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Nguyen N, Chua HC, Drake T, Jo J, Stramel SA, Vuong NN, Gonzales-Luna AJ, Olson K, On Behalf Of The Houston Infectious Diseases Network. Significant Publications on Infectious Diseases Pharmacotherapy in 2021. J Pharm Pract 2024; 37:198-211. [PMID: 36122416 DOI: 10.1177/08971900221128334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To summarize the most noteworthy infectious diseases (ID) pharmacotherapy articles published in peer-reviewed literature in 2021. Summary: Members of the Houston Infectious Diseases Network (HIDN) nominated articles that were deemed to have significant contributions to ID pharmacotherapy in 2021. These nominations included articles pertaining to both general ID, including coronavirus disease 2019 (COVID-19), and human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) pharmacotherapy. A total of 35 articles were nominated by HIDN: 30 articles pertaining to general ID pharmacotherapy and 5 articles with HIV/AIDS focus. To select the most influential articles of 2021, a survey was created and distributed to members of the Society of Infectious Diseases Pharmacists (SIDP). Of the 239 SIDP members who responded to the survey, there were 192 recorded votes for the top 10 general ID pharmacotherapy articles and 47 recorded votes for the top HIV/AIDS article, respectively. The top publications are summarized. Conclusion: Antimicrobial stewardship and the optimal management of infectious disease states continues to be a priority in the midst of the ongoing coronavirus disease 2019 (COVID-19) global pandemic. In light of the sheer volume of ID-related articles published in the past year, this review aims to aid clinicians in remaining up-to-date on key practice-changing ID pharmacotherapy publications from 2021.
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Affiliation(s)
- Nhi Nguyen
- Department of Pharmacy, The University of Texas Medical Branch, Galveston, TX, USA
| | - Hubert C Chua
- Department of Pharmacy, CHI Baylor St Luke's Medical Center, Houston, TX, USA
| | - Ty Drake
- Department of Pharmacy, Houston Methodist Willowbrook Hospital, Houston, TX, USA
| | - Jinhee Jo
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Stefanie Anne Stramel
- Department of Pharmacy, Memorial Hermann Memorial City Medical Center, Houston, TX, USA
| | - Nancy N Vuong
- Division of Pharmacy, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Anne J Gonzales-Luna
- Department of Pharmacy Practice and Translational Research, University of Houston College of Pharmacy, Houston, TX, USA
| | - Kelsey Olson
- Department of Pharmacy, HCA Houston Healthcare Clear Lake, Webster, TX, USA
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Bosun-Arije SF. Commentary: Development of a resource-use measure to capture costs of diabetic foot ulcers to the United Kingdom National Health Service, patients and society. J Res Nurs 2023; 28:579-581. [PMID: 38162712 PMCID: PMC10756168 DOI: 10.1177/17449871231208173] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024] Open
Affiliation(s)
- Stella F Bosun-Arije
- Senior Lecturer and Senior Fellow of Advance HE, Faculty of Health and Education, School of Nursing and Public Health, Manchester Metropolitan University, Manchester, UK
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Papaetis GS, Doukanaris PT, Stylianou ES, Neofytou MS. Successful Outpatient Treatment of Severe Diabetic-Foot Myositis and Osteomyelitis Caused by Extensively Drug-Resistant Enterococcus faecalis with Teicoplanin plus Rifampicin: A Case Report. AMERICAN JOURNAL OF CASE REPORTS 2023; 24:e941337. [PMID: 37910441 PMCID: PMC10626598 DOI: 10.12659/ajcr.941337] [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: 06/02/2023] [Revised: 09/20/2023] [Accepted: 09/05/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Foot ulcers are high-morbidity and debilitating complications of diabetes mellitus, and carry significantly increased rates of associated major amputations. They contribute to significantly worse quality of life. Osteomyelitis is a frequent complication of diabetic foot ulcers, since bacteria can contiguously spread from soft tissues to the bone, involving the cortex first and then the bone marrow. Unfortunately, clinically unsuspected osteomyelitis is frequent in persisting diabetic foot ulcers. It is associated with limb amputations and increased mortality. CASE REPORT We describe a 76-year-old man with long-standing insulin-treated type 2 diabetes, who experienced extensively drug-resistant Enterococcus faecalis diabetic foot myositis and osteomyelitis associated with sepsis. He was successfully treated with surgical debridement combined with the administration of teicoplanin plus rifampicin in the outpatient setting, completing, in total, a twelve-week course of antibiotic therapy. CONCLUSIONS Clinically unsuspected osteomyelitis in patients with persisting diabetic foot ulcers has been associated with infections from highly resistant bacteria. Early and accurate diagnosis of diabetic foot osteomyelitis, as well as proper therapeutic approach (antimicrobial and surgical), is of great importance to reduce the risk of minor and major amputations, septic shock leading to multiple organ failure, and overall mortality.
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Affiliation(s)
- Georgios S. Papaetis
- Internal Medicine and Diabetes Clinic, K.M.P. THERAPIS Paphos Medical Center, Paphos, Cyprus
- CDA College, Paphos, Cyprus
| | | | - Eleni S. Stylianou
- Department of Radiology, Alpha Evresis Diagnostic Center, Bioiatriki Healthcare Group, Nicosia, Cyprus
| | - Michalis S. Neofytou
- Department of Interventional Cardiology, American Medical Center, Nicosia, Cyprus
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Aragón-Sánchez J, Víquez-Molina G, López-Valverde ME, Rojas-Bonilla JM, Murillo-Vargas C. Surgical Diabetic Foot Infections: Is Osteomyelitis Associated With a Worse Prognosis? THE INTERNATIONAL JOURNAL OF LOWER EXTREMITY WOUNDS 2023; 22:36-43. [PMID: 33527862 DOI: 10.1177/1534734620986695] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
It has been reported that patients with diabetes and foot ulcers complicated with osteomyelitis (OM) have a worse prognosis than those complicated with soft tissue infections (STI). Our study aimed to determine whether OM is associated with a worse prognosis in cases of moderate and severe diabetic foot infections requiring surgery. A retrospective series consisted of 150 patients who underwent surgery for diabetic foot infections. We studied the differences between OM versus STI. Furthermore, diabetic foot infections were reclassified into four groups: moderate STI (M-STI), moderate OM (M-OM), severe STI (S-STI), and severe OM (S-OM). The variables associated with prognosis were limb loss, length of hospital stay, duration of antibiotic treatment, recurrence of the infection, and time to healing (both the initial ulcer and the postoperative wound). No differences in limb salvage, hospital stay, duration of antibiotic treatment, recurrence of the infection, and time to healing were found when comparing OM with STI. Patients with M-O had a higher rate of recurrences after initial treatment and a longer time to healing when comparing with M-STI. We didn't find any differences between severe infections with or without OM. In conclusion, we have found in our surgical series of diabetic foot infections that OM is not associated with worse prognosis when comparing with STI regarding limb loss rate, length of hospital stays, duration of antibiotic treatment, recurrence of the infection, and time to healing. The results of the present series should further be confirmed by other authors.
