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Wright A, Wood S, De Silva J, Bell JS. Systemic Antimicrobial Therapy for Diabetic Foot Infections: An Overview of Systematic Reviews. Antibiotics (Basel) 2023; 12:1041. [PMID: 37370360 DOI: 10.3390/antibiotics12061041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 06/01/2023] [Accepted: 06/07/2023] [Indexed: 06/29/2023] Open
Abstract
Diabetic foot infections (DFIs) are a common complication of diabetes; however, there is clinical uncertainty regarding the optimal antimicrobial selection. The aim of this review was to critically evaluate the recent systematic reviews on the efficacy and safety of systemic (parenteral or oral) antimicrobials for DFI. Medline, Embase, CENTRAL, and CINAHL databases and the PROSPERO register were searched from January 2015 to January 2023. Systematic reviews with or without meta-analyses on systemic antimicrobials for DFI, with outcomes of clinical infection resolution or complications, were included. Of the 413 records identified, 6 systematic reviews of 29 individual studies were included. Heterogeneity of individual studies precluded meta-analysis, except for ertapenem versus piperacillin-tazobactam (RR 1.07, 95% CI [0.96-1.19]) and fluoroquinolones versus piperacillin-tazobactam (RR 1.03, 95% CI [0.89-1.20]) in one review. The application of the AMSTAR-2 tool determined two reviews to be of high quality. There was no statistical difference in the clinical resolution of infections for 24 different antimicrobial regimens (penicillins, cephalosporins, carbapenems, fluoroquinolones, vancomycin, metronidazole, clindamycin, linezolid, daptomycin, and tigecycline). However, tigecycline did not meet non-inferiority against ertapenem ± vancomycin (absolute difference -5.5%, 95% CI [-11.0-0.1]) and was associated with a higher incidence of adverse drug events. There is minimal systematic review evidence to suggest one regimen is superior to another for DFI.
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Affiliation(s)
- Angela Wright
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia
- Pharmacy Department, Mackay Base Hospital, Mackay, QLD 4740, Australia
| | - Stephen Wood
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia
| | - Janath De Silva
- Medicine Department, Mackay Base Hospital, Mackay, QLD 4740, Australia
| | - J Simon Bell
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, VIC 3052, Australia
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Soldevila-Boixader L, Murillo O, Waibel FWA, Huber T, Schöni M, Lalji R, Uçkay I. The Epidemiology of Antibiotic-Related Adverse Events in the Treatment of Diabetic Foot Infections: A Narrative Review of the Literature. Antibiotics (Basel) 2023; 12:antibiotics12040774. [PMID: 37107136 PMCID: PMC10135215 DOI: 10.3390/antibiotics12040774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 04/16/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
The use of antibiotics for the treatment of diabetic foot infections (DFIs) over an extended period of time has been shown to be associated with adverse events (AEs), whereas interactions with concomitant patient medications must also be considered. The objective of this narrative review was to summarize the most frequent and most severe AEs reported in prospective trials and observational studies at the global level in DFI. Gastrointestinal intolerances were the most frequent AEs, from 5% to 22% among all therapies; this was more common when prolonged antibiotic administration was combined with oral beta-lactam or clindamycin or a higher dose of tetracyclines. The proportion of symptomatic colitis due to Clostridium difficile was variable depending on the antibiotic used (0.5% to 8%). Noteworthy serious AEs included hepatotoxicity due to beta-lactams (5% to 17%) or quinolones (3%); cytopenia's related to linezolid (5%) and beta-lactams (6%); nausea under rifampicin, and renal failure under cotrimoxazole. Skin rash was found to rarely occur and was commonly associated with the use of penicillins or cotrimoxazole. AEs from prolonged antibiotic use in patients with DFI are costly in terms of longer hospitalization or additional monitoring care and can trigger additional investigations. The best way to prevent AEs is to keep the duration of antibiotic treatment short and with the lowest dose clinically necessary.
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Affiliation(s)
- Laura Soldevila-Boixader
- Infectious Diseases Service, IDIBELL-Hospital Universitari Bellvitge, Universitat de Barcelona, Feixa Llarga s/n, Hospitalet de Llobregat, 08907 Barcelona, Spain
- Research Network for Infectious Diseases (CIBERINFEC), ISCIII, 28029 Madrid, Spain
- Infectiology, Unit for Clinical and Applied Research, Balgrist University Hospital, 8008 Zurich, Switzerland
| | - Oscar Murillo
- Infectious Diseases Service, IDIBELL-Hospital Universitari Bellvitge, Universitat de Barcelona, Feixa Llarga s/n, Hospitalet de Llobregat, 08907 Barcelona, Spain
- Research Network for Infectious Diseases (CIBERINFEC), ISCIII, 28029 Madrid, Spain
| | - Felix W A Waibel
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Tanja Huber
- Hospital Pharmacy, Balgrist University Hospital, 8008 Zurich, Switzerland
| | - Madlaina Schöni
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Rahim Lalji
- EBPI-UWZH Musculoskeletal Epidemiology Research Group, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
- Epidemiology, Biostatistics and Prevention Institute (EBPI), University of Zurich, 8008 Zurich, Switzerland
- University Spine Centre Zurich (UWZH), Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
| | - Ilker Uçkay
- Infectiology, Unit for Clinical and Applied Research, Balgrist University Hospital, 8008 Zurich, Switzerland
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland
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Shi X, Wu Y, Ni H, Guo M, Cheng Q, Xu Y. Efficacy and Safety of Different Antibiotic Therapies for Bone and Joint Infections: A Network Meta-analysis of Randomized Controlled Trials. Curr Pharm Des 2023; 29:2313-2322. [PMID: 37861039 DOI: 10.2174/0113816128236536231010051130] [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: 11/25/2022] [Revised: 05/10/2023] [Accepted: 06/08/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Although an increasing number of antibiotics are being used to treat bone and joint infections, their specific efficacy remains controversial. Thus, we aimed to systematically compare the efficacy and safety of antibiotic therapies for orthopedic infections. METHODS PubMed, Embase, The Cochrane Library, and Web of Science databases were searched from inception to April 2022. Two authors independently and rigorously conducted the screening, data extraction, and quality assessment of the relevant studies. All the extracted data were evaluated using traditional metaanalysis and network meta-analysis by STATA SE 16.0. RESULTS A total of eleven randomized controlled trials (RCTs) involving 1,063 patients were included for data analysis. The analysis results from the NMA indicated that in terms of the clinical effectiveness rate, linezolid (OR: 1.75, 95% CI: 1.01 to 3.02) showed significant efficacy compared to ampicillin/sulbactam. With regard to the microbiological eradication rate, linezolid showed significant efficacy compared to cephalosporins (OR: 8.13, 95% CI: 1.16 to 57.09) and quinolones (OR: 3.51, 95% CI: 1.18 to 10.49). Similar findings were obtained for subgroup populations with diabetic foot infections (DFI). However, linezolid was significantly related to higher adverse events than ampicillin/sulbactam (OR: 3.25, 95% CI: 1.68 to 6.30) and cephalosporins (OR: 18.29, 95% CI: 1.59 to 209.76). CONCLUSION Linezolid appeared to be the most promising treatment regimen for staphylococcal bone and joint infections. However, due to the overall limited evidence, the research results need further high-quality RCTs for confirmation.
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Affiliation(s)
| | - Yipeng Wu
- Department of Orthopedic Surgery, 920th Hospital of Joint Logistics Support Force, Kunming, China
- Kunming Medical University, Kunming, China
- Laboratory of Yunnan Traumatology and Orthopedics Clinical Medical Center, Yunnan Orthopedics and Sports Rehabilitation Clinical Medical Research Center, Department of Orthopedic Surgery, 920th Hospital of Joint Logistics Support Force of PLA, Kunming, China
| | - Haonan Ni
- Kunming Medical University, Kunming, China
| | - Minzheng Guo
- Department of Orthopedic Surgery, 920th Hospital of Joint Logistics Support Force, Kunming, China
| | - Qi Cheng
- Kunming Medical University, Kunming, China
| | - Yongqing Xu
- Laboratory of Yunnan Traumatology and Orthopedics Clinical Medical Center, Yunnan Orthopedics and Sports Rehabilitation Clinical Medical Research Center, Department of Orthopedic Surgery, 920th Hospital of Joint Logistics Support Force of PLA, Kunming, China
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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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Pratama V, Risni HW, Yunir E, Sauriasari R. A Systematic Review of Randomized Controlled Trials of Antibiotic Use in Diabetic Foot Ulcer Infections: Focus on Clinical Cure. Infect Chemother 2022; 54:125-139. [PMID: 35384424 PMCID: PMC8987184 DOI: 10.3947/ic.2021.0144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/19/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The use of antibiotics in diabetic foot ulcer infections (DFUI) is essential in reducing morbidity. Optimal administration of antibiotics can improve clinical outcomes and reduce the risk of antibiotic resistance. This study aims to review the efficacy, in terms of clinical cure, of various regimens and the duration of antibiotic administration in DFUI patients, based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The efficacy based on microbiological response is also reviewed as the secondary outcome. MATERIALS AND METHODS We used three databases, namely PubMed, Scopus, and ScienceDirect, to search for randomized controlled trials (RCTs) in patients with DFUI who required antibiotics. RESULTS A total of 16 studies were included in the systematic review. The study locations and bacterial patterns varied, with the most common pathogen being Staphylococcus aureus. Most studies did not demonstrate a significant difference in clinical cure and pathogen eradication, either in the comparison between systemic and topical antibiotics or in the duration of administration. Some studies had similar characteristics and were analyzed to conclude. These studies showed that ertapenem had comparable efficacy to piperacillin/tazobactam. Similar results were also conducted from studies of piperacillin-tazobactam+amoxicillin-clavulanic acid vs. moxifloxacin. CONCLUSION Most studies have heterogeneous characteristics, possibly due to differences in research location. Therefore, there is no strong evidence to recommend a specific antibiotic with the highest efficacy. However, since all included studies are RCTs, this review provides a good summary in considering antibiotic choices when treating DFUI patients.
