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Mazzolai L, Teixido-Tura G, Lanzi S, Boc V, Bossone E, Brodmann M, Bura-Rivière A, De Backer J, Deglise S, Della Corte A, Heiss C, Kałużna-Oleksy M, Kurpas D, McEniery CM, Mirault T, Pasquet AA, Pitcher A, Schaubroeck HAI, Schlager O, Sirnes PA, Sprynger MG, Stabile E, Steinbach F, Thielmann M, van Kimmenade RRJ, Venermo M, Rodriguez-Palomares JF. 2024 ESC Guidelines for the management of peripheral arterial and aortic diseases. Eur Heart J 2024:ehae179. [PMID: 39210722 DOI: 10.1093/eurheartj/ehae179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024] Open
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Gonçalves J, Guimarães AR, Ferreira HU, Ribeiro S, Moreno T, Borges-Canha M, Meira I, Menino J, Silva F, Pedro J, Neves N, Simão RS, Santos L, Queirós J. Microbiological characterization of neuropathic diabetic foot infection: a retrospective study at a Portuguese tertiary hospital. BMC Infect Dis 2024; 24:791. [PMID: 39107703 PMCID: PMC11305078 DOI: 10.1186/s12879-024-09677-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2024] [Accepted: 07/29/2024] [Indexed: 08/10/2024] Open
Abstract
Diabetic foot infection imposes a significant burden and is the major cause of nontraumatic limb amputation. Adequate patient management with effective antibiotic therapy is crucial.This retrospective cohort study aimed to characterize the microbiology and resistance patterns of moderate to severe neuropathic diabetic foot infection in patients hospitalized at a tertiary referral hospital between January 2020 and June 2023. Deep tissue specimens from ulcers were collected for culture.Sixty inpatients were included (62% male, mean age 59.1 ± 11.5 years). Osteomyelitis was present in 90% of the patients. Among 102 microorganisms (average of 1.91 ± 1.25 pathogens per patient), 60.8% were gram-positive bacteria, 31.4% were gram-negative, 3.92% were anaerobic bacteria, and 3.92% were fungi. Staphylococcus aureus (19%) and Enterococcus faecium (17%) were the most common. Pseudomonas aeruginosa (8%) and bacteria of the Enterobacterales family (24%) accounted for all the isolated gram-negative bacteria. Sixteen percent of Staphylococcus aureus and 67% of coagulase-negative Staphylococci were resistant to methicillin. Resistance to ampicillin was found in 11% of Enterococci. All Pseudomonas aeruginosa isolates were sensitive to piperacillin-tazobactam, ceftazidime, or cefepime. Among the Enterobacterales, resistance rates were 35% for piperacillin-tazobactam, 38% for ceftazidime, 21% for cefepime, and 13% for carbapenems.Although the prevalence of methicillin-resistant staphylococci was lower than that in other studies, carbapenem resistance among gram-negative bacteria warrants attention. This study highlights the importance of understanding local epidemiology for effective diabetic foot infection management and resistance mitigation.
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Affiliation(s)
- Juliana Gonçalves
- Department of Endocrinology, Diabetes and Metabolism, Unidade Local de Saúde de São João, Porto, 4200-319 Portugal
- Faculty of Medicine, Universidade Do Porto, Porto, 4200-319 Portugal
| | - André Rodrigues Guimarães
- Faculty of Medicine, Universidade Do Porto, Porto, 4200-319 Portugal
- Department of Infectious Diseases, Unidade Local de Saúde de São João, Porto, 4200-319 Portugal
| | - Helena Urbano Ferreira
- Department of Endocrinology, Diabetes and Metabolism, Unidade Local de Saúde de São João, Porto, 4200-319 Portugal
- Faculty of Medicine, Universidade Do Porto, Porto, 4200-319 Portugal
| | - Sara Ribeiro
- Department of Endocrinology, Diabetes and Metabolism, Unidade Local de Saúde de São João, Porto, 4200-319 Portugal
- Faculty of Medicine, Universidade Do Porto, Porto, 4200-319 Portugal
| | - Telma Moreno
- Department of Endocrinology, Diabetes and Metabolism, Unidade Local de Saúde de São João, Porto, 4200-319 Portugal
- Faculty of Medicine, Universidade Do Porto, Porto, 4200-319 Portugal
| | - Marta Borges-Canha
- Department of Endocrinology, Diabetes and Metabolism, Unidade Local de Saúde de São João, Porto, 4200-319 Portugal
- Faculty of Medicine, Universidade Do Porto, Porto, 4200-319 Portugal
| | - Inês Meira
- Department of Endocrinology, Diabetes and Metabolism, Unidade Local de Saúde de São João, Porto, 4200-319 Portugal
- Faculty of Medicine, Universidade Do Porto, Porto, 4200-319 Portugal
| | - João Menino
- Department of Endocrinology, Diabetes and Metabolism, Unidade Local de Saúde de São João, Porto, 4200-319 Portugal
- Faculty of Medicine, Universidade Do Porto, Porto, 4200-319 Portugal
| | - Fábia Silva
- Department of Orthopedic and Traumatology, Unidade Local de Saúde de São João, Porto, 4200-319 Portugal
| | - Jorge Pedro
- Department of Endocrinology, Diabetes and Metabolism, Unidade Local de Saúde de São João, Porto, 4200-319 Portugal
- Faculty of Medicine, Universidade Do Porto, Porto, 4200-319 Portugal
| | - Nélia Neves
- Faculty of Medicine, Universidade Do Porto, Porto, 4200-319 Portugal
- Department of Infectious Diseases, Unidade Local de Saúde de São João, Porto, 4200-319 Portugal
| | - Ricardo São Simão
- Department of Orthopedic and Traumatology, Unidade Local de Saúde de São João, Porto, 4200-319 Portugal
| | - Lurdes Santos
- Faculty of Medicine, Universidade Do Porto, Porto, 4200-319 Portugal
- Department of Infectious Diseases, Unidade Local de Saúde de São João, Porto, 4200-319 Portugal
- Intensive Care Unit of Infectious Diseases, Unidade Local de Saúde de São João, Porto, 4200-319 Portugal
| | - Joana Queirós
- Department of Endocrinology, Diabetes and Metabolism, Unidade Local de Saúde de São João, Porto, 4200-319 Portugal
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Jeffcoate W, Boyko EJ, Game F, Cowled P, Senneville E, Fitridge R. Causes, prevention, and management of diabetes-related foot ulcers. Lancet Diabetes Endocrinol 2024; 12:472-482. [PMID: 38824929 DOI: 10.1016/s2213-8587(24)00110-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 06/04/2024]
Abstract
In this Review, we aim to complement the 2023 update of the guidelines of the International Working Group on the Diabetic Foot. We highlight the complexity of the pathological processes that underlie diabetes-related foot ulceration (DFU) and draw attention to the potential implications for clinical management and outcome. Variation observed in the incidence and outcome of DFUs in different communities might result from differences in study populations and the accessibility of care. Comparing differences in incidence, management, and outcome of DFUs in different communities is an essential component of the quality of disease care. Additionally, these comparisons can also highlight the relationship between DFU incidence, management, and outcome and the structure of local clinical services and the availability of staff with the necessary skills. The clinical outcome is, however, also dependent on the availability of multidisciplinary care and the ability of people with DFUs to gain access to that care.
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Affiliation(s)
| | - Edward J Boyko
- VA Puget Sound Health Care System, Seattle, WA, USA; Department of Medicine, University of Washington, Seattle, WA, USA
| | - Fran Game
- University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Prue Cowled
- Discipline of Surgery, The University of Adelaide, Adelaide, SA, Australia
| | - Eric Senneville
- Discipline of Infectious Diseases, The University of Lille, Gustave Dron Hospital, Tourcoing, France
| | - Robert Fitridge
- Discipline of Surgery, The University of Adelaide, Adelaide, SA, Australia; Vascular and Endovascular Service, Royal Adelaide Hospital, Adelaide, SA, Australia.
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Pagani E, Bruno R. Which test(s) can best identify the causative pathogen(s) and result in tailored use of antibiotics? Int Wound J 2024; 21:e14958. [PMID: 38961595 PMCID: PMC11222292 DOI: 10.1111/iwj.14958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Accepted: 06/17/2024] [Indexed: 07/05/2024] Open
Affiliation(s)
| | - Raffaele Bruno
- SC Malattie Infettive Fondazione IRCCS San Matteo PaviaPaviaItaly
- Dipartimento di Scienze Morfologiche Cliniche e DiagnosticheUniversità di PaviaPaviaItaly
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Morton KE, Coghill SH. Staphylococcus aureus Is the Predominant Pathogen in Hospitalised Patients with Diabetes-Related Foot Infections: An Australian Perspective. Antibiotics (Basel) 2024; 13:594. [PMID: 39061276 PMCID: PMC11273989 DOI: 10.3390/antibiotics13070594] [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: 03/15/2024] [Revised: 04/11/2024] [Accepted: 04/30/2024] [Indexed: 07/28/2024] Open
Abstract
Diabetes prevalence continues to increase worldwide, which has led to a rising incidence of diabetes-related foot infections (DFIs). There is significant local variation in the microbiology of DFIs, and Pseudomonas spp. is suggested to be more prevalent in subtropical climates. The aim of this study was to investigate the local microbiological findings in patients admitted to the hospital with DFIs. This retrospective study analysed data from all adult patients diagnosed with diabetes and admitted to the hospital for the treatment of a DFI between 1 January 2021 and 31 December 2022. Both superficial wound swabs and tissue cultures were included. The Infectious Diseases Society of America classification system was used to categorise the severity of the DFI. Patient characteristics and demographics were analysed using descriptive statistics. One hundred fifty-one episodes of care were included. Most of the DFIs were classified as moderate infections 101/151 (67%). The most commonly isolated microorganism was Staphylococcus aureus (33%) followed by normal skin flora (11%) and β-haemolytic streptococci (7%). P. aeruginosa was isolated more commonly in those with chronic DFIs (10%) compared to those with acute DFIs (2%). Despite the frequent identification of S. aureus, 83% of patients received an antipseudomonal antibiotic. The introduction of multidisciplinary DFI rounds should be considered.
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Affiliation(s)
- Kate E. Morton
- Pharmacy Department, Lismore Base Hospital, Lismore, NSW 2480, Australia
| | - Sarah H. Coghill
- Infectious Diseases Department, Lismore Base Hospital, Lismore, NSW 2480, Australia
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Frazee BW. Diabetic Foot Infections in the Emergency Department. Emerg Med Clin North Am 2024; 42:267-285. [PMID: 38641391 DOI: 10.1016/j.emc.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/21/2024]
Abstract
Diabetic foot infection (DFI) is among the most common diabetic complications requiring hospitalization. Prompt emergency department diagnosis and evidence-based management can prevent eventual amputation and associated disability and mortality. Underlying neuropathy, arterial occlusion, immune dysfunction, and hyperglycemia-associated dehydration and ketoacidosis can all contribute to severity and conspire to make DFI diagnosis and management difficult. Serious complications include osteomyelitis, necrotizing infection, and sepsis. Practice guidelines are designed to assist frontline providers with correct diagnosis, categorization, and treatment decisions. Management generally includes a careful lower extremity examination and plain x-ray, obtaining appropriate tissue cultures, and evidence-based antibiotic selection tailored to severity.
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Affiliation(s)
- Bradley W Frazee
- Department of Emergency Medicine, Alameda Health System, Wilma Chan Highland Hospital, 1411 East 31st Street, Oakland, CA 94602, USA.
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Saleem M, Syed Khaja AS, Moursi S, Altamimi TA, Alharbi MS, Usman K, Khan MS, Alaskar A, Alam MJ. Narrative review on nanoparticles based on current evidence: therapeutic agents for diabetic foot infection. NAUNYN-SCHMIEDEBERG'S ARCHIVES OF PHARMACOLOGY 2024:10.1007/s00210-024-03094-8. [PMID: 38639898 DOI: 10.1007/s00210-024-03094-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 04/11/2024] [Indexed: 04/20/2024]
Abstract
Diabetes's effects on wound healing present a major treatment challenge and increase the risk of amputation. When traditional therapies fail, new approaches must be investigated. With their submicron size and improved cellular internalisation, nanoparticles present a viable way to improve diabetic wound healing. They are attractive options because of their innate antibacterial qualities, biocompatibility, and biodegradability. Nanoparticles loaded with organic or inorganic compounds, or embedded in biomimetic matrices such as hydrogels, chitosan, and hyaluronic acid, exhibit excellent anti-inflammatory, antibacterial, and antioxidant properties. Drug delivery systems (DDSs)-more precisely, nanodrug delivery systems (NDDSs)-use the advantages of nanotechnology to get around some of the drawbacks of traditional DDSs. Recent developments show how expertly designed nanocarriers can carry a variety of chemicals, transforming the treatment of diabetic wounds. Biomaterials that deliver customised medications to the wound microenvironment demonstrate potential. Delivery techniques for nanomedicines become more potent than ever, overcoming conventional constraints. Therapeutics for diabetes-induced non-healing wounds are entering a revolutionary era thanks to precisely calibrated nanocarriers that effectively distribute chemicals. This review highlights the therapeutic potential of nanoparticles and outlines the multifunctional nanoparticles of the future that will be used for complete wound healing in diabetics. The investigation of novel nanodrug delivery systems has the potential to revolutionise diabetic wound therapy and provide hope for more efficient and focused therapeutic approaches.
