Diabetic foot infections with osteomyelitis: efficacy of combined surgical and medical treatment

Study of Diabetic Foot Problems Among Patients Attending the Diabetic Foot Clinic at Royal Hampshire County Hospital, United Kingdom: A Single-Centre Experience

Background Patients with diabetes mellitus (DM) are on the rise all over the world. Simultaneously, the complications of DM are also increasing. Diabetes-related foot problems have been another concern among health professionals, especially foot ulcers, osteomyelitis, and amputations. Objectives We determined the prevalence of gender, age, types of DM including non-diabetics, various foot-related presentations, complications, and their outcomes. Methods A retrospective descriptive cross-sectional study was conducted among new patients attending a diabetic foot clinic over a period of six months, from January 1, 2019 to June 30, 2019. To confirm the outcome of the study, all of them were followed up for at least four months from the date of diagnosis. Results The study showed that most patients were males (65.5%). The most common age group for diabetic foot problems was 81-90 years, and about 80% of the foot problems were diagnosed in patients over 60 years. The study disclosed that 86.2% of the population had type 2 DM, 56.9% had ulcers, and 13.8% had osteomyelitis. The outcome of our study demonstrated that 65.5% of the patients were cured and discharged within four months of the diagnosis, but 10.3% of the population needed amputation. During the four-month follow-up period, 3.4% of our study population died due to non-foot-related causes. A total of 48.1% of our ulcer patients were discharged within eight weeks of diagnosis. However, 26% of ulcer patients and 75% of osteomyelitis patients needed more than four months to be discharged. Peripheral neuropathy and peripheral arterial disease (PAD) were present in 91% of ulcer patients. Among our osteomyelitis group, 100% had peripheral neuropathy, and 87.5% had PAD. About 20% of ulcer patients and none of the osteomyelitis patients were diagnosed with chronic kidney disease (CKD) stages beyond 3b. About 2/3rd of our ulcer and osteomyelitis population had an HbA1C level of more than 7.5%. Conclusion Male patients over 60 years of age with type 2 DM are more at risk of developing diabetes-related foot issues. Ulcer with or without osteomyelitis was the most common complication among our study population. Results showed that a significant amount of osteomyelitis patients underwent foot amputation. Poor glycaemic control of HbA1C of more than 7.5%, peripheral neuropathy, and PAD were the most common risk factors for developing foot-related complications. Prolonged use of antibiotics and a dedicated professional team may be needed to manage these complications successfully.

Molecular Characteristics of Staphylococcus aureus Strains Isolated from Nasal Cavity and Wound Infections Among Diabetic Patients

Staphylococcus aureus is the most common pathogen contributing to diabetic foot infections (DFI). Nasal transmission of S. aureus potentially increases the risk of endogenous infection. The aim of this study was to determine the genetic diversity and antibiotic resistance profile of S. aureus isolates in nasal and wound samples from diabetic patients. A cross-sectional study was conducted from July 2018 to September 2019. S. aureus was isolated from the anterior nares and wounds of diabetic patients. All S. aureus isolates were characterized by detection of resistance and virulence genes (mecA, ermA, ermC, hla, hlb, hlg, sea, lukDE, pvl), staphylococcal cassette chromosome mec (SCCmec)-typing and staphylococcal protein A (spa)-typing. A total of 34 S. aureus were isolated from the wounds of 115 diabetic patients with DFI. Twenty-four S. aureus isolates were collected from the anterior nares of patients, and thirteen patients had concurrent S. aureus in nasal and wound specimens. The prevalence of methicillin-resistant S. aureus (MRSA) in nasal specimens was noticeable (41.7%), and the most common spa-type in nasal and wound specimens was t14870. Nearly half of the patients with concurrent S. aureus in wound and nasal specimens had similar isolates from both sites. Our data suggest that detection and screening of S. aureus colonization in the nasal cavity may prevent subsequent endogenous infections, particularly with MRSA strains.

Do Anti-Biofilm Antibiotics Have a Place in the Treatment of Diabetic Foot Osteomyelitis?

