From the diabetic foot ulcer and beyond: how do foot infections spread in patients with diabetes?

Microbiological Species and Antibiotic Resistance in Diabetic and Nondiabetic Lower Extremity Wounds: A Comparative Cross-Sectional Study

Severe lower extremity wounds have an increased risk of complications and limb loss. The aim of this study was to evaluate and compare the microbiological profile and antibiotic resistance of wounds in diabetic and nondiabetic patients. A cross-sectional comparative study was carried out at a public hospital including 111 patients with moderate to severe wound infections. Tissue samples were collected during a surgical procedure. One hundred and four patients (94%) had positive cultures and 88 (79%) had a Gram-negative microorganism. Among the 185 cultured microorganisms, 133 (72%) were Gram-negative species. Pseudomonas aeruginosa (23 cases) was the most isolated Gram-negative species, and Enterococcus faecalis (26 cases) was the most prevalent Gram-positive species. Among 185 isolated species, 45 (24%) were extended-spectrum beta-lactamase producers, 23 (12%) were carbapenem-resistant, and 5 (3%) were methicillin-resistant Staphylococcus aureus. Findings revealed that there was no significant difference in the microbiological profile and antibiotic resistance among patients with lower extremity wounds whether they were diabetic or nondiabetic.

Variation in Systemic Antibiotic Treatment for Diabetic Foot Osteomyelitis in England and Wales: A Multi-Centre Case Review

Background: Diabetic foot osteomyelitis (DFO) is a major complication and can lead to significant morbidity and mortality. Systemic antibiotic therapy is often initiated first line to achieve quiescence of infection. To perform a multi-centre case review of systemic antibiotic intervention to treat adults with DFO in England and Wales and compare with national guidelines 'Diabetic foot problems: prevention and management'. Methods: Eight centres from England and Wales retrospectively collated data from a minimum of five adults (aged ≥ 18 years) from electronic case records. All patients were treated with systemic antibiotics following a new diagnosis of DFO (1 June 2021-31 December 2021). Results: 40 patients (35 males and 5 females) were included; the mean age was 62.3 years (standard deviation (SD) 13.0). Patients commenced systemic oral 14 (35%) or intravenous 26 (65%) antibiotic therapy following a new diagnosis of DFO. Twenty-seven (67.5%) patients were medically or surgically managed in the 12-week period with clinical quiescence of infection. Twenty-one patients (52.5%) had no recurrence of DFO infection within 12 weeks; seventeen (42.5%) of these patients had clinical quiescence of infection with systemic antibiotics alone without surgical intervention and nine (22.5%) of these cases had no recurrence of DFO. There were no cases of major amputation or death. All centres showed significant in-centre variability in systemic antibiotic management; variability was reported in the clinical and quantity indicators specifically to antibiotic selection, single versus dual therapy, mode of delivery and duration of treatment. Conclusions: This case review identifies there is existing variation when treating adults with systemic antibiotics for DFO. Further national guidance is required to standardise service delivery and care to improve patient outcomes.

IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023)

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the management and prevention of diabetes-related foot diseases since 1999. The present guideline is an update of the 2019 IWGDF guideline on the diagnosis and management of foot infections in persons with diabetes mellitus. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used for the development of this guideline. This was structured around identifying clinically relevant questions in the P(A)ICO format, determining patient-important outcomes, systematically reviewing the evidence, assessing the certainty of the evidence, and finally moving from evidence to the recommendation. This guideline was developed for healthcare professionals involved in diabetes-related foot care to inform clinical care around patient-important outcomes. Two systematic reviews from 2019 were updated to inform this guideline, and a total of 149 studies (62 new) meeting inclusion criteria were identified from the updated search and incorporated in this guideline. Updated recommendations are derived from these systematic reviews, and best practice statements made where evidence was not available. Evidence was weighed in light of benefits and harms to arrive at a recommendation. The certainty of the evidence for some recommendations was modified in this update with a more refined application of the GRADE framework centred around patient important outcomes. This is highlighted in the rationale section of this update. A note is also made where the newly identified evidence did not alter the strength or certainty of evidence for previous recommendations. The recommendations presented here continue to cover various aspects of diagnosing soft tissue and bone infections, including the classification scheme for diagnosing infection and its severity. Guidance on how to collect microbiological samples, and how to process them to identify causative pathogens, is also outlined. Finally, we present the approach to treating foot infections in persons with diabetes, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and bone infections; when and how to approach surgical treatment; and which adjunctive treatments may or may not affect the infectious outcomes of diabetes-related foot problems. We believe that following these recommendations will help healthcare professionals provide better care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes-related foot disease.

IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-related Foot Infections (IWGDF/IDSA 2023)

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the management and prevention of diabetes-related foot diseases since 1999. The present guideline is an update of the 2019 IWGDF guideline on the diagnosis and management of foot infections in persons with diabetes mellitus. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used for the development of this guideline. This was structured around identifying clinically relevant questions in the P(A)ICO format, determining patient-important outcomes, systematically reviewing the evidence, assessing the certainty of the evidence, and finally moving from evidence to the recommendation. This guideline was developed for healthcare professionals involved in diabetes-related foot care to inform clinical care around patient-important outcomes. Two systematic reviews from 2019 were updated to inform this guideline, and a total of 149 studies (62 new) meeting inclusion criteria were identified from the updated search and incorporated in this guideline. Updated recommendations are derived from these systematic reviews, and best practice statements made where evidence was not available. Evidence was weighed in light of benefits and harms to arrive at a recommendation. The certainty of the evidence for some recommendations was modified in this update with a more refined application of the GRADE framework centred around patient important outcomes. This is highlighted in the rationale section of this update. A note is also made where the newly identified evidence did not alter the strength or certainty of evidence for previous recommendations. The recommendations presented here continue to cover various aspects of diagnosing soft tissue and bone infections, including the classification scheme for diagnosing infection and its severity. Guidance on how to collect microbiological samples, and how to process them to identify causative pathogens, is also outlined. Finally, we present the approach to treating foot infections in persons with diabetes, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and bone infections; when and how to approach surgical treatment; and which adjunctive treatments may or may not affect the infectious outcomes of diabetes-related foot problems. We believe that following these recommendations will help healthcare professionals provide better care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes-related foot disease.

Understanding the multifaceted etiopathogenesis of foot complications in individuals with diabetes

Diabetes mellitus, a chronic disease of metabolism, is characterized by a disordered production or cellular utilization of insulin. Diabetic foot disease, which comprises the spectrum of infection, ulceration, and gangrene, is one of the most severe complications of diabetes and is the most common cause of hospitalization in diabetic patients. The aim of this study is to provide an evidence-based overview of diabetic foot complications. Due to neuropathy, diabetic foot infections can occur in the form of ulcers and minor skin lesions. In patients with diabetic foot ulcers, ischemia and infection are the main causes of non-healing ulcers and amputations. Hyperglycemia compromises the immune system of individuals with diabetes, leading to persistent inflammation and delayed wound healing. In addition, the treatment of diabetic foot infections is challenging due to difficulty in accurate identification of pathogenic microorganisms and the widespread issue of antimicrobial resistance. As a further complicating factor, the warning signs and symptoms of diabetic foot problems can easily be overlooked. Issues associated with diabetic foot complications include peripheral arterial disease and osteomyelitis; accordingly, the risk of these complications in people with diabetes should be assessed annually. Although antimicrobial agents represent the mainstay of treatment for diabetic foot infections, if peripheral arterial disease is present, revascularization should be considered to prevent limb amputation. A multidisciplinary approach to the prevention, diagnosis, and treatment of diabetic patients, including those with foot ulcers, is of the utmost importance to reduce the cost of treatment and avoid major adverse consequences such as amputation.

A Review of Immunomodulatory Reprogramming by Probiotics in Combating Chronic and Acute Diabetic Foot Ulcers (DFUs)