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Affiliation(s)
- Vincent Pratama
- Faculty of Pharmacy, Universitas Indonesia, Depok, Indonesia
| | | | - Em Yunir
- Division of Endocrinology, Department of Internal Medicine Dr. Cipto Mangunkusumo National Referral Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Rani Sauriasari
- Faculty of Pharmacy, Universitas Indonesia, Depok, Indonesia.
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Macdonald KE, Boeckh S, Stacey HJ, Jones JD. The microbiology of diabetic foot infections: a meta-analysis. BMC Infect Dis 2021; 21:770. [PMID: 34372789 PMCID: PMC8351150 DOI: 10.1186/s12879-021-06516-7] [Citation(s) in RCA: 72] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 07/28/2021] [Indexed: 01/13/2023] Open
Abstract
Background Diabetic foot ulcers are a common complication of poorly controlled diabetes and often become infected, termed diabetic foot infection. There have been numerous studies of the microbiology of diabetic foot infection but no meta-analysis has provided a global overview of these data. This meta-analysis aimed to investigate the prevalence of bacteria isolated from diabetic foot infections using studies of any design which reported diabetic foot infection culture results. Methods The Medline, EMBASE, Web of Science and BIOSIS electronic databases were searched for studies published up to 2019 which contained microbiological culture results from at least 10 diabetic foot infection patients. Two authors independently assessed study eligibility and extracted the data. The main outcome was the prevalence of each bacterial genera or species. Results A total of 112 studies were included, representing 16,159 patients from which 22,198 microbial isolates were obtained. The organism most commonly identified was Staphylococcus aureus, of which 18.0% (95% CI 13.8–22.6%; I2 = 93.8% [93.0–94.5%]) was MRSA. Other highly prevalent organisms were Pseudomonas spp., E. coli and Enterococcus spp. A correlation was identified between Gross National Income and the prevalence of Gram positive or negative organisms in diabetic foot infections. Conclusion The microbiology of diabetic foot infections is diverse, but S. aureus predominates. The correlation between the prevalence of Gram positive and negative organisms and Gross National Income could reflect differences in healthcare provision and sanitation. This meta-analysis has synthesised multiple datasets to provide a global overview of the microbiology of diabetic foot infections that will help direct the development of novel therapeutics. Supplementary Information The online version contains supplementary material available at 10.1186/s12879-021-06516-7.
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Affiliation(s)
- Katherine E Macdonald
- Infection Medicine, Edinburgh Medical School: Biomedical Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Sophie Boeckh
- Faculty of Medicine and Health Sciences, McGill University, 3605 Rue de la Montagne, Montreal, QC, H3G 2M1, Canada
| | - Helen J Stacey
- Edinburgh Medical School, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Joshua D Jones
- Infection Medicine, Edinburgh Medical School: Biomedical Sciences, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Edinburgh, EH16 4SB, UK.
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Julien G, Francois M, Vernet-Garnier V, Bajolet O, Lebrun D, Hentzien M, Ohl X, Diallo S, Bani-Sadr F. Short duration of post-amputation antibiotic therapy in diabetic foot patients with total resection of osteomyelitis. Med Mal Infect 2020; 50:433-435. [PMID: 32360115 DOI: 10.1016/j.medmal.2020.04.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/07/2020] [Accepted: 04/17/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND Short duration of post-amputation antibiotic therapy (2-5 days) is recommended in patients with diabetic foot osteomyelitis after total resection of infected bone tissue. OBJECTIVE To evaluate the long-term effectiveness of short-duration post-amputation antibiotic therapy in diabetic patients with total resection of osteomyelitis assessed by sterile bone bacteriological samples obtained from the resection margin. METHODS The endpoint was the absence of osteomyelitis relapse at 6 months, defined as recurrence of osteomyelitis with the need for surgical revision and/or new bone antibiotic therapy. RESULTS Among 15 patients included, 12 (80%) were cured without recurrence of osteomyelitis at 6 months, with a mean duration of antibiotic therapy of 8.3±5.9 days post surgery. This result is comparable to literature data, while all of them reported longer duration of antibiotic therapy and/or shorter follow-up. CONCLUSION Short duration of post-amputation antibiotic therapy in diabetic patients with sterile bacteriological samples obtained from resection margin seems effective.
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Affiliation(s)
- G Julien
- Department of internal medicine and infectious diseases, Reims teaching hospitals, Reims, France
| | - M Francois
- Department of endocrinology-diabetology, Reims teaching hospitals, Reims, France
| | - V Vernet-Garnier
- Department of bacteriology, Reims teaching hospitals, Reims, France
| | - O Bajolet
- Department of hygiene, Reims teaching hospitals, Reims, France
| | - D Lebrun
- Department of internal medicine and infectious diseases, Manchester hospital, Charleville-Mezieres, France
| | - M Hentzien
- Department of internal medicine and infectious diseases, Reims teaching hospitals, Reims, France
| | - X Ohl
- Department of orthopedic surgery, Reims teaching hospitals, Reims, France
| | - S Diallo
- Department of orthopedic surgery, Reims teaching hospitals, Reims, France
| | - F Bani-Sadr
- Department of internal medicine and infectious diseases, Reims teaching hospitals, Reims, France.
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Peters EJG, Lipsky BA, Senneville É, Abbas ZG, Aragón-Sánchez J, Diggle M, Embil JM, Kono S, Lavery LA, Malone M, Urbančič-Rovan V, Van Asten SA. Interventions in the management of infection in the foot in diabetes: a systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3282. [PMID: 32176437 DOI: 10.1002/dmrr.3282] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 09/01/2019] [Accepted: 09/19/2019] [Indexed: 12/11/2022]
Abstract
The optimal approaches to managing diabetic foot infections remain a challenge for clinicians. Despite an exponential rise in publications investigating different treatment strategies, the various agents studied generally produce comparable results, and high-quality data are scarce. In this systematic review, we searched the medical literature using the PubMed and Embase databases for published studies on the treatment of diabetic foot infections as of June 2018. This systematic review is an update of previous reviews, the first of which was undertaken in 2010 and the most recent in 2014, by the infection committee of the International Working Group of the Diabetic Foot. We defined the context of literature by formulating clinical questions of interest, then developing structured clinical questions (PICOs) to address these. We only included data from controlled studies of an intervention to prevent or cure a diabetic foot infection. Two independent reviewers selected articles for inclusion and then assessed their relevant outcomes and the methodological quality. Our literature search identified a total of 15 327 articles, of which we selected 48 for full-text review; we added five more studies discovered by means other than the systematic literature search. Among these selected articles were 11 high-quality studies published in the last 4 years and two Cochrane systematic reviews. Overall, the outcomes in patients treated with the different antibiotic regimens for both skin and soft tissue infection and osteomyelitis of the diabetic foot were broadly equivalent across studies, except that treatment with tigecycline was inferior to ertapenem (±vancomycin). Similar outcomes were also reported in studies comparing primarily surgical and predominantly antibiotic treatment strategies in selected patients with diabetic foot osteomyelitis. There is insufficient high-quality evidence to assess the effect of various adjunctive therapies, such as negative pressure wound therapy, topical ointments or hyperbaric oxygen, on infection related outcomes of the diabetic foot. In general, the quality of more recent trial designs are better in past years, but there is still a great need for further well-designed trials to produce higher quality evidence to underpin our recommendations.
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Affiliation(s)
- Edgar J G Peters
- Amsterdam UMC, Vrije Universiteit Amsterdam, Department of Internal Medicine, Amsterdam Infection and Immunity Institute, De Boelelaan 1117, Amsterdam, The Netherlands
| | - Benjamin A Lipsky
- Department of Medicine, University of Washington, Seattle, Washington
| | | | - Zulfiqarali G Abbas
- Abbas Medical Centre, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | | | - Mathew Diggle
- Alberta Public Laboratories, University of Alberta Hospital, Edmonton, Canada
| | - John M Embil
- University of Manitoba, Winnipeg, Manitoba, Alberta, Canada
| | - Shigeo Kono
- WHO-Collaborating Centre for Diabetes, National Hospital Organization Kyoto Medical Centre, Kyoto, Japan
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, Texas
| | - Matthew Malone
- School of Medicine, Infectious Diseases and Microbiology, South West Sydney Local Health District, Western Sydney University, Sydney, Australia
| | - Vilma Urbančič-Rovan
- Faculty of Medicine, University Medical Centre, University of Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Suzanne A Van Asten
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
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Fu XL, Ding H, Miao WW, Mao CX, Zhan MQ, Chen HL. Global recurrence rates in diabetic foot ulcers: A systematic review and meta-analysis. Diabetes Metab Res Rev 2019; 35:e3160. [PMID: 30916434 DOI: 10.1002/dmrr.3160] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 02/22/2019] [Accepted: 03/17/2019] [Indexed: 12/23/2022]
Abstract
Recurrence rates of diabetic foot ulcers vary widely in the published literature. The aim of this systematic review is to estimate recurrence rates of diabetic foot ulcers. We did a PubMed search and performed a review of reference lists for studies reporting recurrence of diabetic foot ulcers. The weighted relative risk (RR) and corresponding 95% confidence interval (CI) for recurrence was estimated. Forty-nine studies reporting recurrence of diabetic foot ulcers were included. A pooled estimate for recurrence rate was 22.1% per person-year (py) (95% CI, 19.0-25.2%). Recurrence rate was 24.9% per py in Europe (95% CI, 20.0%-29.7%), 17.8% per py in North America (95% CI, 12.7%-22.9%), 16.9% per py in Africa (95% CI, 4.7%-29.0%), and 17.0% per py in Asia (95% CI, 11.1%-23.0%). Turkey had the highest recurrence rate of 44.4% per py (95% CI, 24.9%-63.9%), and Bangladesh had the lowest of 4.3% per py (95% CI, 2.3%-6.3%). Recurrence rates of diabetic foot ulcers before 2002, between 2002 and 2008, and after 2008 were 22.2% per py (95% CI, 17.6%-26.8%), 21.9% per py (95% CI, 17.0%-26.8%), and 21.8% per py (95% CI, 16.3%-27.2%), respectively. Recurrence rates of diabetic foot ulcers are high. Recurrence rates vary widely in different regions and have decreased recently. More attention towards recurrence of diabetic foot ulcers is urgently required.
