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Jin Y, Huang K, Shao T. [ 18F]Fluorodeoxyglucose ([ 18F]FDG) positron emission tomography and conventional imaging modalities in the diagnosis of diabetic foot osteomyelitis: a meta-analysis. Clin Radiol 2024; 79:e1142-e1151. [PMID: 38880677 DOI: 10.1016/j.crad.2024.05.015] [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: 04/03/2024] [Revised: 05/21/2024] [Accepted: 05/22/2024] [Indexed: 06/18/2024]
Abstract
AIM This meta-analysis aimed to evaluate the comparative diagnostic efficacy of [18F]Fluorodeoxyglucose positron emission tomography ([18F]FDG PET) and conventional imaging, MRI, and white blood cell (WBC) scintigraphy in detecting foot osteomyelitis among diabetic patients. MATERIALS AND METHODS An exhaustive search was conducted within the PubMed and Embase databases to identify publications available up until February 2024. Studies were included if they evaluated the diagnostic efficacy of [18F]FDG PET or the comparative diagnostic performance between PET and (MRI or WBC scintigraphy). Two researchers independently assessed the quality of the included studies, utilizing the Quality Assessment of Diagnostic Performance Studies (QUADAS-2) tool. RESULTS Nine retrospective or prospective studies involving 605 patients were included in the meta-analysis. For [18F]FDG PET, the overall sensitivity was 0.83(95% CI: 0.69-0.94), while the overall specificity was 0.92(95% CI: 0.86-0.97). In the head-to-head comparison, no significant difference of sensitivity was found between [18F]FDG PET and MRI (0.72 vs. 0.68, P=0.81), as well as between [18F]FDG PET and WBC scintigraphy (0.57 vs. 0.66, P=0.64). In addition, specificity was also found to be no significant difference between [18F]FDG PET and MRI (0.90 vs. 0.82, P=0.27), as well as [18F]FDG PET and WBC scintigraphy (0.81 vs. 0.93, P=0.09). CONCLUSION [18F]FDG PET demonstrates similar sensitivity and specificity to MRI and WBC scintigraphy in detecting foot osteomyelitis among diabetic patients. MRI, often cited as a primary choice in guidelines, might be preferred due to its lower cost and lower dose. Further larger sample prospective studies are needed to confirm these findings.
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Affiliation(s)
- Y Jin
- Infectious Disease Department, Tongde Hospital of Zhejiang Province, Hangzhou 310012, China
| | - K Huang
- Department of Orthopedics, Tongde Hospital of Zhejiang Province, Hangzhou 310012, China
| | - T Shao
- Infectious Disease Department, Tongde Hospital of Zhejiang Province, Hangzhou 310012, China.
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Shen D, Huang K, Guo Q, Ma G, Ding L. The Efficacy of Local Antibiotic Delivery Systems Therapy in the Management of Diabetic Foot Osteomyelitis: A Systematic Review and Meta-Analysis. INT J LOW EXTR WOUND 2024:15347346241266062. [PMID: 39033388 DOI: 10.1177/15347346241266062] [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: 07/23/2024]
Abstract
PURPOSE We aim to evaluate the efficacy of local antibiotic delivery systems in patients with diabetic foot osteomyelitis (DFO). METHODS The Web of Science, PubMed, and Embase databases were searched for relevant publications until March 2024. All studies evaluating the efficacy of local antibiotic delivery systems in patients with DFO were included. We calculated pooled risk ratio (RR) with 95% CIs for binary outcomes and mean difference (MD) for continuous outcomes. The Cochrane's risk of bias tool and methodological index for non-randomized studies (MINORS) assessment were used to evaluate the quality of studies. RESULTS A total of 9 studies with 491 patients were included in this analysis. The overall healing rate in antibiotic group was 0.85 (95% CI: 0.67, 0.97). Healing rates were significantly higher in the antibiotic group compared to the control group (RR: 1.18, 95% CI: 1.01, 1.38). Furthermore, recurrence rates and amputation rates have no significantly difference between the antibiotic group and the control group (RR: 0.30, 95% CI: 0.04, 2.12 and RR: 0.22, 95% CI:0.03, 1.91), along with no significantly difference in healing time and hospital stays(MD: -7.87, 95% CI: -20.81, 5.07 and MD:-2.33, 95% CI:-5.17, 0.50). No obvious publication bias was observed in the funnel plot (Egger's test, P = .99). CONCLUSIONS Our meta-analysis found that diabetic foot osteomyelitis patients treated with local antibiotic delivery systems had better healing rates than the control group. However, no significant differences were found in healing time, recurrence, hospital stays, or amputation rates. Larger randomized controlled trials are necessary in the future.
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Affiliation(s)
- Di Shen
- Department of Orthopedic Trauma, Zhuji People's Hospital of Zhejiang Province, Zhuji, China
| | - Kai Huang
- Department of Orthopedics, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Qiaofeng Guo
- Department of Orthopedics, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Gouping Ma
- Department of Orthopedics, Tongde Hospital of Zhejiang Province, Hangzhou, China
| | - Liqing Ding
- Department of Endocrinology, Tongde Hospital of Zhejiang Province, Hangzhou, China
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Kulasegaran N, Vangaveti V, Norton R, Malabu U. The Microbial Diversity and Antimicrobial Susceptibility Profile Underlying Diabetic Foot Osteomyelitis: A Retrospective Study Conducted in North Queensland, Australia. FOOT & ANKLE ORTHOPAEDICS 2024; 9:24730114241281503. [PMID: 39380709 PMCID: PMC11459660 DOI: 10.1177/24730114241281503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2024] Open
Abstract
Background Diabetic foot osteomyelitis (DFO) commonly occurs secondary to ulcerations of the skin. Empirical antibiotic agents are a key element of treatment and their use is dependent on local knowledge of the microbial spectrum of diabetic foot infections. This study aimed to retrospectively analyze the local microbiological profile, including bacterial culture/sensitivity results of DFO, and compare findings with literature. This study also aimed to review the concordance of microbiology results with national guidelines for the future treatment of DFO. Methods A retrospective review of clinical records was performed on patients who presented to the high-risk foot clinic, Townsville University Hospital, between 2018 and 2022. All patients older than 18 years and diagnosed with DFO were included. Our exclusion criteria included all other foot presentations, including trauma, vasculitis, and neoplasms. Results On the basis of the inclusion and exclusion criteria, 124 patients with DFO were selected. Most patients in the cohort were males (70.2%), non-Indigenous (68.5%), aged 50-69 years (55.6%), and with elevated HbA1c levels (>8.6). Chronic kidney disease (39.5%) and ischemic heart disease (41.9%) were common comorbidities. Of the pertinent microbial results, Staphylococcus aureus (~76%) was the most commonly isolated Gram-positive organism. Gram-positive bacteria were significantly increased in the elderly population with DFO (P < .05). All methicillin-resistant S aureus isolates were vancomycin- and cotrimoxazole-sensitive. Pseudomonas aeruginosa was the predominant Gram-negative organism isolated (39.3%). P aeruginosa exhibited low sensitivity to ciprofloxacin. Conclusion This study has enhanced our understanding of the various microbial species underlying DFO at our center and may be generalizable. Level of Evidence Level IV, retrospective case series.
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Affiliation(s)
- Nandini Kulasegaran
- University of Queensland, Brisbane, Queensland, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, Queensland, Australia
| | - Venkat Vangaveti
- Townsville Institute of Health Research and Innovation, Townsville University Hospital, Townsville, Queensland, Australia
- Translational Research in Endocrinology and Diabetes, College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
| | - Robert Norton
- Department of Microbiology, Townsville University Hospital, Townsville, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Usman Malabu
- Translational Research in Endocrinology and Diabetes, College of Medicine and Dentistry, James Cook University, Douglas, Queensland, Australia
- Department of Endocrinology & Diabetes, Townsville University Hospital, Townsville, Queensland, Australia
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Abdulrehman T, Qadri S, Haik Y, Sultan A, Skariah S, Kumar S, Mendoza Z, Yadav KK, Titus A, Khader S. Advances in the targeted theragnostics of osteomyelitis caused by Staphylococcus aureus. Arch Microbiol 2024; 206:288. [PMID: 38834761 DOI: 10.1007/s00203-024-04015-2] [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: 03/31/2024] [Revised: 05/14/2024] [Accepted: 05/20/2024] [Indexed: 06/06/2024]
Abstract
Bone infections caused by Staphylococcus aureus may lead to an inflammatory condition called osteomyelitis, which results in progressive bone loss. Biofilm formation, intracellular survival, and the ability of S. aureus to evade the immune response result in recurrent and persistent infections that present significant challenges in treating osteomyelitis. Moreover, people with diabetes are prone to osteomyelitis due to their compromised immune system, and in life-threatening cases, this may lead to amputation of the affected limbs. In most cases, bone infections are localized; thus, early detection and targeted therapy may prove fruitful in treating S. aureus-related bone infections and preventing the spread of the infection. Specific S. aureus components or overexpressed tissue biomarkers in bone infections could be targeted to deliver active therapeutics, thereby reducing drug dosage and systemic toxicity. Compounds like peptides and antibodies can specifically bind to S. aureus or overexpressed disease markers and combining these with therapeutics or imaging agents can facilitate targeted delivery to the site of infection. The effectiveness of photodynamic therapy and hyperthermia therapy can be increased by the addition of targeting molecules to these therapies enabling site-specific therapy delivery. Strategies like host-directed therapy focus on modulating the host immune mechanisms or signaling pathways utilized by S. aureus for therapeutic efficacy. Targeted therapeutic strategies in conjunction with standard surgical care could be potential treatment strategies for S. aureus-associated osteomyelitis to overcome antibiotic resistance and disease recurrence. This review paper presents information about the targeting strategies and agents for the therapy and diagnostic imaging of S. aureus bone infections.