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Dörr S, Holland-Letz AK, Weisser G, Chatzitomaris A, Lobmann R. Bacterial Diversity, Antibiotic Resistance, and the Risk of Lower Limb Amputation in Younger and Older Individuals With Diabetic Foot Infection. THE INTERNATIONAL JOURNAL OF LOWER EXTREMITY WOUNDS 2023; 22:63-71. [PMID: 33745353 DOI: 10.1177/1534734621992290] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION A diabetic foot infection (DFI) contributes to high mortality and morbidity in diabetics due to its often rapid progressive and intricately treatable infection. DFIs are usually a polymicrobial infection and characterizing the entire bacterial load is still challenging. Prompt and effective treatment of DFI is nevertheless mandatory to safe limbs and lives. It is therefore crucial to know the local pathogen spectrum and its antibiotic susceptibility. METHODS AND MATERIAL For a 12-month period, we investigated 353 individuals with infected diabetic foot ulcer, their bacterial diversity, and antimicrobial susceptibility at fist-time visit in a Diabetic Foot Care Center in southern Germany. RESULTS Cultures yielded 888 species, most of them gram-positive cocci (primary Staphylococcus aureus). The gram-negative sector was mainly formed by Pseudomonas aeruginosa and Enterobacteriacae. Because the prevalence of multiresistant species was surprisingly low (0.9% of isolated strains), we suggest penicillins with β-lactamase inhibitor in case of gram-positive-dominated infection or piperacillin/tazobactam or rather carbapenems with equal efficacy when gram-negative species are involved.
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Affiliation(s)
- Stefan Dörr
- Stuttgart General Hospital, Stuttgart, Germany
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Motaganahalli S, Batrouney A, Perera D, Vogrin S, Trubiano JA. Retrospective study of outcomes of short versus long duration of antibiotic therapy for residual osteomyelitis in surgically resected diabetic foot infection. J Antimicrob Chemother 2022; 78:284-288. [PMID: 36418157 DOI: 10.1093/jac/dkac390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/26/2022] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Optimal treatment duration for residual osteomyelitis (OM) post-amputation in diabetic foot infection (DFI) remains unclear, with resultant heterogeneity in prescribing noted in clinical practice. We aimed to identify a difference in outcomes of long duration of antibiotics (LD) with short duration (SD) in patients with culture-positive proximal bone specimen post-amputation. METHODS In this single-centre retrospective cohort study (Melbourne, Australia), we analysed antibiotic duration of DFI patients requiring amputation with culture-positive proximal bone specimen over a 31 month period (January 2019-September 2021). Primary outcome was reamputation or debridement at the same and/or contiguous site of amputation at 6 months. Secondary outcomes were readmission to hospital and/or recommencement of antibiotics for DFI at the same and/or contiguous site at 6 months. RESULTS Among 92 patients (83% male, median age 67 years), 26 received <4 weeks (SD) and 66 received ≥4 weeks (LD) antibiotic therapy. In the SD group, primary outcome occurred in 9 patients (35%) compared with 15 patients (23%) in the LD group (P = 0.246). Both secondary outcomes occurred in 12 patients (46%) in the SD group compared with 18 patients (27%) in the LD group (P = 0.086). Adjusted logistic regression analysis showed SD was not significantly associated with primary outcome [OR 1.12 (95% CI 0.38-3.31)] or secondary outcomes [OR 1.67 (95% CI 0.60-4.66)]. CONCLUSIONS This single-centre experience did not demonstrate significant difference in outcomes between antibiotic duration of <4 weeks and ≥4 weeks in DFI patients with culture-positive proximal bone specimen post-amputation. These data provide background for larger international randomized control trials to establish optimal treatment duration.
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Affiliation(s)
- S Motaganahalli
- Department of Infectious Diseases, Austin Health, Austin Health, 145 Studley Road-3084, Heidelberg, Victoria, Australia
| | - A Batrouney
- Department of Infectious Diseases, Austin Health, Austin Health, 145 Studley Road-3084, Heidelberg, Victoria, Australia
- Department of Pharmacy, Austin Health, Heidelberg, Victoria
| | - D Perera
- Department of Infectious Diseases, Austin Health, Austin Health, 145 Studley Road-3084, Heidelberg, Victoria, Australia
- Department of Pharmacy, Austin Health, Heidelberg, Victoria
| | - S Vogrin
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Fitzroy, Victoria
| | - J A Trubiano
- Department of Infectious Diseases, Austin Health, Austin Health, 145 Studley Road-3084, Heidelberg, Victoria, Australia
- Department of Pharmacy, Austin Health, Heidelberg, Victoria
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria
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Karthik S, Babu L, Joseph M, Bhatt A, Babu T. Microbiology of diabetic foot osteomyelitis - Is it geographically variable? Foot (Edinb) 2022; 52:101878. [PMID: 35576864 DOI: 10.1016/j.foot.2021.101878] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 07/27/2021] [Accepted: 10/18/2021] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Diabetic foot osteomyelitis (DFO) is a dreaded complication as both diagnosis and treatment of the condition is laborious. However, for proper decision on antibiotics in medical management of DFO, accurate determination of microbes is necessary to narrow the spectrum of coverage and to reduce adverse effects of long-term administration of antibiotics. With differing pattern of use of antimicrobials and their resistance pattern in different countries, it is empirical to determine the microbiological characteristics of bone cultures in DFO from a referral institute in South India. MATERIALS AND METHODS This study was a retrospective chart review of all cases of proven DFO who had consented for debridement and bone culture or those who underwent amputation. Both deep soft tissue (DST) and bone cultures were obtained for aerobic bacteria. Clinical characteristics and site(s) of DFO were recorded. Investigations for peripheral artery disease were performed if clinically indicated. RESULTS In all, 105 patients with DFO were reviewed. Mean age was 62 years and 70% were men. Of those who were screened, 57% had evidence of peripheral arterial disease by arterial doppler. 46% of bone culture samples were sterile. Gram- negative organisms were more common (58%). Following staphylococcus, pseudomonas was the second common isolate. Of total staphylococcal isolates 37% were MRSA and 33% of klebsiella isolates were ESBL producing. Concordance rate between DST and bone cultures was 66%. 90% were mono-bacterial isolates. The commonest site of involvement of DFO was terminal phalanges of toes rather than base of 1st metatarsal. CONCLUSION Widespread use of antibiotics, tropical climate and route of entry of organisms causing DFO differed in our cohort of patients. Further studies from different regions of world would shed light onto different pattern of microbes causing DFO.