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Affiliation(s)
- Xue-Lei Fu
- Bachelor Student. School of Nursing, Nantong University, Nantong, China
| | - Hui Ding
- Bachelor Student. School of Nursing, Nantong University, Nantong, China
| | - Wei-Wei Miao
- Bachelor Student. School of Nursing, Nantong University, Nantong, China
| | - Chun-Xing Mao
- Bachelor Student. School of Nursing, Nantong University, Nantong, China
| | - Min-Qi Zhan
- Bachelor Student. School of Nursing, Nantong University, Nantong, China
| | - Hong-Lin Chen
- School of Public Health, Nantong University, Nantong, China
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10
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Aliakbar AH, Alsaadi MA, Barrak AAZ. Evaluation of the Surgical and Pharmacological Treatment of Diabetic Foot Infection: A Retrospective Study. Open Access Maced J Med Sci 2019; 7:1499-1504. [PMID: 31198462 PMCID: PMC6542384 DOI: 10.3889/oamjms.2019.298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 04/22/2019] [Accepted: 04/23/2019] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Diabetic foot infection is a major cause of patient disabilities and lowers limb amputations, with high treatment costs and hospitalisation requirements. AIM Aim of this study was to evaluate surgical wound care plus antibiotic effects in the treatment of mild and moderate diabetic foot infections. METHODS This retrospective study involved 60 patients with diabetic foot infections with or without osteomyelitis. The patients were categorised as group 1 mild and group 2 moderate. Both groups were treated using local wound debridement and the systemic administration of antibiotics. Group 1 (16) patients were treated with two regimens of oral antibiotics in two regimens, A (amoxicillin/clavulanate + metronidazole) and B (clindamycin + metronidazole), for 10-14 days. Group 2 (42) patients were treated with oral plus intravenous antibiotics in two regimens, A (ampicillin + cloxacillin + metronidazole) and B (lincomycin + metronidazole), for 6 weeks. The patients followed-up with local wound care specialists for 3 months to evaluate the treatment outcomes (cure, improvement, or failure). RESULTS Group 1 had an 80% cure rate under regimen A and a 100% cure rate under regimen B. Group 2 regimen A patients had a 61.5% cure rate and 11.53% improved, while regimen B patients had a 68.75% cure rate and 12.5% improved. Failure in both regimens was 23.8% in 20 patients with osteomyelitis, while 35% were cured and 20% improved during the study period. CONCLUSION Local surgical wound care for 3 months with antibiotic regimens for 6 weeks resulted in good response and cure rates, with lower costs and fewer instances of hospitalisation. Intravenous lincomycin and oral metronidazole achieved higher cure responses for moderate diabetic foot infections.
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Affiliation(s)
| | - Malath Azeez Alsaadi
- Department of Basic Medical Sciences, College of Dentistry, University of Babylon, Babil, Iraq
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11
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Xing K, Huang G, Hua S, Xu G, Li M. Systematic review of randomized controlled trials on antibiotic treatment for osteomyelitis in diabetes. Diabet Med 2019; 36:546-556. [PMID: 30785639 DOI: 10.1111/dme.13935] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/18/2019] [Indexed: 12/28/2022]
Abstract
AIM To evaluate the efficacy of antibiotic therapy in osteomyelitis treatment among people with diabetes. METHODS A systematic search of PubMed, EMBASE, AMED, Web of Science, the WHO trial registry, Cochrane library databases, and ClinicalTrials.gov, in addition to hand-searching, was undertaken in July 2018. Two reviewers independently extracted data. The studies' methodological quality was assessed using the modified Jadad scale. Descriptive analysis was performed. RESULTS Seven randomized controlled trials, with 393 participants in total, were included. The antibiotic regimens, treatments and follow-up durations varied among the trials. The total scores showed that the overall methodological quality of the seven studies was high, despite two studies showing some flaws in double-blinding and withdrawals/drop-outs. Of four studies comparing different antibiotic regimens, three implied a similar remission effect, while one implied that ertapenem ± vancomycin treatment showed a higher remission rate than tigecycline treatment; this conclusion was not robust because of low power and small sample size. In the other three studies, which included two different doses of ciprofloxacin, an antibiotics group and a conservative surgical group, and two durations of the same antibiotic strategy, no significant differences in remission were reported between the groups. No difference was observed in the analyses of microbiological outcomes, superinfections and relapse, except adverse events. CONCLUSIONS There is no definitive evidence supporting the superiority of any particular antibiotic agent, dose, or administration duration in the treatment of osteomyelitis in diabetes. As the included studies had some flaws and limitations, further research is necessary.
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Affiliation(s)
- K Xing
- Department of Orthopaedic Oncology, Honghui Hospital, Xi'an Jiaotong University, College of Medicine, Xi'an, Shaanxi, China
| | - G Huang
- Department of Orthopaedic Oncology, Honghui Hospital, Xi'an Jiaotong University, College of Medicine, Xi'an, Shaanxi, China
| | - S Hua
- Department of Rheumatism and Immunity Branch, Xi an No. 5 Hospital, Xi'an, Shaanxi, China
| | - G Xu
- Department of Neurosurgery, First Affiliated Hospital of Xi'an Medical University, Xi'an, Shaanxi, China
| | - M Li
- Department of Paediatric Orthopedics, Honghui Hospital, Xi'an Jiaotong University, College of Medicine, Xi'an, Shaanxi, China
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12
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Neves JM, Duarte B, Pinto M, Formiga A, Neves J. Diabetic Foot Infection: Causative Pathogens and Empiric Antibiotherapy Considerations—The Experience of a Tertiary Center. INT J LOW EXTR WOUND 2019; 18:122-128. [DOI: 10.1177/1534734619839815] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Most moderate-to-severe diabetic foot infections (DFIs) require hospitalization with urgent surgical approach and administration of empiric antibiotherapy. To ensure optimal antibiotic coverage, regular microbiological background updates are imperative. The purpose is to characterize the microbiological profile and the antibiotic sensitivity pattern of the DFI causative pathogens isolated within a specialized DFI unit of a tertiary hospital, in order to establish evidence-based policies regarding empirical antibiotic use. A cross-sectional study was conducted. Microbiological cultures and corresponding antibiotic sensitivity tests collected from moderate-to-severe DFIs as a first approach to the hospitalized patient were retrieved and analyzed during a 12-month period. Two groups were analyzed: inpatients that had been previously followed at the diabetic foot clinic of the hospital and inpatients without a previous contact with the hospital services. A total of 125 isolates obtained from 87 patients were deemed for analysis. Globally, a predominance of Gram-positive bacteria was observed (60%). Staphylococcus aureus was the most common pathogen. The global ratio of methicillin-sensitive S aureus to methicillin-resistant S aureus (MRSA) was 1.3:1, with similar findings in both groups. According to the antibiotic sensitivity test results, and within the recommended empiric antibiotic regimens for DFI, piperacillin/tazobactam seems to be the most suitable option. Gram-positive bacteria prevail as the main isolates in DFIs. Screening for MRSA-specific risk factors is mandatory. When going for a first empiric therapy, piperacillin/tazobactam is recommended in this institution, and an anti-MRSA agent should be added early, if necessary. We encourage continuous monitoring for the bacterial prevalence in Portuguese diabetic foot centers as it is paramount for the decision making regarding DFI protocols.
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Affiliation(s)
- José Miguel Neves
- Department of Dermatology and Venereology, Centro Hospitalar Universitário de Lisboa Central
| | - Bruno Duarte
- Department of Dermatology and Venereology, Centro Hospitalar Universitário de Lisboa Central
| | - Margarida Pinto
- Microbiology Department, Centro Hospitalar Universitário de Lisboa Central
| | - Ana Formiga
- Diabetic Foot Unit, General Surgery Department, Centro Hospitalar Universitário de Lisboa Central
| | - José Neves
- Diabetic Foot Unit, General Surgery Department, Centro Hospitalar Universitário de Lisboa Central
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13
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Rossel A, Lebowitz D, Gariani K, Abbas M, Kressmann B, Assal M, Tscholl P, Stafylakis D, Uçkay I. Stopping antibiotics after surgical amputation in diabetic foot and ankle infections-A daily practice cohort. Endocrinol Diabetes Metab 2019; 2:e00059. [PMID: 31008367 PMCID: PMC6458464 DOI: 10.1002/edm2.59] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 12/28/2018] [Accepted: 12/30/2018] [Indexed: 11/09/2022] Open
Abstract
OBJECTIVE The appropriate duration of antibiotic therapy for diabetic foot infections (DFI) after surgical amputations in toto is debated. There are discrepancies worldwide. METHODS Using a clinical pathway for adult DFI patients (retrospective cohort analysis), we conducted a cluster-controlled Cox regression analysis. Minimum follow-up was 2 months. RESULTS We followed 482 amputated DFI episodes for a median of 2.1 years after the index episode. The DFIs predominately affected the forefoot (n = 433; 90%). We diagnosed osteomyelitis in 239 cases (239/482; 50%). In total, 47 cases (10%) were complicated by bacteremia, 86 (18%) by abscesses and 139 (29%) presented with cellulitis. Surgical amputation involved the toes (n = 155), midfoot (280) and hindfoot (47). Overall, 178 cases (37%) required revascularization. After amputation, the median duration of antibiotic administration was 7 days (interquartile range, 1-16 days). In 109 cases (25%), antibiotics were discontinued immediately after surgery. Overall, clinical failure occurred in 90 DFIs (17%), due to the same pathogens in only 38 cases. In multivariate analysis, neither duration of total postsurgical antibiotic administration (HR 1.0, 95% CI 0.99-1.01) nor immediate postoperative discontinuation altered failure rate (HR 0.9, 0.5-1.5). CONCLUSION According to our clinical pathway, we found no benefit in continuing postsurgical antibiotic administration in routine amputation for DFI. In the absence of residual infection (ie, resection at clear margins), antibiotics should be discontinued.