Diabetic foot ulcers (DFUs) are characterized by a lack of angiogenesis and distal limb diabetic neuropathy. This makes it possible for opportunistic pathogens to protect the biofilm-encased micro-communities, causing a delay in wound healing. The acute and chronic phases of DFU-associated infections are distinguished by the differential expression of innate proinflammatory cytokines and tumor necrosis factors (TNF-α and -β). Efforts are being made to reduce the microbial bioburden of wounds by using therapies such as debridement, hyperbaric oxygen therapy, shock wave therapy, and empirical antibiotic treatment. However, the constant evolution of pathogens limits the effectiveness of these therapies. In the wound-healing process, continuous homeostasis and remodeling processes by commensal microbes undoubtedly provide a protective barrier against diverse pathogens. Among commensal microbes, probiotics are beneficial microbes that should be administered orally or topically to regulate gut-skin interaction and to activate inflammation and proinflammatory cytokine production. The goal of this review is to bridge the gap between the role of probiotics in managing the innate immune response and the function of proinflammatory mediators in diabetic wound healing. We also highlight probiotic encapsulation or nanoformulations with prebiotics and extracellular vesicles (EVs) as innovative ways to tackle target DFUs.

The effectiveness of systemic antibiotics for osteomyelitis of the foot in adults with diabetes mellitus: a systematic review protocol

Background

Osteomyelitis of the foot is a major complication of diabetes that can be limb and life threatening. Systemic antibiotic pharmacotherapy is often used first line to eradicate infection and allow restoration of devitalised bone.

The aim is to conduct a systematic review of the effectiveness of systemic antibiotics on osteomyelitis of the foot in adults with diabetes mellitus.

Methods

A systematic review of all interventional studies treating osteomyelitis with systemic antibiotics in participants with diabetes mellitus and an ulcer of the foot below the malleoli will be conducted. Studies not available in English and in people below the age of 18 will be excluded. Study selection will follow the Patient Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA-P guidelines). The quality of the studies will be assessed using the Cochrane risk-of-bias tool (RoB 2) for all randomised controlled trials and the Newcastle–Ottawa Scale (NOS) will be used for non-randomised controlled trials. Electronic databases will be searched with no timeline restrictions.

Data Extraction

All identified references will be imported to the Rayyan Application. Studies for eligibility will be screened by two reviewers. One reviewer will perform the data extraction and quality appraisal will be conducted by two authors. If sufficient data is available, the quality will be analysed and a meta-analysis will be performed. Data synthesis will be conducted, and meta-analysis undertaken using RevMan 5.4.1 Meta-analysis software. Non-parametric data may be compared between selective intervention and outcomes.

Discussion

The results of this systematic review will identify the effectiveness of systemic antibiotic therapy on osteomyelitis of the foot in people with diabetes based on the set outcome measure criteria. The findings will establish if there are existing consistent standards or variation in practice when treating diabetic foot osteomyelitis (DFO). The study may establish if guidelines are required to standardise practice when treating DFO with systemic antibiotic therapy. This systematic review protocol will synthesise the existing evidence on the effectiveness of systemic antibiotic therapy for treating DFO.

Trial registration

International Prospective Register for Systematic Reviews (PROSPERO) number CRD42021245424.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13047-022-00554-3.

Surgical management of the acute severely infected diabetic foot - The 'infected diabetic foot attack'. An instructional review

Diabetic Foot Infection (DFI), in its severest form the acute infected 'diabetic foot attack', is a limb and life threatening condition if untreated. Acute infection may lead to tissue necrosis and rapid spread through tissue planes, in the patient with poorly controlled diabetes facilitated by the host status. A combination of soft tissue infection and osteomyelitis may co-exist, in particular if chronic osteomyelitis serves as a persistent source for recurrence of soft tissue infection. This "diabetic foot attack" is characterised by acutely spreading infection and substantial soft tissue necrosis. In the presence of ulceration, the condition is classified by the Infectious Diseases Society of America/International Working Group on the Diabetic Foot (IDSA/IWGDF Class 3 or 4) presentation requiring an urgent surgical intervention by radical debridement of the infection. Thus, 'time is tissue', referring to tissue salvage and maximal limb preservation. Emergent treatment is important for limb salvage and may be life-saving. We provide a narrative current treatment practices in managing severe DFI with severe soft tissue and osseous infection. We address the role of surgery and its adjuvants, the long term outcomes, potential complications and possible future treatment strategies.