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Affiliation(s)
| | - Lakshmi Babu
- Department of Medicine, Silverline Hospital, Kochi, India
| | - Manoj Joseph
- Department of Medicine, Silverline Hospital, Kochi, India
| | | | - Tom Babu
- Department of Endocrinology, Silverline Hospital, Kochi, India
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Pittam B, Chumber R, Vashisht G, Miller S, O'Dowd C, Ledson T, Srinivas-Shankar U. The value of administering intravenous antibiotics during haemodialysis in the treatment of diabetic foot infections. J Wound Care 2022; 31:683-688. [PMID: 36001702 DOI: 10.12968/jowc.2022.31.8.683] [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: 11/11/2022]
Abstract
OBJECTIVE People with diabetes who are on haemodialysis (HD) are at a high risk of diabetic foot infections (DFI) and related complications. We explored the value of treating DFI with intravenous (IV) antibiotics during HD. METHOD This was an observational study of consecutively treated patients with DFIs with IV antibiotics during HD. Data collected included baseline characteristics, IV antibiotics used, details of multidisciplinary interventions and DFI treatment outcome. RESULTS A cohort of 11 patients, mean (±standard deviation) age 62.4±12.7 years, had 15 episodes of treatment with IV antibiotics during HD. Of the patients, six (54.5%) were male and nine (81.8%) had type 2 diabetes. The estimated mean glomerular filtration rate (eGFR) was 11.4±3.9ml/minute. All patients had infected foot ulceration, soft tissue infection, six (54.5%) patients had osteomyelitis, and two (18.2%) had wet gangrene. The commonest IV antibiotic used was vancomycin (10/15 episodes, 66.7%). Other IV antibiotics used were daptomycin and meropenem. In three episodes, oral ciprofloxacin was used with IV antibiotics. The mean duration of antibiotic treatment was 9.2±4.9 weeks. Of the episodes, 11 (73.3%) were treated successfully with IV antibiotics alone and two (13.3%) episodes required minor surgical debridement/amputation. Some 10 (90.9%) members of the cohort had peripheral arterial disease and of those, five (50%) underwent angioplasty during IV antibiotic treatment. CONCLUSION HD provides a good opportunity for treatment with IV antibiotics in DFI. This mode of administration of IV antibiotics, along with multidisciplinary intervention, is associated with ulcer healing and resolution of infection in over three-quarters of patients with DFI. DECLARATION OF INTEREST The authors have no conflicts of interest to declare.
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Affiliation(s)
- Bradley Pittam
- Department of Diabetes and Endocrinology, Department of Pharmacy, Department of Nephrology, Wirral University Teaching Hospital NHS Foundation Trust, UK
| | - Ruby Chumber
- Department of Diabetes and Endocrinology, Department of Pharmacy, Department of Nephrology, Wirral University Teaching Hospital NHS Foundation Trust, UK
| | - Gaurav Vashisht
- Department of Diabetes and Endocrinology, Department of Pharmacy, Department of Nephrology, Wirral University Teaching Hospital NHS Foundation Trust, UK
| | - Sophie Miller
- Department of Diabetes and Endocrinology, Department of Pharmacy, Department of Nephrology, Wirral University Teaching Hospital NHS Foundation Trust, UK
| | - Christina O'Dowd
- Department of Diabetes and Endocrinology, Department of Pharmacy, Department of Nephrology, Wirral University Teaching Hospital NHS Foundation Trust, UK
| | - Thomas Ledson
- Department of Diabetes and Endocrinology, Department of Pharmacy, Department of Nephrology, Wirral University Teaching Hospital NHS Foundation Trust, UK
| | - Upendram Srinivas-Shankar
- Department of Diabetes and Endocrinology, Department of Pharmacy, Department of Nephrology, Wirral University Teaching Hospital NHS Foundation Trust, UK
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The association between bacteria and outcome and the influence of sampling method, in people with a diabetic foot infection. Infection 2022; 51:347-354. [PMID: 35869352 PMCID: PMC10042898 DOI: 10.1007/s15010-022-01884-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Accepted: 06/28/2022] [Indexed: 11/05/2022]
Abstract
Abstract
Purpose
Different bacteria lead to divers diabetic foot infections (DFIs), and some bacteria probably lead to higher amputation and mortality risks. We assessed mortality and amputation risk in relation to bacterial profiles in people DFI and investigated the role of sampling method.
Methods
We included people (> 18 years) with DFI in this retrospective study (2011–2020) at a Dutch tertiary care hospital. We retrieved cultures according to best sampling method: (1) bone biopsy; (2) ulcer bed biopsy; and (3) swab. We aggregated data into a composite determinant, consisting of unrepeated bacteria of one episode of infection, clustered into 5 profiles: (1) Streptococcus and Staphylococcus aureus; (2) coagulase-negative Staphylococcus, Cutibacterium, Corynebacterium and Enterococcus; (3) gram-negative; (4) Anaerobic; and (5) less common gram-positive bacteria. We calculated Hazard Ratio’s (HR’s) using time-dependent-Cox regression for the analyses and investigated effect modification by sampling method.
Results
We included 139 people, with 447 person-years follow-up and 459 episodes of infection. Sampling method modified the association between bacterial profiles and amputation for profile 2. HR’s (95% CI’s) for amputation for bacterial profiles 1–5: 0.7 (0.39–1.1); stratified analysis for profile 2: bone biopsy 0.84 (0.26–2.7), ulcer bed biopsy 0.89 (0.34–2.3), swab 5.9*(2.9–11.8); 1.3 (0.78–2.1); 1.6 (0.91–2.6); 1.6 (0.58–4.5). HR’s (95% CI’s) for mortality for bacterial profiles 1–5: 0.89 (0.49–1.6); 0.73 (0.38–1.4); 2.6*(1.4–4.8); 1.1(0.58–2.2); 0.80(0.19–3.3).