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Affiliation(s)
- Anne Rossel
- Department of Internal MedicineGeneva University HospitalsGenevaSwitzerland
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
| | - Dan Lebowitz
- Department of Internal MedicineGeneva University HospitalsGenevaSwitzerland
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
| | - Karim Gariani
- Department of Internal MedicineGeneva University HospitalsGenevaSwitzerland
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Service of Diabetology and EndocrinologyGeneva University HospitalsGenevaSwitzerland
| | - Mohamed Abbas
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Infection Control ProgramGeneva University HospitalsGenevaSwitzerland
| | - Benjamin Kressmann
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
| | - Mathieu Assal
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- La Colline Hirslanden ClinicGenevaSwitzerland
| | - Philippe Tscholl
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
- Balgrist University HospitalZurichSwitzerland
| | - Dimitrios Stafylakis
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
| | - Ilker Uçkay
- Service of Infectious DiseasesGeneva University HospitalsGenevaSwitzerland
- Infection Control ProgramGeneva University HospitalsGenevaSwitzerland
- Orthopaedic Surgery ServiceGeneva University HospitalsGenevaSwitzerland
- Clinical Pathway of Diabetic Foot InfectionsGeneva University HospitalsGenevaSwitzerland
- Balgrist University HospitalZurichSwitzerland
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14
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Tchero H, Kangambega P, Noubou L, Becsangele B, Fluieraru S, Teot L. Antibiotic therapy of diabetic foot infections: A systematic review of randomized controlled trials. Wound Repair Regen 2018; 26:381-391. [PMID: 30099812 DOI: 10.1111/wrr.12649] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Accepted: 06/05/2018] [Indexed: 12/22/2022]
Abstract
Diabetic foot infection is a common diabetic complication that may end in lower limb amputation if not treated properly. We performed this systematic review to assess the clinical efficacy of different antibiotic regimens, whether systemic or topical, in the treatment of moderate to severe diabetic foot infections. We searched Medline, Web of Science, SCOPUS, Cochrane CENTRAL, and ScienceDirect for randomized controlled trials that evaluated the efficacy of antibiotic regimens in moderate to severe diabetic foot infections. The primary outcome of interest was the clinical efficacy (cure/improvement rates) of the regimens. We included 16 trials (4,158 patients) in this review, from which we extracted 10 comparisons: some trials compared systemic antibiotics to each other, others compared systemic to topical agents, while one study compared the combined topical and systemic agents to systemic antibiotics alone. Qualitative analysis of the findings of these studies showed that: (1) pipracillin/tazobactam was superior to ertapenem in severe infections (clinical resolution rate: 91.5% compared with PIP/TAZ 97.2%, p ≤ 0.04), but had similar efficacy in moderate infections, (2) ertapenem was more effective than tigecycline in moderate to severe infections (absolute difference -5.5, [95% CI -11.0, 0.1]), (3) the adjuvant use of topical agents with systemic antibiotics improved the outcomes, compared with systemic antibiotics alone (p = 0.024), (4) the rates of recurrence and re-ulceration were significantly lower in patients using the amino-penicillin regimen, compared with those using oral/intravenous ofloxacin, and (5) lower rates of complications accompanied the imipenem/cilastatin regimen, compared with the pipracillin/tazobactam regimen (p = 0.13). In conclusion, data from the included studies showed better results for ertapenem when compared with tigecycline; however, it was inferior to pipracillin/tazobactam in severe infections. The adjuvant use of topical agents improves the efficacy of systemic antibiotics in diabetic foot infection.
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Affiliation(s)
- Huidi Tchero
- Department of Trauma and Orthopedics Surgery and Wound Healing Unit, Saint Martin Hospital Center BP 381, CH Saint Martin, Guadeloupe
| | - Pauline Kangambega
- Division of Diabetes, Endocrinology and Metabolism, Pointe-A-Pitre CHRU, Pointe-A-Pitre
| | - Lazarre Noubou
- Department of Trauma and Orthopedics Surgery and Wound Healing Unit, Saint Martin Hospital Center BP 381, CH Saint Martin, Guadeloupe
| | - Beatrice Becsangele
- Wound Healing Unit, Saint Martin Hospital Center, BP 381, CH Saint Martin, Guadeloupe
| | - Sergiu Fluieraru
- Department of Reconstructive and Plastic Surgery, and Wound Healing Unit, University Hospital, Montpellier, France
| | - Luc Teot
- Department of Reconstructive and Plastic Surgery, and Wound Healing Unit, University Hospital, Montpellier, France
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Saltoglu N, Ergonul O, Tulek N, Yemisen M, Kadanali A, Karagoz G, Batirel A, Ak O, Sonmezer C, Eraksoy H, Cagatay A, Surme S, Nemli SA, Demirdal T, Coskun O, Ozturk D, Ceran N, Pehlivanoglu F, Sengoz G, Aslan T, Akkoyunlu Y, Oncul O, Ay H, Mulazımoglu L, Erturk B, Yilmaz F, Yoruk G, Uzun N, Simsek F, Yildirmak T, Yaşar KK, Sonmezoglu M, Küçükardali Y, Tuna N, Karabay O, Ozgunes N, Sargın F. Influence of multidrug resistant organisms on the outcome of diabetic foot infection. Int J Infect Dis 2018; 70:10-14. [PMID: 29476898 DOI: 10.1016/j.ijid.2018.02.013] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Revised: 02/08/2018] [Accepted: 02/13/2018] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES We described the clinical outcomes of the diabetic patients who had foot infections with multidrug resistant organisms. METHODS We included the patients with diabetic foot infections (DFI) from 19 centers, between May 2011 and December 2015. Infection was defined according to IDSA DFI guidelines. Patients with severe infection, complicated moderate infection were hospitalized. The patients were followed-up for 6 months after discharge. RESULTS In total, 791 patients with DFI were included, 531(67%) were male, median age was 62 (19-90). Severe infection was diagnosed in 85 (11%) patients. Osteomyelitis was diagnosed in 291(36.8%) patients. 536 microorganisms were isolated, the most common microorganisms were S. aureus (20%), P. aeruginosa (19%) and E. coli (12%). Methicillin resistance (MR) rate among Staphylococcus aureus isolates was 31%. Multidrug resistant bacteria were detected in 21% of P. aeruginosa isolates. ESBL (+) Gram negative bacteria (GNB) was detected in 38% of E. coli and Klebsiella isolates. Sixty three patients (8%) were re-hospitalized. Of the 791 patiens, 127 (16%) had major amputation, and 24 (3%) patients died. In multivariate analysis, significant predictors for fatality were; dialysis (OR: 8.3, CI: 1.82-38.15, p=0.006), isolation of Klebsiella spp. (OR:7.7, CI: 1.24-47.96, p=0.028), and chronic heart failure (OR: 3, CI: 1.01-9.04, p=0.05). MR Staphylococcus was detected in 21% of the rehospitalized patients, as the most common microorganism (p<0.001). CONCLUSION Among rehospitalized patients, methicillin resistant Staphylococcus infections was detected as the most common agent, and Klebsiella spp. infections were found to be significantly associated with fatality.
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Affiliation(s)
- Nese Saltoglu
- Istanbul University, Cerrahpasa Medical Faculty, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey.