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Affiliation(s)
- Tahir Abdulrehman
- eHealth Program, DeGroote School of Business, McMaster University, Hamilton, ON, Canada
- Health Policy, Management and Informatics, Allied Health, Credit Valley Hospital, Mississauga, ON, Canada
| | - Shahnaz Qadri
- School of Pharmacy, Texas A&M University, Kingsville, USA.
| | - Yousef Haik
- Department of Mechanical & Nuclear Engineering, University of Sharjah, Sharjah, UAE.
| | - Ali Sultan
- Department of Immunology & Microbiology, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Sini Skariah
- Department of Immunology & Microbiology, Weill Cornell Medicine-Qatar, Doha, Qatar
| | - Shourya Kumar
- School of Engineering Medicine, Texas A&M University, Houston, TX, USA
| | - Zachary Mendoza
- School of Engineering Medicine, Texas A&M University, Houston, TX, USA
| | - Kamlesh K Yadav
- School of Engineering Medicine, Texas A&M University, Houston, TX, USA
| | - Anoop Titus
- Department of Preventive Cardiology, Houston Methodist, Houston, TX, USA
| | - Shameer Khader
- School of Public Health, Faculty of Medicine, Imperial College London, London, UK
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Au A, Yii E, Andric A, Wong J, Saunder A, Yii M. Predictors of operative management in diabetic foot ulcers. J Foot Ankle Res 2024; 17:e12024. [PMID: 38797920 PMCID: PMC11296710 DOI: 10.1002/jfa2.12024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 05/13/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND & AIMS Surgery plays a key role in the management of complicated diabetic foot disease (DFD). Currently, indications for medical versus surgical management are poorly defined. Prompt identification of patients who require surgery may reduce morbidities and length of hospital stay. This study aims to analyse factors in DFD that necessitate early surgical interventions. METHODS All patients admitted under a multi-disciplinary diabetic foot team in a tertiary institution over 2 years were included in a retrospective case-control study comparing patients who received medical management and patients who received surgical management. Logistic regression was performed to identify factors associated with surgical management of diabetic foot complications. RESULTS Three hundred and forty patients were included. 49% of patients required surgical management. Toe ulceration, elevated C-reactive protein (CRP), and the presence of osteomyelitis were associated with surgical management. Multivariate analysis calculated an odds ratio (OR) of 1.01 for CRP (p < 0.001), OR 2.19 (p < 0.019) favouring surgical management for forefoot ulcers, and OR 2.2 (p < 0.019) if osteomyelitis was present. CONCLUSIONS Patients with elevated CRP levels, a forefoot diabetic ulcer and established osteomyelitis were more likely to undergo surgical management. Prompt recognition of these patients has the potential benefit of earlier decision making in definitive surgical interventions.
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Affiliation(s)
- Amos Au
- Department of Vascular SurgeryMonash HealthClaytonVictoriaAustralia
| | - Erwin Yii
- Department of Vascular SurgeryEastern HealthBox HillVictoriaAustralia
| | - Ana Andric
- Department of PodiatryMonash HealthClaytonVictoriaAustralia
| | - Jennifer Wong
- Department of EndocrinologyMonash HealthClaytonVictoriaAustralia
| | - Alan Saunder
- Department of Vascular SurgeryMonash HealthClaytonVictoriaAustralia
- Department of SurgerySchool of Clinical Sciences at Monash HealthMonash UniversityClaytonVictoriaAustralia
| | - Ming Yii
- Department of Vascular SurgeryMonash HealthClaytonVictoriaAustralia
- Department of SurgerySchool of Clinical Sciences at Monash HealthMonash UniversityClaytonVictoriaAustralia
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Hsu CC, Lai HY, Lin HY, Pan SC, Cheng NC, Chen LK, Hsiao FY, Lin SW. Recurrence of Diabetic Foot Complications: A Domino Effect Leading to Lethal Consequences-Insights From a National Longitudinal Study. Open Forum Infect Dis 2024; 11:ofae276. [PMID: 38868313 PMCID: PMC11167667 DOI: 10.1093/ofid/ofae276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 05/07/2024] [Indexed: 06/14/2024] Open
Abstract
Background Foot complications are common in people with diabetes mellitus (DM), leading to increased health care utilization, heightened mortality risk, and notable recurrence rates even after treatment. This retrospective cohort study aimed to investigate the impact of repeated occurrence of DM-related foot complications on the risk of all-cause mortality and to identify the potential risk factors associated with repeated events. Methods People with DM admitted with foot complications (ulcer, skin and soft tissue infection, or osteomyelitis) from 2012 to 2014 were identified from Taiwan's National Health Insurance Research Database, with a 3-year follow-up for repeated events. We categorized the study subjects based on their cumulative number of hospital admissions with foot complications. Logistic regression was conducted to explore the potential risk factors associated with repeated diabetic foot events. Kaplan-Meier curves and Cox proportional hazard models were used to examine the associations between repeated diabetic foot events and all-cause mortality. Results In this study, 28 754 eligible individuals were enrolled and classified into 3 groups: no repeated diabetic foot events (76.1%), 1 repeated event (16.0%), and 2 or more repeated events (7.9%). Logistic regression revealed that advanced age, male sex, congestive heart failure, dyslipidemia, hypertension, nephropathy, retinopathy, neuropathy, peripheral vascular disease, diabetes-related preventable hospitalizations, and outpatient visits due to diabetic foot were significantly associated with repeated events of diabetic foot complications. Compared with those with no repeated events, the adjusted hazard ratios for all-cause mortality were 1.26 (95% CI, 1.19-1.34) for 1 repeated event and 1.36 (95% CI, 1.26-1.47) for 2 or more repeated events. Conclusions The significant association between repeated diabetic foot and elevated mortality risk highlights the critical necessity for proactive and targeted patient care within clinical practice. More research to delve into the predictive factors related to the repeated occurrence of diabetic foot is needed to provide additional insights for prevention strategies.
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Affiliation(s)
- Chun-Chien Hsu
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Hsi-Yu Lai
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
- Health Data Research Center, National Taiwan University, Taipei, Taiwan
| | - Hung-Yu Lin
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Sung-Ching Pan
- Division of Infectious Diseases, Department of Internal Medicine, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Nai-Chen Cheng
- Division of Plastic Surgery, Department of Surgery, National Taiwan University Hospital and College of Medicine, Taipei, Taiwan
| | - Liang-Kung Chen
- Center for Healthy Longevity and Aging Sciences, National Yang Ming Chiao Tung University, Taipei, Taiwan
- Center for Geriatrics and Gerontology, Taipei Veterans General Hospital, Taipei, Taiwan
- Taipei Municipal Gan-Dau Hospital, Taipei, Taiwan
| | - Fei-Yuan Hsiao
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Pharmacy, National Taiwan University Hospital, Taipei, Taiwan
| | - Shu-Wen Lin
- Graduate Institute of Clinical Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
- School of Pharmacy, College of Medicine, National Taiwan University, Taipei, Taiwan
- Department of Pharmacy, National Taiwan University Cancer Center, Taipei, Taiwan
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Jin L, Chia RX, Neilson W, Hardman D, Frahm-Jensen G, Jones A. Evaluation of routine proximal bone analysis for microbiology and histopathology in diabetes-related foot infections and osteomyelitis. ANZ J Surg 2024; 94:445-450. [PMID: 38030589 DOI: 10.1111/ans.18805] [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: 01/22/2022] [Revised: 11/17/2023] [Accepted: 11/18/2023] [Indexed: 12/01/2023]
Abstract
PURPOSE The value of proximal bone analysis for surgical clearance of infection remains debated. Real-world practice traditionally utilized proximal bone microbiology rather than histopathology to diagnose residual diabetes-related osteomyelitis of the foot (DFO) post-amputation. We assessed the concordance between proximal bone microbiology and histopathology in determining residual infection and their predictability for revision operation in DFO and diabetes-related foot infection (DFI). METHODOLOGY A single-centre retrospective study was conducted between June and December 2020 at a tertiary institution. We recruited patients with diabetes mellitus who had minor amputations for DFO and DFI and analyzed their proximal bone microbiology, histopathology and outcomes at 6 months. RESULTS Eighty-four patients were recruited; 64 (76.2%) were male. The mean age was 69.3 years. The mean HbA1c was 8.6%. Seventy-seven operations were performed for DFO and 17 for DFI. Negative microbiology showed complete concordance with histopathology; and none had revision operation (P = 0.99). Positive microbiology had 9.8% concordance with histopathology (P = 0.99). Positive histopathology was associated with a higher rate of revision operation (80% vs. 12.5%; P = 0.01). High preoperative C-reactive protein was associated with residual DFO (P = 0.02) and revision operation (P = 0.01). CONCLUSION Positive histopathology was more reliable for determining significant residual DFO and predicting revision operation. Positive microbiology was valuable for guiding antibiotic selection. We suggest routine proximal bone analysis for both histopathology and microbiology to optimize the treatment of DFO and DFI.
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Affiliation(s)
- LongHai Jin
- Department of Vascular Surgery, The Canberra Hospital, Garran, Australian Capital Territory, Australia
| | - Rong Xian Chia
- Department of General Surgery, The Canberra Hospital, Garran, Australian Capital Territory, Australia
| | - Wendell Neilson
- Department of Vascular Surgery, The Canberra Hospital, Garran, Australian Capital Territory, Australia
| | - David Hardman
- Department of Vascular Surgery, The Canberra Hospital, Garran, Australian Capital Territory, Australia
| | - Gert Frahm-Jensen
- Department of Vascular Surgery, The Canberra Hospital, Garran, Australian Capital Territory, Australia
- School of Medicine and Psychology, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Alister Jones
- Department of Vascular Surgery, The Canberra Hospital, Garran, Australian Capital Territory, Australia
- School of Medicine and Psychology, Australian National University, Canberra, Australian Capital Territory, Australia
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Bonnet E, Maulin L, Senneville E, Castan B, Fourcade C, Loubet P, Poitrenaud D, Schuldiner S, Sotto A, Lavigne JP, Lesprit P. Clinical practice recommendations for infectious disease management of diabetic foot infection (DFI) - 2023 SPILF. Infect Dis Now 2024; 54:104832. [PMID: 37952582 DOI: 10.1016/j.idnow.2023.104832] [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: 10/02/2023] [Accepted: 11/03/2023] [Indexed: 11/14/2023]
Abstract
In march 2020, the International Working Group on the Diabetic Foot (IWGDF) published an update of the 2015 guidelines on the diagnosis and management of diabetic foot infection (DFI). While we (the French ID society, SPILF) endorsed some of these recommendations, we wanted to update our own 2006 guidelines and specifically provide informative elements on modalities of microbiological diagnosis and antibiotic treatment (especially first- and second-line regiments, oral switch and duration). The recommendations put forward in the present guidelines are addressed to healthcare professionals managing patients with DFI and more specifically focused on infectious disease management of this type of infection, which clearly needs a multidisciplinary approach. Staging of the severity of the infection is mandatory using the classification drawn up by the IWGDF. Microbiological samples should be taken only in the event of clinical signs suggesting infection in accordance with a strict preliminarily established protocol. Empirical antibiotic therapy should be chosen according to the IWGDF grade of infection and duration of the wound, but must always cover methicillin-sensitive Staphylococcus aureus. Early reevaluation of the patient is a fundamental step, and duration of antibiotic therapy can be shortened in many situations. When osteomyelitis is suspected, standard foot radiograph is the first-line imagery examination and a bone biopsy should be performed for microbiological documentation. Histological analysis of the bone sample is no longer recommended. High dosages of antibiotics are recommended in cases of confirmed osteomyelitis.
