38892792 PMCID: PMC11172556 DOI: 10.3390/jcm13113083] [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: 04/07/2024] [Revised: 05/10/2024] [Accepted: 05/11/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Diabetic foot osteomyelitis (DFO) is a major complication and can lead to significant morbidity and mortality. Systemic antibiotic therapy is often initiated first line to achieve quiescence of infection. To perform a multi-centre case review of systemic antibiotic intervention to treat adults with DFO in England and Wales and compare with national guidelines 'Diabetic foot problems: prevention and management'. Methods: Eight centres from England and Wales retrospectively collated data from a minimum of five adults (aged ≥ 18 years) from electronic case records. All patients were treated with systemic antibiotics following a new diagnosis of DFO (1 June 2021-31 December 2021). Results: 40 patients (35 males and 5 females) were included; the mean age was 62.3 years (standard deviation (SD) 13.0). Patients commenced systemic oral 14 (35%) or intravenous 26 (65%) antibiotic therapy following a new diagnosis of DFO. Twenty-seven (67.5%) patients were medically or surgically managed in the 12-week period with clinical quiescence of infection. Twenty-one patients (52.5%) had no recurrence of DFO infection within 12 weeks; seventeen (42.5%) of these patients had clinical quiescence of infection with systemic antibiotics alone without surgical intervention and nine (22.5%) of these cases had no recurrence of DFO. There were no cases of major amputation or death. All centres showed significant in-centre variability in systemic antibiotic management; variability was reported in the clinical and quantity indicators specifically to antibiotic selection, single versus dual therapy, mode of delivery and duration of treatment. Conclusions: This case review identifies there is existing variation when treating adults with systemic antibiotics for DFO. Further national guidance is required to standardise service delivery and care to improve patient outcomes.
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Affiliation(s)
- Akram Uddin
- Northamptonshire Healthcare NHS Foundation Trust, Northamptonshire NN11 4DY, UK
- Essex Partnership University NHS Foundation Trust, Essex SS4 1RB, UK
| | - David A. Russell
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds LS2 9JT, UK
- Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust, Leeds LS9 7TF, UK
| | - Fran Game
- University Hospitals of Derby & Burton NHS Foundation Trust, Derby DE22 3NE, UK
| | - Derek Santos
- School of Health Sciences, Queen Margaret University, Edinburgh EH21 6UU, UK
| | - Heidi J. Siddle
- Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds LS7 4SA, UK
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Hassold N, Bihan H, Moumba YP, Poilane I, Méchaï F, Assad N, Labbe-Gentils V, Sal M, Koutcha ON, Martin A, Radu D, Martinod E, Cordel H, Vignier N, Tatulashvili S, Berkane N, Carbonnelle E, Bouchaud O, Cosson E. BedBiopsy: Diagnostic performance of bedside ultrasound-guided bone biopsies for the management of diabetic foot infection. DIABETES & METABOLISM 2024; 50:101525. [PMID: 38442769 DOI: 10.1016/j.diabet.2024.101525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 02/21/2024] [Accepted: 02/26/2024] [Indexed: 03/07/2024]
Abstract
OBJECTIVE We aimed to assess the feasibility and diagnostic performance of ultrasound-guided bone biopsies at the bedside of diabetic patients admitted for suspected foot osteitis not requiring surgery. RESEARCH DESIGN AND METHODS In this retrospective monocentric study, we compared the performance of ultrasound-guided (n = 29 consecutive patients, Dec.2020-Oct.2022) versus surgical (n = 24 consecutive patients, Jan.2018-Nov.2020) bone biopsies at confirming or ruling out diabetic foot osteitis (primary outcome). RESULTS Patient characteristics were similar in the two intervention groups, including arteritis prevalence (62.3 %), SINBAD score, and wound location (phalanges 36 %, metatarsus 43 %, and calcaneus 21 %). However, the ultrasound-guided group was older (67 ± 11 versus 60 ± 13 years respectively, P = 0.047) and had more type 2 diabetes (97 % versus 75 %, P = 0.038). Diagnostic performance (i.e., capacity to confirm or rule out suspected osteitis) was similar for ultrasound-guided (28/29 cases: 25 confirmations, 3 invalidations) and surgical (24 confirmations/24) biopsies, P = 0.358. No biopsy-related side effect or complication was observed for either intervention, even for patients on antiaggregation and/or anticoagulation therapy. The mean (± standard deviation) time necessary to perform the biopsy was shorter in the ultrasound-guided group (2.6 ± 3.0 versus 7.2 ± 5.8 days, respectively, P < 0.001) and wound evolution at three months was more favorable (83.3 versus 41.2 %, P = 0.005) (94.4 % versus 66.7 %, respectively, patients with new surgical procedure within six months excluded; P = 0.055). Even though not statistically significant, healing rates in terms of wound and osteitis at six months were also better in the ultrasound-guided group (wound: 40.9 % versus 36.8 %; P = 0.790, and osteitis: 81.8 vs 55.6 % P = 0.071). CONCLUSION In diabetic patients with suspected foot osteitis not requiring surgery, bedside ultrasound-guided bone biopsies may constitute a promising alternative to surgical biopsies. This intervention provided excellent tolerance and microbiological documentation, short lead-times, and more favorable wound prognosis.