| | - Onder Ergonul
- Koc University, Medical Faculty, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Necla Tulek
- Ankara Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Ankara, Turkey
| | - Mucahit Yemisen
- Istanbul University, Cerrahpasa Medical Faculty, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Ayten Kadanali
- Umraniye Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Gul Karagoz
- Umraniye Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Ayse Batirel
- Kartal Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Oznur Ak
- Kartal Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Cagla Sonmezer
- Ankara Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Ankara, Turkey
| | - Haluk Eraksoy
- Istanbul University, Istanbul Medical Faculty, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Atahan Cagatay
- Istanbul University, Istanbul Medical Faculty, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Serkan Surme
- Istanbul University, Cerrahpasa Medical Faculty, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Salih A Nemli
- İzmir Atatürk Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Izmır, Turkey
| | - Tuna Demirdal
- İzmir Atatürk Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Izmır, Turkey
| | - Omer Coskun
- GATA Ankara Hospital, Infectious Diseases and Clinical Microbiology, Ankara, Turkey
| | - Derya Ozturk
- Haydarpaşa Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Nurgul Ceran
- Haydarpaşa Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Filiz Pehlivanoglu
- Haseki Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Gonul Sengoz
- Haseki Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Turan Aslan
- Bezmi Alem University Medical Faculty, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Yasemin Akkoyunlu
- Bezmi Alem University Medical Faculty, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey; Gulhane Haydarpaşa Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Oral Oncul
- Gulhane Haydarpaşa Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Hakan Ay
- Gulhane Haydarpaşa Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Lutfiye Mulazımoglu
- Marmara University Medical Faculty, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Buket Erturk
- Marmara University Medical Faculty, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Fatma Yilmaz
- Medeniyet University Medical Faculty, Goztepe Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Gulsen Yoruk
- Samatya Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Nuray Uzun
- Sisli Etfal Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Funda Simsek
- Okmeydanı Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Taner Yildirmak
- Okmeydanı Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Kadriye Kart Yaşar
- Haseki Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Meral Sonmezoglu
- Yeditepe Üniversity Medical Faculty, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Yasar Küçükardali
- Yeditepe Üniversity Medical Faculty, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Nazan Tuna
- Sakarya University, Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Sakarya, Turkey
| | - Oguz Karabay
- Sakarya University, Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Sakarya, Turkey
| | - Nail Ozgunes
- Medeniyet University Medical Faculty, Goztepe Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Fatma Sargın
- Medeniyet University Medical Faculty, Goztepe Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
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16
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Fry W, McCafferty S, Gooday C, Nunney I, Dhatariya KK. Assessing the Effect of Piperacillin/Tazobactam on Hematological Parameters in Patients Admitted with Moderate or Severe Foot Infections. Diabetes Ther 2018; 9:219-228. [PMID: 29302933 PMCID: PMC5801243 DOI: 10.1007/s13300-017-0357-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Piperacillin/tazobactam is a commonly used antibiotic for the empirical treatment of severe diabetic foot infections. One of the most feared complications of this drug is the development of pancytopenia. The aim of this study was to determine whether the use of piperacillin/tazobactam caused any hematological changes in patients admitted with severe diabetes-related foot infections from a specialist multidisciplinary foot clinic. Specifically, looking at whether it caused anemia, leukopenia, neutropenia, or thrombocytopenia. METHODS A 1-year retrospective analysis of patients admitted to a tertiary care center for treatment of diabetes-related foot infection using piperacillin/tazobactam. Hematological indices, urea and electrolytes, and C-reactive protein (CRP) were recorded pretreatment, during treatment, and posttreatment. HbA1c, vitamin B12, folate, thyroid-stimulating hormone, and free thyroxin were also analyzed to exclude any potential confounders as a cause of pancytopenia. RESULTS A total of 154 patients were admitted between 1 January 2016 and 31 December 2016 who received piperacillin/tazobactam for severe diabetes-related foot infection. On admission, white cell count and CRP were raised and fell significantly within the first 48 h. Other hematological factors did not change. Five patients developed a mild pancytopenia, of which three were unexplained. CONCLUSION In this relatively small cohort, pancytopenia did not occur. As such, piperacillin/tazobactam appeared to have a low risk of adverse hematological outcomes and remains the treatment of choice for severe diabetes-related foot infections.
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Affiliation(s)
- Will Fry
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
| | - Sean McCafferty
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
| | - Catherine Gooday
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, NR4 7UY, UK
| | - Ian Nunney
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK
| | - Ketan K Dhatariya
- Norwich Medical School, University of East Anglia, Norwich, Norfolk, UK.
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, NR4 7UY, UK.
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17
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Takimoto K, Wang Q, Suzuki D, Katayama M, Hayashi Y. Clinical efficacy of piperacillin/tazobactam in the treatment of complicated skin and soft tissue infections. Expert Opin Pharmacother 2017. [PMID: 28627952 DOI: 10.1080/14656566.2017.1341491] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Complicated skin and soft tissue infections (cSSTIs) are skin and soft tissue infections (SSTIs) that involve deep soft tissue. cSSTIs often require surgical intervention and/or hospitalization. cSSTIs are associated with significant mortality and morbidity, and carry a significant burden on health care systems. Piperacillin/tazobactam has been regarded as a standard treatment for cSSTIs because of its antibiotic spectrum, safety and clinical efficacy. Several antibiotics, as compared to piperacillin/tazobactam, have been evaluated in the treatment of cSSTIs. Areas covered: This review summarizes randomized controlled trials (RCTs) evaluating the clinical efficacy of piperacillin/tazobactam for the treatment of cSSTIs. Expert opinion: Piperacillin/tazobactam, which covers most causative organisms in cSSTIs, is the drug of choice for the treatment of cSSTIs. Other options such as ertapenem and moxifloxacin may be reasonable where multiple daily dosing or intravenous administration is inappropriate. But in general, they should be avoided as an empirical treatment because of their highly association with resistant bacteria, which are becoming a global threat. Therefore, piperacilin/tazobactam is appropriate as an empirical therapy for the treatment of SSTIs and should be de-escalated as soon as causative organisms are identified, their drug-sensitivity results are available, and clinical condition becomes stable.
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Affiliation(s)
- Kohei Takimoto
- a Department of Intensive Care Medicine , Kameda Medical Center , Kamogawa , Japan
| | - Qianzhi Wang
- b Postgraduate Education Center , Kameda Medical Center , Kamogawa , Japan
| | - Daisuke Suzuki
- c Department of Infectious Diseases , Kameda Medical Center , Kamogawa , Japan
| | - Mitsuya Katayama
- d Department of General Internal Medicine , Kameda Medical Center , Kamogawa , Japan
| | - Yoshiro Hayashi
- a Department of Intensive Care Medicine , Kameda Medical Center , Kamogawa , Japan
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18
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Xu ZR, Ran XW, Xian Y, Yan XD, Yuan GY, Mu SM, Shen JF, Zhang BS, Gan WJ, Wang J. Ertapenem versus piperacillin/tazobactam for diabetic foot infections in China: a Phase 3, multicentre, randomized, double-blind, active-controlled, non-inferiority trial. J Antimicrob Chemother 2016; 71:1688-96. [PMID: 26888908 DOI: 10.1093/jac/dkw004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 01/04/2016] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES Few randomized controlled studies have compared antibiotic regimens against diabetic foot infections (DFIs) in Chinese patients. We evaluated the efficacy and safety of ertapenem versus piperacillin/tazobactam for the treatment of DFIs in Chinese patients. METHODS Patients with moderate to severe DFIs requiring parenteral antibiotics were randomized in a 1 : 1 ratio to receive ertapenem (1.0 g once daily) or piperacillin/tazobactam (4.5 g every 8 h) by 30 min intravenous (iv) infusions for ≥5 days. The primary outcome was favourable clinical response at discontinuation of iv therapy (DCIV). An evaluable-patient population was identified for primary analysis of non-inferiority at -15%. Safety was assessed. ClinicalTrials.gov: NCT01370616. RESULTS Of 565 patients randomized, 443 patients (ertapenem = 219 and piperacillin/tazobactam = 224) were clinically evaluable for primary analysis. In the clinically evaluable population, the proportions of patients with favourable clinical response at DCIV were 93.6% (205/219) and 97.3% (218/224) in the ertapenem and piperacillin/tazobactam groups, respectively (difference: -3.8%, 95% CI: -8.3%, 0.0%). Ertapenem had a significantly lower favourable clinical response rate (91.5% versus 97.2%, 95% CI for difference: -12.1%, -0.3%) at DCIV in severe DFI patients. In the modified ITT population, 88.8% (237/267) and 90.6% (241/266) of patients in the ertapenem and piperacillin/tazobactam groups, respectively, had favourable clinical responses at DCIV (difference: -1.9%, 95% CI: -7.3%, 3.3%). Microbiological eradications of causative pathogens and adverse events were similar between treatment groups. CONCLUSIONS Treatment with ertapenem was non-inferior to piperacillin/tazobactam in Chinese patients with DFIs. Ertapenem treatment resulted in a markedly lower rate of clinical resolution in severe DFIs.
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Affiliation(s)
| | - Xing-Wu Ran
- West China Hospital, Sichuan University, Chengdu, China
| | - Yang Xian
- Sichuan Academy of Medical Sciences, Sichuan Provincial People's Hospital, Chengdu, China
| | - Xiao-Dong Yan
- The People's Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Guo-Yue Yuan
- Affiliated Hospital of Jiangsu University, Zhenjiang, China
| | | | | | | | - Wei-Jin Gan
- Biostatistics, PAREXEL International, Shanghai, China
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Peters EJ, Lipsky BA, Aragón-Sánchez J, Boyko EJ, Diggle M, Embil JM, Kono S, Lavery LA, Senneville E, Urbančič-Rovan V, Van Asten SA, Jeffcoate WJ. Interventions in the management of infection in the foot in diabetes: a systematic review. Diabetes Metab Res Rev 2016; 32 Suppl 1:145-53. [PMID: 26344844 DOI: 10.1002/dmrr.2706] [Citation(s) in RCA: 56] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The expert panel on diabetic foot infection (DFI) of the International Working Group on the Diabetic Foot conducted a systematic review seeking all published reports relating to any type of treatment for infection of the foot in persons with diabetes published as of 30 June 2014. This review, conducted with both PubMed and EMBASE, was used to update an earlier one undertaken on 30 June 2010 using the same search string. Eligible publications included those that had outcome measures reported for both a treated and a control population that were managed either at the same time, or as part of a before-and-after case design. We did not include studies that contained only information related to definition or diagnosis, but not treatment, of DFI. The current search identified just seven new articles meeting our criteria that were published since the 33 identified with the previous search, making a total of 40 articles from the world literature. The identified articles included 37 randomised controlled trials (RCTs) and three cohort studies with concurrent controls, and included studies on the use of surgical procedures, topical antiseptics, negative pressure wound therapy and hyperbaric oxygen. Among the studies were 15 RCTs that compared outcomes of treatment with new antibiotic preparations compared with a conventional therapy in the management of skin and soft tissue infection. In addition, 10 RCTs and 1 cohort study compared different treatments for osteomyelitis in the diabetic foot. Results of comparisons of different antibiotic regimens generally demonstrated that newly introduced antibiotic regimens appeared to be as effective as conventional therapy (and also more cost-effective in one study), but one study failed to demonstrate non-inferiority of a new antibiotic compared with that of a standard agent. Overall, the available literature was both limited in both the number of studies and the quality of their design. Thus, our systematic review revealed little evidence upon which to make recommendations for treatment of DFIs. There is a great need for further well-designed trials that will provide robust data upon which to make decisions about the most appropriate treatment of both skin and soft tissue infection and osteomyelitis in diabetic patients.