Infrared thermography for monitoring severity and treatment of diabetic foot infections

Monitoring of diabetic foot infections is largely based on clinical assessment, which is limited by moderate reliability. We conducted a prospective study to explore monitoring of thermal asymmetry (difference between mean plantar temperature of the affected and unaffected foot) for the assessment of severity of diabetic foot infections. In patients with moderate or severe diabetic foot infections (International Working Group on the Diabetic Foot infection-grades 3 or 4) we measured thermal asymmetry with an advanced infrared thermography setup during the first 4-5 days of in-hospital treatment, in addition to clinical assessments and tests of serum inflammatory markers (white blood cell counts and C-reactive protein levels). We assessed the change in thermal asymmetry from baseline to final assessment, and investigated its association with infection-grades and serum inflammatory markers. In seven included patients, thermal asymmetry decreased from median 1.8°C (range: -0.6 to 8.4) at baseline to 1.5°C (range: -0.1 to 5.1) at final assessment (P = 0.515). In three patients who improved to infection-grade 2, thermal asymmetry at baseline (median 1.6°C (range: -0.6 to 1.6)) and final assessment (1.5°C (range: 0.4 to 5.1)) remained similar (P = 0.302). In four patients who did not improve to infection-grade 2, thermal asymmetry decreased from median 4.3°C (range: 1.8 to 8.4) to 1.9°C (range: -0.1 to 4.4; P = 0.221). No correlations were found between thermal asymmetry and infection-grades (r = -0.347; P = 0.445), CRP-levels (r = 0.321; P = 0.482) or WBC (r = -0.250; P = 0.589) during the first 4-5 days of hospitalization. Based on these explorative findings we suggest that infrared thermography is of no value for monitoring diabetic foot infections during in-hospital treatment.

Guidelines on the diagnosis and treatment of foot infection in persons with diabetes (IWGDF 2019 update)

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the diagnosis and treatment of foot infection in persons with diabetes and updates the 2015 IWGDF infection guideline. On the basis of patient, intervention, comparison, outcomes (PICOs) developed by the infection committee, in conjunction with internal and external reviewers and consultants, and on systematic reviews the committee conducted on the diagnosis of infection (new) and treatment of infection (updated from 2015), we offer 27 recommendations. These cover various aspects of diagnosing soft tissue and bone infection, including the classification scheme for diagnosing infection and its severity. Of note, we have updated this scheme for the first time since we developed it 15 years ago. We also review the microbiology of diabetic foot infections, including how to collect samples and to process them to identify causative pathogens. Finally, we discuss the approach to treating diabetic foot infections, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and for bone infections, when and how to approach surgical treatment, and which adjunctive treatments we think are or are not useful for the infectious aspects of diabetic foot problems. For this version of the guideline, we also updated four tables and one figure from the 2016 guideline. We think that following the principles of diagnosing and treating diabetic foot infections outlined in this guideline can help clinicians to provide better care for these patients.

Plantar Fasciitis in Diabetic Foot Patients: Risk Factors, Pathophysiology, Diagnosis, and Management

Plantar fasciitis (PF) is a common degenerative disorder and a frequent cause of heel pain, mostly affecting patients in their fourth and fifth decades. Diabetic patients are particularly at risk due to the presence of common risks and co-morbidities such as obesity or a sedentary lifestyle. The diagnosis of PF is mainly clinical. Imaging is not recommended for the initial approach. The initial management is conservative and should include physiotherapy, off-loading, stretching exercises, and nonsteroidal anti-inflammatory drugs. Glucocorticoid injections or surgery is an option at a later stage in recalcitrant cases. The overall management of PF does not differ between patients with diabetic foot problems and non-diabetic patients, although the details can differ. This narrative review summarizes the state of the art in terms of the risk factors, pathophysiology, diagnosis, assessment, and management of PF in diabetic patients.

Communications between the tendons of flexor hallucis longus and flexor digitorum longus: a cadaveric study

INTRODUCTION

Tibialis posterior tendon insufficiency in adult acquired flat foot deformity (AAFFD) is treated by reinforcing the posterior tibial tendon (PTT) using grafts from flexor hallucis longus (FHL) and flexor digitorum longus (FDL). The communication between FHL and FDL will influence the length of the graft that can be harvested from FHL and FDL. In this study, we aim to study the patterns of communications between FHL and FDL tendons and the location of Master Knot of Henry (MKH) and point of division of FDL tendons in Indian population.

MATERIALS AND METHODS

In this observational descriptive study, 36 formalin-fixed cadavers were sourced from Subbaiah Institute of Medical Sciences, Shimoga, Karnataka, India, and JIPMER, Puducherry, India, during the period of 2017-19. Various parameters of the foot to locate the MKH and point of division of FDL tendons and various types of communications between FHL and FDL were observed.