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Affiliation(s)
- Nolan Hassold
- Department of infectious diseases, Avicenne Hospital, Hôpitaux universitaires Paris Seine-Saint-Denis, AP-HP, UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France.
| | - Hélène Bihan
- Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, Department of Endocrinology-Diabetology-Nutrition, CRNH-IdF, CINFO, Bobigny, France; LEPS (Laboratoire Educations et Promotion de la Santé) EA 3412-Université Paris 13, France
| | - Yolène Pambo Moumba
- Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, Department of Endocrinology-Diabetology-Nutrition, CRNH-IdF, CINFO, Bobigny, France
| | | | - Frédéric Méchaï
- Department of infectious diseases, Avicenne Hospital, Hôpitaux universitaires Paris Seine-Saint-Denis, AP-HP, UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France
| | - Nabil Assad
- Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, Department of Endocrinology-Diabetology-Nutrition, CRNH-IdF, CINFO, Bobigny, France
| | - Véronique Labbe-Gentils
- Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, Department of Endocrinology-Diabetology-Nutrition, CRNH-IdF, CINFO, Bobigny, France
| | - Meriem Sal
- Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, Department of Endocrinology-Diabetology-Nutrition, CRNH-IdF, CINFO, Bobigny, France
| | - Omar Nouhou Koutcha
- Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, Department of Endocrinology-Diabetology-Nutrition, CRNH-IdF, CINFO, Bobigny, France
| | - Antoine Martin
- Department of anatomopathology, Avicenne Hospital, Bobigny, France
| | - Dana Radu
- Assistance Publique - Hôpitaux de Paris, Hôpitaux Universitaires Paris Seine-Saint-Denis, Hôpital Avicenne, Chirurgie Thoracique et Vasculaire, Université Sorbonne Paris Nord, Faculté de Médecine SMBH, Bobigny. France
| | - Emmanuel Martinod
- Assistance Publique - Hôpitaux de Paris, Hôpitaux Universitaires Paris Seine-Saint-Denis, Hôpital Avicenne, Chirurgie Thoracique et Vasculaire, Université Sorbonne Paris Nord, Faculté de Médecine SMBH, Bobigny. France
| | - Hugues Cordel
- Department of infectious diseases, Avicenne Hospital, Hôpitaux universitaires Paris Seine-Saint-Denis, AP-HP, UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France
| | - Nicolas Vignier
- Department of infectious diseases, Avicenne Hospital, Hôpitaux universitaires Paris Seine-Saint-Denis, AP-HP, UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France; IAME, INSERM UMR 1137, Université Sorbonne Paris Nord, Bobigny, France
| | - Sopio Tatulashvili
- Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, Department of Endocrinology-Diabetology-Nutrition, CRNH-IdF, CINFO, Bobigny, France
| | - Narimane Berkane
- Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, Department of Endocrinology-Diabetology-Nutrition, CRNH-IdF, CINFO, Bobigny, France
| | | | - Olivier Bouchaud
- Department of infectious diseases, Avicenne Hospital, Hôpitaux universitaires Paris Seine-Saint-Denis, AP-HP, UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France
| | - Emmanuel Cosson
- Avicenne Hospital, Paris 13 University, Sorbonne Paris Cité, Department of Endocrinology-Diabetology-Nutrition, CRNH-IdF, CINFO, Bobigny, France; Equipe de Recherche en Epidémiologie Nutritionnelle (EREN), Université Sorbonne Paris Nord and Université Paris Cité, INSERM, INRAE, CNAM, Center of Research in Epidemiology and StatisticS (CRESS), Bobigny, France
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Debs P, Boutin RD, Smith SE, Babic M, Blankenbaker D, Chandra V, Murphey M, Thottacherry E, Kreulen C, Fayad LM. Chronic Nonspinal Osteomyelitis in Adults: Consensus Recommendations on Percutaneous Bone Biopsies from the Society of Academic Bone Radiologists. Radiology 2024; 311:e231348. [PMID: 38625010 PMCID: PMC11070610 DOI: 10.1148/radiol.231348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 11/06/2023] [Accepted: 11/16/2023] [Indexed: 04/17/2024]
Abstract
The diagnosis and management of chronic nonspinal osteomyelitis can be challenging, and guidelines regarding the appropriateness of performing percutaneous image-guided biopsies to acquire bone samples for microbiological analysis remain limited. An expert panel convened by the Society of Academic Bone Radiologists developed and endorsed consensus statements on the various indications for percutaneous image-guided biopsies to standardize care and eliminate inconsistencies across institutions. The issued statements pertain to several commonly encountered clinical presentations of chronic osteomyelitis and were supported by a literature review. For most patients, MRI can help guide management and effectively rule out osteomyelitis when performed soon after presentation. Additionally, in the appropriate clinical setting, open wounds such as sinus tracts and ulcers, as well as joint fluid aspirates, can be used for microbiological culture to determine the causative microorganism. If MRI findings are positive, surgery is not needed, and alternative sites for microbiological culture are not available, then percutaneous image-guided biopsies can be performed. The expert panel recommends that antibiotics be avoided or discontinued for an optimal period of 2 weeks prior to a biopsy whenever possible. Patients with extensive necrotic decubitus ulcers or other surgical emergencies should not undergo percutaneous image-guided biopsies but rather should be admitted for surgical debridement and intraoperative cultures. Multidisciplinary discussion and approach are crucial to ensure optimal diagnosis and care of patients diagnosed with chronic osteomyelitis.
