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Kipp J, Vesely BD, Fram M, Russell G, Kim-Shapiro JW, Medda AW, Gangopadhyay P. Comparison of Two Techniques for Proximal Margin Analysis of Toe Amputations: A Retrospective Review. J Foot Ankle Surg 2024; 63:464-467. [PMID: 38438099 DOI: 10.1053/j.jfas.2024.02.005] [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: 11/18/2022] [Revised: 09/26/2023] [Accepted: 02/17/2024] [Indexed: 03/06/2024]
Abstract
Toe amputations are a common podiatric procedure for treatment of osteomyelitis. Whether or not the surgeon obtains a surgical cure, thus resolving the infection, can be difficult to assess. Obtaining a proximal bone margin can assist the treatment team in deciding the duration of postoperative antibiotics, need for reoperation, and postoperative care. The two senior surgeons use different methods to analyze proximal bone margins. The first surgeon obtains a microbiologic culture from the remaining bone, either at the proximal phalanx or metatarsal head, following the removal of the toe to be reviewed for osteomyelitis. Per the second surgeon's technique, the pathologist only analyzes the proximal aspect of the amputated toe for presence of osteomyelitis. Our goal is to analyze the reoperation and reamputation rates between the techniques in which the proximal margin specimens are obtained. A retrospective chart review was performed on all isolated toe or partial toe amputations from March 2017 to September 2022. There were 115 patients who met inclusion criteria. Reoperation and reamputation rates were analyzed for positive and negative infection margins from intraoperative cultures. Our study found an overall 28% reoperation rate and 26% reamputation rate for the negative margins group. In the positive proximal margin group, there was an overall 48% reoperation rate and 44% reamputation rate. Our analysis did not find a statistically significant difference between the reamputation rate in the negative margins group and the reamputation rate in the positive margins group. In conclusion, our study found that a positive proximal margin for osteomyelitis exhibited a nearly double reoperation and reamputation rate compared to patients with a negative margin, and that one margin analysis technique was not inferior to the other in regards to the need for additional surgeries.
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Affiliation(s)
- Jennifer Kipp
- Resident Physician, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC
| | - Bryanna D Vesely
- Resident Physician, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC.
| | - Madeline Fram
- Medical Student, Wake Forest University School of Medicine, Winston Salem, NC
| | - Greg Russell
- Senior Biostatistician, Wake Forest University School of Medicine, Winston Salem, NC
| | - Jung Wha Kim-Shapiro
- Assistant Professor, Pathology Department, Wake Forest Baptist Medical Center, Winston Salem, NC
| | - Ashleigh W Medda
- Attending Physician, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC
| | - Paula Gangopadhyay
- Attending Physician, Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston Salem, NC
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Villa F, Marchandin H, Lavigne JP, Schuldiner S, Cellier N, Sotto A, Loubet P. Anaerobes in diabetic foot infections: pathophysiology, epidemiology, virulence, and management. Clin Microbiol Rev 2024:e0014323. [PMID: 38819166 DOI: 10.1128/cmr.00143-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024] Open
Abstract
SUMMARYDiabetic foot infections (DFI) are a public health problem worldwide. DFI are polymicrobial, biofilm-associated infections involving complex bacterial communities organized in functional equivalent pathogroups, all including anaerobes. Indeed, multiple pathophysiological factors favor the growth of anaerobes in this context. However, the prevalence, role, and contribution of anaerobes in wound evolution remain poorly characterized due to their challenging detection. Studies based on culture reviewed herein showed a weighted average of 17% of patients with anaerobes. Comparatively, the weighted average of patients with anaerobes identified by 16S rRNA gene sequencing was 83.8%. Culture largely underestimated not only the presence but also the diversity of anaerobes compared with cultivation-independent approaches but both methods showed that anaerobic Gram-negative bacilli and Gram-positive cocci were the most commonly identified in DFI. Anaerobes were more present in deeper lesions, and their detection was associated with fever, malodorous lesions, and ulcer depth and duration. More specifically, initial abundance of Peptoniphilus spp. was associated with ulcer-impaired healing, Fusobacterium spp. detection was significantly correlated with the duration of DFI, and the presence of Bacteroides spp. was significantly associated with amputation. Antimicrobial resistance of anaerobes in DFI remains slightly studied and warrants more consideration in the context of increasing resistance of the most frequently identified anaerobes in DFI. The high rate of patients with DFI-involving anaerobes, the increased knowledge on the species identified, their virulence factors, and their potential role in wound evolution support recommendations combining debridement and antibiotic therapy effective on anaerobes in moderate and severe DFI.