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Affiliation(s)
- Mohd Saleem
- Department of Pathology, College of Medicine, University of Hail, 55211, Hail, Saudi Arabia.
| | | | - Soha Moursi
- Department of Pathology, College of Medicine, University of Hail, 55211, Hail, Saudi Arabia
| | - Tahani Almofeed Altamimi
- Department of Family Medicine, College of Medicine, University of Hail, 55211, Hail, Saudi Arabia
| | - Mohammed Salem Alharbi
- Department of Internal Medicine, College of Medicine, University of Hail, 55211, Hail, Saudi Arabia
| | - Kauser Usman
- Department of Internal Medicine, King George's Medical University, Lucknow, India
| | - Mohd Shahid Khan
- Department of Microbiology, Integral Institute of Medical Sciences and Research, Lucknow, India
| | - Alwaleed Alaskar
- Department of Diabetes and Endocrinology, King Salman Specialist Hospital, 55211, Hail, Saudi Arabia
| | - Mohammad Jahoor Alam
- Department of Biology, College of Science, University of Hail, 55211, Hail, Saudi Arabia
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Edwards G, Carter A, Wallis C, Hayward G, Moore A. Identifying infection in chronic wounds in a community setting: A systematic review of diagnostic test accuracy studies. J Adv Nurs 2024; 80:73-83. [PMID: 37574778 DOI: 10.1111/jan.15822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 07/05/2023] [Accepted: 07/22/2023] [Indexed: 08/15/2023]
Abstract
AIM To determine the diagnostic accuracy of different methods currently available to identify infection in chronic wounds applicable to adult patients in a community setting. DESIGN Systematic review of diagnostic test accuracy studies. REVIEW METHODS Two authors independently completed screening, data extraction and quality and bias assessments (QUADAS2). Eligible studies compared a method (index test) for detecting infection (diagnosis of interest) with microscopy and culture of either deep tissue biopsy or wound swab (reference test) in adult patients with wounds of >4 weeks duration (participants). The results were synthesized narratively. DATA SOURCES We systematically searched CINAHL, Embase and Medline from 2011 to April 2022. RESULTS Four studies were included, all recruiting from secondary care wound clinics. Two studies assessed the diagnostic accuracy of Moleculight i:X, a bacterial fluorescence imaging device against deep tissue biopsy culture. One study assessed the diagnostic accuracy of the elevation of various enzymes detected in wound fluid against wound swab microscopy of culture. One study assessed the diagnostic accuracy of bacterial protease activity against wound swab microscopy and culture. Sensitivities of these methods ranged from 50 to 75% and specificities from 47 to 100%. CONCLUSION Only a small number of studies were included in this systematic review due to our strict inclusion criteria. We have not identified any methods for diagnosing infection in chronic wounds with either a sufficient quality of evidence to recommend their use in community settings at present. Further research is needed to develop and evaluate appropriate diagnostics for this purpose. IMPACT This study highlights the paucity of research into wound diagnostics in a community setting and should prompt further research in this area. Accurate diagnostic tests have the potential to improve community-based wound care by optimizing antibiotic use and potentially improving healing time. REPORTING METHOD PRISMA-DTA checklist. PATIENT OR PUBLIC CONTRIBUTION The PPI group for the NIHR Community Healthcare MIC were supportive of this topic of work.
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Affiliation(s)
- George Edwards
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, UK
| | - Adam Carter
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, UK
| | - Chloe Wallis
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, UK
| | - Gail Hayward
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, UK
| | - Abigail Moore
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, UK
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9
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Travis DJ, Bradbury J, Benkendorff K. Toward non-invasive collection methods for sampling the microbiome of diabetic foot ulcers. Int Wound J 2023; 20:3731-3737. [PMID: 37501084 PMCID: PMC10588311 DOI: 10.1111/iwj.14267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 05/22/2023] [Indexed: 07/29/2023] Open
Abstract
Identifying the microbiome within chronic diabetic foot ulcers is essential if effective antimicrobial therapies are to be administered. Using culture and 16S rRNA gene sequencing, the aim of this study was to compare the microbiome of paired tissue scraping samples with swab samples, collected from participants during attendance at a high-risk foot clinic. The mean richness of cultured swab and tissue scraping samples was consistent, with anaerobes infrequently isolated from both sample types. Comparing percentage frequencies of detection of selected genera of known and potential pathogens namely Staphylococcus, Streptococcus, Enterococcus, Corynebacterium, Enterobacteriaceae and Pseudomonas from cultured and sequenced swab and tissue scrapings indicated that both collection methods captured varying percentages of all the selected genera. The mean abundance of sequenced samples was not significantly different between swabs and tissue scrapings. The mean richness or number of distinct operational taxonomic units (OTUs) and Shannon's H diversity index were not significantly different between the two collection methods. The mean relative abundance of the selected genera of known and potential pathogens, including anaerobes Anaerococcus and Finegoldia, was higher in swabs compared with tissue scrapings and significantly so in Staphylococcus and Pseudomonas genera. Multivariate analyses confirmed no significant differences between the bacterial community compositions of the paired samples. These results suggest that tissue scrapings and swabs can effectively capture the microbiome of chronic DFUs using culture and 16S rRNA gene sequencing.
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Affiliation(s)
| | - Joanne Bradbury
- Faculty of HealthSouthern Cross UniversityGold CoastAustralia
| | - Kirsten Benkendorff
- National Marine Science Centre, Faculty of Environment, Science and EngineeringSouthern Cross UniversityCoffs HarbourNSWAustralia
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Guo H, Song Q, Mei S, Xue Z, Li J, Ning T. Distribution of multidrug-resistant bacterial infections in diabetic foot ulcers and risk factors for drug resistance: a retrospective analysis. PeerJ 2023; 11:e16162. [PMID: 37842066 PMCID: PMC10569182 DOI: 10.7717/peerj.16162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 09/01/2023] [Indexed: 10/17/2023] Open
Abstract
Objective To investigate the distribution, drug resistance and risk factors of multi-drug resistant bacterias (MDROs) in patients with Type 2 diabetic foot ulcers (DFU). Method The clinical data, foot secretions, pathogenic microorganisms and drug sensitivity tests of 147 patients with type 2 diabetes admitted to our department from January 2018 to December 2021 were analyzed. Patients were divided into two groups according to whether they had been infected with MDROs or not. Seventy-one cases were infected with MDROs as the case group, and the remaining 76 cases were the control group. Chi-square test and t-test were used to analyze the results of MDROs infection and DFU, and logistic multivariate regression was used to evaluate the risk factors of MDROs infection. Results A total of 71 strains were isolated from the MDROs-positive group, with the top three being Staphylococcus aureus (46.48%), Escherichia coli (22.53%), and Pseudomonas aeruginosa (18.31%), respectively. Logistic multifactorial regression analysis showed that history of previous antimicrobial exposure, neuroischemic wound, Wagner grade 3-5, and combined osteomyelitis were associated with Type 2 diabetic foot infection MDROs (P < 0.05). Conclusion Previous history of antimicrobial exposure, neuroischemic wounds, Wagner grade 3-5, and combined osteomyelitis are independent risk factors for MDROs, which can identify the risk factors for MDROs at an early stage and help to identify people at high risk of MDROs infection and take relevant comprehensive treatment in time to slow down the development of the disease.
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Affiliation(s)
- Huihui Guo
- Department of Orthopaedic Surgery, Fuyang People’s Hospital, Fuyang, China
| | - Qiwei Song
- Department of Orthopaedic Surgery, Fuyang People’s Hospital, Fuyang, China
| | - Siwei Mei
- Department of Orthopaedic Surgery, Fuyang People’s Hospital, Fuyang, China
| | - Zhenqiang Xue
- Department of Orthopaedic Surgery, Fuyang People’s Hospital, Fuyang, China
| | - Junjie Li
- Department of Orthopaedic Surgery, Fuyang People’s Hospital, Fuyang, China
| | - Tao Ning
- Department of Orthopaedic Surgery, Fuyang People’s Hospital, Fuyang, China
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Senneville É, Albalawi Z, van Asten SA, Abbas ZG, Allison G, Aragón-Sánchez J, Embil JM, Lavery LA, Alhasan M, Oz O, Uçkay I, Urbančič-Rovan V, Xu ZR, Peters EJG. IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-related Foot Infections (IWGDF/IDSA 2023). Clin Infect Dis 2023:ciad527. [PMID: 37779457 DOI: 10.1093/cid/ciad527] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 06/23/2023] [Indexed: 10/03/2023] Open
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the management and prevention of diabetes-related foot diseases since 1999. The present guideline is an update of the 2019 IWGDF guideline on the diagnosis and management of foot infections in persons with diabetes mellitus. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used for the development of this guideline. This was structured around identifying clinically relevant questions in the P(A)ICO format, determining patient-important outcomes, systematically reviewing the evidence, assessing the certainty of the evidence, and finally moving from evidence to the recommendation. This guideline was developed for healthcare professionals involved in diabetes-related foot care to inform clinical care around patient-important outcomes. Two systematic reviews from 2019 were updated to inform this guideline, and a total of 149 studies (62 new) meeting inclusion criteria were identified from the updated search and incorporated in this guideline. Updated recommendations are derived from these systematic reviews, and best practice statements made where evidence was not available. Evidence was weighed in light of benefits and harms to arrive at a recommendation. The certainty of the evidence for some recommendations was modified in this update with a more refined application of the GRADE framework centred around patient important outcomes. This is highlighted in the rationale section of this update. A note is also made where the newly identified evidence did not alter the strength or certainty of evidence for previous recommendations. The recommendations presented here continue to cover various aspects of diagnosing soft tissue and bone infections, including the classification scheme for diagnosing infection and its severity. Guidance on how to collect microbiological samples, and how to process them to identify causative pathogens, is also outlined. Finally, we present the approach to treating foot infections in persons with diabetes, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and bone infections; when and how to approach surgical treatment; and which adjunctive treatments may or may not affect the infectious outcomes of diabetes-related foot problems. We believe that following these recommendations will help healthcare professionals provide better care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes-related foot disease.
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Affiliation(s)
- Éric Senneville
- Gustave Dron Hospital, Tourcoing, France
- Univ-Lille France, Lille, France
| | - Zaina Albalawi
- Department of Medicine, Division of Endocrinology, Memorial University, St. John's, Newfoundland and Labrador, Canada
| | - Suzanne A van Asten
- Department of Medical Microbiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Zulfiqarali G Abbas
- Abbas Medical Centre, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Geneve Allison
- Department of Medicine, Tufts Medical Center, Boston, Massachusetts, USA
| | | | - John M Embil
- Department of Medicine, Section of Infectious Diseases, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Lawrence A Lavery
- Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Majdi Alhasan
- Department of Medicine, Prisma Health-Midlands, Columbia, South Carolina, USA
| | - Orhan Oz
- UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ilker Uçkay
- Balgrist University Hospital, Zurich, Switzerland
| | - Vilma Urbančič-Rovan
- Faculty of Medicine, University Medical Centre, University of Ljubljana, Ljubljana, Slovenia
| | | | - Edgar J G Peters
- Department of Internal Medicine, Amsterdam UMC, Vrije Universiteit Amsterdam, Section of Infectious Diseases, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Rehabilitation and Development, Amsterdam, The Netherlands
- Amsterdam Infection & Immunity, Infectious Diseases, Amsterdam, The Netherlands
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12
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Moore J, Gooday C, Soliman R, Dhatariya K. Reduction in the prevalence of methicillin-resistant Staphylococcus aureus in tissue and wound swab samples taken from outpatients attending a specialist diabetic foot clinic 2005-2021. Diabet Med 2023; 40:e15081. [PMID: 36883882 DOI: 10.1111/dme.15081] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 02/03/2023] [Accepted: 03/04/2023] [Indexed: 03/09/2023]
Abstract
AIMS To assess annual change in prevalence of methicillin resistant Staphylococcus aureus (MRSA) from tissue and wound swab samples from foot ulcers (DFUs) in people with diabetes between 2005 and 2021. METHODS A retrospective analysis of everyone with MRSA positive wound or tissue swabs taken from our specialist multidisciplinary foot clinic between July 2005 and July 2021. RESULTS A total of 406 MRSA positive isolates from DFU swabs were identified from 185 individuals attending the foot clinic. There were 22 hospital-acquired infections (HAIs) and 159 community-acquired infections (CAIs). Fifty-two per cent (n = 37) of these individuals from 2010 to 2021 (n = 71) had presence of at least three risk factors for MRSA. The total number of swabs sent was 6312 from 1916 individuals living with diabetes. Annual MRSA DFU prevalence peaked in 2008 at 14.6% (n = 38), decreased in 2013 to 5.2% (n = 20) and did not exceed 4% (n = 6) from 2015 to 2021. Hospital MRSA was lowest in 2021 (n = 211), a 76% fall from 2007 (n = 880). Incidence of MRSA HAI from 2015 to 2021 ranged from 5.4% (n = 14) in 2020 to 11.5% (n = 41) in 2018. CONCLUSIONS Prevalence of MRSA in DFU infections treated as outpatients is decreasing in line with falls in hospital acquired blood-borne infections and with overall hospital MRSA incidence. This is likely a reflection of the combination of interventions, including stringent antibiotic prescribing and decolonisation strategies. Reduction in prevalence should have positive impact on outcomes in people living with diabetes, reducing the complication of osteomyelitis and necessity for long-term antibiotic administration.
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Affiliation(s)
- James Moore
- Department of Medicine, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Catherine Gooday
- Foot Clinic, Elsie Bertram Diabetes Centre, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Reham Soliman
- Department of Microbiology, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, UK
| | - Ketan Dhatariya
- Department of Medicine, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Foot Clinic, Elsie Bertram Diabetes Centre, Norfolk & Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
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13
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Schmidt BM, Kaye KS, Armstrong DG, Pop-Busui R. Empirical Antibiotic Therapy in Diabetic Foot Ulcer Infection Increases Hospitalization. Open Forum Infect Dis 2023; 10:ofad495. [PMID: 37849506 PMCID: PMC10578503 DOI: 10.1093/ofid/ofad495] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 10/02/2023] [Indexed: 10/19/2023] Open
Abstract
Background We evaluated the outcomes associated with initial antibiotic management strategies for infected diabetic foot ulcers (DFUs) diagnosed in an outpatient multidisciplinary center. Methods Consecutive outpatient individuals with infected DFUs, stratified according to Infectious Diseases Society of America infection severity, were followed for 1 year from the initial antibiotic administration to treat acute infection. The main outcomes were hospitalization rates for a diabetes-related foot complication within 30 days of diagnosis and requiring an amputation or death during follow-up. Outcomes were analyzed by regression analysis, accounting for demographics, clinical characteristics, and antibiotic therapy. Results Among 147 outpatients with infected DFUs, 116 were included. Infections were categorized as mild (68%), moderate (26%), and severe (6%). Empirical antibiotics (not culture-guided) were prescribed as initial treatment in 39 individuals, while 77 received culture-based antibiotics. There were no differences in demographic or clinical characteristics between the antibiotic administration groups, except for a higher body mass index and prevalence of chronic kidney disease in the empirical cohort. Forty-two infected DFU patients required hospitalization within 30 days of diagnosis for the same reason. The relative risk for hospitalizations was 1.87 greater in those with mild infections when treated with empirical antibiotics compared with culture-directed antibiotics. There were no differences in amputations and/or death at 1 year follow-up. Conclusions These data support obtaining tissue culture to guide antibiotic therapy, regardless of DFU infection severity, to decrease hospitalizations.