The choice of antibiotic regimens for use in patients presenting with diabetic foot osteomyelitis and their duration differs according to the situation. Antibiotics play a more important role in the medical option where no infected bone has been resected, while their role is reduced but not negligible in the case of surgical options. Some studies have reported the presence of biofilm structures in bone samples taken from patients with diabetic foot osteomyelitis, which raises the question of the place of anti-biofilm antibiotic regimens in this setting. During the last two decades, clinical studies have suggested a potential benefit for anti-biofilm antibiotics, mainly rifampicin against staphylococci and fluoroquinolones against gram-negative bacilli. However, no data from randomized controlled studies have been reported so far. The present work provides a summary of the available data on the question of the place of anti-biofilm antibiotics for the treatment of diabetic foot osteomyelitis, but also the potential limitations of such treatments.

Management of diabetic ulcers of the dorsum of the foot and distal leg ulcers

Objective:

Diabetic foot ulceration of toes, forefoot and heel have been extensively studied; however, the dorsum of the foot and the distal leg have rarely been addressed. The objective of this study was to assess diabetic ulcers of the dorsum of the foot and of the distal leg (DUDFDLs) as primary sites, or extended lesions from other foot locations, with regard to possible causes, management and outcomes.

Method:

This was a retrospective study conducted in Jabir Abu Eliz Diabetic Centre (JADC) in Khartoum from January 2018 to August 2019. All patients with a primary DUDFDL, or one extending from a plantar or heel ulcer, were included.

Results:

A cohort of 102 patients with DUDFDLs were studied; 74 (72.5%) were male and 28 (27.5%) were female, with a male-to-female ratio of 2.6:1, and a mean age of 57±12 years. The ulcer was a primary DUDFDL in 38 patients and a secondary ulcer in 64 patients. The outcome in 38 patients with primary DUDFDL was healing without amputation in 26 cases (68.4%), amputation of toes in 12 cases (31.6%), and no major amputation or death. Of the 64 patients presenting with secondary DUDFDL extending from the plantar surface, there was extension to the dorsum of the foot through the forefoot ulcer in 54 patients and through the ankle joint to the distal leg in 10 patients. For the plantar ulcers extending to the dorsum, five cases healed without amputation (9.3%), minor amputation was necessary in 29 cases (53.7%), major amputation in 14 cases (25.9%) and six patients died (11.1%). For the distal leg ulcers with extension through the ankle joint, five healed without amputation and five required minor amputation.

Conclusion:

Primary DUDFDLs had a favourable outcome. Dorsum extension of diabetic foot ulcer from the plantar aspect of the foot carries a high risk for major limb amputation and death.

The Effects of Blue Light on Human Fibroblasts and Diabetic Wound Healing

Diabetes is a serious threat to global health and is among the top 10 causes of death. The Diabetic foot ulcer (DFU) is among the most common and severe complications of the disease. Bacterial infections are common; therefore, timely aggressive management, using multidisciplinary management approaches is needed to prevent complications, morbidity, and mortality, particularly in view of the growing cases of antibiotic-resistant bacteria. Photobiomodulation (PBM) involves the application of low-level light at specific wavelengths to induce cellular photochemical and photophysical responses. Red and near-infrared (NIR) wavelengths have been shown to be beneficial, and recent studies indicate that other wavelengths within the visible spectrum could be helpful as well, including blue light (400–500 nm). Reports of the antimicrobial activity and susceptibility of blue light on several strains of the same bacterium show that many bacteria are less likely to develop resistance to blue light treatment, meaning it is a viable alternative to antibiotic therapy. However, not all studies have shown positive results for wound healing and fibroblast proliferation. This paper presents a critical review of the literature concerning the use of PBM, with a focus on blue light, for tissue healing and diabetic ulcer care, identifies the pros and cons of PBM intervention, and recommends the potential role of PBM for diabetic ulcer care.

Microbiology of diabetic foot osteomyelitis - Is it geographically variable?