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Affiliation(s)
- Patrick Debs
- From The Russell H. Morgan Department of Radiology and Radiological
Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and
Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N
Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and
Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University
School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and
Intervention, Department of Radiology, Brigham and Women’s Hospital,
Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department,
Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.);
Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic
Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and
Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department
of Orthopaedic Surgery, University of California–Davis, Sacramento, Calif
(C.K.)
| | - Robert D. Boutin
- From The Russell H. Morgan Department of Radiology and Radiological
Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and
Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N
Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and
Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University
School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and
Intervention, Department of Radiology, Brigham and Women’s Hospital,
Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department,
Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.);
Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic
Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and
Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department
of Orthopaedic Surgery, University of California–Davis, Sacramento, Calif
(C.K.)
| | - Stacy E. Smith
- From The Russell H. Morgan Department of Radiology and Radiological
Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and
Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N
Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and
Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University
School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and
Intervention, Department of Radiology, Brigham and Women’s Hospital,
Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department,
Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.);
Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic
Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and
Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department
of Orthopaedic Surgery, University of California–Davis, Sacramento, Calif
(C.K.)
| | - Maja Babic
- From The Russell H. Morgan Department of Radiology and Radiological
Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and
Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N
Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and
Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University
School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and
Intervention, Department of Radiology, Brigham and Women’s Hospital,
Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department,
Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.);
Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic
Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and
Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department
of Orthopaedic Surgery, University of California–Davis, Sacramento, Calif
(C.K.)
| | - Donna Blankenbaker
- From The Russell H. Morgan Department of Radiology and Radiological
Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and
Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N
Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and
Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University
School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and
Intervention, Department of Radiology, Brigham and Women’s Hospital,
Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department,
Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.);
Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic
Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and
Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department
of Orthopaedic Surgery, University of California–Davis, Sacramento, Calif
(C.K.)
| | - Venita Chandra
- From The Russell H. Morgan Department of Radiology and Radiological
Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and
Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N
Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and
Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University
School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and
Intervention, Department of Radiology, Brigham and Women’s Hospital,
Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department,
Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.);
Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic
Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and
Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department
of Orthopaedic Surgery, University of California–Davis, Sacramento, Calif
(C.K.)
| | - Mark Murphey
- From The Russell H. Morgan Department of Radiology and Radiological
Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and
Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N
Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and
Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University
School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and
Intervention, Department of Radiology, Brigham and Women’s Hospital,
Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department,
Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.);
Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic
Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and
Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department
of Orthopaedic Surgery, University of California–Davis, Sacramento, Calif
(C.K.)
| | - Elizabeth Thottacherry
- From The Russell H. Morgan Department of Radiology and Radiological
Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and
Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N
Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and
Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University
School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and
Intervention, Department of Radiology, Brigham and Women’s Hospital,
Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department,
Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.);
Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic
Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and
Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department
of Orthopaedic Surgery, University of California–Davis, Sacramento, Calif
(C.K.)
| | - Christopher Kreulen
- From The Russell H. Morgan Department of Radiology and Radiological
Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and
Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N
Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and
Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University
School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and
Intervention, Department of Radiology, Brigham and Women’s Hospital,
Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department,
Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.);
Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic
Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and
Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department
of Orthopaedic Surgery, University of California–Davis, Sacramento, Calif
(C.K.)
| | - Laura M. Fayad
- From The Russell H. Morgan Department of Radiology and Radiological
Science (P.D., L.M.F.), and Departments of Orthopaedic Surgery (L.M.F.) and
Oncology (L.M.F.), The Johns Hopkins University Medical Institutions, 600 N
Wolfe St, JHOC 3014, Baltimore, MD 21287; Department of Radiology (R.D.B.) and
Division of Vascular Surgery, Department of Surgery (V.C.), Stanford University
School of Medicine, Palo Alto, Calif; Division of Musculoskeletal Imaging and
Intervention, Department of Radiology, Brigham and Women’s Hospital,
Harvard Medical School, Boston, Mass (S.E.S.); Infectious Disease Department,
Cleveland Clinic, Cleveland, Ohio (M.B.); Department of Radiology, University of
Wisconsin School of Medicine and Public Health, Madison, Wis (D.B.);
Musculoskeletal Imaging and Neuroradiology, ACR Institute for Radiologic
Pathology, Silver Spring, Md (M.M.); Division of Infectious Diseases and
Geographic Medicine, Stanford University, Stanford, Calif (E.T.); and Department
of Orthopaedic Surgery, University of California–Davis, Sacramento, Calif
(C.K.)