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Affiliation(s)
- Fanny Villa
- VBIC, INSERM U1047, Univ Montpellier, Service des Maladies Infectieuses et Tropicales, CHU Nîmes, Nîmes, France
| | - Hélène Marchandin
- HydroSciences Montpellier, Univ Montpellier, CNRS, IRD, Service de Microbiologie et Hygiène, Hospitalière, CHU Nîmes, Nîmes, France
| | - Jean-Philippe Lavigne
- VBIC, INSERM U1047, Univ Montpellier, Service de Microbiologie et Hygiène Hospitalière, CHU Nîmes, Nîmes, France
| | - Sophie Schuldiner
- VBIC, INSERM U1047, Univ Montpellier, Service des Maladies Métaboliques et Endocriniennes, CHU Nîmes, Nîmes, France
| | | | - Albert Sotto
- VBIC, INSERM U1047, Univ Montpellier, Service des Maladies Infectieuses et Tropicales, CHU Nîmes, Nîmes, France
| | - Paul Loubet
- VBIC, INSERM U1047, Univ Montpellier, Service des Maladies Infectieuses et Tropicales, CHU Nîmes, Nîmes, France
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Akbari MS, Keogh RA, Radin JN, Sanchez-Rosario Y, Johnson MDL, Horswill AR, Kehl-Fie TE, Burcham LR, Doran KS. The impact of nutritional immunity on Group B streptococcal pathogenesis during wound infection. mBio 2023; 14:e0030423. [PMID: 37358277 PMCID: PMC10470527 DOI: 10.1128/mbio.00304-23] [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: 02/07/2023] [Accepted: 05/09/2023] [Indexed: 06/27/2023] Open
Abstract
Group B Streptococcus (GBS) is a Gram-positive pathobiont that can cause adverse health outcomes in neonates and vulnerable adult populations. GBS is one of the most frequently isolated bacteria from diabetic (Db) wound infections but is rarely found in the non-diabetic (nDb) wound environment. Previously, RNA sequencing of wound tissue from Db wound infections in leprdb diabetic mice showed increased expression of neutrophil factors, and genes involved in GBS metal transport such as the zinc (Zn), manganese (Mn), and putative nickel (Ni) import systems. Here, we develop a Streptozotocin-induced diabetic wound model to evaluate the pathogenesis of two invasive strains of GBS, serotypes Ia and V. We observe an increase in metal chelators such as calprotectin (CP) and lipocalin-2 during diabetic wound infections compared to nDb. We find that CP limits GBS survival in wounds of non-diabetic mice but does not impact survival in diabetic wounds. Additionally, we utilize GBS metal transporter mutants and determine that the Zn, Mn, and putative Ni transporters in GBS are dispensable in diabetic wound infection but contributed to bacterial persistence in non-diabetic animals. Collectively, these data suggest that in non-diabetic mice, functional nutritional immunity mediated by CP is effective at mitigating GBS infection, whereas in diabetic mice, the presence of CP is not sufficient to control GBS wound persistence. IMPORTANCE Diabetic wound infections are difficult to treat and often become chronic due to an impaired immune response as well as the presence of bacterial species that establish persistent infections. Group B Streptococcus (GBS) is one of the most frequently isolated bacterial species in diabetic wound infections and, as a result, is one of the leading causes of death from skin and subcutaneous infection. However, GBS is notoriously absent in non-diabetic wounds, and little is known about why this species thrives in diabetic infection. The work herein investigates how alterations in diabetic host immunity may contribute to GBS success during diabetic wound infection.