RESULTS

Among the various types of communications between FHL and FDL tendons, type I was present in 61.76% of cases, type II in 2.94% of cases, type III in 7.35% of cases, type IV in 14.70% of cases, type V in 8.82% of cases, type VI in 0% of cases, type VII in 1.47% of cases and an unusual type in 2.94% of cases.

CONCLUSION

In the present study done in Indian population, we found that type I variety is present more commonly followed by type IV. FHL and FDL tendon grafts can be lengthened based on the communications between them. In type I variety, the communication can be severed at the FDL end to lengthen the tendon graft for harvest.

Soft Tissue Reconstruction with Diabetic Foot Tissue Loss

Although substantial advances have been made in treatment of diabetic foot disease with respect to patient education, preventative measures, early intervention, and prophylactic procedures, most surgical interventions for this condition are reactionary. Patients still primarily present to emergency departments with acute infections and tissue necrosis. The surgical intervention for this results in soft tissue deficit, often with partial foot amputation, through excisional debridement of pathologic tissue. Minimizing this initial soft tissue loss, with subsequent reconstruction of the defect, forms the focus of this article with a detailed anatomic assessment of structures at risk in the forefoot, midfoot and rearfoot.

Modern management of diabetic foot osteomyelitis. The when, how and why of conservative approaches

INTRODUCTION

Diabetic foot osteomyelitis (DFO) has long been considered a complex infection that is both difficult to diagnose and treat, and is associated with a high rate of relapse and limb loss. Areas covered: DFO can usually be diagnosed by a combination of clinical evaluation, serum inflammatory markers and plain X-ray. When the results of these procedures are negative or contradictory, advanced imaging tests or bone biopsy may be necessary. Staphylococcus aureus remains the most frequent microorganism isolated from bone specimens, but infection is often polymicrobial. Antibiotic therapy, preferably with oral agents guided by results of bone culture, for a duration of no more than six weeks, appears to be as safe and effective as surgery in cases of uncomplicated forefoot DFO. Surgery (which should be limb-sparing when possible) is always required for DFO accompanied by necrotizing fasciitis, deep abscess, gangrene or in cases not responding (either clinically or radiographically) to apparently appropriate antibiotic treatment. Expert commentary: Research in the past decade has improved diagnosis and treatment of DFO, and most cases can now be managed with a 'conservative' approach, defined as treatment either exclusively with antibiotics or with surgery removing as little bone and soft tissue as necessary.

Is surgical debridement necessary in the diabetic foot treated with photodynamic therapy?

Background: Diabetic patients are susceptible to developing foot ulcers with serious complications such as osteomyelitis and amputations. Treatment approaches are still empirical and the benefit of usual procedures such as surgical debridement has not been properly evaluated. Photodynamic Therapy (PDT) is a non-invasive and highly efficient method for the treatment of the diabetic foot, being able to eradicate the infection and to stimulate healing, decreasing considerably the amputation risk. In the day-to-day practice of our service, we have been faced with the question whether debridement is necessary before PDT. In here, we designed a study to answer that question.

Methods: Patients were divided in two groups: In one of the groups (n = 17), debridement was performed before PDT and in the other (n = 40) only PDT treatment was performed. PDT sessions were performed once a week in all patients until healing was achieved, as indicated by visual inspection as well as by radiographic and laboratory exams. At the start of the study, the two groups had no statistical differences concerning their clinical features: average age, gender, insulin use, diabetes mellitus onset time and previous amputations.

Results: PDT was effective in the treatment of 100% of the patients showing no relapses after one year of follow up. The group submitted to PDT without previous debridement had a statistically significant (p = 0.036, Mann-Whitney) shorter cure time (29 days, ~27%).

Conclusion: Our data indicates that debridement is not necessary in the treatment of diabetic foot in patients that have enough peripheral arterial perfusion. In addition, we reproduced previous studies confirming that PDT is an efficient, safe, simple and affordable treatment method for the diabetic foot.