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5
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Senneville É, Albalawi Z, van Asten SA, Abbas ZG, Allison G, Aragón-Sánchez J, Embil JM, Lavery LA, Alhasan M, Oz O, Uçkay I, Urbančič-Rovan V, Xu ZR, Peters EJG. Diagnosis of infection in the foot of patients with diabetes: A systematic review. Diabetes Metab Res Rev 2024; 40:e3723. [PMID: 37715722 DOI: 10.1002/dmrr.3723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 08/29/2023] [Indexed: 09/18/2023]
Abstract
BACKGROUND Securing an early accurate diagnosis of diabetic foot infections and assessment of their severity are of paramount importance since these infections can cause great morbidity and potential mortality and present formidable challenges in surgical and antimicrobial treatment. METHODS In June 2022, we searched the literature using PubMed and EMBASE for published studies on the diagnosis of diabetic foot infection (DFI). On the basis of pre-determined criteria, we reviewed prospective controlled, as well as non-controlled, studies in English. We then developed evidence statements based on the included papers. RESULTS We selected a total of 64 papers that met our inclusion criteria. The certainty of the majority of the evidence statements was low because of the weak methodology of nearly all of the studies. The available data suggest that diagnosing diabetic foot infections on the basis of clinical signs and symptoms and classified according to the International Working Group of the Diabetic Foot/Infectious Diseases Society of America scheme correlates with the patient's likelihood of the need for hospitalisation, lower extremity amputation, and risk of death. Elevated levels of selected serum inflammatory markers such as erythrocyte sedimentation rate (ESR), C-reactive protein and procalcitonin are supportive, but not diagnostic, of soft tissue infection. Culturing tissue samples of soft tissues or bone, when care is taken to avoid contamination, provides more accurate microbiological information than culturing superficial (swab) samples. Although non-culture techniques, especially next-generation sequencing, are likely to identify more bacteria from tissue samples including bone than standard cultures, no studies have established a significant impact on the management of patients with DFIs. In patients with suspected diabetic foot osteomyelitis, the combination of a positive probe-to-bone test and elevated ESR supports this diagnosis. Plain X-ray remains the first-line imaging examination when there is suspicion of diabetic foot osteomyelitis (DFO), but advanced imaging methods including magnetic resonance imaging (MRI) and nuclear imaging when MRI is not feasible help in cases when either the diagnosis or the localisation of infection is uncertain. Intra-operative or non-per-wound percutaneous biopsy is the best method to accurately identify bone pathogens in case of a suspicion of a DFO. Bedside percutaneous biopsies are effective and safe and are an option to obtain bone culture data when conventional (i.e. surgical or radiological) procedures are not feasible. CONCLUSIONS The results of this systematic review of the diagnosis of diabetic foot infections provide some guidance for clinicians, but there is still a need for more prospective controlled studies of high quality.
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Affiliation(s)
- Éric Senneville
- Department of Infectious Diseases, Gustave Dron Hospital, Tourcoing, France
- Univ-Lille, Lille, France
| | - Zaina Albalawi
- Department of Medicine, Division of Endocrinology, Memorial University, St. John's, Newfoundland, Canada
| | - Suzanne A van Asten
- Department of Medical Microbiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Zulfiqarali G Abbas
- Abbas Medical Centre, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Geneve Allison
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - John M Embil
- Alberta Public Laboratories, University of Alberta Hospital, Edmonton, Alberta, Canada
| | - Lawrence A Lavery
- Department of Plastic Surgery, Southwestern Medical Center, Dallas, Texas, USA
| | - Majdi Alhasan
- Department of Medicine, Prisma Health-Midlands, Columbia, South Carolina, USA
| | - Orhan Oz
- Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ilker Uçkay
- Department of Infectious Diseases, Balgrist University Hospital, Zurich, Switzerland
| | - Vilma Urbančič-Rovan
- Faculty of Medicine, University Medical Centre, University of Ljubljana, Ljubljana, Slovenia
| | - Zhang-Rong Xu
- Diabetes Centre, The 306th Hospital of PLA, Beijing, China
| | - Edgar J G Peters
- Section of Infectious Diseases, Department of Internal Medicine, Vrije Universiteit Amsterdam, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
- Amsterdam Infection & Immunity, Infectious Diseases, Amsterdam, The Netherlands
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6
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Alkhalfan Y, Lewis TL, Kavarthapu V, Hester T. Investigation and management of diabetic foot osteomyelitis: An update for the foot and ankle orthopaedic surgeon. J Clin Orthop Trauma 2024; 48:102330. [PMID: 38274641 PMCID: PMC10806189 DOI: 10.1016/j.jcot.2023.102330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/13/2023] [Accepted: 12/30/2023] [Indexed: 01/27/2024] Open
Abstract
Diabetic foot osteomyelitis (DFO) poses a significant challenge in the management of diabetic patients, often leading to severe complications and increased morbidity. Effective management of DFO requires a multidisciplinary approach, involving endocrinologists, infectious disease specialists, vascular surgeons, orthopaedic surgeons, and wound care experts. Early diagnosis is paramount, facilitated by advanced imaging techniques such as magnetic resonance imaging (MRI) and bone scintigraphy. Once diagnosed, the treatment strategy hinges on a combination of medical and surgical interventions. Antibiotic therapy, guided by culture results, plays a central role in managing DFO. Tailored regimens targeting the specific pathogens involved are administered, often for prolonged durations. Surgical intervention becomes necessary when conservative measures fall short. Surgical approaches range from minimally invasive procedures, like percutaneous drainage, to more extensive interventions like debridement and bone resection. Prevention of DFO recurrence is equally vital, emphasising glycemic control, meticulous foot care, patient education, monitoring of at-risk signs, revascularization and early intervention when indicated. The management of diabetic foot osteomyelitis mandates a comprehensive strategy that addresses both the infectious and surgical aspects of the condition. A collaborative, interdisciplinary approach ensures timely diagnosis, tailored treatment, and holistic care. Further research into novel therapeutic modalities and long-term outcomes remains essential in refining the management of this complex and debilitating complication of diabetes.
