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Hon K, Nobels F, Senneville É, Uckay I, Maas M, Fitridge R. Assessment and management of diabetes-related foot infection according to the new International Working Group on the Diabetic Foot guidelines 2023-Multidisciplinary grand rounds. Diabetes Metab Res Rev 2024; 40:e3737. [PMID: 37855302 DOI: 10.1002/dmrr.3737] [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: 09/25/2023] [Accepted: 09/30/2023] [Indexed: 10/20/2023]
Abstract
Diabetes-related foot disease is a serious and common complication for people with diabetes mellitus. The gold standard care for a person with diabetes-related foot disease is the involvement of a multidisciplinary foot team engaged in evidence-based care. To date, there are seven International Working Group on the Diabetic Foot (IWGDF) guidelines published to assist healthcare providers in managing diabetes-related foot disease around the world. This review discusses the acute management of diabetes-related foot infection with insights from experts of various specialities (internal medicine, infectious disease, vascular surgery, radiology) with a discussion on the implementation of IWGDF guidelines in real life practice and the challenges that healthcare providers may face.
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Affiliation(s)
- Kay Hon
- Discipline of Surgical Specialties, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - Frank Nobels
- Department of Internal Medicine-Endocrinology, Onze-Lieve-Vrouw Ziekenhuis Aalst, Aalst, Belgium
| | - Éric Senneville
- Infectious Diseases Department, Gustave Dron Hospital, Tourcoing, France
- Univ-Lille, Lille, France
| | - Ilker Uckay
- Balgrist University Hospital, Zurich, Switzerland
| | - Mario Maas
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers (AUMC), Amsterdam, the Netherlands
| | - Robert Fitridge
- Discipline of Surgical Specialties, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Vascular and Endovascular Surgery, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Basil Hetzel Institute for Translational Health Research, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
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Nieuwland AJ, Waibel FWA, Flury A, Lisy M, Berli MC, Lipsky BA, Uçkay İ, Schöni M. Initial antibiotic therapy for postoperative moderate or severe diabetic foot infections: Broad versus narrow spectrum, empirical versus targeted. Diabetes Obes Metab 2023; 25:3290-3297. [PMID: 37533158 DOI: 10.1111/dom.15228] [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: 04/25/2023] [Revised: 07/12/2023] [Accepted: 07/14/2023] [Indexed: 08/04/2023]
Abstract
AIM To retrospectively evaluate clinical and microbiological outcomes after combined surgical and medical therapy for diabetic foot infections (DFIs), stratifying between the empirical versus the targeted nature, and between an empirical broad versus a narrow-spectrum, antibiotic therapy. METHODS We retrospectively assessed the rate of ultimate therapeutic failures for each of three types of initial postoperative antibiotic therapy: adequate empirical therapy; culture-guided therapy; and empirical inadequate therapy with a switch to targeted treatment based on available microbiological results. RESULTS We included data from 332 patients who underwent 716 DFI episodes of surgical debridement, including partial amputations. Clinical failure occurred in 40 of 194 (20.6%) episodes where adequate empirical therapy was given, in 77 of 291 (26.5%) episodes using culture-guided (and correct) therapy from the start, and in 73 of 231 (31.6%) episodes with switching from empirical inadequate therapy to culture-targeted therapy. Equally, a broad-spectrum antibiotic choice could not alter this failure risk. Group comparisons, Kaplan-Meier curves and Cox regression analyses failed to show either statistical superiority or inferiority of any of the initial antibiotic strategies. CONCLUSIONS In this study, the microbiological adequacy of the initial antibiotic regimen after (surgical) debridement for DFI did not alter therapeutic outcomes. We recommend that clinicians follow the stewardship approach of avoiding antibiotic de-escalation and start with a narrow-spectrum regimen based on the local epidemiology.