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Affiliation(s)
- Brian M Schmidt
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan Health, Ann Arbor, Michigan, USA
| | - Keith S Kaye
- Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA
| | - David G Armstrong
- Department of Surgery, Southwestern Academic Limb Salvage Alliance (SALSA), Keck School of Medicine of University of Southern California, Los Angeles, California, USA
| | - Rodica Pop-Busui
- Division of Metabolism, Endocrinology, and Diabetes, Department of Internal Medicine, University of Michigan Health, Ann Arbor, Michigan, USA
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14
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Ulusoy S, Oruc M. Characteristics and management of patients undergoing emergency surgery for diabetic foot attack. ULUS TRAVMA ACIL CER 2023; 29:1122-1129. [PMID: 37791449 PMCID: PMC10644080 DOI: 10.14744/tjtes.2023.06713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 08/30/2023] [Accepted: 08/31/2023] [Indexed: 10/05/2023]
Abstract
BACKGROUND Diabetic foot attack (DFA) is considered one of the worst manifestations of diabetic foot. It is necessary to act quickly to prevent amputation and save the patient's life. The aim of this study is to reveal the characteristic features of DFAs and be a guide to healthcare professionals to manage and refer these patients. METHODS Sixty-five patients with DFAs were analyzed retrospectively. Demographics were collected. All patients' ınfectious dis-eases Society of America/International Working Group on the Diabetic Foot (IDSA/IWDGF) stages, site ıschemia neuropathy, bacterial ınfection and depth (SINBAD) and laboratory risk ındicator for necrotizing fasciitis (LRINEC) scores were calculated. According to these measurements, patients were categorized and statistical results were obtained. RESULTS We found that patients who underwent emergency surgery due to DFA applied to an average of two hospitals before applying to our facility and the median acceptance time since the beginning of the first complaint was 9 days. All patients were IDSA/IWDGF stages three and four. Most of the patients had SINBAD scores between four and six. 60% of the patients were at high risk for necrotizing fasciitis according to the LRINEC score. 58.2% of patients had periferic arterial stenosis and the amputation rate was 69.2%. 21.3% of the patients were followed in the intensive care unit, and our patients' mortality rate was 4.2%. CONCLUSION DFA is an emergency surgical condition that requires high clinical suspicion. If not diagnosed and treated with emergency surgery, it has a high mortality and amputation rate. High white blood cell count in patients, local and systemic signs of inflammation, presence of subcutaneous emphysema in the lower extremities on a direct X-ray radiography, and high blood sugar should be considered as warning signs for DFA. Emergency surgical intervention should be performed on these patients, and if the patient is not in a suitable center for emergency surgery, they should be rapidly referred to a center with experienced clinicians.
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Affiliation(s)
- Serap Ulusoy
- Department of General Surgery, Bilkent City Hospital, Ankara-Türkiye
| | - Mustafa Oruc
- Department of General Surgery, Bilkent City Hospital, Ankara-Türkiye
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15
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Ramirez-GarciaLuna JL, Martinez-Jimenez MA, Fraser RDJ, Bartlett R, Lorincz A, Liu Z, Saiko G, Berry GK. Is my wound infected? A study on the use of hyperspectral imaging to assess wound infection. Front Med (Lausanne) 2023; 10:1165281. [PMID: 37692790 PMCID: PMC10483069 DOI: 10.3389/fmed.2023.1165281] [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: 05/01/2023] [Accepted: 07/13/2023] [Indexed: 09/12/2023] Open
Abstract
Introduction Clinical signs and symptoms (CSS) of infection are a standard part of wound care, yet they can have low specificity and sensitivity, which can further vary due to clinician knowledge, experience, and education. Wound photography is becoming more widely adopted to support wound care. Thermography has been studied in the medical literature to assess signs of perfusion and inflammation for decades. Bacterial fluorescence has recently emerged as a valuable tool to detect a high bacterial load within wounds. Combining these modalities offers a potential objective screening tool for wound infection. Methods A multi-center prospective study of 66 outpatient wound care patients used hyperspectral imaging to collect visible light, thermography, and bacterial fluorescence images. Wounds were assessed and screened using the International Wound Infection Institute (IWII) checklist for CSS of infection. Principal component analysis was performed on the images to identify wounds presenting as infected, inflamed, or non-infected. Results The model could accurately predict all three wound classes (infected, inflamed, and non-infected) with an accuracy of 74%. They performed best on infected wounds (100% sensitivity and 91% specificity) compared to non-inflamed (sensitivity 94%, specificity 70%) and inflamed wounds (85% sensitivity, 77% specificity). Discussion Combining multiple imaging modalities enables the application of models to improve wound assessment. Infection detection by CSS is vulnerable to subjective interpretation and variability based on clinicians' education and skills. Enabling clinicians to use point-of-care hyperspectral imaging may allow earlier infection detection and intervention, possibly preventing delays in wound healing and minimizing adverse events.
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Affiliation(s)
| | | | - Robert D. J. Fraser
- Swift Medical, Toronto, ON, Canada
- Arthur Labatt School of Nursing, Northwestern University, London, ON, Canada
| | | | | | | | - Gennadi Saiko
- Department of Physics, Toronto Metropolitan University, Toronto, ON, Canada
| | - Gregory K. Berry
- Department of Surgery, McGill University Health Centre, Montreal, QC, Canada
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16
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Lee J, Mashayamombe M, Walsh TP, Kuang BKP, Pena GN, Vreugde S, Cooksley C, Carda-Diéguez M, Mira A, Jesudason D, Fitridge R, Zilm PS, Dawson J, Kidd SP. The bacteriology of diabetic foot ulcers and infections and incidence of Staphylococcus aureus Small Colony Variants. J Med Microbiol 2023; 72. [PMID: 37326607 DOI: 10.1099/jmm.0.001716] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/17/2023] Open
Abstract
Introduction. Uninfected diabetes-related foot ulcer (DFU) progression to diabetes-related foot infection (DFI) is a prevalent complication for patients with diabetes. DFI often progresses to osteomyelitis (DFI-OM). Active (growing) Staphylococcus aureus is the most common pathogen in these infections. There is relapse in 40-60 % of cases even when the initial treatment at the DFI stage apparently clears infection.Hypothesis. S. aureus adopts the quasi-dormant Small Colony Variant (SCV) state during DFU and consequently infection, and when present in DFI cases also permits survival in non-diseased tissues as a reservoir to cause relapse.Aim. The aim of this study was to investigate the bacterial factors that facilitate persistent infections.Methodology. People with diabetes were recruited from two tertiary hospitals. Clinical and bacterial data was taken from 153 patients with diabetes (51 from a control group with no ulcer or infection) and samples taken from 102 patients with foot complications to identify bacterial species and their variant colony types, and then compare the bacterial composition in those with uninfected DFU, DFI and those with DFI-OM, of whom samples were taken both from wounds (DFI-OM/W) and bone (DFI-OM/B). Intracellular, extracellular and proximal 'healthy' bone were examined.Results. S. aureus was identified as the most prevalent pathogen in diabetes-related foot pathologies (25 % of all samples). For patients where disease progressed from DFU to DFI-OM, S. aureus was isolated as a diversity of colony types, with increasing numbers of SCVs present. Intracellular (bone) SCVs were found, and even within uninfected bone SCVs were present. Wounds of 24 % of patients with uninfected DFU contained active S. aureus. All patients with a DFI with a wound but not bone infection had previously had S. aureus isolated from an infection (including amputation), representing a relapse.Conclusion. The presence of S. aureus SCVs in recalcitrant pathologies highlights their importance in persistent infections through the colonization of reservoirs, such as bone. The survival of these cells in intracellular bone is an important clinical finding supporting in vitro data. Also, there seems to be a link between the genetics of S. aureus found in deeper infections compared to those only found in DFU.
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Affiliation(s)
- James Lee
- Department of Molecular and Biomedical Sciences, School of Biological Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Research Centre for Infectious Disease (RCID), University of Adelaide, Adelaide, South Australia, Australia
- Australian Centre for Antimicrobial Resistance Ecology (ACARE), University of Adelaide, Adelaide, South Australia, Australia
| | - Matipaishe Mashayamombe
- Department of Vascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Tom P Walsh
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology (QUT), Kelvin Grove, Queensland 4059, Australia
| | - Beatrice K P Kuang
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology (QUT), Kelvin Grove, Queensland 4059, Australia
- Discipline of Surgery, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Guilherme N Pena
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology (QUT), Kelvin Grove, Queensland 4059, Australia
- Discipline of Surgery, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Sarah Vreugde
- Basil Hetzel Institute for Translational Health Research, Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Clare Cooksley
- Basil Hetzel Institute for Translational Health Research, Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Miguel Carda-Diéguez
- Department of Health and Genomics, Center for Advanced Research in Public Health, FISABIO Institute, Valencia, Province of Valencia, Spain
| | - Alex Mira
- Department of Health and Genomics, Center for Advanced Research in Public Health, FISABIO Institute, Valencia, Province of Valencia, Spain
| | - David Jesudason
- Endocrinology Unit, Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Robert Fitridge
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology (QUT), Kelvin Grove, Queensland 4059, Australia
- Discipline of Surgery, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Peter S Zilm
- Adelaide Dental School, University of Adelaide, Adelaide, South Australia, Australia
| | - Joseph Dawson
- School of Clinical Sciences, Faculty of Health, Queensland University of Technology (QUT), Kelvin Grove, Queensland 4059, Australia
- Discipline of Surgery, Adelaide Medical School, University of Adelaide, Adelaide, South Australia, Australia
| | - Stephen P Kidd
- Department of Molecular and Biomedical Sciences, School of Biological Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Research Centre for Infectious Disease (RCID), University of Adelaide, Adelaide, South Australia, Australia
- Australian Centre for Antimicrobial Resistance Ecology (ACARE), University of Adelaide, Adelaide, South Australia, Australia
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17
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Phan S, Feng CH, Huang R, Lee ZX, Moua Y, Phung OJ, Lenhard JR. Relative Abundance and Detection of Pseudomonas aeruginosa from Chronic Wound Infections Globally. Microorganisms 2023; 11:1210. [PMID: 37317184 DOI: 10.3390/microorganisms11051210] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 04/27/2023] [Accepted: 04/29/2023] [Indexed: 06/16/2023] Open
Abstract
Pseudomonas aeruginosa is a difficult-to-treat pathogen that is frequently involved with chronic wound infections. Here, we conducted a literature search of world-wide studies published between 2005 and 2022 that described the microbiological profiles of chronic wound infections. For each continent, a hierarchy of pathogens was created to define the organisms that were most frequently isolated in each region. Except for South America, P. aeruginosa was the second most common organism in each major continent, with Staphylococcus aureus being the most abundant pathogen overall. When individual countries were evaluated, P. aeruginosa was the most frequently isolated organism in several Southeast Asia nations including India and Malaysia. P. aeruginosa was less commonly isolated from diabetic foot infections in North America, Europe, and Africa in comparison to other types of chronic wound infections. Additionally, the Levine wound swab technique may be a quick and painless way to isolate P. aeruginosa from wound infections, but the isolation of P. aeruginosa does not seem to be an informative predictor of the patient's clinical course. A multivariate risk assessment that accounts for the regional frequency of P. aeruginosa isolation may be an appropriate way to guide empiric management of chronic wound infections.
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Affiliation(s)
- Sang Phan
- College of Pharmacy, California Northstate University, Elk Grove, CA 95757, USA
| | - Cafrey He Feng
- College of Pharmacy, California Northstate University, Elk Grove, CA 95757, USA
| | - Raymond Huang
- College of Pharmacy, California Northstate University, Elk Grove, CA 95757, USA
| | - Zeng X Lee
- College of Pharmacy, California Northstate University, Elk Grove, CA 95757, USA
| | - Yer Moua
- College of Pharmacy, California Northstate University, Elk Grove, CA 95757, USA
| | - Olivia J Phung
- College of Pharmacy, California Northstate University, Elk Grove, CA 95757, USA
| | - Justin R Lenhard
- College of Pharmacy, California Northstate University, Elk Grove, CA 95757, USA
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18
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Haghverdian JC, Noori N, Hsu AR. Clinical Pathway for the Management of Diabetic Foot Infections in the Emergency Department. FOOT & ANKLE ORTHOPAEDICS 2023; 8:24730114221148166. [PMID: 36644108 PMCID: PMC9834778 DOI: 10.1177/24730114221148166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
| | - Naudereh Noori
- Department of Orthopaedic Surgery,
University of California-Irvine, Orange, CA, USA
| | - Andrew R. Hsu
- Department of Orthopaedic Surgery,
University of California-Irvine, Orange, CA, USA
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19
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Fu T, Stupnitskaia P, Matoori S. Next-Generation Diagnostic Wound Dressings for Diabetic Wounds. ACS MEASUREMENT SCIENCE AU 2022; 2:377-384. [PMID: 36785663 PMCID: PMC9885997 DOI: 10.1021/acsmeasuresciau.2c00023] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Chronic lower extremity wounds (diabetic foot ulcers) are a serious and prevalent complication of diabetes. These wounds exhibit low healing rates and present a high risk of amputation. Current diagnostic options for foot ulcers are limited to macroscopic wound analysis such as wound depth, implicated tissues, and infection. Molecular diagnostics promises to improve foot ulcer diagnosis, staging, and assessment of the treatment response. In this perspective, we report recent progress in understanding the pathophysiology of diabetic wound healing and point to recently emerged novel molecular targets for wound diagnostics. We discuss selected diagnostic wound dressings under preclinical development that detect one or several inflammatory markers, bacterial secretions, hyperglycemia, and mechanical stress. We also highlight key translational challenges of investigational diagnostic bandages for diabetic foot ulcers.
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20
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Voon K, Vo UG, Hand R, Hiew J, Ritter JC, Hamilton EJ, Manning L. Routine bacterial culture of proximal bone specimens during minor amputation in patients with diabetes-related foot infections has little clinical utility in predicting re-operation or ulcer healing. J Foot Ankle Res 2022; 15:64. [PMID: 35987828 PMCID: PMC9392904 DOI: 10.1186/s13047-022-00563-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 07/31/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Trans-phalangeal and trans-metatarsal amputation, collectively termed 'minor amputations' are important procedures for managing infections of diabetes-related foot ulcers (DFU). Following minor amputation, international guidelines recommend a prolonged course of antibiotics if residual infected bone on intra-operative bone samples are identified, but the quality of the evidence underpinning these guidelines is low. In this study, we examined the concordance of microbiological results from proximal bone cultures compared to results from superficial wound swabs in relation to patient outcomes; with the aim of determining the utility of routinely obtaining marginal bone specimens. METHODS Data was retrospectively collected on 144 individuals who underwent minor amputations for infected DFU at a large Australian tertiary hospital. Concordance was identified for patients with both superficial wound swabs and intra-operative bone samples available. Patient outcomes were monitored up to 6 months post-amputation. The primary outcome was complete healing at 6 months; and secondary outcome measures included further surgery and death. Mann Whitney U testing was performed for bivariate analyses of continuous variables, Chi-Squared testing used for categorical variables and a logistic regression was performed with healing as the dependent variable. RESULTS A moderate-high degree of concordance was observed between microbiological samples, with 38/111 (35%) of patients having discordant wound swab and bone sample microbiology. Discordant results were not associated with adverse outcomes (67.2% with concordant results achieved complete healing compared with 68.6% patients with discordant results; P = 0.89). Revascularisation during admission (0.37 [0.13-0.96], P = 0.04) and amputation of the 5th ray (0.45 [0.21-0.94], P = 0.03) were independent risk factors for non-healing. CONCLUSION There was a moderate-high degree of concordance between superficial wound swab results and intra-operative bone sample microbiology in this patient cohort. Discordance was not associated with adverse outcomes. These results suggest there is little clinical utility in routinely collecting proximal bone as an adjunct to routine wound swabs for culture during minor amputation for an infected DFU.