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Affiliation(s)
- Yousif Alkhalfan
- Guy's and St Thomas' NHS Foundation Trust, Maze Pond, London, SE1 9RT, UK
| | | | - Venu Kavarthapu
- King's Foot and Ankle Unit, King's College Hospital NHS Foundation Trust, UK
| | - Thomas Hester
- King's Foot and Ankle Unit, King's College Hospital NHS Foundation Trust, UK
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Husseini JS, Huang AJ. Discitis-osteomyelitis: optimizing results of percutaneous sampling. Skeletal Radiol 2023; 52:1815-1823. [PMID: 35976405 DOI: 10.1007/s00256-022-04151-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 08/04/2022] [Accepted: 08/05/2022] [Indexed: 02/02/2023]
Abstract
Vertebral discitis-osteomyelitis is an infection of the spine that involves the intervertebral disc and the adjacent vertebral body but may also extend into the paraspinal and epidural soft tissues. If blood cultures and other culture data fail to identify a causative microorganism, percutaneous sampling is indicated to help guide targeted antimicrobial therapy. Despite limited supporting evidence, withholding antimicrobial therapy for up to 2 weeks is recommended to maximize microbiological yield, although literature supporting this recommendation is limited. During the procedure, technical factors that may improve yield include targeting of paraspinal fluid collections or soft tissue abnormalities for sampling, acquiring multiple core samples if possible, and use of larger gauge needles when available. Repeat sampling may be indicated if initial percutaneous biopsy is negative but should be performed no sooner than 72 h after the initial percutaneous biopsy to ensure adequate time for culture results to return.
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Affiliation(s)
- Jad S Husseini
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, 55 Fruit Street Yawkey 6E, Boston, MA, 02114, USA.
| | - Ambrose J Huang
- Division of Musculoskeletal Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, 55 Fruit Street Yawkey 6E, Boston, MA, 02114, USA
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8
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Cortes-Penfield NW, Armstrong DG, Brennan MB, Fayfman M, Ryder JH, Tan TW, Schechter MC. Evaluation and Management of Diabetes-related Foot Infections. Clin Infect Dis 2023; 77:e1-e13. [PMID: 37306693 PMCID: PMC10425200 DOI: 10.1093/cid/ciad255] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Indexed: 06/13/2023] Open
Affiliation(s)
| | - David G Armstrong
- Department of Surgery, University of Southern California, Los Angeles, California, USA
| | - Meghan B Brennan
- Division of Infectious Diseases, University of Wisconsin, Madison, Wisconsin, USA
| | - Maya Fayfman
- Division of Endocrinology and Metabolism, Emory University, Atlanta, Georgia, USA
- Department of Medicine, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Jonathan H Ryder
- Division of Infectious Diseases, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Tze-Woei Tan
- Department of Surgery, University of Southern California, Los Angeles, California, USA
| | - Marcos C Schechter
- Department of Medicine, Grady Memorial Hospital, Atlanta, Georgia, USA
- Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
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Schechter MC, Yao Y, Patel M, Andruski R, Rab S, Wong JR, Santamarina G, Fayfman M, Rajani R, Kempker RR. Outpatient Parenteral Antibiotic Therapy for Diabetic Foot Osteomyelitis in an Uninsured and Underinsured Cohort. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2023; 31:e1219. [PMID: 37520685 PMCID: PMC10373103 DOI: 10.1097/ipc.0000000000001219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
Background Diabetic foot osteomyelitis (DFO) is usually treated with prolonged outpatient parenteral antibiotic therapy (OPAT). Evaluation and treatment of non-antibiotic aspects of DFO (e.g., peripheral artery disease [PAD]) are also recommended. There is limited data regarding OPAT practice patterns and outcomes for DFO. Methods Single-center observational study of patients receiving OPAT for DFO in a large United States public hospital between January 2017 and July 2019. We abstracted data regarding microbiology test, antibiotics, clinical outcomes, and non-antibiotic DFO management. Results Ninety-six patients were included and some had >1 DFO-OPAT course during the study period (106 DFO-OPAT courses included). No culture was obtained in 40 (38%) of courses. Methicillin-resistant S. aureus (MRSA) was cultured in 15 (14%) and P. aeruginosa in 1 (1%) of DFO-OPAT courses. An antibiotic with MRSA activity (vancomycin or daptomycin) was used in 79 (75%) of courses and a parenteral antibiotic with anti-pseudomonal activity was used in 7 (6%) of courses. Acute kidney injury occurred in 19 (18%) DFO-OPAT courses. An ankle-brachial index measurement was obtained during or 6 months prior to the first DFO-OPAT course for 44 (49%) of patients. Forty-two (44%) patients died or had an amputation within 12 months of their initial hospital discharge. Conclusions We found high rates of empiric antibiotic therapy for DFO and low uptake of the non-antibiotic aspects of DFO care. Better implementation of microbiological tests for DFO in addition to stronger integration of infectious disease and non-infectious diseases care could improve DFO outcomes.