INTRODUCTION

Diabetic foot osteomyelitis (DFO) is a dreaded complication as both diagnosis and treatment of the condition is laborious. However, for proper decision on antibiotics in medical management of DFO, accurate determination of microbes is necessary to narrow the spectrum of coverage and to reduce adverse effects of long-term administration of antibiotics. With differing pattern of use of antimicrobials and their resistance pattern in different countries, it is empirical to determine the microbiological characteristics of bone cultures in DFO from a referral institute in South India.

MATERIALS AND METHODS

This study was a retrospective chart review of all cases of proven DFO who had consented for debridement and bone culture or those who underwent amputation. Both deep soft tissue (DST) and bone cultures were obtained for aerobic bacteria. Clinical characteristics and site(s) of DFO were recorded. Investigations for peripheral artery disease were performed if clinically indicated.

RESULTS

In all, 105 patients with DFO were reviewed. Mean age was 62 years and 70% were men. Of those who were screened, 57% had evidence of peripheral arterial disease by arterial doppler. 46% of bone culture samples were sterile. Gram- negative organisms were more common (58%). Following staphylococcus, pseudomonas was the second common isolate. Of total staphylococcal isolates 37% were MRSA and 33% of klebsiella isolates were ESBL producing. Concordance rate between DST and bone cultures was 66%. 90% were mono-bacterial isolates. The commonest site of involvement of DFO was terminal phalanges of toes rather than base of 1st metatarsal.

CONCLUSION

Widespread use of antibiotics, tropical climate and route of entry of organisms causing DFO differed in our cohort of patients. Further studies from different regions of world would shed light onto different pattern of microbes causing DFO.

Diabetic foot ulcer disease in African continent: 'From clinical care to implementation' - Review of diabetic foot in last 60 years - 1960 to 2020

The prevalence of diabetes mellitus is increasing globally and the greatest potential increases in diabetes will occur in Africa. Data suggest that these increases is associated with rapid demographic, sociocultural and economic transitions. There will be a parallel increase in the complications of diabetes and among the various complications those related to diabetic foot disease are associated with the highest morbidity and mortality. Diabetic Peripheral neuropathy (DPN) is the most common cause of diabetic foot complications in African countries; however, peripheral arterial disease (PAD) appears to increase, possibly a result of rising urbanization. Search done for the past six decades (1960 to 2020) on all foot complications. Rates of complications of diabetic foot in last six decades varied by country as follow: DPN: 4-90%; PAD: 0-77%; foot ulcers: 4-61%; amputation rates: 3-61% and high mortality rates reaching to 55%, patients who presented late with infection and gangrene. Educational and prevention programmes are required to curb the growing complications of diabetic foot ulcers in Africa among patients and health care workers. Secondly, it is imperative that governments across the African continent recognise the clinical and public health implications of diabetic foot disease in persons with diabetes.

Medical Versus Surgical Treatment for the Management of Diabetic Foot Osteomyelitis: A Systematic Review

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.

Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition)

In recent years, as living standards have continued to improve, the number of diabetes patients in China, along with the incidence of complications associated with the disease, has been increasing. Among these complications, diabetic foot disease is one of the main causes of disability and death in diabetic patients. Due to the differences in economy, culture, religion and level of medical care available across different regions, preventive and treatment methods and curative results for diabetic foot vary greatly. In multidisciplinary models built around diabetic foot, the timely assessment and diagnosis of wounds and appropriate methods of prevention and treatment with internal and external surgery are key to clinical practice for this pathology. In 2019, under the leadership of the Jiangsu Medical Association and Chinese Diabetes Society, the writing group for the Guidelines on multidisciplinary approaches for the prevention and management of diabetic foot disease (2020 edition) was established with the participation of scholars from the specialist areas of endocrinology, burn injury, vascular surgery, orthopedics, foot and ankle surgery and cardiology. Drawing lessons from diabetic foot guidelines from other countries, this guide analyses clinical practices for diabetic foot, queries the theoretical basis and grades and gives recommendations based on the characteristics of the pathology in China. This paper begins with assessments and diagnoses of diabetic foot, then describes treatments for diabetic foot in detail, and ends with protections for high-risk feet and the prevention of ulcers. This manuscript covers the disciplines of internal medicine, surgical, nursing and rehabilitation and describes a total of 50 recommendations that we hope will provide procedures and protocols for clinicians dealing with diabetic foot.