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Affiliation(s)
- Kimberly Voon
- Multidisciplinary Diabetes Foot Ulcer Service, Fiona Stanley Hospital, Murdoch, Australia
- Department of Endocrinology, Fiona Stanley Hospital, Murdoch, Australia
| | - Uyen G Vo
- Multidisciplinary Diabetes Foot Ulcer Service, Fiona Stanley Hospital, Murdoch, Australia
- Department of Vascular Surgery, Fiona Stanley Hospital, Murdoch, Australia
| | - Robert Hand
- Multidisciplinary Diabetes Foot Ulcer Service, Fiona Stanley Hospital, Murdoch, Australia
- Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, Australia
| | - Jonathan Hiew
- Multidisciplinary Diabetes Foot Ulcer Service, Fiona Stanley Hospital, Murdoch, Australia
- Department of Podiatry, Fiona Stanley Hospital, Murdoch, Australia
| | - Jens Carsten Ritter
- Multidisciplinary Diabetes Foot Ulcer Service, Fiona Stanley Hospital, Murdoch, Australia
- Department of Vascular Surgery, Fiona Stanley Hospital, Murdoch, Australia
- School of Medicine, Curtin University, Bentley, Australia
| | - Emma J Hamilton
- Multidisciplinary Diabetes Foot Ulcer Service, Fiona Stanley Hospital, Murdoch, Australia
- Department of Endocrinology, Fiona Stanley Hospital, Murdoch, Australia
- Medical School, University of Western Australia, Harry Perkins Research Institute, Fiona Stanley Hospital, PO Box 404, Bull Creek, Western Australia, 6149, Australia
| | - Laurens Manning
- Multidisciplinary Diabetes Foot Ulcer Service, Fiona Stanley Hospital, Murdoch, Australia.
- Department of Infectious Diseases, Fiona Stanley Hospital, Murdoch, Australia.
- Medical School, University of Western Australia, Harry Perkins Research Institute, Fiona Stanley Hospital, PO Box 404, Bull Creek, Western Australia, 6149, Australia.
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21
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Baig MS, Banu A, Zehravi M, Rana R, Burle SS, Khan SL, Islam F, Siddiqui FA, Massoud EES, Rahman MH, Cavalu S. An Overview of Diabetic Foot Ulcers and Associated Problems with Special Emphasis on Treatments with Antimicrobials. LIFE (BASEL, SWITZERLAND) 2022; 12:life12071054. [PMID: 35888142 PMCID: PMC9316721 DOI: 10.3390/life12071054] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/07/2022] [Accepted: 07/12/2022] [Indexed: 12/14/2022]
Abstract
One of the most significant challenges of diabetes health care is diabetic foot ulcers (DFU). DFUs are more challenging to cure, and this is particularly true for people who already have a compromised immune system. Pathogenic bacteria and fungi are becoming more resistant to antibiotics, so they may be unable to fight microbial infections at the wound site with the antibiotics we have now. This article discusses the dressings, topical antibacterial treatment, medications and debridement techniques used for DFU and provides a deep discussion of DFU and its associated problems. English-language publications on DFU were gathered from many different databases, such as Scopus, Web of Science, Science Direct, Springer Nature, and Google Scholar. For the treatment of DFU, a multidisciplinary approach involving the use of diagnostic equipment, skills, and experience is required. Preventing amputations starts with patient education and the implementation of new categorization systems. The microbiota involved in DFU can be better understood using novel diagnostic techniques, such as the 16S-ribosomal DNA sequence in bacteria. This could be achieved by using new biological and molecular treatments that have been shown to help prevent infections, to control local inflammation, and to improve the healing process.
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Affiliation(s)
- Mirza Shahed Baig
- Department of Pharmaceutical Chemistry, Y. B. Chavan College of Pharmacy, Aurangabad 431001, India;
| | - Ahmadi Banu
- Department of Pharmacology, Vishnu Institute of Pharmaceutical Education & Research, Narsapur 502313, India;
| | - Mehrukh Zehravi
- Department of Clinical Pharmacy Girls Section, Prince Sattam Bin Abdul Aziz University, Alkharj 11942, Saudi Arabia;
| | - Ritesh Rana
- Department of Pharmaceutics, Adarsh Vijendra Institute of Pharmaceutical Sciences, Shobhit University, Gangoh, Saharanpur 247341, India;
| | - Sushil S. Burle
- Department of Pharmacology, Smt. Kishoritai Bhoyar College of Pharmacy, Kamptee, Nagpur 441002, India;
| | - Sharuk L. Khan
- Department of Pharmaceutical Chemistry, MUP’s College of Pharmacy (B Pharm), Degaon, Risod, Washim 444504, India;
- Correspondence: (S.L.K.); (M.H.R.); (S.C.)
| | - Fahadul Islam
- Department of Pharmacy, Faculty of Allied Health Sciences, Daffodil International University, Dhaka 1207, Bangladesh;
| | - Falak A. Siddiqui
- Department of Pharmaceutical Chemistry, MUP’s College of Pharmacy (B Pharm), Degaon, Risod, Washim 444504, India;
| | - Ehab El Sayed Massoud
- Biology Department, Faculty of Science and Arts in Dahran Aljnoub, King Khalid University, Abha 62529, Saudi Arabia;
- Research Center for Advanced Materials Science (RCAMS), King Khalid University, Abha 61413, Saudi Arabia
- Agriculture Research Centre, Soil, Water and Environment Research Institute, Giza 3725004, Egypt
| | - Md. Habibur Rahman
- Department of Global Medical Science, Wonju College of Medicine, Yonsei University, Wonju 26426, Korea
- Correspondence: (S.L.K.); (M.H.R.); (S.C.)
| | - Simona Cavalu
- Faculty of Medicine and Pharmacy, University of Oradea, Pta 1 Decembrie 10, 410087 Oradea, Romania
- Correspondence: (S.L.K.); (M.H.R.); (S.C.)
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22
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Esposito S, Pagliano P, De Simone G, Pan A, Brambilla P, Gattuso G, Mastroianni C, Kertusha B, Contini C, Massoli L, Francisci D, Priante G, Libanore M, Bicocchi R, Borgia G, Maraolo AE, Brugnaro P, Panese S, Calabresi A, Amendola G, Savalli F, Geraci C, Tedesco A, Fossati S, Carretta A, Santantonio T, Cenderello G, Crisalli MP, Schiaroli E, Rovere P, Masini G, Ferretto R, Cascio A, Colomba C, Gioè C, Tumbarello M, Losito AR, Foti G, Prestileo T, Buscemi C, Iaria C, Iacobello C, Sonia S, Starnini G, Ialungo A, Sapienza M. Epidemiology, aetiology and treatment of skin and soft tissue infections: final report of a prospective multicentre national registry. J Chemother 2022; 34:524-533. [DOI: 10.1080/1120009x.2022.2075170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Silvano Esposito
- Department of Infectious Diseases, University of Salerno, Salerno, Italy
| | - Pasquale Pagliano
- Department of Infectious Diseases, University of Salerno, Salerno, Italy
| | - Giuseppe De Simone
- Department of Infectious Diseases, University of Salerno, Salerno, Italy
| | - Angelo Pan
- Department of Infectious Diseases, Istituti Ospitalieri of Cremona, Cremona, Italy
| | - Paola Brambilla
- Department of Infectious Diseases, Istituti Ospitalieri of Cremona, Cremona, Italy
| | - Gianni Gattuso
- Department of Infectious Diseases, Carlo Poma Hospital, Mantova, Italy
| | - Claudio Mastroianni
- Department of Public Health and Infectious Diseases, Sapienza University, Latina, Italy
| | - Blertha Kertusha
- Department of Public Health and Infectious Diseases, Sapienza University, Latina, Italy
| | - Carlo Contini
- Department of Medical Sciences, Section of Infectious Diseases and Dermatology, University of Ferrara, Ferrara, Italy
| | - Lorenzo Massoli
- Department of Medical Sciences, Section of Infectious Diseases and Dermatology, University of Ferrara, Ferrara, Italy
| | - Daniela Francisci
- Infectious Diseases Clinic, University Hospital “S. Maria”, University of Perugia, Perugia, Italy
| | - Giulia Priante
- Infectious Diseases Clinic, University Hospital “S. Maria”, University of Perugia, Perugia, Italy
| | - Marco Libanore
- Infectious Diseases Unit, Department of Infectious Diseases, S. Anna University Hospital, Ferrara, Italy
| | - Roberto Bicocchi
- Infectious Diseases Unit, Department of Infectious Diseases, S. Anna University Hospital, Ferrara, Italy
| | - Guglielmo Borgia
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Albert Enrico Maraolo
- Department of Clinical Medicine and Surgery, Section of Infectious Diseases, University of Naples Federico II, Naples, Italy
| | - Pierluigi Brugnaro
- Infectious Diseases Department, Ospedale Civile “SS. Giovanni e Paolo”, Venice, Italy
| | - Sandro Panese
- Infectious Diseases Department, Ospedale Civile “SS. Giovanni e Paolo”, Venice, Italy
| | - Alessandra Calabresi
- Emergency Department, Hospital “Santi Antonio e Biagio e C. Arrigo”, Alessandria, Italy
| | - Giovanni Amendola
- Emergency Department, Hospital “Santi Antonio e Biagio e C. Arrigo”, Alessandria, Italy
| | | | - Consuelo Geraci
- Infectious Diseases Unit, Hospital of Trapani, Trapani, Italy
| | - Andrea Tedesco
- Infectious Diseases Unit, Hospital Fracastoro San Bonifacio, Verona, Italy
| | - Sara Fossati
- Infectious Diseases Unit, University Hospital of Trieste, Trieste, Italy
| | - Anna Carretta
- Department of Infectious Diseases, University Hospital “Ospedali Riuniti” of Foggia, Foggia, Italy
| | - Teresa Santantonio
- Department of Infectious Diseases, University Hospital “Ospedali Riuniti” of Foggia, Foggia, Italy
| | | | | | - Elisabetta Schiaroli
- Department of Medicine, Section of Infectious Diseases, University of Perugia, Perugia, Italy
| | | | - Giulia Masini
- Infectious Diseases Unit, Legnago Hospital, Verona, Italy
| | - Roberto Ferretto
- Infectious Diseases Unit, “Alto Vicentino” Santorso Hospital, Vicenza, Italy
| | - Antonio Cascio
- Infectious Diseases Unit, Universita degli Studi di Palermo, Palermo, Italy
| | - Claudia Colomba
- Infectious Diseases Unit, Universita degli Studi di Palermo, Palermo, Italy
| | - Claudia Gioè
- Infectious Diseases Unit, Universita degli Studi di Palermo, Palermo, Italy
| | - Mario Tumbarello
- Institute of Infectious Diseases, Foundation Policlinico Universitario A. Gemelli IRCCS, Cattolica del Sacro Cuore University, Rome, Italy
| | - Angela Raffaella Losito
- Institute of Infectious Diseases, Foundation Policlinico Universitario A. Gemelli IRCCS, Cattolica del Sacro Cuore University, Rome, Italy
| | - Giuseppe Foti
- Infetious Diseases Unit, “Bianchi-Melacrino-Morelli” Hospital, Reggio Calabria, Italy
| | | | | | - Chiara Iaria
- Infectious Diseases Unit, Arnas Civico Hospital, Palermo, Italy
| | | | - Sofia Sonia
- Infectious Diseases Unit, Cannizzaro Hospital, Catania, Italy
| | | | - Anna Ialungo
- Infectious Diseases Unit, Belcolle Hospital, Viterbo, Italy
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Diabetic foot ulcer, antimicrobial remedies and emerging strategies for the treatment. Int J Health Sci (Qassim) 2022. [DOI: 10.53730/ijhs.v6ns3.6199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
According to the International Diabetes Federation's 2015 study, diabetes affects over 415 million people globally (5 million of whom die each year), and the incidence of diabetes is expected to climb to over 640 million (1 in 10) by 2040. (IDF 2015). Diabetes foot ulcers (DFU) are one of the most significant diabetic health consequences. Antimicrobial treatments, such as dressings, topical therapies, medicines, drugs, debridement procedures, molecular, cellular, and gene therapies, plant extracts, antimicrobial peptides, growth factors, devices, ozone, and energy-based therapies, would be the focus of this study. Scopus, Web of Science, Bentham Science, Science Direct, and Google Scholar were among the sources used to compile the English-language publications on DFU. DFU treatment requires a multidisciplinary approach that includes the use of proper diagnostic tools, competence, and experience. To prevent amputations, this starts with patient education and the use of new categories to steer treatment. New diagnostic methods, such as the 16S ribosomal DNA sequence in bacteria, should become available to acquire a better knowledge of the microbiota in DFUs.