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Affiliation(s)
- Marcos C. Schechter
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA
- Grady Health System, Atlanta, GA
| | - Yutong Yao
- Rollings School of Public Health, Emory University, Atlanta, Georgia
| | | | | | | | | | - Gabriel Santamarina
- Grady Health System, Atlanta, GA
- Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA
- Department of Surgery, Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA
| | - Maya Fayfman
- Grady Health System, Atlanta, GA
- Department of Medicine, Division of Endocrinology, Metabolism, and Lipids, Emory University School of Medicine, Atlanta, GA
| | - Ravi Rajani
- Grady Health System, Atlanta, GA
- Department of Surgery, Division of Vascular Surgery, Emory University School of Medicine, Atlanta, GA
| | - Russell R. Kempker
- Department of Medicine, Division of Infectious Diseases, Emory University School of Medicine, Atlanta, GA
- Grady Health System, Atlanta, GA
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10
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Bhasin A, Krueger KM, Williams J, Gulati R, Sisler N, Galvin S. Management patterns and outcomes of patients hospitalized with diabetic foot ulcers at one tertiary care hospital. Intern Emerg Med 2023; 18:185-191. [PMID: 36474123 DOI: 10.1007/s11739-022-03166-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 11/22/2022] [Indexed: 12/12/2022]
Abstract
A diabetic foot ulcer is present in approximately 2.4% of hospitalized patients. Care for diabetic foot ulcers is highly variable. We sought to describe care practice patterns and risk factors for poor outcomes for patients hospitalized with a diabetic foot ulcer in our institution, an 894-bed tertiary care academic hospital located in downtown Chicago, IL. We conducted a retrospective cohort study of patients hospitalized with a diabetic foot ulcer between March 3rd, 2018 and December 31st, 2019. We categorized patients into having an uncomplicated ulcer or a complicated ulcer with cellulitis, wound infection, osteomyelitis, or gangrene. We evaluated rates of diagnostic resource utilization (imaging, cultures, biopsies, and antibiotics) and outcomes of osteomyelitis, amputation, and death. There were 305 patients of interest in the study cohort. A complicated lower extremity ulcer was found in 79% of patients. Amputation was required in 25% of patients, 21% were readmitted, and 13% died. Imaging was obtained in less than 50% of all patients, and in 60% or less of those with osteomyelitis. Bone biopsies were rarely acquired. Empiric antibiotics were prescribed in 77% of patients with osteomyelitis. Male, Black or African-American patients, and those with high Charlson score had the highest risk of poor outcomes. Care practices for patients hospitalized with diabetic foot ulcers were highly variable. Future interventions should target standardization to improve outcomes, with particular attention to health inequities as vulnerable populations have a higher risk of poor outcomes.
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Affiliation(s)
- Ajay Bhasin
- Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, 211 E. Ontario, Suite 700, Chicago, IL, 60611, US.
- Division of Hospital Based Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, US.
| | - Karen Marie Krueger
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, US
| | - Janna Williams
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, US
| | - Reeti Gulati
- Northwestern University Feinberg School of Medicine, Chicago, IL, US
| | - Nathan Sisler
- Northwestern University Feinberg School of Medicine, Chicago, IL, US
| | - Shannon Galvin
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, US
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11
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Hockney SM, Steker D, Bhasin A, Krueger KM, Williams J, Galvin S. Role of bone biopsy and deep tissue culture for antibiotic stewardship in diabetic foot osteomyelitis. J Antimicrob Chemother 2022; 77:3482-3486. [PMID: 36214165 DOI: 10.1093/jac/dkac345] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 09/16/2022] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVES To describe organisms most frequently identified on bone biopsy or deep tissue culture and determine how culture data impacted antibiotic management in patients with diabetic foot osteomyelitis (DFO). METHODS We retrospectively reviewed patients admitted with a diabetic foot ulcer (DFU) between 3 March 2018 and 31 December 2019 and selected for patients diagnosed with infectious osteomyelitis (OM) of the lower extremity. We stratified patients by whether a bone biopsy or deep tissue culture was obtained and compared rates of antibiotic utilization with chi-squared and Fisher's exact tests. RESULTS Of 305 patients with a DFU, 152 (50%) were clinically diagnosed with DFO. Forty-seven patients received 41 deep tissue cultures and 29 bone biopsy cultures for a total of 70 cultures. Of 45 (64%) positive cultures, 36 (80%) had Gram-positive organisms and 19 (42%) had Gram-negative organisms. MDR organisms were isolated in 7 (15%) patients. Culture data resulted in antibiotic changes in 41 (87%) patients. Therapy was narrowed in 29 (62%) patients and broadened due to inadequate empirical coverage in 4 (9%) patients. Culture data from 18 (40%) patients showed susceptibility to an oral treatment regimen with high bioavailability. There was no significant difference in rates of antibiotic utilization at discharge between patients who underwent bone biopsy or deep tissue culture relative to those who did not (77% versus 75%, P = 0.86), although less MRSA coverage was used (34% versus 50%, P = 0.047). CONCLUSIONS In patients with DFO, deep tissue and bone biopsy cultures were infrequently obtained but resulted in targeted therapy changes in most patients. Culture data usually allowed for narrowing of antibiotics but revealed inadequate empirical coverage in a subset of patients.
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Affiliation(s)
- Sara M Hockney
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Danielle Steker
- Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ajay Bhasin
- Division of Hospital Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Hospital Based Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Karen M Krueger
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Janna Williams
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Shannon Galvin
- Division of Infectious Diseases, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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12
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Schechter MC, Sax PE, Cortés-Penfield N. What Is the Best Oral Therapy for Staph aureus Osteomyelitis? NEJM EVIDENCE 2022; 1:EVIDtt2200119. [PMID: 38319854 DOI: 10.1056/evidtt2200119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Best Oral Therapy for Staph aureus OsteomyelitisA 50-year-old patient with diabetes mellitus has a plantar ulcer at the base of the first metatarsal. Cortical erosions are noted; bone biopsy culture yields Staphylococcus aureus susceptible to methicillin, ciprofloxacin, clindamycin, doxycycline, trimethoprim/sulfamethoxazole, linezolid, and rifampin. The plan is for 4 weeks of antibiotic treatment. Which antibiotic should be prescribed?