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Affiliation(s)
- Madeline S. Akbari
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Rebecca A. Keogh
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Jana N. Radin
- Department of Microbiology, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Yamil Sanchez-Rosario
- Department of Immunobiology, University of Arizona College of Medicine—Tucson, Tucson, Arizona, USA
| | - Michael D. L. Johnson
- Department of Immunobiology, University of Arizona College of Medicine—Tucson, Tucson, Arizona, USA
- Valley Fever Center for Excellence, University of Arizona College of Medicine—Tucson, Tucson, Arizona, USA
- BIO5 Institute, University of Arizona College of Medicine—Tucson, Tucson, Arizona, USA
- Asthma and Airway Disease Research Center, University of Arizona College of Medicine—Tucson, Tucson, Arizona, USA
| | - Alexander R. Horswill
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
- Department of Veterans Affairs, VA Eastern Colorado Health Care System, Aurora, Colorado, USA
| | - Thomas E. Kehl-Fie
- Department of Microbiology, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
- Carl R. Woese Institute for Genomic Biology, University of Illinois at Urbana-Champaign, Urbana, Illinois, USA
| | - Lindsey R. Burcham
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Kelly S. Doran
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado, USA
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Gramberg MCTT, Van Hattem JM, Dijkstra JA, Dros E, Nieuwdorp M, Sabelis LWE, Peters EJG. Effect of Prior Antibiotic Use on Culture Results in People with Diabetes and Foot Osteomyelitis. Antibiotics (Basel) 2023; 12:antibiotics12040684. [PMID: 37107046 PMCID: PMC10135220 DOI: 10.3390/antibiotics12040684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/28/2023] [Accepted: 03/30/2023] [Indexed: 04/03/2023] Open
Abstract
Background: Antibiotic use prior to biopsy acquisition in people with diabetes and osteomyelitis of the foot (DFO) might influence bacterial yield in cultures or induce bacterial resistance. Obtaining reliable culture results is pivotal to guide antibiotics for conservative treatment of DFO. Methods: We prospectively analysed cultures of ulcer bed and percutaneous bone biopsies of people with DFO and investigated if antibiotics administered prior to (<2 months up to 7 days) biopsy acquisition led to more negative cultures or increased resistance in virulent bacteria. We calculated relative risks (RR) and 95% confidence intervals (CIs). We stratified analyses according to biopsy type (ulcer bed or bone). Results: We analysed bone and ulcer bed biopsies of 64 people, of whom 29 received prior antibiotics, and found that prior antibiotics did not lead to a higher risk of at least one negative culture (RR 1.3, (CI 0.8–2.0), nor did prior treatment increase the risk of a specific type of negative culture (RR for bone cultures 1.15, (CI 0.75–1.7), RR for ulcer bed cultures 0.92 (CI 0.33–2.6)) or both cultures (RR 1.3 (CI 0.35–4.7), and neither did it increase the risk of antibiotic resistance in the combined bacterial results of ulcer bed and bone cultures (RR 0.64, (CI 0.23–1.8)). Conclusions: Antibiotics administered up to 7 days before obtaining biopsies in people with DFO do not influence culture yield regardless of biopsy type, nor are they associated with more antibiotic resistance.
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Affiliation(s)
- Meryl Cinzía Tila Tamara Gramberg
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine, Section of Infectious Diseases, De Boelelaan 1117, NL-1081HV Amsterdam, The Netherlands
- Amsterdam Institute for Infection and Immunity and Amsterdam Movement Sciences, P.O. Box 22660, NL-1100DD Amsterdam, The Netherlands
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Rehabilitation Medicine, De Boelelaan 1117, NL-1081HV Amsterdam, The Netherlands
- Amsterdam UMC Center for Diabetic Foot Complications (ACDC), P.O. Box 22660, NL-1100DD Amsterdam, The Netherlands
| | - Jarne Marijn Van Hattem
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Medical Microbiology and Infection Prevention, Meibergdreef 9, NL-1100DD Amsterdam, The Netherlands
| | - Jacob Albert Dijkstra
- Department of Pharmacy and Clinical Pharmacology, Amsterdam University Medical Center, NL-1081HV Amsterdam, The Netherlands
| | - Emma Dros
- Department of Pharmacy and Clinical Pharmacology, Amsterdam University Medical Center, NL-1081HV Amsterdam, The Netherlands
| | - Max Nieuwdorp
- Amsterdam UMC Center for Diabetic Foot Complications (ACDC), P.O. Box 22660, NL-1100DD Amsterdam, The Netherlands
- Amsterdam UMC, Location University of Amsterdam, Department of Experimental Vascular Medicine, Meibergdreef 9, NL-1100DD Amsterdam, The Netherlands
| | - Louise Willy Elizabeth Sabelis
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Rehabilitation Medicine, De Boelelaan 1117, NL-1081HV Amsterdam, The Netherlands
- Amsterdam UMC Center for Diabetic Foot Complications (ACDC), P.O. Box 22660, NL-1100DD Amsterdam, The Netherlands