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Keren E, Borer A, Shafat T, Nesher L, Faingelernt Y, Sagi O, Shimoni O, Saidel-Odes L. Multifaceted Strategy Improves Outcomes of Patients Hospitalized with a Diabetic Foot Infection. INT J LOW EXTR WOUND 2022:15347346221093463. [PMID: 35404153 DOI: 10.1177/15347346221093463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Diabetic foot infections (DFIs) are associated with major morbidity, reduced quality of life and increased mortality. Osteomyelitis is a leading cause of lower-extremity amputation in diabetic patients. We aimed to examine whether a multifaceted strategy for treating hospitalized patients with a DFI effectively influenced microbiological culture results and outcomes. A retrospective cohort-study in a 1100-bed, tertiary-care university hospital was conducted. Adult patients with a DFI admitted to the orthopedics department between 2015 and 2019 were included. During the pre-intervention period (2015-2016), one general orthopedic department was in operation. In the post-intervention period (2017-2019), a second department was created with a designated "complicated wound unit". The multifaceted strategy included revising local guidelines for DFI culturing emphasizing bone cultures, correct sample handling, and adjusting antibiotic treatment to culture results. Additionally, a weekly multidisciplinary-team grand round was instigated and post-discharge outpatient follow-up was scheduled. 652 patients with DFIs were included; 101 during the pre-intervention period and 551 during the post-intervention period. Compared to the pre-intervention, during the post-intervention period mainly bone or deep-tissue cultures were performed (9.7% vs. 98.2%, P < 0.001). Bacteriology cultures in the pre-intervention versus post-intervention period revealed: among staphylococcus isolates, fewer methicillin-resistant Staphylococcus aureus detected (20.4% vs. 9.8%, P = 0.010); within Enterobacteriaceae isolates, fewer extended-spectrum β-lactamase producing bacteria detected (51.6% vs. 23.6%, P < 0.001); a decrease in Pseudomonas aeruginosa isolates (28% vs. 10.6%, P < 0.001) and an increase in anaerobic bacterial isolates (0 vs. 11.1%, P < 0.001). On multivariate regression, the post-intervention period (ie multifaceted strategy) was a protective measure against readmissions (P = 0.007 OR 0.50 95% CI 0.30-0.82). We conclude that our interventive multifaceted strategy led to accurate bacterial diagnosis, de-escalation of antibiotic treatment and readmission reduction.
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Affiliation(s)
- Elad Keren
- Orthopedic Department, 26746Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Abraham Borer
- Infection Control and Hospital Epidemiology Unit, 26746Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Infectious Diseases Unit, 26746Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Tali Shafat
- Infectious Diseases Unit, 26746Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Lior Nesher
- Infectious Diseases Unit, 26746Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yaniv Faingelernt
- The Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Orli Sagi
- Clinical Microbiology Laboratory, 26746Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Orly Shimoni
- Hospital Pharmacy, 26746Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Lisa Saidel-Odes
- Infection Control and Hospital Epidemiology Unit, 26746Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Infectious Diseases Unit, 26746Soroka University Medical Center and the Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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25
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Assessment of the Relationship between Clinical Manifestation and Pathogenic Potential of Streptococcus pyogenes Strains-Distribution of Genes and Genotypes of Toxins. Biomedicines 2022; 10:biomedicines10040799. [PMID: 35453547 PMCID: PMC9029580 DOI: 10.3390/biomedicines10040799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/20/2022] [Accepted: 03/25/2022] [Indexed: 02/04/2023] Open
Abstract
Streptococcus pyogenes is one of the most important species among beta-haemolytic streptococci, causing human infections of different localization. It is isolated from clinical specimens relatively frequently. In this study, the frequency and co-occurrence of toxin genes (speA, speB, speC, speH, speJ, speK) among 147 S. pyogenes strains were evaluated, using real-time PCR. In addition, the relationship between the occurrence of these genes and the origin of S. pyogenes strains from selected clinical material was assessed. The speB gene was present with the highest incidence (98.6%), while the speK gene was the least frequent (8.2%) among the tested strains. Based on the presence of the detected genes, the distribution of 17 genotypes was determined. The most common (21.8%), was speA (−) speB (+) speC (−) speH (−) speJ (−) speK (−) genotype. Furthermore, significant variation in the presence of some genes and genotypes of toxins in S. pyogenes strains isolated from different types of clinical material was found. There is a considerable variety and disproportion between the frequency of individual genes and genotypes of toxins in S. pyogenes strains. The relationship between the origin of S. pyogenes isolates and the presence of toxins genes indicates their pathogenic potential in the development of infections of selected localization.
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26
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Xie X, Zhong R, Luo L, Lin X, Huang L, Huang S, Ni L, Chen B, Shen R, Yan L, Duan C. The infection characteristics and autophagy defect of dermal macrophages in STZ-induced diabetic rats skin wound Staphylococcus aureus infection model. IMMUNITY INFLAMMATION AND DISEASE 2021; 9:1428-1438. [PMID: 34647429 PMCID: PMC8589369 DOI: 10.1002/iid3.492] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/18/2021] [Revised: 06/30/2021] [Accepted: 07/05/2021] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Diabetic foot ulcer infection (DFI) is an infectious disease of the skin and soft tissue in diabetics notorious for making rapid progress and being hard to cure. Staphylococcus aureus (S. aureus), most frequently detected in DFI, recently was suggested as an intracellular pathogen that can invade and survive within mammalian host cells. Autophagy in macrophages plays a vital immune role in combating intracellular pathogens through bacterial destruction, but there is a lack of empirical research about the infection characteristics and autophagy in diabetic skin infection. METHODS Here, we used streptozotocin-induced Sprague Dawley rats as a diabetic skin wound model to examine the S. aureus clearance ability and wound healing in vitro. Western blot and immunofluorescence staining were used to evaluate the autophagic flux of the macrophages in diabetic rats dermis, even with S. aureus infection. RESULTS We demonstrated that infections in diabetic rats appeared more severe and more invasive with weakened pathogen clearance ability of the host immune system, which coincided with the suppressed autophagic flux in dermal macrophages, featured by a significant increase in endogenous LC3II/I and in p62. CONCLUSIONS Our results first provided convincing evidence that autophagy of macrophages was dysfunctional in diabetes, especially after being infected by S. aureus, which weakens the intracellular killing of S. aureus, potentially worsens the infections, and accelerates the infection spread in the diabetic rat model. Further understanding of the special immune crosstalk between diabetes host and S. aureus infection through autophagic factors will help to explain the complex clinical phenomenon and guarantee the development of effective therapies for diabetic foot infections.
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Affiliation(s)
- Xiaoying Xie
- Department of Clinical Laboratory, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Rihui Zhong
- Department of Clinical Laboratory, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Ling Luo
- Department of Clinical Laboratory, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Xianghua Lin
- Department of Clinical Laboratory, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Lisi Huang
- Department of Clinical Laboratory, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Songyin Huang
- Department of Clinical Laboratory, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Lijia Ni
- Department of Clinical Laboratory, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Baiji Chen
- Department of Clinical Laboratory, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Rui Shen
- Department of Clinical Laboratory, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Li Yan
- Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China.,Department of Endocrinology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
| | - Chaohui Duan
- Department of Clinical Laboratory, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China.,Guangdong Provincial Key Laboratory of Malignant Tumor Epigenetics and Gene Regulation, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, Guangdong, China
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27
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Jonker L, Smith D, Mark E, Schutter J, Thornthwaite S, Johnston S. Point-of-care testing for bacterial infection in diabetic foot ulcers: a prospective cohort study. J Wound Care 2021; 29:649-657. [PMID: 33175624 DOI: 10.12968/jowc.2020.29.11.649] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To appraise the performance of a new point-of-care wound infection detection kit in diabetic foot ulcers (DFUs), using clinician opinion as the primary comparator. The proprietary swab-based chromatic Glycologic (Glycologic Ltd., UK) detection kit used in this study is designed to detect host response to pathogenic levels of bacteria in wounds. METHOD In high-risk podiatry clinics, patients with DFUs were recruited and infection detection kit test results compared with initial clinician opinion. Chi-squared tests, principal component analysis (PCA) and multiple regression analysis were performed to determine which variables were possibly associated with infection. The variables considered were patients' wound parameters, wider vascular comorbidity and demographics. RESULTS A total of 136 patients, providing 383 wound swabs, were included in the study. Total agreement in terms of DFU wound assessment for infection-between podiatrists' clinical opinion and Glycologic kit test result-was observed in 79% of cases (301/383). For 56 of the 349 negative infection detection kit test results (16%), podiatrists identified a 'possible' or 'definite' infection. Conversely, in 14 of the 307 cases (4.6%) where podiatrists deemed the wound 'not infected', the infection detection kit test showed a colour change. Regression analysis and PCA showed that clinical signs of wound infection, namely erythema, purulence and odour, were all significantly associated with both a positive clinical opinion and infection detection kit test result. However, in the case of the infection detection kit, a patient's number of lesions and vascular comorbidities were also significantly correlated with a positive test result. CONCLUSION A host response to critical pathological levels of bioburden in a wound-as detected with the infection detection kit-may partly be determined by an individual patient's (vascular) health and therefore be person-specific. Further research is indicated to determine the relationship between an infection detection kit test result and the microbiological status of the wound.
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Affiliation(s)
- Leon Jonker
- North Cumbria Integrated Care NHS Foundation Trust, Carlisle
| | - Danielle Smith
- North Cumbria Integrated Care NHS Foundation Trust, Carlisle
| | - Emma Mark
- North Cumbria Integrated Care NHS Foundation Trust, Carlisle
| | - Jose Schutter
- North Cumbria Integrated Care NHS Foundation Trust, Carlisle
| | | | - Shona Johnston
- North Cumbria Integrated Care NHS Foundation Trust, Carlisle
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28
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Sousa R, Carvalho A, Santos AC, Abreu MA. Optimal microbiological sampling for the diagnosis of osteoarticular infection. EFORT Open Rev 2021; 6:390-398. [PMID: 34267930 PMCID: PMC8246105 DOI: 10.1302/2058-5241.6.210011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Infection is a dire complication afflicting every field of orthopaedics and traumatology. If specific clinical, laboratory and imaging parameters are present, infection is often assumed even in the absence of microbiological confirmation. However, apart from confirming infection, knowing the exact infecting pathogen(s) and their antimicrobial susceptibility patterns is paramount to help guide treatment. Every effort should therefore be undertaken with that goal in mind.Not all microbiological findings carry the same relevance, and knowing exactly how and where a sample was collected is key. Several different sampling techniques are available, and one must be aware of both advantages and limitations. Microbiological sampling alternatives in some of the most common clinical scenarios such as native and prosthetic joint infections, osteomyelitis and fracture-related infections, spinal and diabetic foot infections will be discussed.Orthopaedic surgeons should also be aware of basic laboratory sample processing techniques as they have a direct impact on the way specimens should be dealt with and transported to the laboratory. Only by knowing these basic principles will surgeons be able to participate in the multidisciplinary discussion and decision making around how to interpret microbiological findings in each specific patient. Cite this article: EFORT Open Rev 2021;6:390-398. DOI: 10.1302/2058-5241.6.210011.
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Affiliation(s)
- Ricardo Sousa
- Department of Orthopaedics, Centro Hospitalar Universitário do Porto, Porto, Portugal.,Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário do Porto and Grupo TrofaSaude, Portugal
| | - André Carvalho
- Department of Orthopaedics, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Ana Cláudia Santos
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário do Porto and Grupo TrofaSaude, Portugal.,Department of Microbiology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Miguel Araújo Abreu
- Porto Bone and Joint Infection Group (GRIP), Centro Hospitalar Universitário do Porto and Grupo TrofaSaude, Portugal.,Department of Microbiology, Centro Hospitalar Universitário do Porto, Porto, Portugal
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29
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Bekeny JC, Kennedy C, Turissini JD, Naz I, Walters ET, Kim PJ, Evans KK, Steinberg J, Elmarsafi T, Attinger CE. Utility of Porcine-Derived Xenograft as an Adjunct to Split-Thickness Skin Grafting in Lower-Extremity Wounds. J Am Podiatr Med Assoc 2021; 111:466719. [PMID: 34144594 DOI: 10.7547/20-058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Porcine-derived xenograft biological dressings (PXBDs) are occasionally used to prepare chronic wound beds for definitive closure before split-thickness skin grafts (STSGs). We sought to determine whether PXBD influences rate of STSG take in lower-extremity wounds. METHODS Lower-extremity wounds treated with STSGs were retrospectively reviewed. Patients were included in one of two groups: wound bed preparation with PXBD before STSG or no preparation. Patients were excluded if they received wound bed preparation via another method. Patient demographics, comorbidities, wound history, wound bed preparation, and 30- and 60-day outcomes were collected. RESULTS There was no difference in healing outcomes between the PXBD (n = 27) and no preparation (n = 39) groups. At 30- and 60-day follow-up, percentage of STSG take was not significantly different between groups (77.9% versus 79.0%, P30 = .818; 82.2% versus 80.9%, P60 = .422). Mean wound sizes at these follow-up periods were not different (4.4 cm2 versus 5.1 cm2, P30 = .902; 1.2 cm2 versus 1.1 cm2, P60 = .689). The PXBD group had a higher mean ± SD hemoglobin A1c level (8.3 ± 3.5 versus 6.9 ± 1.6; P = .074) and age (64.9 ± 12.8 years versus 56.3 ± 11.9 years; P = .007) versus the no preparation group. CONCLUSIONS Application of PXBDs for wound bed preparation had no effect on wound healing compared with no wound bed preparation. The two groups varied only by mean age and hemoglobin A1c level. The PXBD may be beneficial, but these results call for randomized controlled trials to determine the true impact of PXBDs on wound healing. In addition, PXBDs may have utility outside of clinically oriented outcomes, and future work should address patient-reported outcomes and pain scores with this adjunct.
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30
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Ahluwalia R, Reichert I. Surgical management of the acute severely infected diabetic foot - The 'infected diabetic foot attack'. An instructional review. J Clin Orthop Trauma 2021; 18:114-120. [PMID: 33996456 PMCID: PMC8102754 DOI: 10.1016/j.jcot.2021.04.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 04/05/2021] [Accepted: 04/06/2021] [Indexed: 01/13/2023] Open
Abstract
Diabetic Foot Infection (DFI), in its severest form the acute infected 'diabetic foot attack', is a limb and life threatening condition if untreated. Acute infection may lead to tissue necrosis and rapid spread through tissue planes, in the patient with poorly controlled diabetes facilitated by the host status. A combination of soft tissue infection and osteomyelitis may co-exist, in particular if chronic osteomyelitis serves as a persistent source for recurrence of soft tissue infection. This "diabetic foot attack" is characterised by acutely spreading infection and substantial soft tissue necrosis. In the presence of ulceration, the condition is classified by the Infectious Diseases Society of America/International Working Group on the Diabetic Foot (IDSA/IWGDF Class 3 or 4) presentation requiring an urgent surgical intervention by radical debridement of the infection. Thus, 'time is tissue', referring to tissue salvage and maximal limb preservation. Emergent treatment is important for limb salvage and may be life-saving. We provide a narrative current treatment practices in managing severe DFI with severe soft tissue and osseous infection. We address the role of surgery and its adjuvants, the long term outcomes, potential complications and possible future treatment strategies.
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Affiliation(s)
- R.S. Ahluwalia
- Corresponding author. King’s College Hospital NHS Trust, Bessemer Road, London, SE5 9RS, United Kingdom.