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Affiliation(s)
- Marcos C Schechter
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta
- Grady Memorial Hospital, Atlanta
| | - Paul E Sax
- Division of Infectious Diseases, Brigham and Women's Hospital and Harvard Medical School, Boston
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13
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Keren E, Borer A, Shafat T, Nesher L, Faingelernt Y, Sagi O, Shimoni O, Saidel-Odes L. Multifaceted Strategy Improves Outcomes of Patients Hospitalized with a Diabetic Foot Infection. INT J LOW EXTR WOUND 2022:15347346221093463. [PMID: 35404153 DOI: 10.1177/15347346221093463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Diabetic foot infections (DFIs) are associated with major morbidity, reduced quality of life and increased mortality. Osteomyelitis is a leading cause of lower-extremity amputation in diabetic patients. We aimed to examine whether a multifaceted strategy for treating hospitalized patients with a DFI effectively influenced microbiological culture results and outcomes. A retrospective cohort-study in a 1100-bed, tertiary-care university hospital was conducted. Adult patients with a DFI admitted to the orthopedics department between 2015 and 2019 were included. During the pre-intervention period (2015-2016), one general orthopedic department was in operation. In the post-intervention period (2017-2019), a second department was created with a designated "complicated wound unit". The multifaceted strategy included revising local guidelines for DFI culturing emphasizing bone cultures, correct sample handling, and adjusting antibiotic treatment to culture results. Additionally, a weekly multidisciplinary-team grand round was instigated and post-discharge outpatient follow-up was scheduled. 652 patients with DFIs were included; 101 during the pre-intervention period and 551 during the post-intervention period. Compared to the pre-intervention, during the post-intervention period mainly bone or deep-tissue cultures were performed (9.7% vs. 98.2%, P < 0.001). Bacteriology cultures in the pre-intervention versus post-intervention period revealed: among staphylococcus isolates, fewer methicillin-resistant Staphylococcus aureus detected (20.4% vs. 9.8%, P = 0.010); within Enterobacteriaceae isolates, fewer extended-spectrum β-lactamase producing bacteria detected (51.6% vs. 23.6%, P < 0.001); a decrease in Pseudomonas aeruginosa isolates (28% vs. 10.6%, P < 0.001) and an increase in anaerobic bacterial isolates (0 vs. 11.1%, P < 0.001). On multivariate regression, the post-intervention period (ie multifaceted strategy) was a protective measure against readmissions (P = 0.007 OR 0.50 95% CI 0.30-0.82). We conclude that our interventive multifaceted strategy led to accurate bacterial diagnosis, de-escalation of antibiotic treatment and readmission reduction.
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Affiliation(s)
- Elad Keren
- Orthopedic Department, 26746Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Abraham Borer
- Infection Control and Hospital Epidemiology Unit, 26746Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Infectious Diseases Unit, 26746Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Tali Shafat
- Infectious Diseases Unit, 26746Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Lior Nesher
- Infectious Diseases Unit, 26746Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yaniv Faingelernt
- The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Orli Sagi
- Clinical Microbiology Laboratory, 26746Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Orly Shimoni
- Hospital Pharmacy, 26746Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Lisa Saidel-Odes
- Infection Control and Hospital Epidemiology Unit, 26746Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Infectious Diseases Unit, 26746Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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14
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Bone Biopsy in Suspected Nonvertebral Osteomyelitis: Counterpoint-Limited Yield and Clinical Utility of Image-Guided Percutaneous Needle Biopsy. AJR Am J Roentgenol 2022; 219:197-198. [PMID: 35293235 DOI: 10.2214/ajr.22.27488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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15
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Bone Biopsy in Suspected Nonvertebral Osteomyelitis: Point-Let Bone Be the Guide When Treating Nonvertebral Osteomyelitis. AJR Am J Roentgenol 2022; 219:195-196. [PMID: 35293236 DOI: 10.2214/ajr.22.27642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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16
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Féron F, de Ponfilly GP, Potier L, Gauthier DC, Salle L, Laloi-Michelin M, Munier AL, Jacquier H, Vidal-Trécan T, Julla JB, Carlier A, Abouleka Y, Venteclef N, Grall N, Mercier F, Riveline JP, Senneville É, Gautier JF, Roussel R, Kevorkian JP. Reliability and Safety of Bedside Blind Bone Biopsy Performed by a Diabetologist for the Diagnosis and Treatment of Diabetic Foot Osteomyelitis. Diabetes Care 2021; 44:2480-2486. [PMID: 34475028 DOI: 10.2337/dc20-3170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 08/02/2021] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Bone biopsy (BB) performed by a surgeon or an interventional radiologist is recommended for suspicion of osteomyelitis underlying diabetic foot ulcer (DFU). To facilitate its practice, we developed a procedure allowing bedside blind bone biopsy (B4) by a diabetologist. RESEARCH DESIGN AND METHODS We conducted a three-step observational study consisting of a feasibility and safety phase (phase 1) to assess the success and side effects of B4, a validity phase (phase 2) to compare DFU outcomes between positive (B4+) and negative (B4-) bone cultures, and a performance phase (phase 3) to compare B4 with the conventional surgical or radiological procedure basic bone biopsy (B3). Primary end points were the presence of bone tissue (phase 1) and complete DFU healing with exclusive medical treatment at 12 months (phases 2 and 3). RESULTS In phase 1, 37 consecutive patients with clinical and/or radiological suspicion of DFU osteomyelitis underwent B4. Bone tissue was collected in all patients with few side effects. In phase 2, a B4+ bone culture was found in 40 of 79 (50.6%) participants. Among B4+ patients, complete wound healing after treatment was 57.5%. No statistical difference was observed with patients with B4- bone culture not treated with antibiotics (71.8%, P = 0.18). In phase 3, the proportion of patients with positive BB was lower in B4 (40 of 79, 50.6%) than in B3 (34 of 44, 77.3%, P < 0.01). However, complete healing was similar (64.6% vs. 54.6%, P = 0.28). No difference in rate of culture contamination was observed. CONCLUSIONS B4 is a simple, safe, and efficient procedure for the diagnosis of DFU osteomyelitis with a similar proportion of healing to conventional BB.