Communication of Contrast in the Flexor Hallucis Longus Tendon with Other Pedal Tendons at the Master Knot of Henry

It is important to have a full appreciation of lower-extremity anatomical relationships before undertaking diabetic foot surgery. We sought to evaluate the potential for communication of the flexor hallucis longus (FHL) tendon with other pedal tendons and plantar foot compartments at the master knot of Henry and to provide cadaveric images and computed tomographic (CT) scans of such communications. Computed tomography and subsequent anatomical dissection were performed on embalmed cadaveric limbs. Initially, 5 to 10 mL (1:4 dilution) of iohexol and normal saline was injected into the FHL sheath as it coursed between the two hallux sesamoids. Subsequently, CT scans were obtained in the axial plane using a multidetector CT scanner with sagittal and coronal reformatted images. The limbs were then dissected for specific evaluation of the known variable intertendinous connections between the FHL and flexor digitorum longus (FDL) and quadratus plantae (QP) muscles. One cadaver demonstrated retrograde flow of contrast into the four individual tendons of the FDL, with observation of a large intertendinous slip between the FHL and FDL on dissection. Another cadaver demonstrated contrast filling in the QP with an associated intertendinous slip between the FHL and QP on dissection. These results indicate that the master knot of Henry (the location in the plantar aspect of the midfoot where the FHL and FDL tendons decussate, with the FDL passing superficially over the FHL) has at least the potential to serve as one source of communication in diabetic foot infections from the medial plantar compartment and FHL to the central and lateral compartments via the FDL and to the rearfoot via the QP.

Risk Factors for Foot Amputation in Patients Hospitalized for Diabetic Foot Infection

The aim of this study was to identify and quantify risk factors for amputation in diabetic patients hospitalized for foot infections. This cross-sectional study comprised 100 patients with diabetic infectious complications in the lower limbs. The variables investigated were related to diabetes, infection, and treatment compliance. Multiple Cox regression analysis was performed to identify the variables independently associated with the outcome of amputation. The most prevalent chronic complications were neuropathy and hypertension. Most patients presented with a neuroischemic foot (86%). The Morisky test showed that 72% were not compliant with diabetes treatment. Regarding patient outcome, 61% progressed to amputation, 14% to debridement, and 9% to revascularization. The results showed a 42% higher risk for progression to amputation in patients with previous use of antimicrobials. Also, the amputation risk was 26% higher for those less compliant with diabetes treatment. An increase of one point in the Wagner ulcer classification criteria corresponded to a 65% increase in the risk of amputation. Undergoing conservative, nonsurgical procedures prior to admission provided a 63% reduction in the risk of amputation. Knowledge of these factors is critical to enable multidisciplinary teams to develop treatment plans for these patients so as to prevent the need for amputation.

Opioid use in the management of diabetic peripheral neuropathy (DPN) in a large commercially insured population

OBJECTIVE

To examine the proportion of diabetic peripheral neuropathy (DPN) patients receiving pharmacologic DPN treatments and specifically to identify the rates and factors associated with opioid use and first-line opioid use.

METHODS

A 10% sample of IMS-LifeLink claims data from 1998 through 2008 was used. The study population consisted of diabetic patients who met DPN criteria using a validated DPN algorithm. Multivariable logistic regression controlling for demographics, comorbidities, and other clinical characteristics was used to identify factors associated with any DPN pharmacologic treatment, any opioid use, and first-line opioid treatment. Sensitivity analyses were conducted to explore variations in exclusion criteria as well as opioid use definitions.

RESULTS

A total of 666 DPN patients met inclusion criteria and pharmacologic treatment was received by 288 patients (43.24%) and of those, 154 (53.47%) had DPN-related opioid use and 96 (33.33%) received opioid as first-line treatment. Persons with diabetic complications were more likely to use opioids (odds ratio=4.53; 95% confidence interval, 1.09-18.92). Food and Drug Administration-approved DPN agents duloxetine 1.04% (n=3) and pregabalin 5.56% (n=16) had much lower rates of use. DPN-related drug use and DPN-related opioid usage increased as we used less restrictive samples in sensitivity analyses.

CONCLUSIONS

Opioids were the most frequently prescribed first-line agents for DPN. More than 50% of DPN patients remained untreated with pharmacologic agents 1 year after a DPN diagnosis.