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Affiliation(s)
- E Bonnet
- Service des Maladies Infectieuses et Tropicales, CHU Toulouse-Purpan, 31059 Toulouse, France.
| | - L Maulin
- Maladies Infectieuses, CH du Pays d'Aix, 13100 Aix en Provence, France
| | - E Senneville
- Service Universitaire des Maladies Infectieuses, CH Dron, 59200 Tourcoing, France
| | - B Castan
- Service de Médecine Interne et Maladies Infectieuses, CH Périgueux, 24019 Périgueux, France
| | - C Fourcade
- Equipe Mobile d'Infectiologie, Clinique Pasteur, Clinavenir, 31300 Toulouse, France
| | - P Loubet
- Service des Maladies Infectieuses et Tropicales, CHU Caremeau, 30029 Nîmes, France
| | - D Poitrenaud
- Unité Fonctionnelle d'Infectiologie, CH Notre Dame de la Miséricorde, 20000 Ajaccio, France
| | - S Schuldiner
- Service des Maladies Métaboliques et Endocriniennes, CHU Caremeau, 30029 Nîmes, France
| | - A Sotto
- Service des Maladies Infectieuses et Tropicales, CHU Caremeau, 30029 Nîmes, France
| | - J P Lavigne
- Service de Microbiologie et Hygiène Hospitalière, CHU Caremeau, 30029 Nîmes, France
| | - P Lesprit
- Maladies Infectieuses, CHU Grenoble Alpes, 38043, Grenoble, France
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Boucher A, Pradier M, Lafondesmurs B, Thill P, Patoz P, Blondiaux N, Joulie D, Hennart B, Robineau O, Senneville E. Dalbavancin as salvage therapy in difficult-to-treat patients for diabetes-related foot osteomyelitis. Infect Dis Now 2024; 54:104835. [PMID: 37972818 DOI: 10.1016/j.idnow.2023.104835] [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: 07/18/2023] [Revised: 11/09/2023] [Accepted: 11/13/2023] [Indexed: 11/19/2023]
Abstract
OBJECTIVES We aimed to describe the efficacy and safety of dalbavancin in treatment of patients with diabetes-related foot osteomyelitis with bone culture confirmation. PATIENTS AND METHODS Between January 2019 and December 2021, all consecutive patients receiving at least one 1500 mg dose of dalbavancin for diabetes-related foot osteomyelitis were included in a retrospective study. Remission was defined as absence of relapsing infection or need for surgery at the initial or a contiguous site during 6-month follow-up from the last dose of dalbavancin. RESULTS Thirteen patients were included. Eleven (85%) patients were surgically treated. Six (46%) patients received dalbavancin as first-line treatment and 7 (54%) as second-line treatment due to adverse events related to previous treatments. One adverse event was reported. At 6-month follow-up, 11 patients were evaluable and 9 (82%) were in remission. CONCLUSIONS In the study, dalbavancin was well-tolerated and showed microbiological and clinical efficacy.
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Affiliation(s)
- Anne Boucher
- Service Universitaire des maladies Infectieuses et du Voyageur, Centre Hospitalier Gustave Dron, F-59200, Tourcoing, France.
| | - Maxime Pradier
- Service Universitaire des maladies Infectieuses et du Voyageur, Centre Hospitalier Gustave Dron, F-59200, Tourcoing, France
| | - Barthelemy Lafondesmurs
- Service Universitaire des maladies Infectieuses et du Voyageur, Centre Hospitalier Gustave Dron, F-59200, Tourcoing, France
| | - Pauline Thill
- Service Universitaire des maladies Infectieuses et du Voyageur, Centre Hospitalier Gustave Dron, F-59200, Tourcoing, France
| | - Pierre Patoz
- Laboratoire de Microbiologie, Centre Hospitalier Gustave Dron, F-59200, Tourcoing, France
| | - Nicolas Blondiaux
- Laboratoire de Microbiologie, Centre Hospitalier Gustave Dron, F-59200, Tourcoing, France
| | - Donatienne Joulie
- Service de Chirurgie Orthopédique et Traumatologique, Centre Hospitalier Gustave Dron, F-59200, Tourcoing, France
| | - Benjamin Hennart
- Service de Toxicologie-Génopathies, Centre Hospitalier Universitaire de Lille, F-59000, Lille, France
| | - Olivier Robineau
- Service Universitaire des maladies Infectieuses et du Voyageur, Centre Hospitalier Gustave Dron, F-59200, Tourcoing, France; Université de Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, F-59000, Lille, France
| | - Eric Senneville
- Service Universitaire des maladies Infectieuses et du Voyageur, Centre Hospitalier Gustave Dron, F-59200, Tourcoing, France; Université de Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, F-59000, Lille, France
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10
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Alkhalfan Y, Lewis TL, Kavarthapu V, Hester T. Investigation and management of diabetic foot osteomyelitis: An update for the foot and ankle orthopaedic surgeon. J Clin Orthop Trauma 2024; 48:102330. [PMID: 38274641 PMCID: PMC10806189 DOI: 10.1016/j.jcot.2023.102330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 12/13/2023] [Accepted: 12/30/2023] [Indexed: 01/27/2024] Open
Abstract
Diabetic foot osteomyelitis (DFO) poses a significant challenge in the management of diabetic patients, often leading to severe complications and increased morbidity. Effective management of DFO requires a multidisciplinary approach, involving endocrinologists, infectious disease specialists, vascular surgeons, orthopaedic surgeons, and wound care experts. Early diagnosis is paramount, facilitated by advanced imaging techniques such as magnetic resonance imaging (MRI) and bone scintigraphy. Once diagnosed, the treatment strategy hinges on a combination of medical and surgical interventions. Antibiotic therapy, guided by culture results, plays a central role in managing DFO. Tailored regimens targeting the specific pathogens involved are administered, often for prolonged durations. Surgical intervention becomes necessary when conservative measures fall short. Surgical approaches range from minimally invasive procedures, like percutaneous drainage, to more extensive interventions like debridement and bone resection. Prevention of DFO recurrence is equally vital, emphasising glycemic control, meticulous foot care, patient education, monitoring of at-risk signs, revascularization and early intervention when indicated. The management of diabetic foot osteomyelitis mandates a comprehensive strategy that addresses both the infectious and surgical aspects of the condition. A collaborative, interdisciplinary approach ensures timely diagnosis, tailored treatment, and holistic care. Further research into novel therapeutic modalities and long-term outcomes remains essential in refining the management of this complex and debilitating complication of diabetes.
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Affiliation(s)
- Yousif Alkhalfan
- Guy's and St Thomas' NHS Foundation Trust, Maze Pond, London, SE1 9RT, UK
| | | | - Venu Kavarthapu
- King's Foot and Ankle Unit, King's College Hospital NHS Foundation Trust, UK
| | - Thomas Hester
- King's Foot and Ankle Unit, King's College Hospital NHS Foundation Trust, UK
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Bakadia BM, Qaed Ahmed AA, Lamboni L, Shi Z, Mutu Mukole B, Zheng R, Pierre Mbang M, Zhang B, Gauthier M, Yang G. Engineering homologous platelet-rich plasma, platelet-rich plasma-derived exosomes, and mesenchymal stem cell-derived exosomes-based dual-crosslinked hydrogels as bioactive diabetic wound dressings. Bioact Mater 2023; 28:74-94. [PMID: 37234363 PMCID: PMC10206161 DOI: 10.1016/j.bioactmat.2023.05.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 04/23/2023] [Accepted: 05/03/2023] [Indexed: 05/27/2023] Open
Abstract
The management of diabetic wounds remains a critical therapeutic challenge. Platelet-rich plasma (PRP) gel, PRP-derived exosomes (PRP-Exos), and mesenchymal stem cell-derived exosomes (MSC-Exos) have demonstrated therapeutic potential in wound treatment. Unfortunately, their poor mechanical properties, the short half-lives of growth factors (GFs), and the burst release of GFs and exosomes have limited their clinical applications. Furthermore, proteases in diabetic wounds degrade GFs, which hampers wound repair. Silk fibroin is an enzyme-immobilization biomaterial that could protect GFs from proteases. Herein, we developed novel dual-crosslinked hydrogels based on silk protein (SP) (sericin and fibroin), including SP@PRP, SP@MSC-Exos, and SP@PRP-Exos, to promote diabetic wound healing synergistically. SP@PRP was prepared from PRP and SP using calcium gluconate/thrombin as agonist, while SP@PRP-Exos and SP@MSC-Exos were derived from exosomes and SP with genipin as crosslinker. SP provided improved mechanical properties and enabled the sustained release of GFs and exosomes, thereby overcoming the limitations of PRP and exosomes in wound healing. The dual-crosslinked hydrogels displayed shear-induced thinning, self-healing, and eradication of microbial biofilms in a bone-mimicking environment. In vivo, the dual-crosslinked hydrogels contributed to faster diabetic wound healing than PRP and SP by upregulating GFs expression, down-regulating matrix metalloproteinase-9 expression, and by promoting an anti-NETotic effect, angiogenesis, and re-epithelialization. Hence, these dual-crosslinked hydrogels have the potential to be translated into a new generation of diabetic wound dressings.
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Affiliation(s)
- Bianza Moise Bakadia
- Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, 430074, China
- Institut Supérieur des Techniques Médicales de Lubumbashi, Lubumbashi, Congo
| | - Abeer Ahmed Qaed Ahmed
- Department of Molecular Medicine, Biochemistry Unit, University of Pavia, 27100, Pavia, Italy
| | - Lallepak Lamboni
- Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, 430074, China
| | - Zhijun Shi
- Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, 430074, China
| | | | - Ruizhu Zheng
- Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, 430074, China
| | - Mazono Pierre Mbang
- Institut Supérieur des Techniques Médicales de Lubumbashi, Lubumbashi, Congo
| | - Bi Zhang
- College of Life Science and Technology, Key Laboratory of Molecular Biophysics of MOE, Huazhong University of Science and Technology, Wuhan, China
| | - Mario Gauthier
- Department of Chemistry, University of Waterloo, Waterloo, Ontario, N2L 3G1, Canada
| | - Guang Yang
- Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan, 430074, China
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Calvo-Wright MDM, Álvaro-Afonso FJ, López-Moral M, García-Álvarez Y, García-Morales E, Lázaro-Martínez JL. Is the Combination of Plain X-ray and Probe-to-Bone Test Useful for Diagnosing Diabetic Foot Osteomyelitis? A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:5369. [PMID: 37629412 PMCID: PMC10455253 DOI: 10.3390/jcm12165369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Revised: 08/08/2023] [Accepted: 08/15/2023] [Indexed: 08/27/2023] Open
Abstract
A systematic review and meta-analysis was conducted to assess the diagnostic accuracy of the combination of plain X-ray and probe-to-bone (PTB) test for diagnosing diabetic foot osteomyelitis (DFO). This systematic review has been registered in PROSPERO (a prospective international register of systematic reviews; identification code CRD42023436757). A literature search was conducted for each test separately along with a third search for their combination. A total of 18 articles were found and divided into three groups for separate analysis and comparison. All selected studies were evaluated using STROBE guidelines to assess the quality of reporting for observational studies. Meta-DiSc software was used to analyze the collected data. Concerning the diagnostic accuracy variables for each case, the pooled sensitivity (SEN) was higher for the combination of PTB and plain X-ray [0.94 (PTB + X-ray) vs. 0.91 (PTB) vs. 0.76 (X-ray)], as was the diagnostic odds ratio (DOR) (82.212 (PTB + X-ray) vs. 57.444 (PTB) vs. 4.897 (X-ray)). The specificity (SPE) and positive likelihood ratio (LR+) were equally satisfactory for the diagnostic combination but somewhat lower than for PTB alone (SPE: 0.83 (PTB + X-ray) vs. 0.86 (PTB) vs. 0.76 (X-ray); LR+: 5.684 (PTB + X-ray) vs. 6.344 (PTB) vs. 1.969 (X-ray)). The combination of PTB and plain X-ray showed high diagnostic accuracy comparable to that of MRI and histopathology diagnosis (the gold standard), so it could be considered useful for the diagnosis of DFO. In addition, this diagnostic combination is accessible and inexpensive but requires training and experience to correctly interpret the results. Therefore, recommendations for this technique should be included in the context of specialized units with a high prevalence of DFO.