Conclusions
In people with DFI, there was no association between bacterial profiles in ulcer bed and bone biopsies and amputation. Only in swab cultures, low-pathogenic bacteria (profile 2), were associated with a higher amputation risk. Infection with gram-negative bacteria was associated with a higher mortality risk. This study underlined the possible negative outcome of DFI treatment based on swabs cultures.
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Masters EA, Ricciardi BF, Bentley KLDM, Moriarty TF, Schwarz EM, Muthukrishnan G. Skeletal infections: microbial pathogenesis, immunity and clinical management. Nat Rev Microbiol 2022; 20:385-400. [PMID: 35169289 PMCID: PMC8852989 DOI: 10.1038/s41579-022-00686-0] [Citation(s) in RCA: 146] [Impact Index Per Article: 73.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/07/2022] [Indexed: 12/13/2022]
Abstract
Osteomyelitis remains one of the greatest risks in orthopaedic surgery. Although many organisms are linked to skeletal infections, Staphylococcus aureus remains the most prevalent and devastating causative pathogen. Important discoveries have uncovered novel mechanisms of S. aureus pathogenesis and persistence within bone tissue, including implant-associated biofilms, abscesses and invasion of the osteocyte lacuno-canalicular network. However, little clinical progress has been made in the prevention and eradication of skeletal infection as treatment algorithms and outcomes have only incrementally changed over the past half century. In this Review, we discuss the mechanisms of persistence and immune evasion in S. aureus infection of the skeletal system as well as features of other osteomyelitis-causing pathogens in implant-associated and native bone infections. We also describe how the host fails to eradicate bacterial bone infections, and how this new information may lead to the development of novel interventions. Finally, we discuss the clinical management of skeletal infection, including osteomyelitis classification and strategies to treat skeletal infections with emerging technologies that could translate to the clinic in the future.
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Affiliation(s)
- Elysia A Masters
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Biomedical Engineering, University of Rochester Medical Center, Rochester, NY, USA
| | - Benjamin F Ricciardi
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
| | - Karen L de Mesy Bentley
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
- Department of Pathology and Laboratory Medicine, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Edward M Schwarz
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA.
- Department of Biomedical Engineering, University of Rochester Medical Center, Rochester, NY, USA.
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA.
| | - Gowrishankar Muthukrishnan
- Center for Musculoskeletal Research, University of Rochester Medical Center, Rochester, NY, USA
- Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, NY, USA
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Uddin A, Russell D, Game F, Santos D, Siddle HJ. The effectiveness of systemic antibiotics for osteomyelitis of the foot in adults with diabetes mellitus: a systematic review protocol. J Foot Ankle Res 2022; 15:48. [PMID: 35710432 PMCID: PMC9204875 DOI: 10.1186/s13047-022-00554-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 06/08/2022] [Indexed: 11/21/2022] Open
Abstract
Background Osteomyelitis of the foot is a major complication of diabetes that can be limb and life threatening. Systemic antibiotic pharmacotherapy is often used first line to eradicate infection and allow restoration of devitalised bone. The aim is to conduct a systematic review of the effectiveness of systemic antibiotics on osteomyelitis of the foot in adults with diabetes mellitus. Methods A systematic review of all interventional studies treating osteomyelitis with systemic antibiotics in participants with diabetes mellitus and an ulcer of the foot below the malleoli will be conducted. Studies not available in English and in people below the age of 18 will be excluded. Study selection will follow the Patient Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA-P guidelines). The quality of the studies will be assessed using the Cochrane risk-of-bias tool (RoB 2) for all randomised controlled trials and the Newcastle–Ottawa Scale (NOS) will be used for non-randomised controlled trials. Electronic databases will be searched with no timeline restrictions. Data Extraction All identified references will be imported to the Rayyan Application. Studies for eligibility will be screened by two reviewers. One reviewer will perform the data extraction and quality appraisal will be conducted by two authors. If sufficient data is available, the quality will be analysed and a meta-analysis will be performed. Data synthesis will be conducted, and meta-analysis undertaken using RevMan 5.4.1 Meta-analysis software. Non-parametric data may be compared between selective intervention and outcomes. Discussion The results of this systematic review will identify the effectiveness of systemic antibiotic therapy on osteomyelitis of the foot in people with diabetes based on the set outcome measure criteria. The findings will establish if there are existing consistent standards or variation in practice when treating diabetic foot osteomyelitis (DFO). The study may establish if guidelines are required to standardise practice when treating DFO with systemic antibiotic therapy. This systematic review protocol will synthesise the existing evidence on the effectiveness of systemic antibiotic therapy for treating DFO. Trial registration International Prospective Register for Systematic Reviews (PROSPERO) number CRD42021245424.
Supplementary Information The online version contains supplementary material available at 10.1186/s13047-022-00554-3.
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Affiliation(s)
- Akram Uddin
- Northamptonshire Healthcare NHS Foundation Trust, Essex Partnership University NHS Foundation Trust & University of Nottingham, Nottingham, UK. .,Department of Podiatric Surgery. Danetre Hospital, London Road, Northamptonshire, NN11 4DY, UK.