Compartment syndrome of the foot associated with a delayed presentation of acute limb ischemia

Compartment syndrome of the leg is a well-recognized complication known to follow urgent revascularization done for acute limb ischemia, but compartment syndrome of the foot has not been reported after the ischemia-reperfusion sequence. Herein we report a case of foot fasciotomy done for compartment syndrome that occurred after urgent revascularization. We suggest that foot fasciotomies should be considered in particular circumstances of acute lower leg ischemia, such as infrapopliteal thromboembolic events, prolonged ischemia, and persistent or worsening foot symptoms that follow revascularization and calf fasciotomies.

Great toe necrosis predicts an unfavorable limb salvage prognosis

Summary:

The initial location of necrosis may affect the limb salvage rate. This study of 130 patients with chronic toe ulcers or gangrene was performed to assess whether the location of initial necrosis in the toes affected limb salvage prognosis. The patients were divided into 2 groups according to whether the initial necrosis was in the great toe or in other toes. Limb salvage prognosis was determined retrospectively. In the great toe group, the rates of total toe loss and major amputation were 50.0% and 24.4%, respectively. When the initial necrosis was in other toes, these rates were 27.3% and 9.3%, respectively. Great toe necrosis is associated with significantly higher rates of total toe loss (odds ratio = 3.10; P = 0.003; 95% confidence interval, 1.43−6.68) and major amputation (odds ratio = 3.66; P = 0.007; 95% confidence interval, 1.37−9.79). The great toe is supplied by 3 source arteries, whereas the lesser toes are fed by 1 or 2 arteries. Therefore, necrosis initiating from the great toe may reflect the presence of severe vascular disorders. The great toe is also anatomically connected to much of the foot via the tendons. Infection is more likely to spread along these tendons, which may reduce limb prognosis. Thus, the initial location of necrosis may be predictive of limb prognosis.

Minor Amputation and Palliative Wound Care as a Strategy to Avoid Major Amputation in Patients With Foot Infections and Severe Peripheral Arterial Disease

Foot infections occurring in patients with severe peripheral arterial disease (PAD) who are not considered candidates for revascularization and limb salvage efforts are generally treated with major amputations. Herein we describe our early experiences in managing foot infections with minor amputations and palliative wound care as a strategy to avoid the functional disability often associated with major amputations. Patients with severe PAD that underwent minor amputations and subsequent palliative wound care for moderate/severe infections were paired with age-matched controls with PAD that underwent primary major amputations for foot infections. Eleven patients who underwent minor amputations and palliative wound care of 13 limbs were compared to an age-matched cohort of 12 patients undergoing 13 major amputations.The median age was 80 years in both groups. Survival at 1 and 2 years did not differ significantly between groups. All patients who were ambulatory and/or independently living remained so following palliative management; in contrast, major amputation changed ambulatory status in 75% of patients and independent living status in 50%. Palliative management did not result in ascending/systemic sepsis or progressive necrosis. The need for reoperations was uncommon in both groups. In summary, minor amputations and operative drainage with subsequent palliative wound care appears to be a safe management option in patients with severe PAD and moderate or severe foot infections that are not candidates for revascularization. Palliative management may result in less functional impairment than major amputation.

Current therapies for diabetic foot infections and osteomyelitis

Treatment of the patient with a diabetic foot infection and underlying osteomyelitis is currently an evolving process, often complicated by neuropathy, peripheral vascular disease, and renal insufficiency. Understanding which patients require hospitalization, intravenous antibiotic therapy, and urgent operative intervention may ultimately prevent the spread of infection or major limb amputation. The treating surgeon should focus on accurate and early diagnosis, proper antibiosis, and appropriate surgical debridement to eradicate infection while preserving function with a plantar-grade foot.

Which cleansing care is better, foot bath or shower? Analysis of 236 limb ulcers

Foot baths and showering are two widely used methods to cleanse limb ulcers. However, some clinicians warn that foot baths may contribute to the spread of infection at the ulcer site. This study aimed to retrospectively investigate the relationship between cleansing methods and the limb prognoses of 236 patients with chronic limb ulcers. These patients were divided into two groups according to the method used to cleanse their ulcers, foot bath and showering. Limb prognosis, including loss of all toes and major amputation, was retrospectively analysed. The rates of loss of all toes and major amputation were 53·0% and 30% in the foot bath group, and 35·3% and 18·4% in the showering group, respectively. The rates of loss of all toes (adjusted odds ratios = 2·07; P = 0·0066; 95% confidence intervals, 1·22-3·50) and major amputation (adjusted odds ratio = 1·90; P = 0·037; 95% confidence intervals, 1·03-3·50) were significantly higher in the foot bath group than those in the showering group. Our results demonstrate that showering is preferable to foot baths for the cleansing of chronic limb ulcers. Clinicians should be cautious that inappropriate cleansing may cause ulcer infections to spread.