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Affiliation(s)
| | - Francisco Javier Álvaro-Afonso
- Diabetic Foot Unit, Clínica Universitaria de Podología, Facultad de Enfermería, Fisioterapia and Podología, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain; (M.d.M.C.-W.); (M.L.-M.); (Y.G.-Á.); (E.G.-M.); (J.L.L.-M.)
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13
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Rajab AAH, Hegazy WAH. What’s old is new again: Insights into diabetic foot microbiome. World J Diabetes 2023; 14:680-704. [PMID: 37383589 PMCID: PMC10294069 DOI: 10.4239/wjd.v14.i6.680] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 02/20/2023] [Accepted: 04/10/2023] [Indexed: 06/14/2023] Open
Abstract
Diabetes is a chronic disease that is considered one of the most stubborn global health problems that continues to defy the efforts of scientists and physicians. The prevalence of diabetes in the global population continues to grow to alarming levels year after year, causing an increase in the incidence of diabetes complications and health care costs all over the world. One major complication of diabetes is the high susceptibility to infections especially in the lower limbs due to the immunocompromised state of diabetic patients, which is considered a definitive factor in all cases. Diabetic foot infections continue to be one of the most common infections in diabetic patients that are associated with a high risk of serious complications such as bone infection, limb amputations, and life-threatening systemic infections. In this review, we discussed the circumstances associated with the high risk of infection in diabetic patients as well as some of the most commonly isolated pathogens from diabetic foot infections and the related virulence behavior. In addition, we shed light on the different treatment strategies that aim at eradicating the infection.
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Affiliation(s)
- Azza A H Rajab
- Department of Microbiology and Immunology, Faculty of Pharmacy, Zagazig University, Zagzig 44511, Egypt
| | - Wael A H Hegazy
- Department of Microbiology and Immunology, Faculty of Pharmacy, Zagazig University, Zagzig 44511, Egypt
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14
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Kavarthapu V, Giddie J, Kommalapati V, Casey J, Bates M, Vas P. Evaluation of Adjuvant Antibiotic Loaded Injectable Bio-Composite Material in Diabetic Foot Osteomyelitis and Charcot Foot Reconstruction. J Clin Med 2023; 12:jcm12093239. [PMID: 37176679 PMCID: PMC10179343 DOI: 10.3390/jcm12093239] [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: 02/20/2023] [Revised: 04/07/2023] [Accepted: 04/18/2023] [Indexed: 05/15/2023] Open
Abstract
The management of diabetic foot osteomyelitis (DFO) is extremely challenging with high amputation rates reported alongside a five-year mortality risk of more than fifty percent. We describe our experience in using adjuvant antibiotic-loaded bio-composite material (Cerament) in the surgical management of DFO and infected Charcot foot reconstruction. We undertook a retrospective evaluation of 53 consecutive patients (54 feet) who underwent Gentamicin or Vancomycin-loaded Cerament application during surgery. The feet were categorised into two groups: Group 1, with infected ulcer and DFO, managed with radical debridement only (n = 17), and Group 2, requiring reconstruction surgery for infected and deformed Charcot foot. Group 2 was further subdivided into 2a, with feet previously cleared of infection and undergoing a single-stage reconstruction (n = 19), and 2b, with feet having an active infection managed with a two-stage reconstruction (n = 18). The mean age was 56 years (27-83) and 59% (31/53) were males. The mean BMI was 30.2 kg/m2 (20.8-45.5). Foot ulcers were present in 69% (37/54) feet. At a mean follow-up of 30 months (12-98), there were two patients lost to follow up and the mortality rate was 11% (n = 5). The mean duration of post-operative systemic antibiotic administration was 20 days (4-42). Thirteen out of fifteen feet (87%) in group 1 achieved complete eradication of infection. There was a 100% primary ulcer resolution, 100% limb salvage and 76% bony union rate within Group 2. However, five patients, all in group 2, required reoperations due to problems with bone union. The use of antibiotic-loaded Cerament resulted in a high proportion of patients achieving infection clearance, functional limb salvage and decrease in the duration of postoperative antibiotic therapy. Larger, preferably randomised, studies are required to further validate these observations.
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Affiliation(s)
- Venu Kavarthapu
- Department of Orthopedic Surgery, King's College NHS Foundation Trust, London SE5 9RS, UK
| | - Jasdeep Giddie
- Department of Orthopedic Surgery, King's College NHS Foundation Trust, London SE5 9RS, UK
| | - Varun Kommalapati
- Department of Orthopedic Surgery, King's College NHS Foundation Trust, London SE5 9RS, UK
| | - Joanne Casey
- Diabetes Foot Clinic, King's College NHS Foundation Trust, London SE5 9RS, UK
| | - Maureen Bates
- Diabetes Foot Clinic, King's College NHS Foundation Trust, London SE5 9RS, UK
| | - Prashanth Vas
- Diabetes Foot Clinic, King's College NHS Foundation Trust, London SE5 9RS, UK
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Tang Y, Huang Y, Luo L, Xu M, Deng D, Fang Z, Zhao X, Chen M. Level of 25-hydroxyvitamin D and vitamin D receptor in diabetic foot ulcer and factor associated with diabetic foot ulcers. Diabetol Metab Syndr 2023; 15:30. [PMID: 36829206 PMCID: PMC9951493 DOI: 10.1186/s13098-023-01002-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/17/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND At present, there is no clinical study to elucidate the correlation between vitamin D deficiency and the incidence of diabetic foot osteomyelitis (DFO).This study aims to clarify levels of 25-hydroxyvitamin D [25(OH)VD] in peripheral blood and vitamin D receptor (VDR) expression in wound margin tissues (T-VDR) of patients with type 2 diabetes mellitus (T2DM) with diabetic foot ulcer (DFU) and DFO, and to determine its correlation with treatment outcomes of DFU and DFO, and and its value as a potential biomarker for the diagnosis of DFU and DFO. METHODS 156 T2DM patients with DFU (DFU group), 100 T2DM patients without DFU (T2DM group), and 100 healthy controls (NC group). The DFU group patients were subdivided into DFO (n = 80) and NDFO groups (n = 76). The level of serum 25(OH)VD was measured via chemiluminescence immunoassay, and T-VDR expression level was determined by quantitative real-time PCR. RESULTS The levels of serum 25(OH)VD in the DFU group were significantly lower than the T2DM group [(10.3 (5.8, 18.7) vs 15.7 (8.6, 24.6) ng/mL, P = 0.002)]. Similarly, the levels of serum 25(OH)VD and T-VDR expression in the DFO group were statistically lower than the NDFO group [9.2 (5.2, 20.5) vs 12.8 (6.9, 22.1) ng/mL, P = 0.006)], [1.96 (0.61, 3.97) vs 3.11 (1.36, 5.11), P = 0.004)], respectively. Furthermore, the levels of serum 25(OH)VD and T-VDR expression in DFU patients were positively correlated with the ulcer healing rate of foot ulcer after 8 weeks of treatment ( P = 0.031, P = 0.016, respectively). Multivariate logistic regression analysis showed that low level of serum 25(OH)VD was an independent risk factor for DFU and DFO (ORDFU = 2.42, ORDFO = 3.05, P = 0.008, 0.001, respectively), and decreased T-VDR expression level was an independent risk factor for DFO (OR = 2.83, P = 0.004). Meanwhile, the ROC curve analysis indicated that the AUC of serum 25(OH)VD level for the diagnosis of DFU and DFO was 0.821 (95% CI, 0.754-0.886, P < 0.001) and 0.786 (95%CI, 0.643-0.867, P < 0.001), respectively. When establishing a diagnosis of DFO, the AUC of T-VDR expression level was 0.703 (95%CI: 0.618-0.853, P < 0.001). CONCLUSIONS The levels of serum 25(OH)VD and T-VDR expression in DFU and DFO decreased. Serum 25(OH)VD and T-VDR are potentially valuable biomarkers for diagnosis and prognosis of DFU and DFO. .
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Affiliation(s)
- Ying Tang
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui People’s Republic of China
| | - Yixuan Huang
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui People’s Republic of China
| | - Li Luo
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui People’s Republic of China
| | - Murong Xu
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui People’s Republic of China
| | - Datong Deng
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui People’s Republic of China
| | - Zhaohui Fang
- Department of Endocrinology, The First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, Anhui People’s Republic of China
| | - Xiaotong Zhao
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui People’s Republic of China
| | - Mingwei Chen
- Department of Endocrinology, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui People’s Republic of China
- Department of Endocrinology, The First Affiliated Hospital of Anhui University of Traditional Chinese Medicine, Hefei, Anhui People’s Republic of China
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Álvaro-Afonso FJ, García-Álvarez Y, Tardáguila-García A, García-Madrid M, López-Moral M, Lázaro-Martínez JL. Bacterial Diversity and Antibiotic Resistance in Patients with Diabetic Foot Osteomyelitis. Antibiotics (Basel) 2023; 12:antibiotics12020212. [PMID: 36830123 PMCID: PMC9951858 DOI: 10.3390/antibiotics12020212] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 01/16/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
This study analysed the bacterial diversity, antibiotic susceptibility, and resistance in patients with complications of diabetic foot osteomyelitis (DFO). A retrospective observational study was carried out between September 2019 and September 2022 and involved 215 outpatients with a diagnosis of DFO at a specialized diabetic foot unit. A total of 204 positive bone cultures were isolated, including 62.7% monomicrobial cultures, and 37.3% were formed with at least two microorganisms. We observed that Proteus spp., Coagulase-negative staphylococci (CoNS), Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, and Corynebacterium were the most frequently isolated microorganisms and accounted for more than 10% of the DFO cases. With stratification by Gram-positive (GP) and Gram-negative (GN) bacteria, we observed that 91.6% of cultures presented at least one GP bacteria species, and 50.4% presented at least one GN bacteria species. The most common GP species were CoNS (29%), S. aureus (25.8%), and Corynebacterium spp. (14%). The most frequent GN species consisted of Proteus spp. (32%), P. aeruginosa (23.3%), and E. coli (17.5%). The main antibiotics with resistance to GP-dominated infections were penicillins without β-lactamase inhibitor, and those in GN-dominated infections were sulfonamides and penicillins without β-lactamase. Significant differences were not observed in mean healing time in DFU with acute osteomyelitis (12.76 weeks (4.50;18)) compared to chronic osteomyelitis (15.31 weeks (7;18.25); p = 0.101) and when comparing cases with soft tissue infection (15.95 (6;20)) and those without such an infection (16.59 (7.25;19.75), p = 0.618). This study shows that when treatment of DFO is based on early surgical treatment, the type of DFO and the presence of soft infection are not associated with different or worse prognoses.