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Affiliation(s)
- Florine Féron
- Department of Diabetes and Endocrinology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Gauthier Péan de Ponfilly
- Department of Microbiology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Louis Potier
- Department of Diabetes, Endocrinology, and Nutrition, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France.,Cordeliers Research Centre, INSERM, Immunity and Metabolism in Diabetes Laboratory, Sorbonne University, Université de Paris, Paris, France
| | - Diane-Cécile Gauthier
- Department of Diabetes and Endocrinology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Laurence Salle
- Department of Diabetes and Endocrinology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Marie Laloi-Michelin
- Department of Diabetes and Endocrinology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Anne-Lise Munier
- Department of Infectious Disease, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Hervé Jacquier
- Department of Microbiology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Tiphaine Vidal-Trécan
- Department of Diabetes and Endocrinology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Jean-Baptiste Julla
- Department of Diabetes and Endocrinology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France.,Cordeliers Research Centre, INSERM, Immunity and Metabolism in Diabetes Laboratory, Sorbonne University, Université de Paris, Paris, France
| | - Aurélie Carlier
- Department of Diabetes, Endocrinology, and Nutrition, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Yawa Abouleka
- Department of Diabetes, Endocrinology, and Nutrition, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Nicolas Venteclef
- Cordeliers Research Centre, INSERM, Immunity and Metabolism in Diabetes Laboratory, Sorbonne University, Université de Paris, Paris, France
| | - Nathalie Grall
- Department of Microbiology, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
| | - Frédéric Mercier
- Department of Surgery, Parc Monceau International Clinic, Paris, France
| | - Jean-Pierre Riveline
- Department of Diabetes and Endocrinology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France.,Cordeliers Research Centre, INSERM, Immunity and Metabolism in Diabetes Laboratory, Sorbonne University, Université de Paris, Paris, France
| | - Éric Senneville
- Department of Infectious Disease, Gustave Dron Hospital, Tourcoing, France
| | - Jean-François Gautier
- Department of Diabetes and Endocrinology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France.,Cordeliers Research Centre, INSERM, Immunity and Metabolism in Diabetes Laboratory, Sorbonne University, Université de Paris, Paris, France
| | - Ronan Roussel
- Department of Diabetes, Endocrinology, and Nutrition, Bichat Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France.,Cordeliers Research Centre, INSERM, Immunity and Metabolism in Diabetes Laboratory, Sorbonne University, Université de Paris, Paris, France
| | - Jean-Philippe Kevorkian
- Department of Diabetes and Endocrinology, Lariboisière Hospital, Assistance Publique-Hôpitaux de Paris, Université de Paris, Paris, France
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Sousa R, Carvalho A, Santos AC, Abreu MA. Optimal microbiological sampling for the diagnosis of osteoarticular infection. EFORT Open Rev 2021; 6:390-398. [PMID: 34267930 PMCID: PMC8246105 DOI: 10.1302/2058-5241.6.210011] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Infection is a dire complication afflicting every field of orthopaedics and traumatology. If specific clinical, laboratory and imaging parameters are present, infection is often assumed even in the absence of microbiological confirmation. However, apart from confirming infection, knowing the exact infecting pathogen(s) and their antimicrobial susceptibility patterns is paramount to help guide treatment. Every effort should therefore be undertaken with that goal in mind.Not all microbiological findings carry the same relevance, and knowing exactly how and where a sample was collected is key. Several different sampling techniques are available, and one must be aware of both advantages and limitations. Microbiological sampling alternatives in some of the most common clinical scenarios such as native and prosthetic joint infections, osteomyelitis and fracture-related infections, spinal and diabetic foot infections will be discussed.Orthopaedic surgeons should also be aware of basic laboratory sample processing techniques as they have a direct impact on the way specimens should be dealt with and transported to the laboratory. Only by knowing these basic principles will surgeons be able to participate in the multidisciplinary discussion and decision making around how to interpret microbiological findings in each specific patient. Cite this article: EFORT Open Rev 2021;6:390-398. DOI: 10.1302/2058-5241.6.210011.
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Affiliation(s)
- Ricardo Sousa
- Department of Orthopaedics, Centro Hospitalar Universitário do Porto, Porto, Portugal.,Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário do Porto and Grupo TrofaSaude, Portugal
| | - André Carvalho
- Department of Orthopaedics, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Ana Cláudia Santos
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário do Porto and Grupo TrofaSaude, Portugal.,Department of Microbiology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Miguel Araújo Abreu
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário do Porto and Grupo TrofaSaude, Portugal.,Department of Microbiology, Centro Hospitalar Universitário do Porto, Porto, Portugal
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