Registry number: IPGRP-2020cn124

A Meta-analysis of the Types and Outcomes of Conservative Excisional Surgery for Recalcitrant or Infected Diabetic Toe Ulcers

Although they occur frequently, diabetic toe ulcers (DTUs) are poorly investigated. Long-term antibiotics or toe amputation are the usual indications for complicated DTU treatment. Some authors reported good to excellent results following conservative surgery (CS) for recalcitrant or infected wounds; yet no systematic review has been published. Seven studies, comprising 290 patients with 317 ulcers, met the inclusion criteria of this meta-analysis. Three types of CS were found: resection arthroplasty of the interphalangeal joint, toe-sparing bone excision (internal pedal amputation), and distal Symes amputation. The meta-analytical results were as follows: healing rate of 98.3%, healing time of 6.8 ± 3.9 weeks, recurrence rate of 2.3%, wound dehiscence/recurrent infection rate of 6.4%, skin necrosis rate of 2.8%, and revision surgery rate of 7.4%. Subgroup analyses showed no significant differences in outcomes between recalcitrant ulcers and infected ulcers nor between surgery types. Significance was found in relation to ulcer location; when compared with the hallux, DTU on the lesser toes demonstrated better outcomes. Compared with the reported overall results of standard of care associated with antibiotics or toe amputation of complicated DTUs in the literature, CS seems to be a better option for the treatment of recalcitrant or infected DTUs. Levels of Evidence: Level III.

An evidence based narrative review on treatment of diabetic foot osteomyelitis

OBJECTIVE

The diagnosis of diabetic food infection is usually clinical, and its severity is related to location and depth of the lesion, and the presence of necrosis or gangrene. Osteomyelitis of the foot and ankle can be extremely debilitating, and, in the preantibiotic era acute staphylococcal osteomyelitis carried a mortality rate of 50%. The microbiology of diabetic foot osteomyelitis (DFO) is usually polymicrobial. Indeed, gram-negative and gram-positive bacilli can be identified using molecular techniques applied to bone biopsies compared to conventional techniques. The aim of the present study is to report a complete overview regarding medical and surgical management of diabetic foot osteomyelitis (DFO) in combination or alone.

MATERIALS AND METHODS

We performed a search in PubMed and Scopus electronic databases (up to January 2019) of articles assessing the epidemiology, diagnostic strategy and pharmacological treatment of diabetic foot infection. In the search strategy, we used various combinations of the following key terms: infection, orthopaedic, diabetic foot, management, DFO.

RESULTS

This article discusses the definition, epidemiology, microbiological assessment, clinical evaluation, pharmacological and surgical management and a comparison between them, of DFO. After the initial literature search and removal of duplicate records, a total of 756 potentially relevant citations were identified. After a further screening and according to the inclusion criteria, a total of 65 articles were included in the present review.

CONCLUSION

The association of antibiotic and surgical therapy seems to be more effective compared to each one alone. The lack of comparison studies and randomized controlled trials makes it difficult to give information about the efficacy of the different management therapies.

Osteomyelitis of the First Metatarsal Head Treated With Joint-Preserving Surgery and a Synthetic Resorbable Bone Graft Substitute: A Case Report

Managing infections of the first metatarsophalangeal joint can be demanding because many patients present with late-stage infection and partial or total amputation of the first ray or the phalanx could be necessary. We describe such a patient who was successfully treated with a calcium-based resorbable bone substitute that preserved the first metatarsophalangeal joint. A 38-year-old female presented to our department with a foot infection. Examination revealed a methicillin-susceptible Staphylococcus aureus infection of the first metatarsophalangeal joint. The histopathologic findings confirmed active osteomyelitis of the first metatarsal head. The metatarsophalangeal joint was debrided with open synovectomy, the metatarsal head was curetted, and the bone defect was filled with 2 mL of a synthetic bone graft substitute. Two years later, she reported no problems with function or pain, the joint had full range of motion, and she had no local or systemic signs of infection. The most recent radiographs revealed no damage to the first metatarsophalangeal joint. A synthetic bone graft substitute can be a good alternative for treating forefoot infections when the soft tissues are intact and the bone defect is not so large that partial or full amputation is necessary.