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Affiliation(s)
- Francisco Javier Álvaro-Afonso
- Diabetic Foot Unit, Clínica Universitaria de Podología, Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - Yolanda García-Álvarez
- Diabetic Foot Unit, Clínica Universitaria de Podología, Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
- Correspondence: ; Tel.: +34-913941609
| | - Aroa Tardáguila-García
- Diabetic Foot Unit, Clínica Universitaria de Podología, Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - Marta García-Madrid
- Diabetic Foot Unit, Clínica Universitaria de Podología, Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - Mateo López-Moral
- Diabetic Foot Unit, Clínica Universitaria de Podología, Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
| | - José Luis Lázaro-Martínez
- Diabetic Foot Unit, Clínica Universitaria de Podología, Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid, 28040 Madrid, Spain
- Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), 28040 Madrid, Spain
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Variables That Could Influence Healing Time in Patients with Diabetic Foot Osteomyelitis. J Clin Med 2023; 12:jcm12010345. [PMID: 36615145 PMCID: PMC9820935 DOI: 10.3390/jcm12010345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 12/27/2022] [Accepted: 12/29/2022] [Indexed: 01/03/2023] Open
Abstract
AIM To compare the healing time in patients with diabetic foot osteomyelitis according to the presence or absence of clinical signs of infection, variation of blood parameters, the presence of different radiological signs, and the treatment received for the management of osteomyelitis. METHODS A prospective observational study was carried out in a specialised Diabetic Foot Unit between November 2014 and November 2018. A total of 116 patients with osteomyelitis were included in the study (treated by either a surgical or medical approach). During the baseline visit, we assessed the diagnosis of osteomyelitis, demographic characteristics and medical history, vascular and neurological examination, clinical signs of infection, increased blood parameters, radiological signs of osteomyelitis, and the treatment to manage osteomyelitis. We analysed the association between the presence of clinical signs of infection, variation of blood parameters, presence of radiological signs, and treatment received for management of osteomyelitis with the healing time. RESULTS The mean time to ulcer healing was 15.8 ± 9.7 weeks. Concerning healing times, we did not find an association with the presence of clinical signs of infection or with the increase in blood parameters, except in the case of eosinophils, which with higher values appear to increase the healing time (U = 66, z = -2.880, p = 0.004). Likewise, no relationship has been found between healing time and the appearance of the different radiological signs of osteomyelitis, nor depending on the treatment administered for the management of osteomyelitis. CONCLUSION High levels of eosinophils are associated with a longer healing time of diabetic foot ulcers complicated with osteomyelitis, finding no other factors related to increased healing time.
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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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19
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Could X-ray Predict Long-term Complications in Patients with Diabetic Foot Osteomyelitis? Adv Skin Wound Care 2022; 35:1-5. [PMID: 35856615 DOI: 10.1097/01.asw.0000834460.20632.18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To analyze the association between radiologic changes on plain X-rays in patients with diabetic foot osteomyelitis and the development of complications at the 1-year follow-up. METHODS A prospective, observational study was conducted involving 115 patients with diabetic foot osteomyelitis. X-ray features that were evaluated during 1-year follow-up visits included affected bone marrow, active periosteal reaction, sequestrum, cortical disruption, and other types of signs. Researchers analyzed the association between the presence of X-ray changes and complication development, such as bone or soft tissue infections, ulcer recurrence, reulceration, amputation, death, and other diabetic foot disease-related events. RESULTS During follow-up, of 115 patients included in the study, 33 patients (28.7%) showed radiologic changes, and 85 (73.9%) developed complications. The presence of radiologic changes after ulcer healing had a significant association with complication development during the 1-year follow-up in addition to those found at different follow-up visits. Patients who showed radiologic changes had higher percentages of complications during the 1-year follow-up, and patients without radiologic changes had lower percentages of complications. CONCLUSIONS The presence of radiologic changes is related to the development of complications in patients who suffer from diabetic foot osteomyelitis.
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Tardáguila-García A, Sanz-Corbalán I, López-Moral M, García-Madrid M, García-Morales E, Lázaro-Martínez JL. Are Digital Arthroplasty and Arthrodesis Useful and Safe Surgical Techniques for the Management of Patients with Diabetic Foot? Adv Skin Wound Care 2022; 35:1-6. [PMID: 35723960 DOI: 10.1097/01.asw.0000831088.63458.d3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To analyze and compare the development of short- and long-term complications in patients with diabetic foot after digital arthroplasty or arthrodesis. METHODS The authors reviewed patient records from January 2017 to March 2020. Patients were treated by digital arthroplasty or arthrodesis to correct toe deformity (elective or prophylactic surgery), achieve ulcer healing in toes (curative surgery), or manage toe infection (emergent surgery). During 1-year follow-up, researchers registered short- and long-term complications. Researchers analyzed the association between the type of surgery and the development of short- and long-term complications. RESULTS Forty-four patients (83.0%) received arthroplasty, and nine (17.0%) received arthrodesis. The mean time to heal from ulcers was 5.2 ± 5.2 weeks. A significant association was observed between arthrodesis and the development of long-term complications (P = .044; odds ratio, 5.1; 95% confidence interval, 0.9-27.2). No differences were observed between type of surgery and short- or long-term complications. Moreover, both short- and long-term complications were related to longer time to heal (respectively, 7.6 ± 6.0 vs 2.1 ± 0.5 weeks, P < .001; and 6.3 ± 6.2 vs 4.2 ± 4.0 weeks, P = .039). CONCLUSIONS Digital arthroplasty or arthrodesis are good options for managing patients with diabetic foot who require digital deformity correction to achieve digital ulcer healing or management of diabetic foot infection in phalanges.
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Affiliation(s)
- Aroa Tardáguila-García
- At the Diabetic Foot Unit, Clínica Universitaria de Podología, Facultad de Enfermería, Fisioterapia y Podología, Universidad Complutense de Madrid and Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC) 28040, Madrid, Spain, Aroa Tardáguila-García, DPM, PhD; Irene Sanz-Corbalán, DPM, PhD; Mateo López-Moral, DPM, PhD; Marta García-Madrid, DPM; Esther García-Morales, DPM, PhD; and José Luis Lázaro-Martínez, DPM, PhD, are Podiatrists. The authors have disclosed no financial relationships related to this article. Submitted July 27, 2021; accepted in revised form September 7, 2021
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21
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Maurer S, Hepp Z, McCallin S, Waibel F, Romero F, Zorman Y, Lipsky B, Uçkay İ. Short and oral antimicrobial therapy for diabetic foot infection: a narrative review of current knowledge. J Bone Jt Infect 2022; 7:61-70. [PMID: 35415069 PMCID: PMC8990364 DOI: 10.5194/jbji-7-61-2022] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/17/2022] [Indexed: 02/06/2023] Open
Abstract
Diabetic foot infection is a frequent complication in long-standing diabetes mellitus. For antimicrobial therapy of this infection, both the optimal duration and the route of administration are often based more on expert opinion than on published evidence. We reviewed the scientific literature, specifically seeking prospective trials, and aimed at addressing two clinical issues: (1) shortening the currently recommended antibiotic duration and (2) using oral (rather than parenteral) therapy, especially after the patient has undergone debridement and revascularization. We also reviewed some older key articles that are critical to our understanding of the treatment of these infections, particularly with respect to diabetic foot osteomyelitis. Our conclusion is that the maximum duration of antibiotic therapy for osteomyelitis should be no more than to 4-6 weeks and might even be shorter in selected cases. In the future, in addition to conducting randomized trials and propagating national and international guidance, we should also explore innovative strategies, such as intraosseous antibiotic agents and bacteriophages.
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Affiliation(s)
- Steven M. Maurer
- Orthopedic Surgery, Balgrist University Hospital, University of
Zurich, Zurich, Switzerland
| | - Zehra S. Hepp
- Orthopedic Surgery, Balgrist University Hospital, University of
Zurich, Zurich, Switzerland
- Internal Medicine, Balgrist University Hospital, University of
Zurich, Zurich, Switzerland
| | - Shawna McCallin
- Clinical and Phage Research, Balgrist University Hospital, University
of Zurich, Zurich, Switzerland
| | - Felix W. A. Waibel
- Orthopedic Surgery, Balgrist University Hospital, University of
Zurich, Zurich, Switzerland
| | - Federico C. Romero
- Department of Infectious Diseases, Sanatorio
Allende Hospital, Córdoba, Argentina
| | - Yılmaz Zorman
- Cardiovascular Surgery Department, Koç University Hospital,
Istanbul, Turkey
| | | | - İlker Uçkay
- Infectiology, Balgrist University Hospital, University of Zurich, Zurich,
Switzerland
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22
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Seng L, Drovandi A, Fernando ME, Golledge J. Opinions about the most appropriate surgical management of diabetes-related foot infection: a cross-sectional survey. J Foot Ankle Res 2022; 15:18. [PMID: 35232476 PMCID: PMC8889647 DOI: 10.1186/s13047-022-00523-w] [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: 08/30/2021] [Accepted: 02/21/2022] [Indexed: 11/18/2022] Open
Abstract
Background There is a lack of high quality evidence to guide the optimal management of diabetes-related foot infection, particularly in cases of severe diabetes-related foot infection and diabetes-related foot osteomyelitis. This study examined the opinions of surgeons about the preferred management of severe diabetes-related foot infection. Methods Vascular and orthopaedic surgeons in Australia and New Zealand were invited to complete an online survey via email. The survey included multi-choice and open-ended questions on clinical management of diabetes-related foot infection. Responses of vascular surgeons and orthopaedic surgeons were compared using non-parametric statistical tests. Open-text responses were examined using inductive content analysis. Results 29 vascular and 20 orthopaedic surgeons completed the survey. One-third (28.6%) used best-practice guidelines to assist in decisions about foot infection management. Areas for guideline improvement identified included more specific advice regarding the indications for available treatments, more recommendations about non-surgical patient management and advice on how management can be varied in regions with limited health service resource. The probe-to-bone test and magnetic resonance imaging were the preferred methods of diagnosing osteomyelitis. Approximately half (51.2%) of respondents indicated piperacillin combined with tazobactam as the preferred antibiotic choice for empirical treatment of severe diabetes-related foot infection. Negative pressure wound therapy was the most common way of managing a wound following debridement. All vascular surgeons (100%) made revascularisation decisions based on the severity of ischemia while most orthopaedic surgeons (66.7%) were likely to refer to vascular surgeons to make revascularisation decisions. Vascular surgeons preferred using wound swabs while orthopaedic surgeons favoured tissue or bone biopsies to determine the choice of antibiotic. Respondents perceived a moderate variation in management decisions between specialists and supported the need for randomised controlled trials to test different management pathways. Conclusions Most vascular and orthopaedic surgeons do not use best-practice guidelines to assist in decisions about management of diabetes-related foot infection. Vascular and orthopaedic surgeons appear to have different preferences for wound sampling to determine choice of antibiotic. There is a need for higher quality evidence to clarify best practice for managing diabetes-related foot infection. Supplementary Information The online version contains supplementary material available at 10.1186/s13047-022-00523-w.