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Macauley M, Adams G, Mackenny P, Kubelka I, Scott E, Buckworth R, Biddiscombe C, Aitkins C, Lake H, Matthews V, Ashraff S, Ashwell S. Microbiological evaluation of resection margins of the infected diabetic foot ulcer. Diabet Med 2021; 38:e14440. [PMID: 33113230 DOI: 10.1111/dme.14440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 11/23/2020] [Indexed: 01/22/2023]
Abstract
AIM To evaluate the impact of surgical debridement on the microbiology of resection margins of an infected diabetic foot ulcer and to compare the use of marginal sampling as a guide for antimicrobial therapy. METHODS Forty consecutive participants were studied. Tissue samples from infected diabetic foot ulcers were obtained at first contact by podiatrists. After surgical debridement to macroscopically healthy tissue, multiple samples were obtained from the margins of the residuum and also from excised non-viable tissue. Debridement was done by a single surgeon. Bacterial species were classified according to pathogenic potential a priori into Red Group-Definite pathogen causing infection, Yellow Group-Likely to be causing infection if present in more than one specimen and Green Group -Commensals, not causing infection. RESULTS There was a relative reduction of 49% (p = 0.002) in bacteria in the most pathogenic (red) group, and 59% (p = 0.002) in the yellow group in podiatry samples compared with resection specimen. Positive cultures from margins of the residuum were observed in 75% of cases. There was a relative reduction of 67% (p = 0.0001) in bacteria in the red and 48% (p = 0.06) in the yellow group in marginal samples from the residuum compared with podiatry samples. CONCLUSIONS After surgical debridement to healthy tissue, positive cultures from marginal tissue samples provided vital information on the presence of pathogenic bacteria. This allowed antibiotics to be individualised post-surgical debridement.
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Affiliation(s)
- Mavin Macauley
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
| | - George Adams
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
| | - Paul Mackenny
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
- Orthopaedic Department Hartlepool, North Tees and Hartlepool NHS Foundation Trust, Hartlepool, UK
| | - Igor Kubelka
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
| | - Emma Scott
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
| | - Rebecca Buckworth
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
| | - Claire Biddiscombe
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
| | - Christopher Aitkins
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
| | - Hannah Lake
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
| | - Vicky Matthews
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
| | - Suhel Ashraff
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
| | - Simon Ashwell
- Diabetes and Endocrinology, South Tees Hospitals NHS Trust, Middlesbrough, Teesside, UK
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Malone M, Erasmus A, Schwarzer S, Lau NS, Ahmad M, Dickson HG. Utilisation of the 2019 IWGDF diabetic foot infection guidelines to benchmark practice and improve the delivery of care in persons with diabetic foot infections. J Foot Ankle Res 2021; 14:10. [PMID: 33509233 PMCID: PMC7842064 DOI: 10.1186/s13047-021-00448-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/07/2021] [Indexed: 12/15/2022] Open
Abstract
Aims To utilise the 2019 International Working Group on the Diabetic Foot (IWGDF) - diabetic foot infection (DFI) guidelines as an audit tool for clinical practice in patients with diabetes attending a High-Risk Foot Service. Methods Data from 93 consecutive patients were collected over a 19-month period in patients attending a High-Risk Foot Service. The diagnosis and management of each patient in the sample were compared against the 2019 IWGDF DFI guidelines, grouped into four categories: Diagnosis, Microbiology, Treatment of soft tissue infection, and Surgical treatment and osteomyelitis. Deficits in performance were recorded using the recommendations as a benchmark standard. Results There were 109 DFI events. Nineteen (63%) of the recommendations were met, 7 (24%) were partially met, and four (13%) recommendations were not met. Fourteen of the sample had no documented requests for full blood counts. Tissue was obtained for culture in 32 (29%) of the sample. No percutaneous bone biopsies were performed. Only 13 (28%) patients had intraoperative bone specimens sent for culture and sensitivities, with no bone specimens sent for histopathology. Modification of antibiotic therapy following available culture results was low, occurring in 12 out of 63 possible occasions (19%). The duration of antibiotic regimens in PEDIS 2 infections and osteomyelitis was greater than that recommended. Conclusions Utilising the IWGDF DFI guidelines to benchmark clinical practice is a useful tool to identify gaps in clinical performance or service delivery and may help to improve patient care. Supplementary Information The online version contains supplementary material available at 10.1186/s13047-021-00448-w.
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Affiliation(s)
- Matthew Malone
- High Risk Foot Service, Liverpool Hospital, South Western Sydney LHD, Liverpool, Sydney, NSW, 2170, Australia. .,South West Sydney Limb Preservation and Wound Research Academic Unit, South Western Sydney LHD, Liverpool, Sydney, NSW, 2170, Australia. .,Ingham Institute of Applied Medical Research, 1 Campbell Street, Liverpool, NSW, 2170, Australia.
| | - Adriaan Erasmus
- High Risk Foot Service, Liverpool Hospital, South Western Sydney LHD, Liverpool, Sydney, NSW, 2170, Australia.,South West Sydney Limb Preservation and Wound Research Academic Unit, South Western Sydney LHD, Liverpool, Sydney, NSW, 2170, Australia
| | - Saskia Schwarzer
- High Risk Foot Service, Liverpool Hospital, South Western Sydney LHD, Liverpool, Sydney, NSW, 2170, Australia.,South West Sydney Limb Preservation and Wound Research Academic Unit, South Western Sydney LHD, Liverpool, Sydney, NSW, 2170, Australia
| | - Namson S Lau
- High Risk Foot Service, Liverpool Hospital, South Western Sydney LHD, Liverpool, Sydney, NSW, 2170, Australia.,South West Clinical School, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Mehtab Ahmad
- Department of Vascular Surgery, Liverpool Hospital, South Western Sydney LHD, Liverpool, Sydney, Australia
| | - Hugh G Dickson
- High Risk Foot Service, Liverpool Hospital, South Western Sydney LHD, Liverpool, Sydney, NSW, 2170, Australia.,South West Sydney Limb Preservation and Wound Research Academic Unit, South Western Sydney LHD, Liverpool, Sydney, NSW, 2170, Australia
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Li X, Cheng Q, Du Z, Zhu S, Cheng C. Microbiological Concordance in the Management of Diabetic Foot Ulcer Infections with Osteomyelitis, on the Basis of Cultures of Different Specimens at a Diabetic Foot Center in China. Diabetes Metab Syndr Obes 2021; 14:1493-1503. [PMID: 33854348 PMCID: PMC8040074 DOI: 10.2147/dmso.s296484] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 03/11/2021] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE This study aimed to assess the microbiological concordance between swab and soft tissue cultures, and corresponding bone specimen cultures from patients with diabetic foot osteomyelitis (DFO). We aimed to analyze the bone specimens' antimicrobial susceptibilities, and to improve clinical management of diabetic foot ulcer infections by using proper antibiotics. METHODS The microbial culture results of ulcer swabs, and soft tissue and bone tissue specimens, and the antimicrobial susceptibility tests of bone specimens from patients with DFO were analyzed in a single diabetic foot center. RESULTS A total of 60 patients with results from three specimens were included. Staphylococcus aureus was the most common bacterium isolated from the three specimens. The microbiological results for the three specimens were identical in 12 cases, the culture results from swabs and bone tissue specimens were identical in 14 cases, and the results from soft tissue and bone tissue were identical in 46 cases. The concordance of the results of pathogens isolated between soft tissue and bone specimen cultures was higher than that between the swab and bone cultures. Gram-positive bacteria were more sensitive to moxifloxacin, linezolid, and vancomycin, while Gram-negative bacteria were more sensitive to piperacillin/tazobactam, cefoperazone/sulbactam, and carbapenems. CONCLUSION Soft tissue culture results have more reliable microbiological concordance to identify DFO bacteria than swab culture results and targeted antibiotic therapy for DFO should be based on antimicrobial susceptibility testing in bone tissue specimen cultures.
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Affiliation(s)
- Xuemei Li
- Department of Pharmacy, Chongqing Health Center for Women and Children, Chongqing, People’s Republic of China
- Department of Pharmacy, First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Qingfeng Cheng
- Department of Endocrinology, First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Zhipeng Du
- Department of Endocrinology, First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Shenyin Zhu
- Department of Pharmacy, First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
- Shenyin Zhu Department of Pharmacy, First Affiliated Hospital of Chongqing Medical University, No. 1, Yixueyuan Road, Yuzhong District, Chongqing, 400016, People’s Republic of China Tel +86 23 8901 2401 Fax +86 23 68811793 Email
| | - Chao Cheng
- Department of Critical Care Medicine, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, Hubei, People’s Republic of China
- Correspondence: Chao Cheng Department of Critical Care Medicine, Xiangyang Central Hospital, Affiliated Hospital of Hubei University of Arts and Science, No. 136, Jingzhou Street, Xiangcheng District, Hubei, 441021, People’s Republic of ChinaTel +86 23 8901 2401Fax +86 23 68811793 Email
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Vainieri E, Ahluwalia R, Slim H, Walton D, Manu C, Taori S, Wilkins J, Huang DY, Edmonds M, Rashid H, Kavarthapu V, Vas PRJ. Outcomes after Emergency Admission with a Diabetic Foot Attack Indicate a High Rate of Healing and Limb Salvage But Increased Mortality: 18-Month Follow-up Study. Exp Clin Endocrinol Diabetes 2020; 130:165-171. [PMID: 33352595 DOI: 10.1055/a-1322-4811] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
AIM The diabetic foot attack (DFA) is perhaps the most devastating form of diabetic foot infection, presenting with rapidly progressive skin and tissue necrosis, threatening both limb and life. However, clinical outcome data in this specific group of patients are not available. METHODS Analysis of 106 consecutive patients who underwent emergency hospitalisation for DFA (TEXAS Grade 3B or 3D and Infectious Diseases Society of America (IDSA) Class 4 criteria). Outcomes evaluated were: 1) Healing 2) major amputation 3) death 4) not healed. The first outcome reached in one of these four categories over the follow-up period (18.4±3.6 months) was considered. We also estimated amputation free survival. RESULTS Overall, 57.5% (n=61) healed, 5.6% (n=6) underwent major amputation, 23.5% (n=25) died without healing and 13.2% (n=14) were alive without healing. Predictive factors associated with outcomes were: Healing (age<60, p=0.0017; no Peripheral arterial disease (PAD) p= 0.002; not on dialysis p=0.006); major amputation (CRP>100 mg/L, p=0.001; gram+ve organisms, p=0.0013; dialysis, p= 0.001), and for death (age>60, p= 0.0001; gram+ve organisms p=0.004; presence of PAD, p=0.0032; CRP, p=0.034). The major amputation free survival was 71% during the first 12 months from admission, however it had reduced to 55.4% by the end of the follow-up period. CONCLUSIONS In a unique population of hospitalised individuals with DFA, we report excellent healing and limb salvage rates using a dedicated protocol in a multidisciplinary setting. An additional novel finding was the concerning observation that such an admission was associated with high 18-month mortality, almost all of which was after discharge from hospital.
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Affiliation(s)
- Erika Vainieri
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Raju Ahluwalia
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Hani Slim
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Daina Walton
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Chris Manu
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Surabhi Taori
- King's College Hospital NHS Foundation Trust, London, United Kingdom.,School of Immunology & Microbial Sciences, Kings College, London, United Kingdom
| | - Jason Wilkins
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Dean Y Huang
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Mike Edmonds
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Hisham Rashid
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Venu Kavarthapu
- King's College Hospital NHS Foundation Trust, London, United Kingdom
| | - Prashanth R J Vas
- King's College Hospital NHS Foundation Trust, London, United Kingdom.,Institute of Diabetes, Endocrinology and Obesity, King's Health Partners, London, United Kingdom
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Surme S, Ozdemir YE, Ozdemir MS. Swab Samples in Diabetic Foot Infections: Easy to Obtain but Difficult to Interpret. Surg Infect (Larchmt) 2020; 22:587. [PMID: 33211629 DOI: 10.1089/sur.2020.395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Serkan Surme
- Department of Infectious Diseases and Clinical Microbiology, Haseki Training and Research Hospital, Istanbul, Turkey
| | - Yusuf Emre Ozdemir
- Department of Infectious Diseases and Clinical Microbiology, Bakirkoy Sadi Konuk Training and Research Hospital, Istanbul, Turkey
| | - Meryem Sahin Ozdemir
- Department of Infectious Diseases and Clinical Microbiology, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
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36
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Laakso M, Kiiski J, Karppelin M, Helminen M, Kaartinen I. Pathogens Causing Diabetic Foot Infection and the Reliability of the Superficial Culture. Surg Infect (Larchmt) 2020; 22:334-339. [PMID: 32746723 DOI: 10.1089/sur.2020.072] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Diabetic foot infection (DFI) is a severe complication of diabetes and a leading cause of hospitalization in the population with diabetes. Empirical intravenous antibiotic agents are initiated according to guidelines based on previously published data on typical pathogens. Therefore, regular evaluation of the pathogens in DFI and their resistance is important to validate current therapies. We evaluated the most current data on bacterial cultures in patients treated at our hospital for DFI and the resistance to the most common antibiotic agents, as well as the reliability of superficial cultures compared with deep tissue cultures. Patients and Methods: This retrospective study was performed at the University Hospital of Tampere and comprised 325 patients with 405 hospitalizations for DFI during the years 2010-2014. Results: The most frequent pathogens in superficial and deep samples were Staphylococcus aureus (36.9%), gram-negative bacilli (24.6%), and β-hemolytic streptococci (BHS, 19.5%). Septicemia was caused most often by Staphylococcus aureus and BHS (34.6% each). The specificity of superficial culture was 91.8%-92.8% and sensitivity 66.7%-87.5%. Conclusions: This study indicates the need to cover Staphylococcus aureus, BHS, and gram-negative bacilli when treating DFI. The reliability of superficial culture was surprisingly good.