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Affiliation(s)
- Arend J Nieuwland
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Felix W A Waibel
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Andreas Flury
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Marcus Lisy
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Martin C Berli
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Benjamin A Lipsky
- Department of Medicine, University of Washington, Seattle, Washington, USA
| | - İlker Uçkay
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Infectiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
- Unit for Clinical and Applied Research, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
| | - Madlaina Schöni
- Department of Orthopedic Surgery, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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Vliegenthart-Jongbloed K, Jacobs J. Not recommended fixed-dose antibiotic combinations in low- and middle-income countries - the example of Tanzania. Antimicrob Resist Infect Control 2023; 12:37. [PMID: 37076936 PMCID: PMC10116708 DOI: 10.1186/s13756-023-01238-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 03/30/2023] [Indexed: 04/21/2023] Open
Abstract
BACKGROUND Fixed-dose combinations (FDC) are medicine formulations that combine two or more ingredients in fixed ratios in a single dose form. Although advantageous in tuberculosis and malaria (efficacy, adherence, protection against resistance), only a few antibiotic FDC (FDC-AB) have been developed along full microbiological, pharmacological and clinical validation and safety studies. The World Health Organization (WHO) database of Access, Watch and Reserve (AWaRe) antibiotics contains, since 2021, a list of "Not Recommended" FDC-AB (n = 103) which are rejected for use in clinical practice. BODY: The share of non-recommended FDC-AB in global antimicrobial use (2000-2015) was < 3% but substantially higher in middle income countries. The share increases over time, but recent data particular concerning sub-Saharan Africa are rare. Along three non-recommended FDC-AB listed in the Tanzanian National Essential Medicine List (ampicillin-cloxacillin, flucloxacillin-amoxicillin and ceftriaxone-sulbactam) we discuss the concerns and reasons behind use of these products. Non-recommended FDC-AB have poor rationale (ratios of both ingredients), lack evidence of efficacy (pharmacological, microbiological and clinical), have difficulties in dosing (underdosing of the single ingredients, absence of pediatric dosing) and risks of safety (additive toxicity). They are expected to fuel antimicrobial resistance (unnecessary broad spectrum coverage) and are incompatible with antimicrobial stewardship. The specific context of low- and middle-income countries contributes to their increased use: at the side of prescriber and supplier are the lack of diagnostics, poor training in antibiotic prescribing, patients' preferences, role-model of senior prescribers and pharmaceutical promotion. International market mechanisms include economic motivation for development, branding and promotion, poor access to the single antibiotic forms and weak national regulatory capacity. CONCLUSION AND IMPLICATIONS There is an urgent need for monitoring consumption of non-recommended FDC-AB in low- and middle-income countries, particular in Sub-Saharan Africa. A multinational and multisectoral antimicrobial stewardship strategy is needed in order to abolish the use of non-recommended FDC-AB.
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Affiliation(s)
- Klaske Vliegenthart-Jongbloed
- Haydom Lutheran Hospital, Haydom, United Republic of Tanzania.
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC, Rotterdam, the Netherlands.
| | - Jan Jacobs
- Department of Clinical Sciences, Institute of Tropical Medicine Antwerp, Antwerp, Belgium
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium
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4
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Bendtsen MAF, Hanberg P, Slater J, Hansen J, Öbrink-Hansen K, Stilling M, Bue M. Steady-state concentrations of flucloxacillin in porcine vertebral cancellous bone and intervertebral disc following oral and intravenous administration assessed by microdialysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:1508-1514. [PMID: 35488132 DOI: 10.1007/s00586-022-07208-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/03/2022] [Accepted: 04/05/2022] [Indexed: 11/30/2022]
Abstract
AIMS Flucloxacillin is a frequently used antibiotic in the treatment of spondylodiscitis. We assessed steady-state concentrations and time above minimal inhibitory concentration (fT > MIC) of flucloxacillin in the intervertebral disc, vertebral cancellous bone, subcutaneous tissue and plasma, after intravenous and oral administration. METHODS Sixteen pigs were randomized into two groups; Group Peroral (Group PO) and Group Intravenous (Group IV) received 1 g flucloxacillin every 6 h for 24 h orally or intravenously. Microdialysis was used for sampling in the compartments of interest. A flucloxacillin target of 50% fT > MIC was applied for three MIC targets: 0.125, 0.5 and 2.0 μg/mL. RESULTS Intravenous administration resulted in significantly longer fT > MIC for all targets. Target attainment was only reached for the low target of 0.125 μg/mL in Group IV in vertebral cancellous bone, subcutaneous tissue, and plasma (intervertebral disc 47%). In Group IV, mean fT > MIC values in the investigated compartments were in the range of 47-67% of the dosing interval for 0.125 μg/mL, 20-35% for 0.5 μg/mL, and 0-15% for 2.0 μg/mL. In Group PO, mean fT > MIC values for 0.125 μg/mL were in the range of 1-33%. No pigs reached a concentration of 0.5 μg/mL in any of the investigated compartments in Group PO. CONCLUSION Administration of 1 g flucloxacillin every 6 h resulted in surprisingly low steady-state fT > MIC after intravenous and oral administration. However, intravenous administration resulted in significantly higher concentrations across compartments compared to oral administration. Sufficient target tissue concentrations for treatment of spondylodiscitis may require a dose increase or alternative dosing regimens.