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Affiliation(s)
- E J Peters
- VU University Medical Centre, Amsterdam, The Netherlands
| | - B A Lipsky
- Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
- University of Oxford, Oxford, UK
| | | | - E J Boyko
- Seattle Epidemiologic Research and Information Centre-Department of Veterans Affairs Puget Sound Health Care System and the University of Washington, Seattle, WA, USA
| | - M Diggle
- Nottingham University Hospitals Trust, Nottingham, UK
| | - J M Embil
- University of Manitoba, Winnipeg, MB, Canada
| | - S Kono
- WHO-collaborating Centre for Diabetes, National Hospital Organisation, Kyoto Medical Centre, Kyoto, Japan
| | - L A Lavery
- University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, TX, USA
| | | | | | - S A Van Asten
- VU University Medical Centre, Amsterdam, The Netherlands
- University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, TX, USA
| | - W J Jeffcoate
- Nottingham University Hospitals Trust, Nottingham, UK
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Saltoglu N, Yemisen M, Ergonul O, Kadanali A, Karagoz G, Batirel A, Ak O, Eraksoy H, Cagatay A, Vatan A, Sengoz G, Pehlivanoglu F, Aslan T, Akkoyunlu Y, Engin D, Ceran N, Erturk B, Mulazimoglu L, Oncul O, Ay H, Sargin F, Ozgunes N, Simsek F, Yildirmak T, Tuna N, Karabay O, Yasar K, Uzun N, Kucukardali Y, Sonmezoglu M, Yilmaz F, Tozalgan U, Ozer S, Ozyazar M. Predictors for limb loss among patient with diabetic foot infections: an observational retrospective multicentric study in Turkey. Clin Microbiol Infect 2015; 21:659-64. [PMID: 25861844 DOI: 10.1016/j.cmi.2015.03.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Revised: 03/08/2015] [Accepted: 03/20/2015] [Indexed: 11/29/2022]
Abstract
We aimed to investigate the predictors for limb loss among patients with diabetes who have complicated skin/soft-tissue infections. In this observational study, consecutive patients with diabetic foot infection (DFI) from 17 centres in Turkey, between May 2011 and May 2013 were included. The Turkish DFI Working Group performed the study. Predictors of limb loss were investigated by multivariate analysis. In total, 455 patients with DFI were included. Median age was 61 years, 68% were male, 65% of the patients were hospitalized, 52% of the patients had used antibiotics within the last month, and 121 (27%) had osteomyelitis. Of the 208 microorganisms isolated, 92 (44.2%) were Gram-positive cocci and 114 (54.8%) were Gram-negative rods (GNR). The most common GNR was Pseudomonas; the second was Escherichia coli, with extended spectrum β-lactamase positivity of 33%. Methicillin-resistant Staphylococcus species were found in 14% (29/208). Amputations were performed in 126/455 (28%) patients, 44/126 (34%) of these were major amputations. In multivariate analysis, significant predictors for limb loss were, male gender (OR 1.75, 95% CI 1.04-2.96, p 0.034), duration of diabetes >20 years (OR 1.9, 95% CI 1.18-3.11, p 0.008), infected ulcer versus cellulitis (OR 1.9, 95% CI 1.11-3.18, p 0.019), history of peripheral vascular disease (OR 2, 95% CI 1.26-3.27, p 0.004), retinopathy (OR 2.25, 95% CI 1.19-4.25, p 0.012), erythrocyte sedimentation rate >70 mm/hr (OR 1.6, 95% CI 1.01-2.68, p 0.05), and infection with GNR (OR 1.8, 95% CI 1.08-3.02, p 0.02). Multivariate analysis revealed that, besides the known risk factors such as male gender, duration of diabetes >20 years, infected ulcers, history of peripheral vascular disease and retinopathy, detection of GNR was a significant predictor of limb loss.
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Affiliation(s)
- N Saltoglu
- Istanbul University, Cerrahpasa Medical School, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey.
| | - M Yemisen
- Istanbul University, Cerrahpasa Medical School, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - O Ergonul
- Koc University, School of Medicine, Infectious Diseases, Istanbul, Turkey
| | - A Kadanali
- Umraniye Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - G Karagoz
- Umraniye Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - A Batirel
- Dr Lutfi Kirdar Kartal Training and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - O Ak
- Dr Lutfi Kirdar Kartal Training and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - H Eraksoy
- Istanbul University, Istanbul Medical Faculty, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - A Cagatay
- Istanbul University, Istanbul Medical Faculty, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - A Vatan
- Istanbul University, Cerrahpasa Medical School, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - G Sengoz
- Haseki Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - F Pehlivanoglu
- Haseki Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - T Aslan
- Bezmialem University, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Y Akkoyunlu
- Bezmialem University, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - D Engin
- Haydarpasa Numune Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - N Ceran
- Haydarpasa Numune Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - B Erturk
- Marmara University, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - L Mulazimoglu
- Marmara University, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - O Oncul
- Gulhane Military Medical Faculty, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - H Ay
- Gulhane Military Medical Faculty, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - F Sargin
- Goztepe Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - N Ozgunes
- Goztepe Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - F Simsek
- Okmeydani Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - T Yildirmak
- Okmeydani Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - N Tuna
- Sakarya University Medical Faculty, Infectious Diseases and Clinical Microbiology, Sakarya, Turkey
| | - O Karabay
- Sakarya University Medical Faculty, Infectious Diseases and Clinical Microbiology, Sakarya, Turkey
| | - K Yasar
- Bakırkoy Dr. Sadi Konuk Training and Research Hospital, Department of Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - N Uzun
- Sisli Etfal Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - Y Kucukardali
- Yeditepe University Medical Faculty, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - M Sonmezoglu
- Yeditepe University Medical Faculty, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - F Yilmaz
- Goztepe Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - U Tozalgan
- Samatya Education and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - S Ozer
- Dr Lutfi Kirdar Kartal Training and Research Hospital, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
| | - M Ozyazar
- Istanbul University, Cerrahpasa Medical School, Infectious Diseases and Clinical Microbiology, Istanbul, Turkey
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Abbas M, Uçkay I, Lipsky BA. In diabetic foot infections antibiotics are to treat infection, not to heal wounds. Expert Opin Pharmacother 2015; 16:821-32. [PMID: 25736920 DOI: 10.1517/14656566.2015.1021780] [Citation(s) in RCA: 86] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Diabetic foot ulcers, especially when they become infected, are a leading cause of morbidity and may lead to severe consequences, such as amputation. Optimal treatment of these diabetic foot problems usually requires a multidisciplinary approach, typically including wound debridement, pressure off-loading, glycemic control, surgical interventions and occasionally other adjunctive measures. AREAS COVERED Antibiotic therapy is required for most clinically infected wounds, but not for uninfected ulcers. Unfortunately, clinicians often prescribe antibiotics when they are not indicated, and even when indicated the regimen is frequently broader spectrum than needed and given for longer than necessary. Many agents are available for intravenous, oral or topical therapy, but no single antibiotic or combination is optimal. Overuse of antibiotics has negative effects for the patient, the health care system and society. Unnecessary antibiotic therapy further promotes the problem of antibiotic resistance. EXPERT OPINION The rationale for prescribing topical, oral or parenteral antibiotics for patients with a diabetic foot wound is to treat clinically evident infection. Available published evidence suggests that there is no reason to prescribe antibiotic therapy for an uninfected foot wound as either prophylaxis against infection or in the hope that it will hasten healing of the wound.
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Affiliation(s)
- Mohamed Abbas
- University of Geneva, Geneva University Hospitals and Medical School, Service of Infectious Diseases , 4, rue Gabrielle Perret-Gentil, 1211 Geneva 14 , Switzerland +41 22 372 33 11 ;
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In vitro spectrum of pexiganan activity when tested against pathogens from diabetic foot infections and with selected resistance mechanisms. Antimicrob Agents Chemother 2015; 59:1751-4. [PMID: 25583717 DOI: 10.1128/aac.04773-14] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Pexiganan, a 22-amino-acid synthetic cationic peptide, is currently in phase 3 clinical trials as a topical antimicrobial agent for the treatment of mild infections associated with diabetic foot ulcers. Bacterial isolates from the 2013 SENTRY Antimicrobial Surveillance Program designated as pathogens from diabetic foot infections (DFI) and Gram-negative and -positive pathogens from various infection types that harbored selected resistance mechanisms/phenotypes were tested against pexiganan in reference cation-adjusted Mueller-Hinton broth. The MIC50 and MIC90 against all organisms tested from DFI were 16 and 32 μg/ml, respectively. Escherichia coli, Klebsiella pneumoniae, Citrobacter koseri, Enterobacter cloacae, Acinetobacter species, and Pseudomonas aeruginosa MIC values ranged from 8 to 16 μg/ml. Pexiganan MIC values among Staphylococcus aureus (methicillin-resistant S. aureus [MRSA] and methicillin-susceptible S. aureus [MSSA]), beta-hemolytic streptococci, and Enterococcus faecium ranged from 8 to 32 μg/ml. Pexiganan activity was not adversely affected for members of the family Enterobacteriaceae or P. aeruginosa that produced β-lactamases or resistance mechanisms to other commonly used antimicrobial agents. Decreased susceptibility to vancomycin did not affect pexiganan activity against S. aureus or E. faecium. Enterococcus faecalis appears to be intrinsically less susceptible to pexiganan (MIC, 32 to 256 μg/ml). The "all organism" MIC90 of 32 μg/ml for pexiganan in this study was >250-fold below the pexiganan concentration in the cream/delivery vehicle being developed for topical use.