| | - David Russell
- Leeds Institute of Clinical Trials Research, University of Leeds (and Leeds Vascular Institute, Leeds Teaching Hospitals NHS Trust), Leeds, LS2 9JT, UK
| | - Fran Game
- University Hospitals of Derby & Burton NHS Foundation Trust, Derby, UK
| | | | - Heidi J Siddle
- Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, UK
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12
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Mingoia M, Conte C, Di Rienzo A, Dimmito MP, Marinucci L, Magi G, Turkez H, Cufaro MC, Del Boccio P, Di Stefano A, Cacciatore I. Synthesis and Biological Evaluation of Novel Cinnamic Acid-Based Antimicrobials. Pharmaceuticals (Basel) 2022; 15:ph15020228. [PMID: 35215340 PMCID: PMC8878811 DOI: 10.3390/ph15020228] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2022] [Revised: 02/11/2022] [Accepted: 02/12/2022] [Indexed: 12/15/2022] Open
Abstract
The main antimicrobial resistance (AMR) nosocomial strains (ESKAPE pathogens such as Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp.) are the most widespread bacteria in cutaneous infections. In this work we report the synthesis, in silico skin permeability prediction, antimicrobial, antibiofilm, and wound healing properties of novel cinnamic acid-based antimicrobials (DM1–11) as novel antibacterial drugs for the treatment of ESKAPE-related skin infections. Antimicrobial and wound healing scratch assays were performed to evaluate the antibacterial properties of DM1–11. In silico skin permeability capabilities of DM1–11 were evaluated using Swiss-ADME online database. Cytotoxicity assays were performed on keratinocytes and fibroblasts. DM2, bearing a catechol group on the aromatic ring of the cinnamic portion of the molecule, possesses a significant antibacterial activity against S. aureus (MIC range 16–64 mg/L) and contrasts the biofilm-mediated S. epidermidis infection at low concentrations. Wound healing assays showed that wound closure in 48 h was observed in DM2-treated keratinocytes with a better healing pattern at all the used concentrations (0.1, 1.0, and 10 µM). A potential good skin permeation for DM2, that could guarantee its effectiveness at the target site, was also observed. Cytotoxicity studies revealed that DM2 may be a safe compound for topical use. Taking together all these data confirm that DM2 could represent a safe wound-healing topical agent for the treatment of skin wound infections caused by two of main Gram-positive bacteria belonging to ESKAPE microorganisms.
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Affiliation(s)
- Marina Mingoia
- Department of Biomedical Sciences and Public Health, Medical School, Polytechnic University of Marche, 60121 Ancona, Italy; (M.M.); (G.M.)
| | - Carmela Conte
- Department of Pharmaceutical Sciences, University of Perugia, Via Fabretti, 48, 06123 Perugia, Italy;
| | - Annalisa Di Rienzo
- Department of Pharmacy, University “G. d’Annunzio” of Chieti-Pescara, Via dei Vestini 31, 66100 Chieti Scalo, Italy; (A.D.R.); (M.P.D.); (M.C.C.); (P.D.B.); (A.D.S.)
| | - Marilisa Pia Dimmito
- Department of Pharmacy, University “G. d’Annunzio” of Chieti-Pescara, Via dei Vestini 31, 66100 Chieti Scalo, Italy; (A.D.R.); (M.P.D.); (M.C.C.); (P.D.B.); (A.D.S.)
| | - Lorella Marinucci
- Department of Medicine and Surgery, University of Perugia, S. Andrea Delle Fratte, 06156 Perugia, Italy;
| | - Gloria Magi
- Department of Biomedical Sciences and Public Health, Medical School, Polytechnic University of Marche, 60121 Ancona, Italy; (M.M.); (G.M.)
| | - Hasan Turkez
- Department of Medical Biology, Faculty of Medicine, Ataturk University, 25240 Erzurum, Turkey;
| | - Maria Concetta Cufaro
- Department of Pharmacy, University “G. d’Annunzio” of Chieti-Pescara, Via dei Vestini 31, 66100 Chieti Scalo, Italy; (A.D.R.); (M.P.D.); (M.C.C.); (P.D.B.); (A.D.S.)
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, Via dei Vestini 31, 66100 Chieti Scalo, Italy
| | - Piero Del Boccio
- Department of Pharmacy, University “G. d’Annunzio” of Chieti-Pescara, Via dei Vestini 31, 66100 Chieti Scalo, Italy; (A.D.R.); (M.P.D.); (M.C.C.); (P.D.B.); (A.D.S.)
- Center for Advanced Studies and Technology (CAST), University “G. d’Annunzio” of Chieti-Pescara, Via dei Vestini 31, 66100 Chieti Scalo, Italy
| | - Antonio Di Stefano
- Department of Pharmacy, University “G. d’Annunzio” of Chieti-Pescara, Via dei Vestini 31, 66100 Chieti Scalo, Italy; (A.D.R.); (M.P.D.); (M.C.C.); (P.D.B.); (A.D.S.)
| | - Ivana Cacciatore
- Department of Pharmacy, University “G. d’Annunzio” of Chieti-Pescara, Via dei Vestini 31, 66100 Chieti Scalo, Italy; (A.D.R.); (M.P.D.); (M.C.C.); (P.D.B.); (A.D.S.)
- Correspondence: ; Tel.: +39-871-355-44-75
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Aragón-Sánchez J, Víquez-Molina G, López-Valverde ME, Aragón-Hernández J, Rojas-Bonilla JM, Murillo-Vargas C. Long-term Mortality of a Cohort of Patients Undergoing Surgical Treatment for Diabetic Foot Infections. An 8-year Follow-up Study. INT J LOW EXTR WOUND 2021; 22:314-320. [PMID: 33909492 DOI: 10.1177/15347346211009425] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
We analyzed a retrospective cohort of 150 patients with diabetic foot infections (DFIs) who underwent surgical treatment to determine long-term outcomes. The median follow-up of the series was 7.6 years. Cox's proportional hazards model for survival time was performed and hazard ratios (HRs) were estimated. Survival times were plotted using the Kaplan-Meier method. Fifteen patients (10%) required readmission after discharge from the hospital for a recurrence of the infection. Ninety patients (60%) had re-ulcerations. Forty-nine (54.4% of those re-ulcerated) required new admission and 24 of them (26.6% of those re-ulcerated) finally required a new amputation. Overall cumulative survival rates at 1, 5, and 8 years were 95%, 78%, and 64%, respectively. Predictive variables of long-term mortality were insulin treatment (HR: 2.0, 95% CI: 1.1-3.6, P = .01), female sex (HR: 3.1, 95% CI: 1.7-5.3, P<.01) and estimated glomerular filtration rate (eGFR) <60 ml/min/1.73 m2 (HR: 2.2, 95% CI: 1.1-4.2, P = .01). In conclusion, patients undergoing surgical treatment for DFIs had a high rate of recurrences and mortality. Women, patients who underwent treatment with insulin, and those with eGFR <60 ml/min/1.73 m2 had a higher risk of long-term mortality.