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Affiliation(s)
- Mathias A F Bendtsen
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.
- Aarhus Microdialysis Research Group, Aarhus University Hospital, Aarhus, Denmark.
- Department of Orthopedic Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus, Denmark.
| | - Pelle Hanberg
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- Aarhus Microdialysis Research Group, Aarhus University Hospital, Aarhus, Denmark
- Department of Orthopedic Surgery, Horsens Regional Hospital, Horsens, Denmark
| | - Josefine Slater
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- Aarhus Microdialysis Research Group, Aarhus University Hospital, Aarhus, Denmark
- Department of Orthopedic Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus, Denmark
| | - Jakob Hansen
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- Institute of Forensic Medicine, Aarhus University, Aarhus, Denmark
| | - Kristina Öbrink-Hansen
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Maiken Stilling
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- Aarhus Microdialysis Research Group, Aarhus University Hospital, Aarhus, Denmark
- Department of Orthopedic Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus, Denmark
| | - Mats Bue
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- Aarhus Microdialysis Research Group, Aarhus University Hospital, Aarhus, Denmark
- Department of Orthopedic Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus, Denmark
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Kutskaya AM, Serkov SA, Voronin VV, Ledovskaya MS, Polynski MV. Negligible Substituent Effect as Key to Synthetic Versatility: a Computational‐Experimental Study of Vinyl Ethers Addition to Nitrile Oxides. ChemistrySelect 2022. [DOI: 10.1002/slct.202200174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- Anastasia M. Kutskaya
- Institute of Chemistry Saint Petersburg State University Universitetsky Prospect 26 Saint Petersburg 198504 Russia
| | - Semyon A. Serkov
- Institute of Chemistry Saint Petersburg State University Universitetsky Prospect 26 Saint Petersburg 198504 Russia
| | - Vladimir V. Voronin
- Institute of Chemistry Saint Petersburg State University Universitetsky Prospect 26 Saint Petersburg 198504 Russia
| | - Maria S. Ledovskaya
- Institute of Chemistry Saint Petersburg State University Universitetsky Prospect 26 Saint Petersburg 198504 Russia
| | - Mikhail V. Polynski
- Institute of Chemistry Saint Petersburg State University Universitetsky Prospect 26 Saint Petersburg 198504 Russia
- Zelinsky Institute of Organic Chemistry Russian Academy of Sciences Leninsky Prospect 47 Moscow 119991 Russia
- MSU Faculty of Chemistry Leninskiye Gory 1–3 Moscow 119991 Russia
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Population Pharmacokinetics of Flucloxacillin In Bone and Soft Tissue- Standard Dosing is Not Sufficient to Achieve Therapeutic Concentrations. Pharm Res 2022; 39:1633-1643. [PMID: 35233728 DOI: 10.1007/s11095-022-03197-y] [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: 11/10/2021] [Accepted: 02/11/2022] [Indexed: 10/19/2022]
Abstract