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Shiber S, Yahav D, Avni T, Leibovici L, Paul M. β-Lactam/β-lactamase inhibitors versus carbapenems for the treatment of sepsis: systematic review and meta-analysis of randomized controlled trials. J Antimicrob Chemother 2014; 70:41-7. [PMID: 25261419 DOI: 10.1093/jac/dku351] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Data on the relative efficacy of β-lactam/β-lactamase inhibitors (BL/BLIs) versus carbapenems are scant. METHODS This is a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing any BL/BLI versus any carbapenem for the treatment of sepsis. The primary outcome was all-cause mortality. A broad search was conducted with no restrictions on language, publication status or date. Two reviewers independently applied the inclusion criteria and extracted the data. Assessment of risk of bias was performed using the domain-based approach. Subgroup analyses were used to investigate heterogeneity and focus on patient groups more likely to harbour ESBL-positive bacteria. Risk ratios (RRs) with 95% CIs were calculated and pooled. RESULTS Thirty-one RCTs were included. There was no difference between BL/BLIs and carbapenems in terms of mortality (RR 0.98, 95% CI 0.79-1.20), without heterogeneity. No differences were observed with regard to clinical or microbiological failure and bacterial superinfections. The results were not affected by risk of bias. No differences were detected in the subgroups of patients with nosocomial infections, Gram-negative infections and neutropenic fever. Adverse events requiring discontinuation were more common with BL/BLIs, on account of an increased incidence of diarrhoea. However, Clostridium difficile-associated diarrhoea (RR 0.29, 95% CI 0.10-0.87) was more frequent with carbapenems and seizures were more frequent with imipenem (RR 0.21, 95% CI 0.05-0.93). CONCLUSIONS No differences in efficacy between BL/BLIs and carbapenems exist in RCTs including patient populations with a certain, albeit unknown, rate of ESBL-positive bacteria causing infections.
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Affiliation(s)
- Shachaf Shiber
- Emergency Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Dafna Yahav
- Unit of Infectious Diseases, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel
| | - Tomer Avni
- Medicine E, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Leonard Leibovici
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel Medicine E, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel
| | - Mical Paul
- Sackler Faculty of Medicine, Tel-Aviv University, Ramat Aviv, Israel Unit of Infectious Diseases, Rambam Health Care Center, Haifa, Israel
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Moenster R, Linneman T, Finnegan P, Hand S, Thomas Z, McDonald J. Acute renal failure associated with vancomycin and β-lactams for the treatment of osteomyelitis in diabetics: piperacillin–tazobactam as compared with cefepime. Clin Microbiol Infect 2014; 20:O384-9. [DOI: 10.1111/1469-0691.12410] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Revised: 07/20/2013] [Accepted: 09/23/2013] [Indexed: 11/29/2022]
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The microbiologic profile of diabetic foot infections in Turkey: a 20-year systematic review. Eur J Clin Microbiol Infect Dis 2014; 33:871-8. [DOI: 10.1007/s10096-014-2047-5] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2013] [Accepted: 01/02/2014] [Indexed: 01/08/2023]
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Abstract
Foot infections are common in persons with diabetes mellitus. Most diabetic foot infections occur in a foot ulcer, which serves as a point of entry for pathogens. Unchecked, infection can spread contiguously to involve underlying tissues, including bone. A diabetic foot infection is often the pivotal event leading to lower extremity amputation, which account for about 60% of all amputations in developed countries. Given the crucial role infections play in the cascade toward amputation, all clinicians who see diabetic patients should have at least a basic understanding of how to diagnose and treat this problem.
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Affiliation(s)
- Edgar J G Peters
- Department of Internal Medicine, VU University Medical Center, Room ZH4A35, PO Box 7057, Amsterdam NL-1007MB, The Netherlands.
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27
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Demetriou M, Papanas N, Panopoulou M, Papatheodorou K, Bounovas A, Maltezos E. Tissue and Swab Culture in Diabetic Foot Infections. INT J LOW EXTR WOUND 2013; 12:87-93. [DOI: 10.1177/1534734613481975] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
We evaluated the diagnostic performance of swabs versus tissue cultures in 28 diabetic patients with neuropathic (group A) and 22 diabetic patients with neuroischemic foot ulcer (group B) and the differences in bacterial isolates between the 2 groups. In group A, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of swab cultures for the diagnosis of infection were 100%, 40%, 88.5%, and 100%, respectively. In group B, the corresponding values were 100%, 22.2%, 65%, and 100%. In group A, sensitivity, specificity, PPV, and NPV of swab cultures for the identification of pathogens were 100%, 14.3%, 53.8%, and 100%, respectively. In group B, the corresponding values were 100%, 18.2%, 55%, and 100%. In each group, Staphylococcus aureus and Pseudomonas aeruginosa were the most common isolates. The number of isolates was significantly higher on swab versus tissue cultures only in group A ( P = .033). No differences were observed between groups in number of isolates and colony forming units. In conclusion, swab cultures are highly sensitive but less specific and have an excellent NPV both in diabetic patients with neuropathic and in those with neuroischemic foot ulcer. There are no differences between the groups in microbial load.
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Affiliation(s)
- Maria Demetriou
- Democritus University of Thrace, University Hospital of Alexandroupolis, Greece
| | - Nikolaos Papanas
- Democritus University of Thrace, University Hospital of Alexandroupolis, Greece
| | - Maria Panopoulou
- Democritus University of Thrace, University Hospital of Alexandroupolis, Greece
| | | | - Anastasios Bounovas
- Democritus University of Thrace, University Hospital of Alexandroupolis, Greece
| | - Efstratios Maltezos
- Democritus University of Thrace, University Hospital of Alexandroupolis, Greece
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28
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Aragón-Sánchez J, Lipsky BA, Lázaro-Martínez JL. Gram-Negative Diabetic Foot Osteomyelitis. INT J LOW EXTR WOUND 2013; 12:63-8. [PMID: 23446368 DOI: 10.1177/1534734613477423] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Osteomyelitis frequently complicates infections in the feet of patients with diabetes. Gram-positive cocci, especially Staphylococcus aureus, are the most commonly isolated pathogens, but gram-negative bacteria also cause some cases of diabetic foot osteomyelitis (DFO). These gram-negatives require different antibiotic regimens than those commonly directed at gram-positives. There are, however, few data on factors related to their presence and how they influence the clinical picture. We conducted a retrospective study to determine the variables associated with the isolation of gram-negative bacteria from bone samples in cases of DFO and the clinical presentation of these infections. Among 341 cases of DFO, 150 had a gram-negative isolate (alone or combined with a gram-positive isolate) comprising 44.0% of all patients and 50.8% of those with a positive bone culture. Compared with gram-positive infections, wounds with gram-negative organisms more often had a fetid odor, necrotic tissue, signs of soft tissue infection accompanying osteomyelitis, and clinically severe infection. By multivariate analysis, the predictive variables related to an increased likelihood of isolating gram-negatives from bone samples were glycated hemoglobin <7% (odds ratio [OR] = 2.0, 95% confidence interval [CI] = 1.1-3.5) and a wound caused by traumatic injury (OR = 2.0, 95% CI = 1.0-3.9). Overall, patients whose bone samples contained gram-negatives had a statistically significantly higher prevalence of leukocytosis and higher white blood cell counts than those without gram-negatives. In conclusion, gram-negative organisms were isolated in nearly half of our cases of DFO and were associated with more severe infections, higher white blood cell counts, lower glycated hemoglobin levels, and wounds of traumatic etiology.
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Affiliation(s)
| | - Benjamin A. Lipsky
- University of Washington, Seattle, WA, USA
- University of Oxford, Oxford, UK
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Johnson SW, Drew RH, May DB. How long to treat with antibiotics following amputation in patients with diabetic foot infections? Are the 2012 IDSA DFI guidelines reasonable? J Clin Pharm Ther 2013; 38:85-8. [DOI: 10.1111/jcpt.12034] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 11/13/2012] [Indexed: 11/30/2022]
Affiliation(s)
- S. W. Johnson
- Campbell University College of Pharmacy and Health Sciences; Buies Creek NC USA
- Forsyth Medical Center; Winston-Salem NC USA
| | - R. H. Drew
- Campbell University College of Pharmacy and Health Sciences; Buies Creek NC USA
- Duke University Medical Center; Durham NC USA
| | - D. B. May
- Campbell University College of Pharmacy and Health Sciences; Buies Creek NC USA
- Duke University Medical Center; Durham NC USA
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Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJG, Armstrong DG, Deery HG, Embil JM, Joseph WS, Karchmer AW, Pinzur MS, Senneville E. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2012; 54:e132-73. [PMID: 22619242 DOI: 10.1093/cid/cis346] [Citation(s) in RCA: 1089] [Impact Index Per Article: 90.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Foot infections are a common and serious problem in persons with diabetes. Diabetic foot infections (DFIs) typically begin in a wound, most often a neuropathic ulceration. While all wounds are colonized with microorganisms, the presence of infection is defined by ≥2 classic findings of inflammation or purulence. Infections are then classified into mild (superficial and limited in size and depth), moderate (deeper or more extensive), or severe (accompanied by systemic signs or metabolic perturbations). This classification system, along with a vascular assessment, helps determine which patients should be hospitalized, which may require special imaging procedures or surgical interventions, and which will require amputation. Most DFIs are polymicrobial, with aerobic gram-positive cocci (GPC), and especially staphylococci, the most common causative organisms. Aerobic gram-negative bacilli are frequently copathogens in infections that are chronic or follow antibiotic treatment, and obligate anaerobes may be copathogens in ischemic or necrotic wounds. Wounds without evidence of soft tissue or bone infection do not require antibiotic therapy. For infected wounds, obtain a post-debridement specimen (preferably of tissue) for aerobic and anaerobic culture. Empiric antibiotic therapy can be narrowly targeted at GPC in many acutely infected patients, but those at risk for infection with antibiotic-resistant organisms or with chronic, previously treated, or severe infections usually require broader spectrum regimens. Imaging is helpful in most DFIs; plain radiographs may be sufficient, but magnetic resonance imaging is far more sensitive and specific. Osteomyelitis occurs in many diabetic patients with a foot wound and can be difficult to diagnose (optimally defined by bone culture and histology) and treat (often requiring surgical debridement or resection, and/or prolonged antibiotic therapy). Most DFIs require some surgical intervention, ranging from minor (debridement) to major (resection, amputation). Wounds must also be properly dressed and off-loaded of pressure, and patients need regular follow-up. An ischemic foot may require revascularization, and some nonresponding patients may benefit from selected adjunctive measures. Employing multidisciplinary foot teams improves outcomes. Clinicians and healthcare organizations should attempt to monitor, and thereby improve, their outcomes and processes in caring for DFIs.