Optimal management of diabetic foot osteomyelitis: challenges and solutions

Purpose: Diabetic foot osteomyelitis (DFO) is the most frequent infection associated with diabetic foot ulcers, occurs in >20% of moderate infections and 50%-60% of severe infections, and is associated with high rates of amputation. DFO represents a challenge in both diagnosis and therapy, and many consequences of its condition are related to late diagnosis, delayed referral, or ill-indicated treatment. This review aimed to analyze the current evidence on DFO management and to discuss advantages and disadvantages of different treatment options. Methods: A narrative review of the evidence was begun by searching Medline and PubMed databases for studies using the keywords "management", "diabetic foot", "osteomyelitis", and "diabetic foot osteomyelitis" from 2008 to 2018. Results: We found a great variety of studies focusing on both medical and surgical therapies showing a similar rate of effectiveness and outcomes; however, the main factors in choosing one over the other seem to be associated with the presence of soft-tissue infection or ischemia and the clinical presentation of DFO. Conclusion: Further randomized controlled trials with large samples and long-term follow-up are necessary to demonstrate secondary outcomes, such as recurrence, recurrent ulceration, and reinfection associated with both medical and surgical options.

Characteristics, prevalence, and outcomes of diabetic foot ulcers in Africa. A systemic review and meta-analysis

BACKGROUND

Among non-communicable diseases, diabetes represents a growing public health problem in Africa, where diabetes-related needs remain mostly unmet and the disabling features of foot are worsened by hygienic, cultural, and healthcare issues. We aimed to review clinical characteristics, prevalence, and outcomes of patients with diabetic foot ulcer in Africa.

METHODS

We searched the literature for cross-sectional and longitudinal studies reporting the characteristics of patients with diabetic foot in African countries, with a particular focus on ulcer prevalence, amputation rate, and mortality.

FINDINGS

Fifty-five full-text papers and ten abstracts were retrieved, reporting data from 19 African countries on 56,173 diabetic patients. According to the data collected, the overall prevalence of foot ulcers was 13% and increased over time, especially since 2001. Approximately 15% of patients with foot lesions underwent major amputation and 14.2% died during hospitalization. In patients with diabetic ulcers, insulin therapy was uncommon and neuropathy was the most common predisposing factor, but the prevalence of peripheral arterial disease correlated with amputation rates. Amputation and mortality decreased over time, probably as result of the implementation of screening programs in the last ten years. Mortality was directly related to previous amputation.

INTERPRETATION

The diabetic foot disease in Africa is a growing problem and is burden by high rate of in-hospital mortality. Educational interventions and screening programs including evaluation of the vascular status may play a crucial role to counter diabetic foot disease in Africa.

Diabetic Foot Infections: Update on Management

PURPOSE OF REVIEW

Diabetic foot infections (DFIs) are common in patients with diabetes mellitus complicated by foot ulcers and can be classified in different categories based on their severity. In this report, we present the diagnosis and management of DFIs according to their classification.

RECENT FINDINGS

While appropriate antibiotic regiments and surgical techniques for the treatment of DFIs are well established, new technologies and techniques for example in medical imaging, wound care modalities, and supplementary therapy approaches show potentially promising results in preventing DFIs. As with every complex disease, fine tuning DFI management can be challenging as it requires careful evaluation of different parameters. It demands timely action, close collaboration of different specialties, and patient cooperation.

Treatment options for diabetic foot osteomyelitis

INTRODUCTION

Diabetic foot osteomyelitis therapeutical options are based on antibiotic therapy and surgical resection of the infected bone(s). Surgical and medical approaches of patients suffering from a diabetic foot osteomyelitis do not oppose but are complementary and need to be discussed as a tailored manner. Areas covered: The aim of the present article is to discuss data issued from the most recent guidelines of the Infectious Diseases Society of America and the International Working Group on the Diabetic Foot on the management of the diabetic foot infection and from a search in the current literature using the terms diabetic foot osteomyelitis and treatment/therapy/therapeutical in both PubMed and Medline, restricted to the last five years. Expert opinion: Surgical removal of the entire infected bone(s) has been considered in the past as the standard treatment but medical approach of these patients has now proven efficacy in selected situations. The current emergence of bacteria, especially among Gram negative rods, resistant to almost all the available antibiotics gradually augments the complexity of the management of these patients and is likely to decrease the place of the medical approach and to worsen the outcome of these infections in the next future.