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Lipsky BA, Uçkay İ. Treating Diabetic Foot Osteomyelitis: A Practical State-of-the-Art Update. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:339. [PMID: 33916055 PMCID: PMC8066570 DOI: 10.3390/medicina57040339] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 12/17/2022]
Abstract
Background and Objectives: Diabetic foot osteomyelitis (DFO) can be difficult to treat and securing optimal clinical outcomes requires a multidisciplinary approach involving a wide variety of medical, surgical and other health care professionals, as well as the patient. Results of studies conducted in the past few years have allowed experts to formulate guidelines that can improve clinical outcomes. Material and Methods: We conducted a narrative review of the literature on treat- ment of DFO, with an emphasis on studies published in the last two years, especially regarding antimicrobial therapies and surgical approached to treatment of DFO, supplemented by our own extensive clinical and research experience in this field. Results: Major amputations were once com- mon for DFO but, with improved diagnostic and surgical techniques, "conservative" surgery (foot- sparing, resecting only the infected and necrotic bone) is becoming commonplace, especially for forefoot infections. Traditional antibiotic therapy, which has been administered predominantly in- travenously and frequently for several months, can often be replaced by appropriately selected oral antibiotic regimens following only a brief (or even no) parenteral therapy, and given for no more than 6 weeks. Based on ongoing studies, the recommended duration of treatment may soon be even shorter, especially for cases in which a substantial portion of the infected bone has been resected. Using the results of cultures (preferably of bone specimens) and antimicrobial stewardship princi- ples allows clinicians to select evidence-based antibiotic regimens, often of a limited pathogen spec- trum. Intra-osseous antimicrobial and surgical approaches to treatment are also evolving in light of ongoing research. Conclusions: In this narrative, evidenced-based review, taking consideration of principles of antimicrobial stewardship and good surgical practice, we have highlighted the recent literature and offered practical, state-of-the-art advice on the antibiotic and surgical management of DFO.
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Affiliation(s)
- Benjamin A. Lipsky
- Department of Medicine, University of Washington, Seattle, WA 98116, USA
| | - İlker Uçkay
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, 8008 Zurich, Switzerland;
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15
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Interplay between ESKAPE Pathogens and Immunity in Skin Infections: An Overview of the Major Determinants of Virulence and Antibiotic Resistance. Pathogens 2021; 10:pathogens10020148. [PMID: 33540588 PMCID: PMC7912840 DOI: 10.3390/pathogens10020148] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 01/26/2021] [Accepted: 01/27/2021] [Indexed: 12/16/2022] Open
Abstract
The skin is the largest organ in the human body, acting as a physical and immunological barrier against pathogenic microorganisms. The cutaneous lesions constitute a gateway for microbial contamination that can lead to chronic wounds and other invasive infections. Chronic wounds are considered as serious public health problems due the related social, psychological and economic consequences. The group of bacteria known as ESKAPE (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa and Enterobacter sp.) are among the most prevalent bacteria in cutaneous infections. These pathogens have a high level of incidence in hospital environments and several strains present phenotypes of multidrug resistance. In this review, we discuss some important aspects of skin immunology and the involvement of ESKAPE in wound infections. First, we introduce some fundamental aspects of skin physiology and immunology related to cutaneous infections. Following this, the major virulence factors involved in colonization and tissue damage are highlighted, as well as the most frequently detected antimicrobial resistance genes. ESKAPE pathogens express several virulence determinants that overcome the skin's physical and immunological barriers, enabling them to cause severe wound infections. The high ability these bacteria to acquire resistance is alarming, particularly in the hospital settings where immunocompromised individuals are exposed to these pathogens. Knowledge about the virulence and resistance markers of these species is important in order to develop new strategies to detect and treat their associated infections.
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Gazzaruso C, Gallotti P, Pujia A, Montalcini T, Giustina A, Coppola A. Predictors of healing, ulcer recurrence and persistence, amputation and mortality in type 2 diabetic patients with diabetic foot: a 10-year retrospective cohort study. Endocrine 2021; 71:59-68. [PMID: 32712853 DOI: 10.1007/s12020-020-02431-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 07/18/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE Predictors of outcome of diabetic foot ulcer (DFU) are important to improve the management of patients. Aim of the study was to find these predictors in type 2 diabetic patients with DFU. METHODS We recruited 583 patients. They were followed-up by a multidisciplinary team. A holistic and conservative approach was used and all risk factors and co-morbidities were aggressively treated. RESULTS During the follow-up period, 79.6% of patients healed in a mean time of 7.6 ± 3.8 months, 6.9% showed DFU persistence, 9.9% had minor amputations, and 3.6% experienced major amputation. Seventeen percent of the patients died. Among patients who healed, 37.1% of them showed DFU recurrence. Impairment of renal function was associated to DFU persistence, amputation, and mortality. Previous cardiovascular disease predicted DFU persistence, DFU recurrence, and mortality. Lower BMI predicted DFU persistence and mortality. Osteomyelitis was a predictor of amputation and death. Markers of peripheral artery disease (PAD) predicted minor amputation and DFU recurrence. Our study shows a relatively low incidence of complications of DFU. CONCLUSIONS Some predictors of outcome of DFU were confirmed and new predictors, like BMI and markers of PAD, were found. Our new findings suggest future strategies for nutrition support and revascularization. In addition, a holistic and conservative approach may improve the prognosis.
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Affiliation(s)
- Carmine Gazzaruso
- Diabetes and Endocrine, Metabolic and Vascular Diseases Unit and the Centre for Applied Clinical Research (Ce.R.C.A.), Clinical Institute "Beato Matteo" (Hospital Group San Donato), Corso Pavia 84, 27029, Vigevano, Italy.