- Amsterdam Movement Sciences, P.O. Box 22660, NL-1100DD Amsterdam, The Netherlands
| | - Edgar Josephus Gerardus Peters
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine, Section of Infectious Diseases, De Boelelaan 1117, NL-1081HV Amsterdam, The Netherlands
- Amsterdam Institute for Infection and Immunity and Amsterdam Movement Sciences, P.O. Box 22660, NL-1100DD Amsterdam, The Netherlands
- Amsterdam UMC Center for Diabetic Foot Complications (ACDC), P.O. Box 22660, NL-1100DD Amsterdam, The Netherlands
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5
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Keogh RA, Haeberle AL, Langouët-Astrié CJ, Kavanaugh JS, Schmidt EP, Moore GD, Horswill AR, Doran KS. Group B Streptococcus adaptation promotes survival in a hyperinflammatory diabetic wound environment. SCIENCE ADVANCES 2022; 8:eadd3221. [PMID: 36367946 PMCID: PMC9651866 DOI: 10.1126/sciadv.add3221] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 09/22/2022] [Indexed: 06/16/2023]
Abstract
Diabetic wounds have poor healing outcomes due to the presence of numerous pathogens and a dysregulated immune response. Group B Streptococcus (GBS) is commonly isolated from diabetic wound infections, but the mechanisms of GBS virulence during these infections have not been investigated. Here, we develop a murine model of GBS diabetic wound infection and, using dual RNA sequencing, demonstrate that GBS infection triggers an inflammatory response. GBS adapts to this hyperinflammatory environment by up-regulating virulence factors including those known to be regulated by the two-component system covRS, such as the surface protein pbsP, and the cyl operon, which is responsible for hemolysin/pigmentation production. We recover hyperpigmented/hemolytic GBS colonies from the murine diabetic wound, which we determined encode mutations in covR. We further demonstrate that GBS mutants in cylE and pbsP are attenuated in the diabetic wound. This foundational study provides insight into the pathogenesis of GBS diabetic wound infections.
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Affiliation(s)
- Rebecca A. Keogh
- Department of Immunology and Microbiology, University of Colorado Anschutz, Aurora, CO, USA
| | - Amanda L. Haeberle
- Department of Immunology and Microbiology, University of Colorado Anschutz, Aurora, CO, USA
| | | | - Jeffrey S. Kavanaugh
- Department of Immunology and Microbiology, University of Colorado Anschutz, Aurora, CO, USA
| | - Eric P. Schmidt
- Department of Medicine–Pulmonary Sciences and Critical Care, University of Colorado Anschutz, Aurora, CO, USA
| | - Garrett D. Moore
- Department of Orthopedics, University of Colorado, Anschutz Medical Campus, Aurora, CO, USA
| | - Alexander R. Horswill
- Department of Immunology and Microbiology, University of Colorado Anschutz, Aurora, CO, USA
- Department of Veterans Affairs Eastern Colorado Healthcare System, Aurora, CO, USA
| | - Kelly S. Doran
- Department of Immunology and Microbiology, University of Colorado Anschutz, Aurora, CO, USA
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6
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The association between bacteria and outcome and the influence of sampling method, in people with a diabetic foot infection. Infection 2022; 51:347-354. [PMID: 35869352 PMCID: PMC10042898 DOI: 10.1007/s15010-022-01884-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 06/28/2022] [Indexed: 11/05/2022]
Abstract
Abstract
Purpose
Different bacteria lead to divers diabetic foot infections (DFIs), and some bacteria probably lead to higher amputation and mortality risks. We assessed mortality and amputation risk in relation to bacterial profiles in people DFI and investigated the role of sampling method.
Methods
We included people (> 18 years) with DFI in this retrospective study (2011–2020) at a Dutch tertiary care hospital. We retrieved cultures according to best sampling method: (1) bone biopsy; (2) ulcer bed biopsy; and (3) swab. We aggregated data into a composite determinant, consisting of unrepeated bacteria of one episode of infection, clustered into 5 profiles: (1) Streptococcus and Staphylococcus aureus; (2) coagulase-negative Staphylococcus, Cutibacterium, Corynebacterium and Enterococcus; (3) gram-negative; (4) Anaerobic; and (5) less common gram-positive bacteria. We calculated Hazard Ratio’s (HR’s) using time-dependent-Cox regression for the analyses and investigated effect modification by sampling method.
Results
We included 139 people, with 447 person-years follow-up and 459 episodes of infection. Sampling method modified the association between bacterial profiles and amputation for profile 2. HR’s (95% CI’s) for amputation for bacterial profiles 1–5: 0.7 (0.39–1.1); stratified analysis for profile 2: bone biopsy 0.84 (0.26–2.7), ulcer bed biopsy 0.89 (0.34–2.3), swab 5.9*(2.9–11.8); 1.3 (0.78–2.1); 1.6 (0.91–2.6); 1.6 (0.58–4.5). HR’s (95% CI’s) for mortality for bacterial profiles 1–5: 0.89 (0.49–1.6); 0.73 (0.38–1.4); 2.6*(1.4–4.8); 1.1(0.58–2.2); 0.80(0.19–3.3).