Blue Laser Inhibits Bacterial Growth of Staphylococcus aureus, Escherichia coli, and Pseudomonas aeruginosa

OBJECTIVE

The purpose of this study was to analyze the influence of blue laser on bacterial growth of the main species that usually colonize cutaneous ulcers, as well as its effect over time following irradiation.

BACKGROUND DATA

The use of blue laser has been described as an adjuvant therapeutic method to inhibit bacterial growth, but there is no consensus about the best parameters to be used.

METHODS

Strains of Staphylococcus aureus ATCC 25923, Pseudomonas aeruginosa ATCC 27853, and Escherichia coli ATCC 25922 were suspended in saline solution at a concentration of 1.5×10(3) colony forming units (CFU)/mL. Next, 300 μL of this suspension was transferred to a microtitulation plate and exposed to a single blue laser irradiation (450 nm) at fluences of 0 (control), 3, 6, 12, 18, and 24 J/cm(2). Each suspension was spread over the surface of a Petri plate before being incubated at 37°C, and counts of CFU were determined after 24 and 48 h.

RESULTS

Blue laser inhibited the growth of S. aureus and P. aeruginosa at fluences >6 J/cm(2). On the other hand, E. coli was inhibited at all fluences tested, except at 24 J/cm(2).

CONCLUSIONS

Blue laser light was capable of inhibiting bacterial growth at low fluences over time, thus presenting no time-dependent effect.

Diagnosing osteomyelitis in the diabetic foot: a pilot study to examine the sensitivity and specificity of Tc(99m) white blood cell-labelled single photon emission computed tomography/computed tomography

Diabetic foot ulceration poses a significant threat of osteomyelitis (OM) and subsequent amputation. The diagnosis of OM via imaging studies is difficult as radiographic findings do not present immediately and advanced imaging studies may be contraindicated or unavailable. A novel diagnostic tool has been developed which synthesises technetium-99 white blood cell-labelled single-photon emission computed tomography and computed tomography (Tc(99m) WBC labelled-SPECT/CT) imaging, effectively enhancing anatomic detail. The aim of this pilot study was to determine the validity and reliability of this novel imaging technique in patients with diabetic foot ulcers in a Veterans Affairs healthcare facility. A retrospective review was performed on consecutive patients who met the inclusion criteria (n = 14) and underwent Tc(99m) WBC-labelled SPECT/CT for suspected OM. Histopathologic analysis of bone specimen (when available) and International Working Group on the Diabetic Foot consensus criteria were used as a reference standard. The sensitivity and specificity of Tc(99m) WBC-labelled SPECT/CT were 87·50% [confidence interval (CI): 64·58-110·42%] and 71·43% (CI: 37·96-104·90%), respectively. Negative predictive value (NPV) and positive predictive value (PPV) were 83·33% (CI: 53·51-113·15%) and 77·78% (CI: 50·62-104·94%), respectively, with a likelihood ratio (LR) of 3·063 and an accuracy of 80%. These findings suggest Tc(99m) WBC-labelled SPECT/CT can be useful in imaging OM in patients with diabetic foot ulcers.

Do Diabetic Foot Infections With Methicillin-Resistant Staphylococcus aureus Differ From Those With Other Pathogens?