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Affiliation(s)
- Miska Laakso
- The Doctoral School, Health Sciences, Tampere, Finland
| | - Juha Kiiski
- Unit of Plastic Surgery, Department of Musculoskeletal Surgery and Diseases, Development and Innovation Centre, Tampere University Hospital, Tampere, Finland.,Faculty of Medicine and Life Sciences, University of Tampere, Health Sciences, Tampere, Finland
| | - Matti Karppelin
- Department of Infectious Diseases, Development and Innovation Centre, Tampere University Hospital, Tampere, Finland
| | - Mika Helminen
- Faculty of Social Sciences, Health Sciences, Tampere, Finland.,Research, Development and Innovation Centre, Tampere University Hospital, Tampere, Finland
| | - Ilkka Kaartinen
- Unit of Plastic Surgery, Department of Musculoskeletal Surgery and Diseases, Development and Innovation Centre, Tampere University Hospital, Tampere, Finland
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Travis J, Malone M, Hu H, Baten A, Johani K, Huygens F, Vickery K, Benkendorff K. The microbiome of diabetic foot ulcers: a comparison of swab and tissue biopsy wound sampling techniques using 16S rRNA gene sequencing. BMC Microbiol 2020; 20:163. [PMID: 32546123 PMCID: PMC7296698 DOI: 10.1186/s12866-020-01843-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 06/03/2020] [Indexed: 12/18/2022] Open
Abstract
Background Health-care professionals need to collect wound samples to identify potential pathogens that contribute to wound infection. Obtaining appropriate samples from diabetic foot ulcers (DFUs) where there is a suspicion of infection is of high importance. Paired swabs and tissue biopsies were collected from DFUs and both sampling techniques were compared using 16S rRNA gene sequencing. Results Mean bacterial abundance determined using quantitative polymerase chain reaction (qPCR) was significantly lower in tissue biopsies (p = 0.03). The mean number of reads across all samples was significantly higher in wound swabs \documentclass[12pt]{minimal}
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\begin{document}$$ \Big(\overline{X} $$\end{document}(X¯ = 32,014) compared to tissue (\documentclass[12pt]{minimal}
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\begin{document}$$ \overline{X} $$\end{document}X¯ = 15,256, p = 0.001). Tissue biopsies exhibited greater overall diversity of bacteria relative to swabs (Shannon’s H diversity p = 0.009). However, based on a presence/absence analysis of all paired samples, the frequency of occurrence of bacteria from genera of known and potential pathogens was generally higher in wound swabs than tissue biopsies. Multivariate analysis identified significantly different bacterial communities in swabs compared to tissue (p = 0.001). There was minimal correlation between paired wound swabs and tissue biopsies in the number and types of microorganisms. RELATE analysis revealed low concordance between paired DFU swab and tissue biopsy samples (Rho = 0.043, p = 0.34). Conclusions Using 16S rRNA gene sequencing this study identifies the potential for using less invasive swabs to recover high relative abundances of known and potential pathogen genera from DFUs when compared to the gold standard collection method of tissue biopsy.
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Affiliation(s)
- J Travis
- School of Environment, Science and Engineering, Southern Cross University, Lismore, NSW, Australia
| | - M Malone
- Limb Preservation and Wound Research Academic Unit, Western Sydney LHD, Liverpool, Sydney, NSW, 2170, Australia.,Infectious Diseases and Microbiology, School of Medicine, Western Sydney University, Campbelltown Campus, Liverpool, Sydney, 2170, Australia.,Ingham Institute of Applied Medical Research, Liverpool, Sydney, NSW, 2170, Australia
| | - H Hu
- Surgical Infection Research Group Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - A Baten
- Agresearch, Grasslands Research Centre, Palmerston North, New Zealand
| | - K Johani
- Ingham Institute of Applied Medical Research, Liverpool, Sydney, NSW, 2170, Australia.,Central Military Laboratories and Blood Bank, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - F Huygens
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Herston, QLD, Australia.,School of Biomedical Science, Queensland University of Technology, Brisbane, Australia
| | - K Vickery
- Surgical Infection Research Group Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - K Benkendorff
- School of Environment, Science and Engineering, Southern Cross University, Lismore, NSW, Australia. .,National Marine Science Centre, 2 Bay Drive, Coffs Harbour, NSW, Australia.
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38
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Manas AB, Taori S, Ahluwalia R, Slim H, Manu C, Rashid H, Kavarthapu V, Edmonds M, Vas PRJ. Admission Time Deep Swab Specimens Compared With Surgical Bone Sampling in Hospitalized Individuals With Diabetic Foot Osteomyelitis and Soft Tissue Infection. INT J LOW EXTR WOUND 2020; 20:300-308. [PMID: 32370639 DOI: 10.1177/1534734620916386] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Whether deep swab cultures taken at admission reliably identify pathogens compared to surgical bone specimens in hospitalized individuals with diabetic foot osteomyelitis and soft tissue infection is unclear. Comparison of microbiological isolates between a deep wound swab (DWS) taken at the time of admission through the actively infected, discharging ulcer probing to the bone and the subsequent surgical bone sample (SBS) taken during surgical debridement was made. A total of 63 subjects (age 60.8 ± 13.5 years, 75% male, 80% Type 2 diabetes, HbA1C 8.9%±2.2%) were included. The proportion of Gram-positive (DWS 49% v SBS 52%) and Gram-negative (DWS 60% v SBS 60%) isolates was similar between the techniques. However, the overall concordance of isolates between the two techniques was only fair (κ=0.302). The best concordance was observed for Staphylococcus aureus (κ=0.571) and MRSA (κ=0.644). There was a correlation between number of isolates in SBS with prior antibiotic therapy of any duration (r= -0.358, p=0.005) and with the duration of ulceration (r=0.296, p=0.045); no clinical correlations were found for DWS. Prior antibiotic therapy (p=0.03) and duration of ulceration <8 weeks (p=0.025) were predictive of negative growth on SBS. In conclusion, we found only a fair concordance between deep wound swabs acquired at admission and surgical bone specimens in those presenting with a severe diabetic foot infection and features of osteomyelitis. Ensuring early surgical debridement of all infected tissue and obtaining bone specimens should be considered a clinical priority, which may also reduce the likelihood of negative growth on SBS.
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Affiliation(s)
| | - Surabhi Taori
- Diabetes Foot Unit, King's College Hospital, London, UK
- School of Immunology & Microbial Sciences, King's College, London, UK
| | | | - Hani Slim
- Diabetes Foot Unit, King's College Hospital, London, UK
| | - C Manu
- Diabetes Foot Unit, King's College Hospital, London, UK
| | - Hisham Rashid
- Diabetes Foot Unit, King's College Hospital, London, UK
| | | | | | - Prashanth R J Vas
- Diabetes Foot Unit, King's College Hospital, London, UK
- Institute of Diabetes, Endocrinology and Obesity, King's Health Partners, London, UK
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Utility of Methicillin-Resistant Staphylococcus aureus Nares Screening for Patients with a Diabetic Foot Infection. Antimicrob Agents Chemother 2020; 64:AAC.02213-19. [PMID: 31988097 DOI: 10.1128/aac.02213-19] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 01/18/2020] [Indexed: 11/20/2022] Open
Abstract
Treatment of suspected methicillin-resistant Staphylococcus aureus (MRSA) is a cornerstone of severe diabetic foot infections; however, antibiotics can be associated with toxicity. The objective of this study was to determine the negative predictive value (NPV) of MRSA nares screening in the determination of subsequent MRSA in patients with a diabetic foot infection. This was a retrospective cohort study across Veterans Affairs (VA) medical centers from 1 January 2007 to 1 January 2018. Data from patients with an International Classification of Diseases (ICD) code for a diabetic foot infection with MRSA nares screening, and subsequent cultures were evaluated for the presence of MRSA. NPVs were calculated for the entire cohort, as well as for a subgroup representing deep cultures. Additionally, the distribution of all pathogens isolated from diabetic foot infections was determined. A total of 8,163 episodes were included in the analysis for NPV. The NPV of MRSA nares screening for MRSA diabetic foot infection was 89.6%. For the deep cultures, the NPV was 89.2%. The NPV for cultures originating from the foot was 89.7%, and the NPV for those originating from the toe was 89.4%. There were 17,822 pathogens isolated from the diabetic foot cultures. MRSA was isolated in 7.5% of cultures, and methicillin-susceptible S. aureus was isolated in 24.8%. Enterococcus was identified in 14.7% of cultures, Proteus in 7.3%, and Pseudomonas in 6.8% of cultures. Given the high NPVs, the use of MRSA nares screening may be appropriate as a stewardship tool for deescalation and avoidance of empirical anti-MRSA therapy in patients who are not nasal carries of MRSA.
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40
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Senneville É, Lipsky BA, Abbas ZG, Aragón-Sánchez J, Diggle M, Embil JM, Kono S, Lavery LA, Malone M, van Asten SA, Urbančič-Rovan V, Peters EJG. Diagnosis of infection in the foot in diabetes: a systematic review. Diabetes Metab Res Rev 2020; 36 Suppl 1:e3281. [PMID: 32176440 DOI: 10.1002/dmrr.3281] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [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: 12/15/2022]
Abstract
BACKGROUND Securing an early accurate diagnosis of diabetic foot infections and assessment of their severity are of paramount importance since these infections can cause great morbidity and potentially mortality and present formidable challenges in surgical and antimicrobial treatment. METHODS In June 2018, we searched the literature using PuEbMed and EMBASE for published studies on the diagnosis of diabetic foot infection. On the basis of predetermined criteria, we reviewed prospective controlled, as well as noncontrolled, studies in any language, seeking translations for those not in English. We then developed evidence statements on the basis of the included papers. RESULTS From the 4242 records screened, we selected 35 papers that met our inclusion criteria. The quality of all but one of the evidence statements was low because of the weak methodology of nearly all of the studies. The available data suggest that diagnosing diabetic foot infections on the basis of clinical signs and symptoms and classified according to the International Working Group of the Diabetic Foot scheme correlates with the patient's likelihood of ulcer healing, of lower extremity amputation, and risk of death. Elevated levels of selected serum inflammatory markers are supportive, but not diagnostic, of soft tissue or bone infection. In patients with suspected diabetic foot osteomyelitis, both a positive probe-to-bone test and an elevated erythrocyte sedimentation rate are strongly associated with its presence. Culturing tissue samples of soft tissues or bone, when care is taken to avoid contamination, provides more accurate microbiological information than culturing superficial (swab) samples. Plain X-ray remains the first-line imaging examination when there is suspicion of diabetic foot osteomyelitis, but advanced imaging methods help in cases when either the diagnosis or the localization of infection is uncertain. CONCLUSION The results of this first reported systematic review on the diagnosis of diabetic foot infections provide some guidance for clinicians, but there is a need for more prospective controlled studies of high quality.
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Affiliation(s)
- Éric Senneville
- Gustave Dron Hospital, Tourcoing, France
- Lille University, France
| | | | - 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, Alberta, Canada
| | - John M Embil
- University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shigeo Kono
- WHO-Collaborating Centre for Diabetes, National Hospital Organization Kyoto Medical Centre, Kyoto, Japan
| | - Lawrence A Lavery
- University of Texas Southwestern Medical Center and Parkland Hospital, Dallas, TX
| | - Matthew Malone
- School of Medicine, Infectious Diseases and Microbiology, Western Sydney University, Sydney, New South Wales, Australia
- South West Sydney Local Health District, Sydney, New South Wales, Australia
| | - Suzanne A van Asten
- Faculty of Medicine, University Medical Centre, University of Ljubljana, Ljubljana, Slovenia
| | - Vilma Urbančič-Rovan
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Edgar J G Peters
- Department of Internal Medicine, Section of Infectious Diseases, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam Infection and Immunity Institute, Amsterdam, The Netherlands
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41
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Lipsky BA, Senneville É, Abbas ZG, Aragón-Sánchez J, Diggle M, Embil JM, Kono S, Lavery LA, Malone M, van Asten SA, Urbančič-Rovan V, Peters EJG. Guidelines on the diagnosis and treatment of foot infection in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 2020; 36 Suppl 1:e3280. [PMID: 32176444 DOI: 10.1002/dmrr.3280] [Citation(s) in RCA: 304] [Impact Index Per Article: 76.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/01/2019] [Accepted: 05/20/2019] [Indexed: 12/17/2022]
Abstract
The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the diagnosis and treatment of foot infection in persons with diabetes and updates the 2015 IWGDF infection guideline. On the basis of patient, intervention, comparison, outcomes (PICOs) developed by the infection committee, in conjunction with internal and external reviewers and consultants, and on systematic reviews the committee conducted on the diagnosis of infection (new) and treatment of infection (updated from 2015), we offer 27 recommendations. These cover various aspects of diagnosing soft tissue and bone infection, including the classification scheme for diagnosing infection and its severity. Of note, we have updated this scheme for the first time since we developed it 15 years ago. We also review the microbiology of diabetic foot infections, including how to collect samples and to process them to identify causative pathogens. Finally, we discuss the approach to treating diabetic foot infections, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and for bone infections, when and how to approach surgical treatment, and which adjunctive treatments we think are or are not useful for the infectious aspects of diabetic foot problems. For this version of the guideline, we also updated four tables and one figure from the 2016 guideline. We think that following the principles of diagnosing and treating diabetic foot infections outlined in this guideline can help clinicians to provide better care for these patients.
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Affiliation(s)
- Benjamin A Lipsky
- Department of Medicine, University of Washington, Seattle, Washington
- Green Templeton College, University of Oxford, Oxford, UK
| | | | - 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, Alberta, Canada
| | - John M Embil
- University of Manitoba, Winnipeg, Manitoba, Canada
| | - Shigeo Kono
- WHO-collaborating Centre for Diabetes, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Lawrence A Lavery
- Department of Plastic Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Matthew Malone
- South West Sydney Local Health District, School of Medicine, Infectious Diseases and Microbiology, Western Sydney University, Sydney, New South Wales, Australia
| | | | - Vilma Urbančič-Rovan
- Faculty of Medicine, University Medical Centre, University of Ljubljana, Ljubljana, Slovenia
| | - Edgar J G Peters
- Department of Internal Medicine, Infection and Immunity Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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42
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Ertuğrul B, Uçkay I, Schöni M, Peter-Riesch B, Lipsky BA. Management of diabetic foot infections in the light of recent literature and new international guidelines. Expert Rev Anti Infect Ther 2020; 18:293-305. [PMID: 32052672 DOI: 10.1080/14787210.2020.1730177] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Introduction: In May 2019 the International Working Group on the Diabetic Foot (IWGDF) launched their quadrennially updated guidelines on the management of diabetic foot infections (DFIs). Concomitantly, the number of new publications regarding DFI increased.Areas covered: The IWGDF committee developed and addressed key questions and produced evidence-based recommendations related to diagnosing and treating DFIs. This narrative review provides an overview of this new guideline and also of other recently published literature in the field of DFIs.Expert opinion: The 2019 IWGDF guidelines provide an authoritative, international, evidence-based approach to diagnosing and treating DFIs. The 27 recommendations are supported by systematic reviews of both diagnosis and interventions. Our review of this guideline, along with other recent publications in the field, allows us to offer state-of-the-art guidance for caring for these difficult infections. As the evidence base for management of DFIs remains suboptimal, we need further research to improve the management of DFIs.