Ascending infection of foot tendons in diabetic patients

Bone and soft tissue infection in the foot of diabetic patients is a well-described issue in the literature. A sound anatomical knowledge of the foot anatomy and compartments is mandatory to understand the mechanisms of infection spread. We describe four cases of diabetic foot infection complicated by long ascending infection. All did not respond initially to antibiotic treatment and the usual surgical debridement and were cured only after excision of the infected tendons. We highlight a rare but serious complication of the diabetic foot disease not commonly seen by the surgical community. We hope that this report raises the awareness of this condition so that a prompt diagnosis is made and appropriate treatment started, thereby reducing the risk of major lower limb amputations.

Revision Surgery for Diabetic Foot Infections

Revision surgery (RS) is frequently needed to control diabetic foot infections. It is the aim of this retrospective observational study to analyze the variables associated with undergoing RS and the variables associated with undergoing a major amputation when RS was required. We conducted a retrospective study of patients with diabetes treated in our department during 10 years (January 1, 2000 to January 1, 2010) who had foot infections identifying those who required RS. In all, 167 out of 417 patients (40%) with diabetes who underwent surgery for foot infections underwent RS for persistent infection. The predictive variables related to undergoing revision surgery were erythrocyte sedimentation rate >70 mm/h (odds ratio [OR] = 1.6, 95% confidence interval [CI] = 1.1-2.6), leukocytosis (OR = 1.6, 95% CI = 1.1-2.5), peripheral arterial disease (OR = 1.5, 95% CI = 1.0-2.4), and isolation of gram-negative rods from tissue biopsy (OR = 2.2, 95% CI = 1.5-3.4). Seventy-nine out of 167 patients (47.3) who underwent RS required a higher level of surgery achieving a limb salvage rate of 70.7%. Predictive variables related to undergoing a major amputation after RS were persistent infection located in the bone (OR = 0.08, 95% CI = 0.03-0.22), ischemic heart disease (OR = 3.4, 95% CI = 1.4-8.5), 2 or more reoperations (OR = 3.0, 95% CI = 1.2-7.1), isolation of gram-negative rods from tissue biopsy (OR = 3.3, 95% CI = 1.3-8.4), and peripheral arterial disease (OR = 6.5, 95% CI = 1.9-22.8). Despite the fact that 40% of patients underwent reoperations for diabetic foot infections and 47.3% of them required a higher level of surgery, a high rate of limb salvage could be achieved.

Determinants of microbial load in infected diabetic foot ulcers: a pilot study

We examined the determinants of microbial load in infected diabetic foot ulcers in 62 patients (38 men and 24 women, mean age: 65.63 ± 12.71 years) with clinically infected diabetic foot ulcers. Tissue cultures were taken from ulcers by 4 mm punches. Ulcer grade (University of Texas classification), neuropathy disability score (NDS), neuropathy symptom score (NSS), ankle-brachial index (ABI), perfusion, extent, depth, infection, and sensation (PEDIS) grade of diabetic foot infection, and laboratory parameters were evaluated in all patients. Total microbial load was positively correlated with the number of isolates on tissue cultures (r s = 0.544, P < 0.001), white blood cell count (WBC) (r s = 0.273, P = 0.032), and platelet count (PLT) (r s = 0.306, P = 0.015). It also exhibited a borderline insignificant positive correlation with PEDIS infection grade (r s = 0.246, P = 0.053). In stepwise linear regression analysis, the number of isolates on tissue cultures and WBC were identified as the only two significant parameters accounting for 38% of the variation in the log of total microbial load (adjusted R (2) = 0.380, P < 0.001). In conclusion, patients with infected diabetic foot ulcer exhibit a positive correlation of total microbial load with the number of isolates on tissue cultures, WBC and PLT.