| | - Pietro Gallotti
- Diabetes and Endocrine, Metabolic and Vascular Diseases Unit and the Centre for Applied Clinical Research (Ce.R.C.A.), Clinical Institute "Beato Matteo" (Hospital Group San Donato), Corso Pavia 84, 27029, Vigevano, Italy
| | - Arturo Pujia
- Department of Clinical and Experimental Medicine, Nutrition Unit, University Magna Grecia, Germaneto, Catanzaro, Italy
| | - Tiziana Montalcini
- Department of Clinical and Experimental Medicine, Nutrition Unit, University Magna Grecia, Germaneto, Catanzaro, Italy
| | - Andrea Giustina
- Unit and Chair of Endocrinology, IRCCS Ospedale San Raffaele and University Vita e Salute, Milan, Italy
| | - Adriana Coppola
- Diabetes and Endocrine, Metabolic and Vascular Diseases Unit and the Centre for Applied Clinical Research (Ce.R.C.A.), Clinical Institute "Beato Matteo" (Hospital Group San Donato), Corso Pavia 84, 27029, Vigevano, Italy
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17
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Gariani K, Pham TT, Kressmann B, Jornayvaz FR, Gastaldi G, Stafylakis D, Philippe J, Lipsky BA, Uçkay İ. Three versus six weeks of antibiotic therapy for diabetic foot osteomyelitis: A prospective, randomized, non-inferiority pilot trial. Clin Infect Dis 2020; 73:e1539-e1545. [PMID: 33242083 DOI: 10.1093/cid/ciaa1758] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In patients with diabetic foot osteomyelitis (DFO) who underwent surgical debridement, we investigated whether a short (3 weeks), compared with a long (6 weeks) duration of systemic antibiotic treatment is associated with non-inferior results for clinical remission and adverse events (AE). METHODS In this prospective, randomized, non-inferiority, pilot trial, we randomized (allocation 1:1), patients with DFO after surgical debridement to either a 3-week or a 6-week course of antibiotic therapy. The minimal duration of follow-up after end of therapy was two months. We compared outcomes using Cox regression and non-inferiority analyses (25% margin, power 80%). RESULTS Among 93 enrolled patients (18% females; median age 65 years), 44 were randomized to the 3-week arm and 49 to the 6-week arm. The median number of surgical debridement was 1 (range, 0-2 interventions). In the intention-to-treat (ITT) population, remission occurred in 37 (84%) of the patients in the 3-week arm compared to 36 (73%) in the 6-week arm (p=0.21). The number of AE was similar in the two study arms (17/44 vs. 16/49; p=0.51), as were the remission incidences in the per-protocol (PP) population (33/39 vs. 32/43; p=0.26). In multivariate analysis, treatment with the shorter antibiotic course was not significantly associated with remission (for the ITT population, hazard ratio 1.1, 95%CI 0.6-1.7; for the PP population hazard ratio 0.8, 95%CI 0.5-1.4). CONCLUSIONS In this randomized, controlled pilot trial, a post-debridement systemic antibiotic therapy course for DFO of 3-weeks gave similar (and statistically non-inferior) incidences of remission and AE to a course of 6 weeks.
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Affiliation(s)
- Karim Gariani
- Service of Endocrinology, Diabetes, Hypertension and Nutrition, Geneva University Hospitals, Geneva, Switzerland
| | - Truong-Thanh Pham
- Service of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland.,Orthopedic Surgery Service, Geneva University Hospitals, Geneva, Switzerland
| | - Benjamin Kressmann
- Service of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland.,Orthopedic Surgery Service, Geneva University Hospitals, Geneva, Switzerland
| | - François R Jornayvaz
- Service of Endocrinology, Diabetes, Hypertension and Nutrition, Geneva University Hospitals, Geneva, Switzerland
| | - Giacomo Gastaldi
- Service of Endocrinology, Diabetes, Hypertension and Nutrition, Geneva University Hospitals, Geneva, Switzerland
| | | | - Jacques Philippe
- Service of Endocrinology, Diabetes, Hypertension and Nutrition, Geneva University Hospitals, Geneva, Switzerland
| | - Benjamin A Lipsky
- Service of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - İlker Uçkay
- Service of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland.,Orthopedic Surgery Service, Geneva University Hospitals, Geneva, Switzerland.,Infectiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,Unit for Clinical and Applied Research, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Machado C, Teixeira S, Fonseca L, Abreu M, Carvalho A, Pereira MT, Amaral C, Freitas C, Ferreira L, Neto HR, Loureiro L, Martins J, Costa L, Gomes A, Pereira J, Guimarães R, Pinto S, Carvalho R. Evolutionary trends in bacteria isolated from moderate and severe diabetic foot infections in a Portuguese tertiary center. Diabetes Metab Syndr 2020; 14:205-209. [PMID: 32171163 DOI: 10.1016/j.dsx.2020.02.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 02/15/2020] [Accepted: 02/16/2020] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Diabetic Foot infections (DFI) are a major cause of hospitalization in patients with diabetes. The microbiological study of diabetic ulcers is essential to adequate antibiotic therapy and to minimize the selection of resistant microorganisms. The aim of this study was to characterize and to compare the evolution of isolated microorganisms between the biennium 2010-2011 and 2016-2017, in hospitalized patients with DFI. MATERIAL AND METHODS Retrospective evaluation of the clinical and analytical data of patients who were admitted due to DFI in 2010-2011 (group 2010/11) and 2016-2017 (group 2016/17). Only the first hospitalization for each patient was included. An adequate descriptive and comparative statistical analysis was performed. RESULTS There were 274 admissions due to DFI, 151 in 2010/11 and 123 in 2016/17. There was an increase in admissions due to neuroischemic DFI (51.0% in 2010/11 to 61.8% in 2016/17, p = 0.048). Staphylococcus aureus (SA) was the most common isolate in 2010/11 (26.7%). In 2016/17 most cultures were mixed polymicrobial and isolation of Enterobacteriaceae and Pseudomonas aeruginosa increased from 2010/11 to 2016/17 (15.9% to 30.6%, p = 0.001, and 9.1% to 13.7%, p = 0.048, respectively). CONCLUSION There was an increase in the prevalence of neuroischemic DFU. The Enterobacteriaceae family replaced SA as the most prevalent pathogen in DFI, with an increase in the isolation of gram-negative microorganisms and mixed polymicrobial cultures. Chronic neuroischemic infected ulcers usually present distinct bacterial isolates; knowledge about the most common agents is warranted in order to better select empiric antibiotic therapy.