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Affiliation(s)
- Leonard Seng
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, 4811, Townsville, Queensland, Australia
| | - Aaron Drovandi
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, 4811, Townsville, Queensland, Australia
| | - Malindu E Fernando
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, 4811, Townsville, Queensland, Australia.,Faculty of Health and Medicine, School of Health Sciences, University of Newcastle, Newcastle, New South Wales, Australia.,Ulcer and wound Healing consortium (UHEAL), Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, 4811, Townsville, Queensland, Australia. .,Ulcer and wound Healing consortium (UHEAL), Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, Queensland, Australia. .,Department of Vascular and Endovascular Surgery, Townsville University Hospital, Townsville, Queensland, Australia.
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23
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Shademani A, Jackson JK, Thompson CJ, Chiao M. Controlled and localized antibiotics delivery using magnetic-responsive beads for synergistic treatment of orthopedic infection. J Biomed Mater Res A 2022; 110:1036-1051. [PMID: 34997805 DOI: 10.1002/jbm.a.37350] [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: 09/17/2021] [Revised: 12/06/2021] [Accepted: 12/09/2021] [Indexed: 11/07/2022]
Abstract
Antibiotic-loaded bone cement beads have been a reliable passive delivery system for the localized treatment of osteomyelitis; however, low, and unregulated drug release rates limit the ability of this system to maintain therapeutic concentrations. This problem is further amplified by drug-resistant pathogens that might invade or evolve under these conditions. Furthermore, currently available bone cements are incompatible with some antibiotics. The proposed device resembles conventional bone cement beads but contains an on-demand drug delivery magnetic sponge that provides actively controlled release of antibiotics. The slightly porous structure facilitates some drug diffusion while further drug release may be controlled remotely via magnetic actuation. Additionally, a combination of silver nitrate and gentamicin are used in the device as these agents are shown to display a synergistic antibacterial activity in vitro using checkerboard and time-kill assays. The device releases gentamicin and silver in both actuation and diffusion modes over 7 days. The in vitro bacterial studies demonstrate the efficacy of the released agents alone, and synergistically in combination, against Methicillin-resistant Staphylococcus aureus and Escherichia coli. The proposed device offers a facile fabrication process which allows control of the release profile by engineering hole configurations or manipulating magnetic field strength to provide the most effective therapy.
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Affiliation(s)
- Ali Shademani
- School of Biomedical Engineering, University of British Columbia, Vancouver, British Columbia, Canada
| | - John K Jackson
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Charles J Thompson
- Department of Microbiology and Immunology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mu Chiao
- Department of Mechanical Engineering, University of British Columbia, Vancouver, British Columbia, Canada
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24
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Meloni M, Lazaro-Martínez JL, Ahluwalia R, Bouillet B, Izzo V, Di Venanzio M, Iacopi E, Manu C, Garcia-Klepzig JL, Sánchez-Ríos JP, Lüedemann C, De Buruaga VRS, Vouillarmet J, Guillaumat J, Aleandri AR, Giurato L, Edmonds M, Piaggesi A, Van Acker K, Uccioli L. Effectiveness of fast-track pathway for diabetic foot ulcerations. Acta Diabetol 2021; 58:1351-1358. [PMID: 33942178 PMCID: PMC8413149 DOI: 10.1007/s00592-021-01721-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 04/12/2021] [Indexed: 01/22/2023]
Abstract
AIM To investigate the effectiveness of fast-track pathway (FTP) in the management of diabetic foot ulceration (DFU) after 2 years of implementation. METHODS The study group was composed of patients who referred to a specialized DF centre due to DFUs. Those were divided in two groups: early referral (ER) and late referral (LR) patients. According to FTP, ER were considered patients who referred after 2 weeks in the case of uncomplicated non-healing ulcers (superficial, not infected, not ischemic), within 4 days in the case of complicated ulcers (ischemic, deep, mild infection) and within 24 h in the case of severely complicated ulcers (abscess, wet gangrene, fever). Healing, healing time, minor and major amputation, hospitalization, and survival were evaluated. The follow-up was 6 months. RESULTS Two hundred patients were recruited. The mean age was 70 ± 13 years, 62.5% were male, 91% were affected by type 2 diabetes with a mean duration of 18 ± 11 years. Within the group, 79.5% had ER while 20.5% had LR. ER patients showed increased rates of healing (89.9 vs. 41.5%, p = 0.001), reduced healing time (10 vs. 16 weeks, p = 0.0002), lower rates of minor (17.6 vs. 75.6%, p < 0.0001) and major amputation (0.6 vs. 36.6%, p < 0.0001), hospitalization (47.1 vs. 82.9%, p = 0.001), and mortality (4.4 vs. 19.5%, p = 0.02) in comparison to LR. At multivariate analysis, ER was an independent predictor of healing, while LR was an independent predictor for minor and major amputation and hospitalization. CONCLUSION After the FTP implementation, less cases of LR were reported in comparison to ER. ER was an independent predictor of positive outcomes such as healing, healing time, limb salvage, hospitalization, and survival.
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Affiliation(s)
- Marco Meloni
- Diabetic Foot Unit, University of Rome Tor Vergata, Viale Oxford 81, 00133, Rome, Italy.
| | | | - Raju Ahluwalia
- Department of Trauma and Ortophaedic Department, King ́s College Hospital, London, UK
| | | | - Valentina Izzo
- Diabetic Foot Unit, University of Rome Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
| | | | - Elisabetta Iacopi
- Diabetic Foot Section, University of Pisa, Ospedale Di Cisanello, Pisa, Italy
| | - Chris Manu
- Diabetic Foot Clinic, King's College Hospital, Denmark Hill, London, UK
| | | | | | | | | | | | | | | | - Laura Giurato
- Diabetic Foot Unit, University of Rome Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
| | - Micheal Edmonds
- Diabetic Foot Clinic, King's College Hospital, Denmark Hill, London, UK
| | - Alberto Piaggesi
- Diabetic Foot Section, University of Pisa, Ospedale Di Cisanello, Pisa, Italy
| | | | - Luigi Uccioli
- Diabetic Foot Unit, University of Rome Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
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25
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Meloni M, Morosetti D, Giurato L, Stefanini M, Loreni G, Doddi M, Panunzi A, Bellia A, Gandini R, Brocco E, Lazaro-Martinez JL, Lauro D, Uccioli L. Foot Revascularization Avoids Major Amputation in Persons with Diabetes and Ischaemic Foot Ulcers. J Clin Med 2021; 10:3977. [PMID: 34501432 PMCID: PMC8432560 DOI: 10.3390/jcm10173977] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 08/22/2021] [Accepted: 09/02/2021] [Indexed: 11/23/2022] Open
Abstract
The study aims to evaluate the effectiveness of foot revascularization in persons with diabetic foot ulcers (DFUs) and below-the-ankle (BTA) arterial disease. Consecutive patients referred for a new active ischaemic DFU requiring lower limb revascularization were considered. Among those, only patients with a BTA arterial disease were included. Revascularization procedures were retrospectively analysed: in the case of successful foot revascularization (recanalization of pedal artery, or plantar arteries or both) or not, patients were respectively divided in two groups, successful foot perfusion (SFP) and failed foot perfusion (FFP). Healing, minor and major amputation at 12 months of follow-up were evaluated and compared. Eighty patients (80) were included. The mean age was 70.5 ± 10.9 years, 55 (68.7%) were male, 72 (90%) were affected by type 2 diabetes with a mean duration of 22.7 ± 11.3 years. Overall 45 (56.2%) patients healed, 47 (58.7%) had minor amputation and 13 (16.2%) major amputation. Outcomes for SFP and FFP were respectively: healing (89.3 vs. 9.1%, p < 0.0001), minor amputation (44.7 vs. 78.8%, p = 0.0001), major amputation (2.1 vs. 36.3%, p < 0.0001). Failed foot revascularization resulted an independent predictor of non-healing, minor amputation, and major amputation. Foot revascularization is mandatory to achieve healing and avoid major amputation in persons with ischaemic DFU and BTA arterial disease.
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Affiliation(s)
- Marco Meloni
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (L.G.); (A.P.); (A.B.); (D.L.); (L.U.)
| | - Daniele Morosetti
- Department of Interventional Radiology, University of Rome “Tor Vergata”, 00133 Rome, Italy; (D.M.); (R.G.)
| | - Laura Giurato
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (L.G.); (A.P.); (A.B.); (D.L.); (L.U.)
| | - Matteo Stefanini
- Department of Radiology, Casilino Polyclinic, 00169 Rome, Italy;
| | - Giorgio Loreni
- Department of Interventional Radiology, Sandro Pertini Hospital, 00157 Rome, Italy; (G.L.); (M.D.)
- Diabetic Foot Centre, Abano Terme Polyclinic, 35031 Abano Terme, Italy;
| | - Marco Doddi
- Department of Interventional Radiology, Sandro Pertini Hospital, 00157 Rome, Italy; (G.L.); (M.D.)
| | - Andrea Panunzi
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (L.G.); (A.P.); (A.B.); (D.L.); (L.U.)
| | - Alfonso Bellia
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (L.G.); (A.P.); (A.B.); (D.L.); (L.U.)
| | - Roberto Gandini
- Department of Interventional Radiology, University of Rome “Tor Vergata”, 00133 Rome, Italy; (D.M.); (R.G.)
| | - Enrico Brocco
- Diabetic Foot Centre, Abano Terme Polyclinic, 35031 Abano Terme, Italy;
| | - José Luis Lazaro-Martinez
- Instituto de Investigacion Sanitaria San Carlo Hospital, Complutense University of Madrid, 28040 Madrid, Spain;
| | - Davide Lauro
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (L.G.); (A.P.); (A.B.); (D.L.); (L.U.)
| | - Luigi Uccioli
- Department of Systems Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (L.G.); (A.P.); (A.B.); (D.L.); (L.U.)