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Affiliation(s)
- Bülent Ertuğrul
- Infectious Diseases and Clinical Microbiology, Adnan Menderes University, Aydın, Turkey
| | - Ilker Uçkay
- Infectiology, Balgrist University Hospital, Zurich, Switzerland
| | - Madlaina Schöni
- Orthopedic Department, Balgrist University Hospital, Zurich, Switzerland
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Schwarzer S, James GA, Goeres D, Bjarnsholt T, Vickery K, Percival SL, Stoodley P, Schultz G, Jensen SO, Malone M. The efficacy of topical agents used in wounds for managing chronic biofilm infections: A systematic review. J Infect 2019; 80:261-270. [PMID: 31899281 DOI: 10.1016/j.jinf.2019.12.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 12/18/2019] [Accepted: 12/24/2019] [Indexed: 12/19/2022]
Abstract
OBJECTIVES Clinicians have increasingly adopted the widespread use of topical agents to manage chronic wound infections, despite limited data on their effectiveness in vivo. This study sought to evaluate the evidence for commonly employed topical agents used in wounds for the purpose of treating chronic infections caused by biofilm. METHOD We included in vitro, animal and human in vivo studies where topical agents were tested for their efficacy against biofilms, for use in wound care. For human studies, we only included those which utilised appropriate identification techniques for visualising and confirming the presence of biofilms. RESULT A total of 640 articles were identified, with 43 included after meeting eligibility. In vitro testing accounted for 90% (n = 39) of all included studies, five studies using animal models and three human in vivo studies. Sixteen different laboratory models were utilised, with the most frequent being the minimum biofilm eradication concentration (MBEC™) / well plate assay (38%, n = 15 of 39). A total of 44 commercially available topical agents were grouped into twelve categories with the most commonly tested agents being silver, iodine and polyhexamethylene biguanide (PHMB). In vitro results on efficacy demonstrated iodine as having the highest mean log10 reductions of all agents (4.81, ±3.14). CONCLUSION There is large disparity in the translation of laboratory studies to researchers undertaking human trials relating to the effectiveness of commercially available topical agents. There is insufficient human in vivo evidence to definitively recommend any commercially available topical agent over another for the treatment of chronic wound biofilms. The heterogeneity identified between study designs (in vitro to in vivo) further limits the generalisability of results.
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Affiliation(s)
- S Schwarzer
- South West Sydney Limb Preservation and Wound Research, South West Sydney Local Health District, Sydney, Australia.
| | - G A James
- Centre for Biofilm Engineering, Montana State University, Bozeman, MT, United States
| | - D Goeres
- Centre for Biofilm Engineering, Montana State University, Bozeman, MT, United States
| | - T Bjarnsholt
- Department of Immunology and Microbiology, Costerton Biofilm Centre, University of Copenhagen, Copenhagen, Denmark; Department of Clinical Microbiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - K Vickery
- Surgical Infection Research Group, Faculty of Medicine and Health Sciences, Macquarie University, Sydney Australia
| | - S L Percival
- 5D Health Protection Group Ltd, Centre of Excellence in Biofilm Science (CEBS), Liverpool Bio-Innovation Hub, Liverpool UK
| | - P Stoodley
- Departments of Microbial Infection and Immunity, and Orthopaedics, Ohio State University, Columbus, OH, United States
| | - G Schultz
- Department of Obstetrics & Gynecology, Institute for Wound Research, University of Florida, Gainesville, FL, United States
| | - S O Jensen
- South West Sydney Limb Preservation and Wound Research, South West Sydney Local Health District, Sydney, Australia; Infectious Diseases and Microbiology, School of Medicine, Ingham Institute for Applied Medical Research, Western Sydney University, United States
| | - M Malone
- South West Sydney Limb Preservation and Wound Research, South West Sydney Local Health District, Sydney, Australia; Infectious Diseases and Microbiology, School of Medicine, Ingham Institute for Applied Medical Research, Western Sydney University, United States
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44
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Chastain CA, Klopfenstein N, Serezani CH, Aronoff DM. A Clinical Review of Diabetic Foot Infections. Clin Podiatr Med Surg 2019; 36:381-395. [PMID: 31079605 DOI: 10.1016/j.cpm.2019.02.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
"Diabetic foot infections (DFIs) are a common cause of morbidity and mortality. This article summarizes current knowledge regarding DFI epidemiology, disease pathogenesis, and the impact of antimicrobial resistance among DFI. An evidence-based approach to clinical assessment, diagnosing osteomyelitis, as well as medical and surgical treatment is discussed, including a review of empiric and directed antibiotic treatment recommendations. The current state and needs of the clinical literature are identified throughout, with a discussion of the supporting role of infectious diseases specialists as well as future directions of the field."
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Affiliation(s)
- Cody A Chastain
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, A-2200 Medical Center North, Nashville, TN 37232-2582, USA
| | - Nathan Klopfenstein
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, A-2200 Medical Center North, Nashville, TN 37232-2582, USA; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, 1161 21st Avenue South, A-2200 Medical Center North, Nashville, TN 37232-2582, USA
| | - Carlos H Serezani
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, A-2200 Medical Center North, Nashville, TN 37232-2582, USA; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, 1161 21st Avenue South, A-2200 Medical Center North, Nashville, TN 37232-2582, USA. https://twitter.com/HSerezani
| | - David M Aronoff
- Division of Infectious Diseases, Department of Medicine, Vanderbilt University Medical Center, 1161 21st Avenue South, A-2200 Medical Center North, Nashville, TN 37232-2582, USA; Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, 1161 21st Avenue South, A-2200 Medical Center North, Nashville, TN 37232-2582, USA.
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45
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Sloan TJ, Turton JC, Tyson J, Musgrove A, Fleming VM, Lister MM, Loose MW, Sockett RE, Diggle M, Game FL, Jeffcoate W. Examining diabetic heel ulcers through an ecological lens: microbial community dynamics associated with healing and infection. J Med Microbiol 2019; 68:230-240. [DOI: 10.1099/jmm.0.000907] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Affiliation(s)
- Tim J. Sloan
- 2Department of Clinical Microbiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
- 1School of Life Sciences, University of Nottingham, Nottingham, UK
- 3Path Links Pathology, Northern Lincolnshire and Goole NHS Foundation Trust, Lincolnshire, UK
| | - James C. Turton
- 1School of Life Sciences, University of Nottingham, Nottingham, UK
- 2Department of Clinical Microbiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Jess Tyson
- 1School of Life Sciences, University of Nottingham, Nottingham, UK
| | - Alison Musgrove
- 4Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Vicki M. Fleming
- 2Department of Clinical Microbiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Michelle M. Lister
- 2Department of Clinical Microbiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Matthew W. Loose
- 1School of Life Sciences, University of Nottingham, Nottingham, UK
| | | | - Mathew Diggle
- 2Department of Clinical Microbiology, Queen’s Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Frances L. Game
- 4Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, Nottingham University Hospitals NHS Trust, Nottingham, UK
- 5Department of Diabetes and Endocrinology, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| | - William Jeffcoate
- 4Foot Ulcer Trials Unit, Department of Diabetes and Endocrinology, Nottingham University Hospitals NHS Trust, Nottingham, UK
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46
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Esposito S, De Simone G, Pan A, Brambilla P, Gattuso G, Mastroianni C, Kertusha B, Contini C, Massoli L, Francisci D, Priante G, Libanore M, Bicocchi R, Borgia G, Maraolo AE, Brugnaro P, Panese S, Calabresi A, Amendola G, Savalli F, Geraci C, Tedesco A, Fossati S, Carretta A, Santantonio T, Cenderello G, Crisalli MP, Schiaroli E, Rovere P, Masini G, Ferretto R, Cascio A, Colomba C, Gioè C, Tumbarello M, Losito AR, Foti G, Prestileo T, Buscemi C, Chiara I, Iacobello C, Sonia S, Starnini G, Ialungo A, Sapienza M. Epidemiology and Microbiology of Skin and Soft Tissue Infections: Preliminary Results of a National Registry. J Chemother 2018; 31:9-14. [PMID: 30508410 DOI: 10.1080/1120009x.2018.1536320] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Skin and soft tissue infections (SSTIs) represent a wide range of clinical conditions characterized by a considerable variety of clinical presentations and severity. Their aetiology can also vary, with numerous possible causative pathogens. While other authors previously published analyses on several types of SSTI and on restricted types of patients, we conducted a large nationwide surveillance programme on behalf of the Italian Society of Infectious and Tropical Diseases to assess the clinical and microbiological characteristics of the whole SSTI spectrum, from mild to severe life-threatening infections, in both inpatients and outpatients. Twenty-five Infectious Diseases (ID) Centres throughout Italy collected prospectively data concerning both the clinical and microbiological diagnosis of patients affected by SSTIs via an electronic case report form. All the cases included in our database, independently from their severity, have been managed by ID specialists joining the study while SSTIs from other wards/clinics have been excluded from this analysis. Here, we report the preliminary results of our study, referring to a 12-month period (October 2016-September 2017). During this period, the study population included 254 adult patients and a total of 291 SSTI diagnoses were posed, with 36 patients presenting more than one SSTIs. The type of infection diagnosed, the aetiological micro-organisms involved and some notes on their antimicrobial susceptibilities were collected and are reported herein. The enrichment of our registry is ongoing, but these preliminary results suggest that further analysis could soon provide useful information to better understand the national epidemiologic data and the current clinical management of SSTIs in Italy.
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Affiliation(s)
- Silvano Esposito
- a Department of Infectious Diseases , University of Salerno , Salerno , Italy
| | - Giuseppe De Simone
- a Department of Infectious Diseases , University of Salerno , Salerno , Italy
| | - Angelo Pan
- b Department of Infectious Diseases , Istituti Ospitalieri of Cremona , Cremona , Italy
| | - Paola Brambilla
- b Department of Infectious Diseases , Istituti Ospitalieri of Cremona , Cremona , Italy
| | - Gianno Gattuso
- c Department of Infectious Diseases , Carlo Poma Hospital , Mantova , Italy
| | - Claudio Mastroianni
- d Department of Public Health and Infectious Diseases , Sapienza University , Latina , Italy
| | - Blerta Kertusha
- d Department of Public Health and Infectious Diseases , Sapienza University , Latina , Italy
| | - Carlo Contini
- e Department of Medical Sciences, Section of Infectious Diseases and Dermatology , University of Ferrara , Ferrara , Italy
| | - Lorenzo Massoli
- e Department of Medical Sciences, Section of Infectious Diseases and Dermatology , University of Ferrara , Ferrara , Italy
| | - Daniela Francisci
- f Infectious Diseases Clinic, University Hospital "S. Maria" , University of Perugia , Perugia , Italy
| | - Giulia Priante
- f Infectious Diseases Clinic, University Hospital "S. Maria" , University of Perugia , Perugia , Italy
| | - Marco Libanore
- g Infectious Diseases Unit, Department of Infectious Diseases , S. Anna University Hospital , Ferrara , Italy
| | - Roberto Bicocchi
- g Infectious Diseases Unit, Department of Infectious Diseases , S. Anna University Hospital , Ferrara , Italy
| | - Guglielmo Borgia
- h Department of Clinical Medicine and Surgery, Section of Infectious Diseases , University of Naples Federico II , Naples , Italy
| | - Alberto Enrico Maraolo
- h Department of Clinical Medicine and Surgery, Section of Infectious Diseases , University of Naples Federico II , Naples , Italy
| | - Pierluigi Brugnaro
- i Infectious Diseases Department , Ospedale Civile "SS. Giovanni e Paolo" , Venice , Italy
| | - Sandro Panese
- i Infectious Diseases Department , Ospedale Civile "SS. Giovanni e Paolo" , Venice , Italy
| | - Alessandra Calabresi
- j Emergency Department , Hospital "Santi Antonio e Biagio e C. Arrigo" , Alessandria , Italy
| | - Giovanni Amendola
- j Emergency Department , Hospital "Santi Antonio e Biagio e C. Arrigo" , Alessandria , Italy
| | | | - Consuelo Geraci
- k Infectious Diseases Unit , Hospital of Trapani , Trapani , Italy
| | - Andrea Tedesco
- l Infectious Diseases Unit , Hospital Fracastoro San Bonifacio , Verona , Italy
| | - Sara Fossati
- m Infectious Diseases Unit , University Hospital of Trieste , Trieste , Italy
| | - Anna Carretta
- n Department of Infectious Diseases , University Hospital "Ospedali Riuniti" of Foggia , Foggia , Italy
| | - Teresa Santantonio
- n Department of Infectious Diseases , University Hospital "Ospedali Riuniti" of Foggia , Foggia , Italy
| | | | | | - Elisabetta Schiaroli
- p Department of Medicine, Section of Infectious Diseases , University of Perugia , Perugia , Italy
| | | | - Giulia Masini
- q Infectious Diseases Unit , Legnago Hospital , Verona , Italy
| | - Roberto Ferretto
- r Infectious Diseases Unit , "Alto Vicentino" Santorso Hospital , Vicenza , Italy
| | - Antonio Cascio
- s Infectious Diseases Unit , Università degli Studi di Palermo , Palermo , Italy
| | - Claudia Colomba
- s Infectious Diseases Unit , Università degli Studi di Palermo , Palermo , Italy
| | - Claudia Gioè
- s Infectious Diseases Unit , Università degli Studi di Palermo , Palermo , Italy
| | - Mario Tumbarello
- t Institute of Infectious Diseases , Foundation Policlinico Universitario A. Gemelli IRCCS, Cattolica del Sacro Cuore University , Rome , Italy
| | - Angela Raffaella Losito
- t Institute of Infectious Diseases , Foundation Policlinico Universitario A. Gemelli IRCCS, Cattolica del Sacro Cuore University , Rome , Italy
| | - Giuseppe Foti
- u Infetious Diseases Unit , "Bianchi-Melacrino-Morelli" Hospital , Reggio Calabria , Italy
| | - Tullio Prestileo
- v Infectious Diseases Unit , Arnas Civico Hospital , Palermo , Italy
| | - Calogero Buscemi
- v Infectious Diseases Unit , Arnas Civico Hospital , Palermo , Italy
| | - Iaria Chiara
- v Infectious Diseases Unit , Arnas Civico Hospital , Palermo , Italy
| | | | - Sofia Sonia
- w Infectious Diseases Unit , Cannizzaro Hospital , Catania , Italy
| | - Giulio Starnini
- x Infectious Diseases Unit , Belcolle Hospital , Viterbo , Italy
| | - Anna Ialungo
- x Infectious Diseases Unit , Belcolle Hospital , Viterbo , Italy
| | - Mauro Sapienza
- y UOC Medicina Interna , Ospedale Umberto I , Enna , Italy
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