There is controversy as to whether or not diabetic foot infections (DFIs) caused by methicillin-resistant Staphylococcus aureus (MRSA) are associated with worse outcomes than DFIs caused by other pathogens. To address this issue we performed a nonsystematic literature search of published articles in English language journals seeking studies reporting on the outcomes of DFIs related to their microbiology. We retrieved 48 articles published from 1999 to 2013 that described a total of 7771 cases of DFI. The overall proportion of DFIs with an isolate of S aureus was about 30%; just over one third of these (11% of all cases) were MRSA strains. Among the DFI cases caused by MRSA 1543 were episodes of soft tissue infections and 113 of osteomyelitis, while non-MRSA organisms caused 5761 soft tissue infections and 354 cases of osteomyelitis. Only 5 of the included articles attempted a comparison between DFI caused by MRSA and those caused by other pathogens, with no clear differences noted. The median total duration of antibiotic therapy for DFI caused by MRSA was 26 days, of which a median of 10 days was given intravenously. Only a few articles reported the proportion of patients with a recurrence, but they often did not differentiate between MRSA and non-MRSA cases. Four publications reported a worse functional or microbiological outcome in MRSA, compared to non-MRSA, cases, but the findings were variable and differences did not seem to be significant. Many trials failed to adjust for case-mix or to definitively demonstrate a relationship between microbiology and outcomes. Few of the articles specifically commented on whether the MRSA isolates were health care- or community-acquired strains. Notwithstanding the substantial limitations of the available literature, there does not appear to be a need for any special treatment for DFI caused by MRSA. The current guidelines for treating according to established international recommendations seem appropriate.

Diabetic foot infections: state-of-the-art

Foot infections are frequent and potentially devastating complications of diabetes. Unchecked, infection can progress contiguously to involve the deeper soft tissues and ultimately the bone. Foot ulcers in people with diabetes are most often the consequence of one or more of the following: peripheral sensory neuropathy, motor neuropathy and gait disorders, peripheral arterial insufficiency or immunological impairments. Infection develops in over half of foot ulcers and is the factor that most often leads to lower extremity amputation. These amputations are associated with substantial morbidity, reduced quality of life and major financial costs. Most infections can be successfully treated with optimal wound care, antibiotic therapy and surgical procedures. Employing evidence-based guidelines, multidisciplinary teams and institution-specific clinical pathways provides the best approach to guide clinicians through this multifaceted problem. All clinicians regularly seeing people with diabetes should have an understanding of how to prevent, diagnose and treat foot infections, which requires familiarity with the pathophysiology of the problem and the literature supporting currently recommended care.

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.

Diabetic foot infections with osteomyelitis: efficacy of combined surgical and medical treatment

Diabetic foot infections are a high risk for lower extremity amputation in patients with dense peripheral neuropathy and/or peripheral vascular disease. When they present with concomitant osteomyelitis, it poses a great challenge to the surgical and medical teams with continuing debates regarding the treatment strategy. A cohort prospective study conducted between October 2005 and October 2010 included 330 diabetic patients with osteomyelitis mainly involving the forefoot (study group) and 1,808 patients without foot osteomyelitis (control group). Diagnosis of osteomyelitis was based on probing to bone test with bone cultures for microbiological studies and/or repeated plain radiographic findings. Surgical treatment included debridement, sequestrectomy, resections of metatarsal and digital bones, or toe amputation. Antibiotics were started as empirical and modified according to the final culture and sensitivities for all patients. Patients were followed for at least 1 year after wound healing. The mean age of the study group was 56.7 years (SD = 11.4) compared to the control group of 56.3 years (SD = 12.1), while the male to female ratio was 3:1. At initial presentation, 82.1% (n=271) of the study group had an ulcer penetrating the bone or joint level. The most common pathogens were Staphylococcus aureus (33.3%), Pseudomonas aeruginosa (32.2%), and Escherichia coli (22.2%) with an almost similar pattern in the control group. In the study group, wound healing occurred in less than 6 months in 73% of patients compared to 89.9% in the control group. In the study group, 52 patients (15.8%) had a major lower extremity amputation versus 61 in the control group (3.4%) (P=0.001). During the postoperative follow-up visits, 12.1% of patients in each group developed wound recurrence. In conclusion, combined surgical and medical treatment for diabetic foot osteomyelitis can achieve acceptable limb salvage rate and also reduce the duration of time to healing along with the duration of antibiotic treatment and wound recurrence rate.