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Schmidt BM, Erb-Downward J, Ranjan P, Dickson R. Metagenomics to Identify Pathogens in Diabetic Foot Ulcers and the Potential Impact for Clinical Care. Curr Diab Rep 2021; 21:26. [PMID: 34152440 DOI: 10.1007/s11892-021-01391-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/28/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE OF REVIEW Diabetes mellitus may affect every third adult American by 2050, and about one-third will develop a diabetic foot ulcer (DFU) during their lifetime. The current standard of care results in healing of less than 50% of all DFUs. Many individuals with DFU develop limb-threatening infection which place them at risk for additional morbidity and mortality. We review research associated with culture-independent next-generation sequencing techniques pertaining to diabetic foot ulcers and their potential for clinical application. RECENT FINDINGS Diabetic foot ulcers are a growing problem and clinicians are limited by their reliance on conventional culture. Metagenomic sequencing technology provides an unparalleled viewpoint of the polymicrobial constituency of DFU. The microbiome techniques used to study the microbial constituency of DFU may offer insight to improve care for these patients, but without standardized approaches in research based on real-world clinical practices, a significant knowledge gap will remain.
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Affiliation(s)
- Brian M Schmidt
- Division of Metabolism, Endocrinology & Diabetes, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, 48109, USA.
- University of Michigan Medical School, 24 Frank Lloyd Wright Drive Lobby C, Ann Arbor, MI, 48109, USA.
| | - John Erb-Downward
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Piyush Ranjan
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Robert Dickson
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA
- Michigan Center for Integrative Research in Critical Care, Ann Arbor, MI, USA
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Tardáguila-García A, García-Álvarez Y, García-Morales E, López-Moral M, Sanz-Corbalán I, Lázaro-Martínez JL. Long-Term Complications after Surgical or Medical Treatment of Predominantly Forefoot Diabetic Foot Osteomyelitis: 1 Year Follow Up. J Clin Med 2021; 10:jcm10091943. [PMID: 34062728 PMCID: PMC8124200 DOI: 10.3390/jcm10091943] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/28/2021] [Accepted: 04/29/2021] [Indexed: 12/22/2022] Open
Abstract
AIM To compare long-term complications according to the treatment received for management of diabetic foot osteomyelitis (surgical or medical) at 1 year follow up. DESIGN AND PARTICIPANTS A prospective observational study was conducted involving 116 patients with diabetic foot osteomyelitis. The patients received surgical or medical treatment based on the principles described in the literature. To register the development of a complication, both groups of treatments were followed-up 1 year after the ulcer had healed. RESULTS Ninety-six (82.8%) patients received surgical treatment and 20 (17.2%) medical treatment. No differences were found in the time to healing between both groups of treatment, 15.7 ± 9.2 weeks in the surgical group versus 16.4 ± 12.1 weeks in the medical group; p = 0.103. During follow up, 85 (73.3%) patients developed complications without differences between both groups, 68 (70.8%) in the surgical group versus 17 (85%) in the medical group (p = 0.193). The most common complication in both groups was re-ulceration. We did not observe significant differences comparing complication-free time survival between both treatments (p = 0.665). CONCLUSION The onset of complications after healing in patients who suffered from diabetic foot osteomyelitis was not associated with the treatment received. Surgical and medical approaches to the management of diabetic foot osteomyelitis produced similar results in long-term follow up.
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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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Medical Versus Surgical Treatment for the Management of Diabetic Foot Osteomyelitis: A Systematic Review. J Clin Med 2021; 10:jcm10061237. [PMID: 33802685 PMCID: PMC8002587 DOI: 10.3390/jcm10061237] [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] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 03/02/2021] [Accepted: 03/11/2021] [Indexed: 12/27/2022] Open
Abstract
A systematic review and quality assessment was performed to assess the management of diabetic foot osteomyelitis by medical or surgical treatment. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) checklist was used. All selected studies were evaluated using the Cochrane Risk of Bias Tool to assess the risk of bias for randomized controlled trials. The literature was revised using PubMed (Medline) and Embase (Elsevier) up to September 2020 to identify clinical trials assessing medical or surgical treatment to manage diabetic foot osteomyelitis. A total of six clinical trials that met our inclusion criteria, with a total of 308 participants. Healing rate, complete closure of the wound, and type of complications were the outcomes evaluated. Risk of bias assessment showed that only two of the six clinical trials included in the systematic review had a low risk of bias. Based on our findings, we believe that the management of diabetic foot osteomyelitis remains challenging. There are few high-quality clinical trials that both stratify clinical presentations and compare these treatments. We conclude that the available evidence is insufficient to identify the best option to cure diabetic foot osteomyelitis.
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30
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Gariani K, Lebowitz D, Kressmann B, Gariani J, Uçkay I. X-Ray Versus Magnetic Resonance Imaging in Diabetic Foot Osteomyelitis: A Clinical Comparison. Curr Diabetes Rev 2021; 17:373-377. [PMID: 32729421 DOI: 10.2174/1573399816999200729124134] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 07/13/2020] [Accepted: 07/15/2020] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Radiographic imaging is an important diagnostic tool in diabetic foot osteomyelitis (DFO). It is unknown whether DFO cases diagnosed with conventional X-ray versus positive Magnetic Resonance Imaging (MRI) differ regarding epidemiology and treatment outcome. Theoretically, signs of inflammation on MRI without bone lesions might be easier to treat. METHODS Our clinical pathway for diabetic foot infections discourages the use of MRI for the diagnosis of DFO. We compared the epidemiology and therapy of non-amputated DFO with positive features on conventional X-ray, MRI, or both. Radiology specialists interpreted the images. The intraoperative aspect of bone during amputation and the results of bone cultures were considered the gold standard for DFO diagnosis. RESULTS We prospectively followed 390 DFO episodes in 186 adult patients for a median of 2.9 years and performed 318 conventional X-rays (median costs 100 Swiss Francs; 100 US$) and 47 (47/390; 12%) MRI scans (median 800 Swiss Francs; 800 US $). Among them, 18 episodes were associated with positive MRI findings but lacked bone lesions on X-ray. After debridement, the median duration of systemic antibiotics was 28 days for MRI-only episodes and 30 days for X-ray-positive cases (Wilcoxonranksum- test; p=0.26). The corresponding median numbers of surgical debridements were 1 and 1; and recurrence was witnessed in 25% and 28%, respectively. In multivariate logistic regression analysis, MRI-only episodes did not alter the remission rate (odds ratio 0.5, 95%CI 0.1-5.2). CONCLUSION According to our clinical pathway, DFO episodes with positive MRI findings only did not differ epidemiologically from the remaining DFO cases and did not influence the choice of therapy nor remission rate.
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Affiliation(s)
- Karim Gariani
- Division of Endocrinology, Diabetes, Hypertension and Nutrition, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Dan Lebowitz
- Division of Endocrinology, Diabetes, Hypertension and Nutrition, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland
| | - Benjamin Kressmann
- Clinical Pathway of Diabetic Foot Infections, University of Geneva Hospitals and Medical School, 1211 Geneva, Switzerland
| | - Joanna Gariani
- Department of Radiology, Geneva University Hospitals, Geneva, Switzerland
| | - Ilker Uçkay
- Clinical Pathway of Diabetic Foot Infections, University of Geneva Hospitals and Medical School, 1211 Geneva, Switzerland
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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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Lázaro-Martínez JL, García-Madrid M, García-Álvarez Y, Álvaro-Afonso FJ, Sanz-Corbalán I, García-Morales E. Conservative surgery for chronic diabetic foot osteomyelitis: Procedures and recommendations. J Clin Orthop Trauma 2020; 16:86-98. [PMID: 33680830 PMCID: PMC7919928 DOI: 10.1016/j.jcot.2020.12.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 11/14/2020] [Accepted: 12/13/2020] [Indexed: 02/07/2023] Open
Abstract
Osteomyelitis (OM) is the most frequent infection associated with diabetic foot ulcers (DFU) that typically involve the forefoot, the most common location of DFU. Conservative surgical procedures could be attractive alternative that reduces minor and major amputations and avoid future recurrence thus preserving the functionally of the foot. This review aimed to analyze and describe the current evidence on conservative diabetic foot osteomyelitis (DFO) surgical procedures depending on DFU location and indications. A narrative revision of the evidence was carried out by searching Medline through PubMed databases from inception to late July 2020 to identify retrospective, prospective, and randomized controlled trials pertaining to conservative DFO procedures on the forefoot. Seven types of conservative surgical procedures for DFO treatment in the forefoot are described in this review: (1) partial or total distal phalangectomy, (2) arthroplasty of the proximal or distal interphalangeal joint, (3) distal Syme amputation, (4) percutaneous flexor tenotomy, (5) sesamoidectomy, (6) arthroplasty of the metatarsophalangeal joint, and (7) metatarsal head resection. When indicated, conservative surgery for DFUs in patients with chronic forefoot OM is a safe and effective option that increases the chances of healing and reduces the possibility of limb loss and death compared with radical amputation procedures. Since a lack of sufficient evidence supporting this procedure exists, future investigations should be focused on the random clinical trial (RCT) design. The results of prospective trials could help surgeons select the appropriate procedure in each case in order to minimize complications.
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Pintado JF, Gibaja W, Vallejos RA, Rosas W, Guerra-Farfan E, Nuñez JH. How COVID-19 has affected emergent visits to a Latin-American trauma department: Experience at a Peruvian national trauma referral center. Injury 2020; 51:2834-2839. [PMID: 33162012 PMCID: PMC7606069 DOI: 10.1016/j.injury.2020.11.005] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/24/2020] [Accepted: 11/01/2020] [Indexed: 02/02/2023]
Abstract
INTRODUCTION By May 2020, Peru was the country with the third most COVID-19 cases in the Americas. The current study's overall aim was to examine the impact of the current COVID-19 outbreak on the number of non-COVID-related patient presentations to a major national emergency traumatology/orthopedics referral center in Latin America. METHODS An observational study was performed at one of Peru's main tertiary trauma referral centers, during the current COVID-19 pandemic. Numbers of non-follow-up patients presenting to the traumatology/ orthopedics service were counted and compared between January through April 2019 and January through April 2020; and between the month immediately prior to the Peruvian government's implementation of national lock-down measures (Feb 16-Mar 15; Period 1) and the month immediately following (Mar 16-Apr 15; Period 2). The number of surgery service hospitalizations also was compared pre- versus post lockdown initiation (Period 1 vs. 2), as were patient characteristics and outcomes, like age, sex, discharge disposition, mortality, indications for hospital admission, and COVID-19 status. RESULT Comparing 2019 and 2020, no appreciable differences were detected in the number of patients seen in either January or February. However, relative to March and April 2019, the numbers of patients seen in March and April 2020 (the two months after the first Peruvian case of COVID-19 was detected) were reduced by 55.8 and 88.6%, respectively. Comparing the months immediately pre and post lockdown, the number of service patients declined by 79.9% in April, while the number of hospitalizations declined by 30.9%. The number of admissions for various surgical indications either remained stable or declined in parallel with the overall decline in admissions for all indications except for osteoporotic hip fractures and diabetic foot ulcers (both of which increased proportional to the overall number of admissions) and for hand and foot fractures, both of which decreased. CONCLUSION At our hospital, not all indications for traumatology/orthopedics service utilization declined despite the national government's directive to reduce non-COVID-related consultations and admissions. Some disorders presented with even greater frequency, which must be considered when developing contingencies for the reallocation of healthcare resources during a pandemic.