Conclusions
In people with DFI, there was no association between bacterial profiles in ulcer bed and bone biopsies and amputation. Only in swab cultures, low-pathogenic bacteria (profile 2), were associated with a higher amputation risk. Infection with gram-negative bacteria was associated with a higher mortality risk. This study underlined the possible negative outcome of DFI treatment based on swabs cultures.
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Sertic M, Parkes L, Mattiassi S, Pritzker K, Gardam M, Murphy K. The Efficacy of Computed Tomography-Guided Percutaneous Spine Biopsies in Determining a Causative Organism in Cases of Suspected Infection: A Systematic Review. Can Assoc Radiol J 2019; 70:96-103. [DOI: 10.1016/j.carj.2018.09.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 09/02/2018] [Accepted: 09/07/2018] [Indexed: 12/20/2022] Open
Abstract
Purpose In suspected spondylodiscitis and vertebral osteomyelitis, computed tomography (CT)-guided biopsies are often performed to determine a causative organism and guide antimicrobial therapy. The aim of this study is to determine the diagnostic culture yield of CT-guided biopsies performed in cases of suspected spinal infections. Methods A literature search of PubMed and MEDLINE up to April 2017 was performed for keywords “CT guided vertebral biopsy infection,” “CT-guided spine biopsy infection,” “CT guided spine biopsy yield,” and “CT guided vertebral biopsy yield.” Inclusion criteria primarily consisted of studies exclusively using CT-guided biopsies in cases of suspected infectious lesions only. After study selection, published articles were analysed to determine diagnostic culture yield. Descriptive statistics were applied. Results 220 search results were screened; 11 met our inclusion criteria and were reviewed. In total, 647 biopsies of suspected infectious spinal lesions were performed. Positive cultures were obtained in 241 cases. Upon excluding one paper's skewed results, the net pooled results culture yield was 33%. Several cultures grew multiple organisms, leading to a total of 244 species identified. Most common isolated organisms include S taphylococcus aureus (n = 83), coagulase-negative S taphylococcus (n = 45), and Mycobacteria (n = 38). Conclusions The diagnostic culture yield of CT-guided biopsies in cases of suspected spinal infection is 33%. In the majority of cases, a causative organism is not identified. This suggests that improvements can be made in biopsy technique and specimen transfer to optimize culture yield and increase the clinical value of the procedure.
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Affiliation(s)
- Madeleine Sertic
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Leighanne Parkes
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sabrina Mattiassi
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
| | - Kenneth Pritzker
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Michael Gardam
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kieran Murphy
- Department of Medical Imaging, University of Toronto, Toronto, Ontario, Canada
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Kwon KT, Armstrong DG. Microbiology and Antimicrobial Therapy for Diabetic Foot Infections. Infect Chemother 2018; 50:11-20. [PMID: 29637748 PMCID: PMC5895826 DOI: 10.3947/ic.2018.50.1.11] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2018] [Indexed: 02/06/2023] Open
Abstract
In addition to being the prime factor associated with amputation, diabetic foot infections (DFIs) are associated with major morbidity, increasing mortality, and reduced quality of life. The choice of appropriate antibiotics is very important in order to reduce treatment failure, antimicrobial resistance, adverse events, and costs. We reviewed articles on microbiology and antimicrobial therapy and discuss antibiotic selection in Korean patients with DFIs. Similar to Western countries, Staphylococcus aureus is the most common pathogen, with Streptococcus, Enterococcus, Enterobacteriaceae and Pseudomonas also prevalent in Korea. It is recommended that antibiotics are not prescribed for clinically uninfected wounds and that empirical antibiotics be selected based on the clinical features, disease severity, and local antimicrobial resistance patterns. Narrow-spectrum oral antibiotics can be administered for mild infections and broad-spectrum parenteral antibiotics should be administered for some moderate and severe infections. In cases with risk factors for methicillin-resistant S. aureus or Pseudomonas, empirical antibiotics to cover each pathogen should be considered. The Health Insurance Review and Assessment Service standards should also be considered when choosing empirical antibiotics. In Korea, nationwide studies need to be conducted and DFI guidelines should be developed.
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Affiliation(s)
- Ki Tae Kwon
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu, Korea
| | - David G Armstrong
- Southwestern Academic Limb Salvage Alliance (SALSA), Department of Surgery of Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.
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