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Affiliation(s)
- Catarina Machado
- Department of Endocrinology, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal.
| | - Sofia Teixeira
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Do Porto, Portugal
| | - Liliana Fonseca
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Do Porto, Portugal
| | - Miguel Abreu
- Department of Infectious Diseases, Centro Hospitalar Do Porto, Portugal
| | - André Carvalho
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Do Porto, Portugal
| | - Maria Teresa Pereira
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Do Porto, Portugal
| | - Cláudia Amaral
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Do Porto, Portugal
| | - Cláudia Freitas
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Do Porto, Portugal
| | - Lia Ferreira
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Do Porto, Portugal
| | - Helena Rei Neto
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Do Porto, Portugal
| | - Luís Loureiro
- Department of Angiology and Vascular Surgery, Centro Hospitalar do Porto, Portugal
| | - Joana Martins
- Department of Angiology and Vascular Surgery, Centro Hospitalar do Porto, Portugal
| | - Luís Costa
- Department of Orthopaedics and Traumatology, Centro Hospitalar Do Porto, Portugal
| | - André Gomes
- Department of Orthopaedics and Traumatology, Centro Hospitalar Do Porto, Portugal
| | - Joel Pereira
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Do Porto, Portugal
| | - Rosa Guimarães
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Do Porto, Portugal
| | - Sara Pinto
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Do Porto, Portugal
| | - Rui Carvalho
- Department of Endocrinology, Diabetes and Metabolism, Centro Hospitalar Do Porto, Portugal
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Wilson BM, Bessesen MT, Doros G, Brown ST, Saade E, Hermos J, Perez F, Skalweit M, Spellberg B, Bonomo RA. Adjunctive Rifampin Therapy For Diabetic Foot Osteomyelitis in the Veterans Health Administration. JAMA Netw Open 2019; 2:e1916003. [PMID: 31755948 PMCID: PMC6902814 DOI: 10.1001/jamanetworkopen.2019.16003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
IMPORTANCE Among patients diagnosed with diabetes, the lifetime incidence of foot ulcers is 15%. Infection is a common complication of foot ulcers, and 20% to 60% of infections result in diabetic foot osteomyelitis (DFO). Current treatment guidelines do not endorse any specific antibiotic agent for DFO, but small clinical trials suggest the addition of rifampin to antimicrobial regimens results in improved cure rates for osteomyelitis. OBJECTIVE To compare the clinical outcomes of patients treated for DFO in the Veterans Health Administration (VHA) with and without adjunctive rifampin. DESIGN, SETTING, AND PARTICIPANTS This observational cohort study used VHA databases to identify index DFO cases from January 1, 2009, through December 31, 2013, and analyzed patients alive and without high-level amputation at 90 days after diagnosis in whom antibiotic therapy was initiated within 6 weeks of diagnosis. Patients with death or major amputation within 90 days of diagnosis, who were not treated with systemic antibiotics dispensed by the VHA within 6 weeks of diagnosis, or who were treated at facilities where rifampin was not dispensed for DFO were excluded. The retrospective cohort to inform the planning of a multisite randomized clinical trial was first investigated in spring 2015; retrospective analysis was performed from February 2017 through September 2019. EXPOSURES Patients initiating rifampin therapy within 6 weeks of the DFO diagnosis and receiving the drug for at least 14 days within 90 days of diagnosis were considered treated with rifampin. Patients not administered rifampin within 90 days of diagnosis served as the comparator group. MAIN OUTCOMES AND MEASURES A combined end point of mortality or amputation within 2 years of diagnosis was analyzed. Differences in times to event were evaluated using log-rank tests. Differences in event rates were compared using χ2 tests and multivariable logistic regression. RESULTS The analysis population included 130 patients treated with rifampin and 6044 treated without rifampin (total of 6174; 6085 men [98.6%]; mean [SD] age, 64.9 [9.7] years). Lower event rates were observed among the rifampin group (35 of 130 [26.9%] vs 2250 of 6044 [37.2%]; P = .02). Patients treated with rifampin were younger (mean [SD] age, 62.2 [9.4] vs 64.9 [9.6] years), had fewer comorbidities (mean [SD] Charlson comorbidity index score, 3.5 [1.8] vs 4.0 [2.2]), had more infectious disease specialty consultations (63 of 130 [48.5%] vs 1960 of 6044 [32.4%]), and more often had Staphylococcus aureus identified in cultures (55 of 130 [42.3%] vs 1755 of 6044 [29.0%]) than patients not treated with rifampin. A logistic regression estimating the odds of events and controlling for these and other covariates yielded a significant association of rifampin (odds ratio, 0.65; 95% CI, 0.43-0.96; P = .04). CONCLUSIONS AND RELEVANCE In this cohort study, patients administered rifampin experienced lower rates of death and amputation than patients not treated with rifampin, which remained significant after adjustment for confounders. These results coupled with existing evidence from small clinical trials suggest the addition of rifampin to current treatment regimens may be a useful antimicrobial option in the treatment of DFO.
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Affiliation(s)
- Brigid M. Wilson
- Research Service and Geriatric Research, Education, and Clinical Center (GRECC),VA Northeast Ohio Healthcare System, Cleveland
- Division of Infectious Diseases, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Mary T. Bessesen
- Division of Infectious Diseases, University of Colorado, Denver, School of Medicine, Department of Veterans Affairs Eastern Colorado Healthcare System, Aurora
| | - Gheorghe Doros
- Massachusetts Veterans Epidemiology Research and Information Center, Boston
- Boston University School of Medicine, Boston, Massachusetts
| | - Sheldon T. Brown
- James J. Peters Veterans Affairs Medical Center, Bronx, New York
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Elie Saade
- Division of Infectious Diseases, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Research Service, VA Northeast Ohio Healthcare System, Cleveland
- University Hospitals of Cleveland, Cleveland, Ohio
| | - John Hermos
- Massachusetts Veterans Epidemiology Research and Information Center, Boston
- Veterans Affairs Boston Healthcare System, Boston, Massachusetts
- Department of General Internal Medicine, Boston University, Boston, Massachusetts
| | - Federico Perez
- Division of Infectious Diseases, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Medicine Service and GRECC, VA Northeast Ohio Healthcare System, Cleveland
| | - Marion Skalweit
- Medicine Service and GRECC, VA Northeast Ohio Healthcare System, Cleveland
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Biochemistry, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Brad Spellberg
- Los Angeles County and University of Southern California Medical Center, Los Angeles
- Department of Medicine, Keck School of Medicine of University of Southern California, Los Angeles
| | - Robert A. Bonomo
- Medicine Service and GRECC, VA Northeast Ohio Healthcare System, Cleveland
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Biochemistry, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Pharmacology, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Molecular Biology and Microbiology, Case Western Reserve University School of Medicine, Cleveland, Ohio
- Department of Proteomics and Bioinformatics, Case Western Reserve University School of Medicine, Cleveland, Ohio
- CWRU (Case Western Reserve University)–Cleveland VAMC Center for Antimicrobial Resistance and Epidemiology, Cleveland, Ohio
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