PURPOSE Flucloxacillin is a β-lactam penicillin commonly used in the treatment of bone and soft tissue infections. In a recent porcine study, we found surprisingly low time for which the free concentration was maintained above the minimal inhibitory concentration (fT>MIC) in bone and soft tissue, following flucloxacillin oral (PO) and intravenous (IV) administration at 1g every 6h (q6h). In addition to plasma, sampling was obtained from subcutaneous tissue, knee joint, cancellous bone and cortical bone, using microdialysis. To identify flucloxacillin dosing regimens that result in theoretically therapeutic concentrations, we developed a population pharmacokinetic (PK) model for the porcine data, and combined it with a human flucloxacillin population PK model for simulations. METHODS A four-compartment model was developed, and various dosing regimens and modes of administration were simulated. Predicted concentrations were compared to %fT>MIC (0.5 mg/L and 2 mg/L). RESULTS Continuous infusion (CI) resulted in higher %fT>MIC compared to intermittent administration. For intermittent IV dosing (4, 8 and 12g/24h), fT>MIC (0.5 mg/L) was ≥70% in plasma, and ranged between 42-96% in the sampled tissue in a typical individual. By applying CI, 4g/day was sufficient to achieve ≥98% fT>MIC (0.5 mg/L) in all sampled tissues. For MIC 2 mg/L, ≥50% fT>MIC was only achieved in plasma at CI 8 and 12g/24h and IV 3g q6h. CONCLUSIONS To reach efficacious flucloxacillin bone and tissue concentrations, dose increment or continuous infusion needs to be considered.
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Drennan PG, Green JK, Gardiner SJ, Metcalf SCL, Kirkpatrick CMJ, Everts RJ, Zhang M, Chambers ST. Population pharmacokinetics of free flucloxacillin in patients treated with oral flucloxacillin plus probenecid. Br J Clin Pharmacol 2021; 87:4681-4690. [PMID: 33963595 DOI: 10.1111/bcp.14887] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2020] [Revised: 04/22/2021] [Accepted: 05/02/2021] [Indexed: 12/27/2022] Open
Abstract
Oral flucloxacillin may be coadministered with probenecid to reduce flucloxacillin clearance and increase attainment of pharmacokinetic-pharmacodynamic (PK/PD) targets. The aims of this study were to develop a population PK model of free flucloxacillin when administered orally with probenecid, and to identify optimal dosing regimens for this combination. METHODS We performed a prospective observational study of adults (45 participants) treated with oral flucloxacillin 1000 mg and probenecid 500 mg 8-hourly for proven or probable staphylococcal infections. Steady-state mid-dose-interval flucloxacillin measurements (45 concentrations) were combined with existing data from a crossover study of healthy participants receiving flucloxacillin with and without probenecid (11 participants, 363 concentrations). We developed a population pharmacokinetic model of free flucloxacillin concentrations within Monolix, and used Monte Carlo simulation to explore optimal dosing regimens to attain PK/PD targets proposed in the literature (free drug time above minimum inhibitory concentration). RESULTS Flucloxacillin disposition was best described by a 1-compartment model with a lag time and first-order absorption. Free flucloxacillin clearance depended on probenecid, allometrically-scaled fat free mass (FFM) and estimated glomerular filtration rate (eGFR). Predicted PK/PD target attainment was suboptimal with standard dosing regimens with flucloxacillin alone, but substantially improved in the presence of probenecid. CONCLUSION The simulation results reported can be used to identify dose regimens that optimise flucloxacillin exposure according to eGFR and FFM. Patients with higher FFM and eGFR may require the addition of probenecid and 6-hourly dosing to achieve PK/PD targets. The regimen was well-tolerated, suggesting a potential for further evaluation in controlled clinical trials to establish efficacy.