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Affiliation(s)
- Benjamin A Lipsky
- Department of Medicine, University of Washington, Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA.
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From Ulcer to Infection: An Update on Clinical Practice and Adjunctive Treatments of Diabetic Foot Ulcers. Curr Infect Dis Rep 2012; 14:540-50. [DOI: 10.1007/s11908-012-0283-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Abstract
Diabetic foot infections (DFIs) are a commonly encountered medical problem. They are associated with an increased frequency and length of hospitalization and risk for lower-extremity amputation. Furthermore, they have substantial economic consequences. Patients with diabetes mellitus are particularly susceptible to foot infections because of neuropathy, vascular insufficiency, and diminished neutrophil function. The approach to managing DFIs starts with determining if an infection exists. If an infection exists, then the type, severity, extent of infection, and risk factors for resistant organisms should be determined through history, physical examination, and additional laboratory and radiological testing. Optimal management requires surgical debridement, pressure offloading, effective antibiotic therapy, wound care and moisture, maintaining good vascular supply, and correction of metabolic abnormalities, such as hyperglycemia, through a multidisciplinary team. Empiric antibiotics for DFIs vary based on the severity of the infection, but must include anti-staphylococcal coverage.
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Affiliation(s)
- Mazen S Bader
- McMaster University, Faculty of Health Sciences, Division of Infectious Diseases, Hamilton, Ontario, Canada.
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Abstract
Every 30 s, a lower limb is amputated due to diabetes. Of all amputations in diabetic patients 85% are preceded by a foot ulcer which subsequently deteriorates to a severe infection or gangrene. There is a complexity of factors related to healing of foot ulcers including strategies for treatment of decreased perfusion, oedema, pain, infection, metabolic disturbances, malnutrition, non-weight bearing, wound treatment, foot surgery, and management of intercurrent disease. Patients with diabetic foot ulcer and decreased perfusion do often not have rest pain or claudication and as a consequence non-invasive vascular testing is recommended for early recognition of ulcers in need of revascularisation to achieve healing. A diabetic foot infection is a potentially limb-threatening condition. Infection is diagnosed by the presence or increased rate of signs inflammation. Often these signs are less marked than expected. Imaging studies can diagnose or better define deep, soft tissue purulent collections and are frequently needed to detect pathological findings in bone. The initial antimicrobial treatment as well as duration of treatment is empiric. There is a substantial delay in wound healing in diabetic foot ulcer which has been related to various abnormalities. Several new treatments related to these abnormalities have been explored in wound healing with various successes. An essential part of the strategy to achieve healing is an effective offloading. Many interventions with advanced wound management have failed due to not recognizing the need for effective offloading. A multidisciplinary approach to wounds and foot ulcer has been successfully implemented in different centres with a substantial decrease in amputation rate.
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Affiliation(s)
- Jan Apelqvist
- Department of Endocrinology, University Hospital of Skåne (SUS), 205 02, Malmö, Sweden.
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Ertugrul BM, Oncul O, Tulek N, Willke A, Sacar S, Tunccan OG, Yilmaz E, Kaya O, Ozturk B, Turhan O, Yapar N, Ture M, Akin F. A prospective, multi-center study: factors related to the management of diabetic foot infections. Eur J Clin Microbiol Infect Dis 2012; 31:2345-52. [PMID: 22354524 DOI: 10.1007/s10096-012-1574-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Accepted: 01/28/2012] [Indexed: 10/28/2022]
Abstract
The Turkish Association of Clinical Microbiology and Infectious Diseases, Diabetic Foot Infections Working Group conducted a prospective study to determine the factors affecting the outcomes of diabetic foot infections. A total of 96 patients were enrolled in the study. Microbiological assessment was performed in 86 patients. A total of 115 causative bacteria were isolated from 71 patients. The most frequently isolated bacterial species was Pseudomonas aeruginosa (n = 21, 18.3%). Among cases with bacterial growth, 37 patients (43%) were infected with 38 (33%) antibiotic-resistant bacteria. The mean (±SD) antibiotics cost was 2,220.42 (±994.59) USD in cases infected with resistant bacteria, while it was 1,206.60 (±1,160.6) USD in patients infected with susceptible bacteria (p < 0.001). According to the logistic regression analysis, the risk factors related to the growth of resistant bacteria were previous amputation (p = 0.018, OR = 7.229) and antibiotics administration within the last 30 days (p = 0.032, OR = 3.796); that related to the development of osteomyelitis was wound size >4.5 cm(2) (p = 0.041, OR = 2.8); and that related to the failure of the treatment was the growth of resistant bacteria (p = 0.016, OR = 5.333). Diabetic foot osteomyelitis is usually a chronic infection and requires surgical therapy. Amputation is the accepted form of treatment for osteomyelitis. Limited limb-saving surgery and prolonged antibiotic therapy directed toward the definitive causative bacteria are most appropriate. This may decrease limb loss through amputations. As a result the infections caused by resistant bacteria may lead to a high cost of antibiotherapy, prolonged hospitalization duration, and failure of the treatment.
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Affiliation(s)
- B M Ertugrul
- School of Medicine, Department of Infectious Diseases and Clinical Microbiology, University of Adnan Menderes, 09100, Aydin, Turkey.
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Peters EJG, Lipsky BA, Berendt AR, Embil JM, Lavery LA, Senneville E, Urbančič-Rovan V, Bakker K, Jeffcoate WJ. A systematic review of the effectiveness of interventions in the management of infection in the diabetic foot. Diabetes Metab Res Rev 2012; 28 Suppl 1:142-62. [PMID: 22271738 DOI: 10.1002/dmrr.2247] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
The International Working Group on the Diabetic Foot expert panel on infection conducted a systematic review of the published evidence relating to treatment of foot infection in diabetes. Our search of the literature published prior to August 2010 identified 7517 articles, 29 of which fulfilled predefined criteria for detailed data extraction. Four additional eligible papers were identified from other sources. Of the total of 33 studies, 29 were randomized controlled trials, and four were cohort studies. Among 12 studies comparing different antibiotic regimens in the management of skin and soft-tissue infection, none reported a better response with any particular regimen. Of seven studies that compared antibiotic regimens in patients with infection involving both soft tissue and bone, one reported a better clinical outcome in those treated with cefoxitin compared with ampicillin/sulbactam, but the others reported no differences between treatment regimens. In two health economic analyses, there was a small saving using one regimen versus another. No published data support the superiority of any particular route of delivery of systemic antibiotics or clarify the optimal duration of antibiotic therapy in either soft-tissue infection or osteomyelitis. In one non-randomized cohort study, the outcome of treatment of osteomyelitis was better when the antibiotic choice was based on culture of bone specimens as opposed to wound swabs, but this study was not randomized, and the results may have been affected by confounding factors. Results from two studies suggested that early surgical intervention was associated with a significant reduction in major amputation, but the methodological quality of both was low. In two studies, the use of superoxidized water was associated with a better outcome than soap or povidone iodine, but both had a high risk of bias. Studies using granulocyte-colony stimulating factor reported mixed results. There was no improvement in infection outcomes associated with hyperbaric oxygen therapy. No benefit has been reported with any other intervention, and, overall, there are currently no trial data to justify the adoption of any particular therapeutic approach in diabetic patients with infection of either soft tissue or bone of the foot.
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Affiliation(s)
- E J G Peters
- Department of Internal Medicine, VU University Medical Centre, Amsterdam, The Netherlands.
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Diabetic foot infection: a critical review of recent randomized clinical trials on antibiotic therapy. Int J Infect Dis 2011; 15:e601-10. [DOI: 10.1016/j.ijid.2011.05.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Revised: 04/29/2011] [Accepted: 05/03/2011] [Indexed: 11/20/2022] Open
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Abstract
Osteomyelitis is a common and challenging condition for hospitalists to manage. The 3 main types of osteomyelitis that are commonly seen in the hospital setting are 1) contiguous spread from decubitus or diabetic ulcers, 2) hematogenous spread, such as in vertebral or long bone metaphyses, and 3) infections associated with a prosthetic joint. In patients with diabetes, osteomyelitis is the underlying cause of about 20% of foot infections, and greatly increases the chance that the patient will eventually need an amputation and be subject to perioperative risks. Osteomyelitis from hematogenous spread is increasing. The prevalence of vertebral osteomyelitis is also increasing, particularly in intravenous drug users and patients treated with immune-modulating agents. Prosthetic joint infections are perhaps the most challenging type to treat, and require hospitalists, orthopedic surgeons, and infectious disease specialists to work closely together to plan for effective treatment. Due to increasing antibiotic resistance, the microorganisms involved are also proving more difficult to treat. Emerging resistance to the commonly used antibiotics is resulting in changes in treatment choices. Community-acquired methicillin-resistant Staphylococcus aureus is commonly seen, and there is increasing concern about emerging vancomycin resistance. Treatment of osteomyelitis is still based largely on expert opinion rather than evidence from controlled studies.
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Affiliation(s)
- William R Howell
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT84134, USA.
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