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Affiliation(s)
- Juan F. Pintado
- Department of Traumatology and Orthopedic Surgery, Edgardo Rebagliati Martins Hospital, Jesús María 15072, Lima, Perú,Corresponding authors
| | - William Gibaja
- Department of Traumatology and Orthopedic Surgery, Edgardo Rebagliati Martins Hospital, Jesús María 15072, Lima, Perú
| | - Rodrigo A. Vallejos
- Department of Traumatology and Orthopedic Surgery, Edgardo Rebagliati Martins Hospital, Jesús María 15072, Lima, Perú
| | - William Rosas
- Department of Traumatology and Orthopedic Surgery, Edgardo Rebagliati Martins Hospital, Jesús María 15072, Lima, Perú
| | - Ernesto Guerra-Farfan
- Department of Traumatology and Orthopedic Surgery, Mutua de Terrassa Hospital. Terrassa, Plaça del Doctor Robert, 5, 08221 Terrassa, Barcelona, Spain
| | - Jorge H. Nuñez
- Department of Traumatology and Orthopedic Surgery, University Hospital of Vall d'Hebron. Barcelona, Passeig de la Vall d'Hebron, 119-129, 08035 Barcelona, Spain,Department of Traumatology and Orthopedic Surgery, Mutua de Terrassa Hospital. Terrassa, Plaça del Doctor Robert, 5, 08221 Terrassa, Barcelona, Spain,Corresponding authors
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Utility of Blood Parameters to Detect Complications during Long-Term Follow-Up in Patients with Diabetic Foot Osteomyelitis. J Clin Med 2020; 9:jcm9113768. [PMID: 33266483 PMCID: PMC7700132 DOI: 10.3390/jcm9113768] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/14/2020] [Accepted: 11/19/2020] [Indexed: 01/10/2023] Open
Abstract
The evidence is still unclear regarding the role of blood parameters in detecting complications in patients who suffer from diabetic foot osteomyelitis (DFO). In this study, the aim was to identify the capacity of different blood parameters in the diagnosis and prediction of the onset of complications. A cross-sectional prospective study was carried out with 116 DFO patients. The following blood parameters were evaluated during 1 year of follow-up: leukocytes, neutrophils, lymphocytes, monocytes, eosinophils, basophils, erythrocyte sedimentation rate (ESR), glycemia, glycosylated hemoglobin, C-reactive protein (CRP), alkaline phosphatase, albumin, and creatinine. Complication events were assessed for each participant during the study period. We investigated the association between blood parameter values and the onset of complication events by conducting a receiver operating characteristic curve analysis. Eighty-five (73.3%) patients developed complications. Regarding blood parameters, higher values of lymphocytes and albumin were predictive factors at the 12-month follow-up once the ulcer had healed. Higher values of ESR had predictive and diagnostic value for the onset of complication events, and higher values of CRP and hyperglycemia were diagnostic factors since they were elevated during the occurrence of an event. In conclusion, after suffering from DFO, the elevation of lymphocytes, ESR, CRP, albumin, and glycemia could be useful in detecting and diagnosing patients who are likely to develop a complication. Serial blood tests are a useful tool for early detection by healthcare professionals to prevent complications.
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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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Vas PRJ, Demetriou M, Papanas N. Oral antibiotic therapy in diabetic foot osteomyelitis: one small step or a giant leap of faith? ANNALS OF TRANSLATIONAL MEDICINE 2020; 7:S266. [PMID: 32015985 DOI: 10.21037/atm.2019.12.53] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Maria Demetriou
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Nikolaos Papanas
- Diabetes Centre-Diabetic Foot Clinic, Second Department of Internal Medicine, Democritus University of Thrace, Alexandroupolis, Greece
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Huang JF, Wu QN, Zheng XQ, Sun XL, Wu CY, Wang XB, Wu CW, Wang B, Wang XY, Bergman M, Wu AM. The Characteristics and Mortality of Osteoporosis, Osteomyelitis, or Rheumatoid Arthritis in the Diabetes Population: A Retrospective Study. Int J Endocrinol 2020; 2020:8821978. [PMID: 33224196 PMCID: PMC7669351 DOI: 10.1155/2020/8821978] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 09/05/2020] [Accepted: 10/22/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Patients with diabetes mellitus are prone to develop osteoporosis, osteomyelitis, or rheumatoid arthritis (RA). Furthermore, the presence of these complications in those with diabetes may lead to higher mortality. The aim of our study was to assess characteristics and mortality of osteoporosis, osteomyelitis, or rheumatoid arthritis in individuals with diabetes. METHODS We analyzed osteoporosis, osteomyelitis, and RA deaths associated with diabetes from 1999-2017 using the CDC WONDER system (CDC WONDER; https://wonder.cdc.gov). We used ICD-10 codes to categorize the underlying and contributing causes of death. Crude mortality rates (CMR) and age-adjusted mortality rates (AAMR) per 1,000,000 person-years were calculated. RESULTS The AAMR for osteoporosis in the population with diabetes was significantly higher in females (AAMR: 4.17, 95% CI: 4.10-4.24) than in males (AAMR: 1.12, 95% CI: 1.07-1.16). Deaths due to osteoporosis increased gradually from 1999, peaked in 2003 (AAMR: 3.78, 95% CI: 3.55-4.00), and reached a nadir in 2016 (AAMR: 2.32, 95% CI: 2.15-2.48). The AAMR for RA associated with diabetes was slightly higher in females (AAMR: 4.04, 95% CI: 3.98-4.11) than in males (AAMR: 2.45, 95% CI: 2.39-2.51). The mortality rate due to RA increased slightly from 1999 (AAMR: 3.18, 95% CI: 2.97-3.39) to 2017 (AAMR: 3.20, 95% CI: 3.02-3.38). The AAMR for osteomyelitis associated with diabetes was higher in males (AAMR: 4.36, 95% CI: 4.28-4.44) than in females (AAMR: 2.31, 95% CI: 2.26-2.36). From 1999 to 2017, the AAMR from osteomyelitis in this population was 2.63 (95% CI: 2.44-2.82) per 1,000,000 person-years in 1999 and 4.25 (95% CI: 4.05-4.46) per 1,000,000 person-years in 2017. CONCLUSIONS We found an increase in the age-adjusted mortality rates of RA and osteomyelitis and a decrease of osteoporosis associated with diabetes from 1999 to 2017. We suggest that increased attention should therefore be given to these diseases in the population with diabetes, especially in efforts to develop preventative and treatment strategies.
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Affiliation(s)
- Jin-Feng Huang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325027, China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang 325027, China
| | - Qi-Nan Wu
- Endocrinology and Nephrology Department, Chongqing University Cancer Hospital and Chongqing Cancer Institute and Chongqing Cancer Hospital, Chongqing, China
| | - Xuan-Qi Zheng
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325027, China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang 325027, China
| | - Xiao-Lei Sun
- Department of Orthopaedics, Tianjin Hospital, Tianjin 300210, China
| | - Chen-Yu Wu
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325027, China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang 325027, China
| | - Xiao-Bing Wang
- Department of Rheumatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Chen-Wei Wu
- Diabetes Center and Department of Endocrinology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bin Wang
- Department of Sports Medicine and Adult Reconstruction Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing 210009, China
| | - Xiang-Yang Wang
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325027, China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang 325027, China
| | - Michael Bergman
- NYU Grossman School of Medicine, NYU Langone Diabetes Prevention Program, New York, NY 10016, USA
| | - Ai-Min Wu
- Department of Orthopaedics, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325027, China
- The Second School of Medicine, Wenzhou Medical University, Wenzhou, Zhejiang 325027, China
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Jiang X, Li N, Yuan Y, Yang C, Chen Y, Ma Y, Wang J, Du D, Boey J, Armstrong DG, Deng W. Limb Salvage and Prevention of Ulcer Recurrence in a Chronic Refractory Diabetic Foot Osteomyelitis. Diabetes Metab Syndr Obes 2020; 13:2289-2296. [PMID: 32636663 PMCID: PMC7335304 DOI: 10.2147/dmso.s254586] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Accepted: 06/10/2020] [Indexed: 12/17/2022] Open
Abstract
Biomechanical changes caused by structural foot deformities predispose patients to plantar ulceration. Plantar ulcer recurrence often leads to osteomyelitis, which is more commonly observed in patients with diabetes. Once the infection of diabetic foot ulcer (DFU) spreads and is complicated by osteomyelitis, treatment becomes more complicated and difficult. Osteomyelitis treatment remains challenging because of low drug concentration within the tissue caused by poor circulation and inadequate localized nutrition. Moreover, tissues around plantar ulcers are fewer and are thin, making the formation of granulation tissues difficult due to elevated plantar pressure. Furthermore, the skin around the wound is excessively keratinized, and the epidermis is hard to regenerate. Meanwhile, skin grafting at that site is often not successful due to poor blood circulation. Therefore, it is technically challenging to manage diabetic pressure plantar ulcer with osteomyelitis and prevent its recurrence. Here, we present a case of chronic DFU complicated by osteomyelitis due to foot deformity. The ulcer was successfully healed using advanced wound repair technology comprising of surgical bone resection, vancomycin-loaded bone cement implant, negative-pressure wound therapy, and autologous platelet-rich gel. Subsequently, preventive foot care with custom-made offloading footwear was prescribed. The plantar ulcer did not recur and improvement in biomechanical parameters was observed after the intervention. This case represents an effective and comprehensive management strategy for limb salvage and prevention in patients with complicated foot conditions.
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Affiliation(s)
- Xiaoyan Jiang
- Department of Endocrinology and Nephrology, Diabetic Foot Center, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, People’s Republic of China
| | - Ning Li
- Department of Endocrinology and Nephrology, Diabetic Foot Center, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, People’s Republic of China
| | - Yi Yuan
- Department of Endocrinology and Nephrology, Diabetic Foot Center, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, People’s Republic of China
| | - Cheng Yang
- Department of Endocrinology and Nephrology, Diabetic Foot Center, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, People’s Republic of China
| | - Yan Chen
- Department of Endocrinology and Nephrology, Diabetic Foot Center, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, People’s Republic of China
| | - Yu Ma
- Department of Endocrinology and Nephrology, Diabetic Foot Center, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, People’s Republic of China
| | - Jianbai Wang
- Department of Traumatology, Diabetic Foot Center, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, People’s Republic of China
| | - Dingyuan Du
- Department of Traumatology, Diabetic Foot Center, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, People’s Republic of China
| | - Johnson Boey
- Department of Podiatry, National University Hospital, Singapore
| | - David G Armstrong
- Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Wuquan Deng
- Department of Endocrinology and Nephrology, Diabetic Foot Center, Chongqing Emergency Medical Center, Chongqing University Central Hospital, Chongqing, People’s Republic of China
- Correspondence: Wuquan Deng Department of Endocrinology and Nephrology, Chongqing University Central Hospital, Chongqing Emergency Medical Center, No. 1 Jiankang Road, Chongqing400014, People’s Republic of ChinaTel +86 23 63692186 Email
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