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Affiliation(s)
- Philip G Drennan
- Department of Microbiology and Infectious Diseases, Royal Prince Alfred Hospital, Sydney, Australia.,Department of Microbiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Jared K Green
- Department of Infectious Diseases, Christchurch Hospital, Christchurch, New Zealand
| | - Sharon J Gardiner
- Department of Infectious Diseases, Christchurch Hospital, Christchurch, New Zealand.,Department of Clinical Pharmacology, Christchurch Hospital, Christchurch, New Zealand.,Department of Pharmacy, Christchurch Hospital, Christchurch, New Zealand
| | - Sarah C L Metcalf
- Department of Infectious Diseases, Christchurch Hospital, Christchurch, New Zealand
| | - Carl M J Kirkpatrick
- Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Melbourne, Australia
| | | | - Mei Zhang
- Department of Medicine, University of Otago, Christchurch, New Zealand.,Toxicology, Canterbury Health Laboratories, Christchurch, New Zealand
| | - Stephen T Chambers
- Department of Infectious Diseases, Christchurch Hospital, Christchurch, New Zealand.,Department of Pathology, University of Otago, Christchurch, New Zealand
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8
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Bendtsen MAF, Bue M, Hanberg P, Slater J, Thomassen MB, Hansen J, Søballe K, Öbrink-Hansen K, Stilling M. Flucloxacillin bone and soft tissue concentrations assessed by microdialysis in pigs after intravenous and oral administration. Bone Joint Res 2021; 10:60-67. [PMID: 33448872 PMCID: PMC7845458 DOI: 10.1302/2046-3758.101.bjr-2020-0250.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Aims Flucloxacillin is commonly administered intravenously for perioperative antimicrobial prophylaxis, while oral administration is typical for prophylaxis following smaller traumatic wounds. We assessed the time, for which the free flucloxacillin concentration was maintained above the minimum inhibitory concentration (fT > MIC) for methicillin-susceptible Staphylococcus aureus in soft and bone tissue, after intravenous and oral administration, using microdialysis in a porcine model. Methods A total of 16 pigs were randomly allocated to either intravenous (Group IV) or oral (Group PO) flucloxacillin 1 g every six hours during a 24-hour period. Microdialysis was used for sampling in cancellous and cortical bone, subcutaneous tissue, and the knee joint. In addition, plasma was sampled. The flucloxacillin fT > MIC was evaluated using a low MIC target (0.5 μg/ml) and a high MIC target (2.0 μg/ml). Results Intravenous administration resulted in longer fT > MIC (0.5 μg/ml) compared to oral administration, except for cortical bone. In Group IV, all pigs reached a concentration of 0.5 μg/ml in all compartments. The mean fT > MIC (0.5 μg/ml) was 149 minutes (95% confidence interval (CI) 119 to 179; range 68 to 323) in subcutaneous tissue and 61 minutes (95% CI 29 to 94; range 0 to 121) to 106 minutes (95% CI 76 to 136; range 71 to 154) in bone tissue. In Group PO, 0/8 pigs reached a concentration of 0.5 μg/ml in all compartments. For the high MIC target (2.0 μg/ml), fT > MIC was close to zero minutes in both groups across compartments. Conclusion Although intravenous administration of flucloxacillin 1 g provided higher fT > MIC for the low MIC target compared to oral administration, concentrations were surprisingly low, particularly for bone tissue. Achievement of sufficient bone and soft tissue flucloxacillin concentrations may require a dose increase or continuous administration. Cite this article: Bone Joint Res 2021;10(1):60–67.
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Affiliation(s)
- Mathias A F Bendtsen
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.,Aarhus Microdialysis Research Group, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Mats Bue
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.,Aarhus Microdialysis Research Group, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Pelle Hanberg
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.,Aarhus Microdialysis Research Group, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthopedic Surgery, Horsens Regional Hospital, Horsens, Denmark
| | - Josefine Slater
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.,Aarhus Microdialysis Research Group, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Maja B Thomassen
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.,Aarhus Microdialysis Research Group, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Jakob Hansen
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.,Institute of Forensic Medicine, Aarhus University, Aarhus, Denmark
| | - Kjeld Søballe
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.,Aarhus Microdialysis Research Group, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Kristina Öbrink-Hansen
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.,Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Maiken Stilling
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.,Aarhus Microdialysis Research Group, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus, Denmark
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Gariani K, Pham TT, Kressmann B, Jornayvaz FR, Gastaldi G, Stafylakis D, Philippe J, Lipsky BA, Uçkay İ. Three versus six weeks of antibiotic therapy for diabetic foot osteomyelitis: A prospective, randomized, non-inferiority pilot trial. Clin Infect Dis 2020; 73:e1539-e1545. [PMID: 33242083 DOI: 10.1093/cid/ciaa1758] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND In patients with diabetic foot osteomyelitis (DFO) who underwent surgical debridement, we investigated whether a short (3 weeks), compared with a long (6 weeks) duration of systemic antibiotic treatment is associated with non-inferior results for clinical remission and adverse events (AE). METHODS In this prospective, randomized, non-inferiority, pilot trial, we randomized (allocation 1:1), patients with DFO after surgical debridement to either a 3-week or a 6-week course of antibiotic therapy. The minimal duration of follow-up after end of therapy was two months. We compared outcomes using Cox regression and non-inferiority analyses (25% margin, power 80%). RESULTS Among 93 enrolled patients (18% females; median age 65 years), 44 were randomized to the 3-week arm and 49 to the 6-week arm. The median number of surgical debridement was 1 (range, 0-2 interventions). In the intention-to-treat (ITT) population, remission occurred in 37 (84%) of the patients in the 3-week arm compared to 36 (73%) in the 6-week arm (p=0.21). The number of AE was similar in the two study arms (17/44 vs. 16/49; p=0.51), as were the remission incidences in the per-protocol (PP) population (33/39 vs. 32/43; p=0.26). In multivariate analysis, treatment with the shorter antibiotic course was not significantly associated with remission (for the ITT population, hazard ratio 1.1, 95%CI 0.6-1.7; for the PP population hazard ratio 0.8, 95%CI 0.5-1.4). CONCLUSIONS In this randomized, controlled pilot trial, a post-debridement systemic antibiotic therapy course for DFO of 3-weeks gave similar (and statistically non-inferior) incidences of remission and AE to a course of 6 weeks.
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Affiliation(s)
- Karim Gariani
- Service of Endocrinology, Diabetes, Hypertension and Nutrition, Geneva University Hospitals, Geneva, Switzerland
| | - Truong-Thanh Pham
- Service of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland.,Orthopedic Surgery Service, Geneva University Hospitals, Geneva, Switzerland
| | - Benjamin Kressmann
- Service of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland.,Orthopedic Surgery Service, Geneva University Hospitals, Geneva, Switzerland
| | - François R Jornayvaz
- Service of Endocrinology, Diabetes, Hypertension and Nutrition, Geneva University Hospitals, Geneva, Switzerland
| | - Giacomo Gastaldi
- Service of Endocrinology, Diabetes, Hypertension and Nutrition, Geneva University Hospitals, Geneva, Switzerland
| | | | - Jacques Philippe
- Service of Endocrinology, Diabetes, Hypertension and Nutrition, Geneva University Hospitals, Geneva, Switzerland
| | - Benjamin A Lipsky
- Service of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - İlker Uçkay
- Service of Infectious Diseases, Geneva University Hospitals, Geneva, Switzerland.,Orthopedic Surgery Service, Geneva University Hospitals, Geneva, Switzerland.,Infectiology, Balgrist University Hospital, University of Zurich, Zurich, Switzerland.,Unit for Clinical and Applied Research, Balgrist University Hospital, University of Zurich, Zurich, Switzerland
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10
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Tevell S, Christensson B. Oral Flucloxacillin for Staphylococcal Osteomyelitis: Obsolete or Underused? J Bone Jt Infect 2020; 5:25-27. [PMID: 32117686 PMCID: PMC7045530 DOI: 10.7150/jbji.42852] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 12/09/2019] [Indexed: 01/12/2023] Open
Affiliation(s)
- Staffan Tevell
- Department of Infectious Diseases, Karlstad Hospital and Centre for Clinical Research, Värmland County Council, Karlstad, Sweden and School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Bertil Christensson
- Department of Infectious Diseases, Skåne University Hospital, Lund and Department of Clinical Sciences, Division of Infection Medicine, Lund University, Lund, Sweden
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