Infected diabetic foot ulcers decision making

NewsBot · Oct 5, 2021

Anatomic and Treatment Descriptive Features of Foot Infections Presenting With Radiographic Soft Tissue Emphysema
Hyun Shim et al
J Foot Ankle Surg 2021 Sep 9

Foot infections associated with soft tissue emphysema, or the radiographic appearance of gas, are widely considered to necessitate urgent decompression with excisional debridement of the necrotic and infectious tissue burden. The objective of this investigation was to describe anatomic features and clinical outcomes associated with the presence of soft tissue emphysema in foot infections. A retrospective chart review was performed of 62 subjects meeting selection criteria. These were primarily male (74.2%), with a history of diabetes mellitus (85.5%), and without a history of previous lower extremity revascularization (98.4%). The primary radiographic location of the soft tissue emphysema was most frequently in the forefoot (61.3%), followed by the midfoot (21.0%), and rearfoot (16.1%). The soft tissue emphysema was most frequently observed primarily in the dorsal foot tissue (49.2%), followed by both dorsal and plantar foot tissue (27.4%), and the plantar foot tissue (24.2%). The soft tissue emphysema was confined to the primary anatomic location in 74.2% of subjects, while 25.8% of cases demonstrated extension into a more proximal anatomic area. Eighty-two percent of subjects underwent a bedside incision and drainage procedure on presentation in the emergency department, and 95.2% underwent a formal incision and drainage procedure in the operating room at 1.05 ± 0.79 (0-5) postadmission days. Twenty-seven percent of subjects had an unplanned 30-day readmission and 17.7% underwent an unplanned reoperation within 30 days following the index discharge. Fifty-two percent of subjects underwent a minor or major amputation during the index admission, while 33.9% eventually resulted in major limb amputation within 12 months. We hope that this investigation adds to the body of knowledge and provides expectations with respect to the evaluation and treatment of foot soft tissue infections complicated by the presence of radiographic soft tissue emphysema.
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NewsBot · Oct 11, 2021

Association Between Diabetic Foot Infection Wound Culture Positivity and 1-Year Admission for Invasive Infection: A Multicenter Cohort Study
Westyn Branch-Elliman et al
Open Forum Infect Dis. 2021 Apr 2;8(7)

Inpatients with culture-positive diabetic foot infections are at elevated risk for subsequent invasive infection with the same causative organism. In outpatients with index diabetic foot ulcers, we found that wound culture positivity was independently associated with increased odds of 1-year admission for systemic infection when compared with culture-negative wounds.
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NewsBot · Oct 13, 2021

Anatomic and Treatment Descriptive Features of Foot Infections Presenting With Radiographic Soft Tissue Emphysema
Hyun Shim et al
September 08, 2021

Foot infections associated with soft tissue emphysema, or the radiographic appearance of gas, are widely considered to necessitate urgent decompression with excisional debridement of the necrotic and infectious tissue burden. The objective of this investigation was to describe anatomic features and clinical outcomes associated with the presence of soft tissue emphysema in foot infections. A retrospective chart review was performed of 62 subjects meeting selection criteria. These were primarily male (74.2%), with a history of diabetes mellitus (85.5%), and without a history of previous lower extremity revascularization (98.4%). The primary radiographic location of the soft tissue emphysema was most frequently in the forefoot (61.3%), followed by the midfoot (21.0%), and rearfoot (16.1%). The soft tissue emphysema was most frequently observed primarily in the dorsal foot tissue (49.2%), followed by both dorsal and plantar foot tissue (27.4%), and the plantar foot tissue (24.2%). The soft tissue emphysema was confined to the primary anatomic location in 74.2% of subjects, while 25.8% of cases demonstrated extension into a more proximal anatomic area. Eighty-two percent of subjects underwent a bedside incision and drainage procedure on presentation in the emergency department, and 95.2% underwent a formal incision and drainage procedure in the operating room at 1.05 ± 0.79 (0-5) postadmission days. Twenty-seven percent of subjects had an unplanned 30-day readmission and 17.7% underwent an unplanned reoperation within 30 days following the index discharge. Fifty-two percent of subjects underwent a minor or major amputation during the index admission, while 33.9% eventually resulted in major limb amputation within 12 months. We hope that this investigation adds to the body of knowledge and provides expectations with respect to the evaluation and treatment of foot soft tissue infections complicated by the presence of radiographic soft tissue emphysema.
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NewsBot · Oct 17, 2021

Predictors and outcomes of diabetic foot ulcer infection with ESBL producing bacteria in a large tertiary center
Michal Leibovitch et al
Int J Infect Dis. 2021 Oct 12

Objectives: We sought to describe predictors and outcomes of infection with ESBL producing bacteria in patients with an acute diabetic foot infection (DFI).

Methods: Records of patients admitted with acute DFI to a large tertiary hospital during the years 2014-2018 were reviewed. We collected demographic, clinical and laboratory data as well as outcomes regarding amputations and mortality. Only cultures obtained during the first two weeks following admission were considered.

Results: Cultures were available for 493 patients, 121 (24.5%) included bacteria suspected of being ESBL producers. Patients infected with ESBL producing bacteria were older, more likely to have peripheral vascular disease (PVD) and had higher SINBAD and Wagner scores upon admission. They were also more likely to have been hospitalized in the recent 6 months. Major amputations were more prevalent in patients with vs. without ESBL producing bacterial infection (30.6% vs. 19.4%, p=0.010), yet overall amputations and mortality rates were similar.

Conclusions: ESBL producing bacteria are common pathogens in DFI, more prevalent in older patients with PVD, advanced ulcers and recent hospitalization. They are associated with higher rates of major amputation. These considerations may support the choice of empirical antibiotic therapy in patients admitted with an acute infected DFI.
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NewsBot · Oct 19, 2021

Predictors and outcomes of diabetic foot ulcer infection with ESBL producing bacteria in a large tertiary center
MichalLeibovitch et al
International Journal of Infectious Diseases; 12 October 2021

Highlights
•The prevalence of ESBL producing bacteria in patients with diabetic foot infection was 25%
•The annual rate of ESBL infection did not change over the years
•Patients with ESBL infection had higher SINBAD and Wagner scores upon admission.
•They were more likely to have been hospitalized in the recent 6 months
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Objectives
We sought to describe predictors and outcomes of infection with ESBL producing bacteria in patients with an acute diabetic foot infection (DFI).

Methods
Records of patients admitted with acute DFI to a large tertiary hospital during the years 2014-2018 were reviewed. We collected demographic, clinical and laboratory data as well as outcomes regarding amputations and mortality. Only cultures obtained during the first two weeks following admission were considered.

Results
Cultures were available for 493 patients, 121 (24.5%) included bacteria suspected of being ESBL producers. Patients infected with ESBL producing bacteria were older, more likely to have peripheral vascular disease (PVD) and had higher SINBAD and Wagner scores upon admission. They were also more likely to have been hospitalized in the recent 6 months. Major amputations were more prevalent in patients with vs. without ESBL producing bacterial infection (30.6% vs. 19.4%, p=0.010), yet overall amputations and mortality rates were similar.

Conclusions
ESBL producing bacteria are common pathogens in DFI, more prevalent in older patients with PVD, advanced ulcers and recent hospitalization. They are associated with higher rates of major amputation. These considerations may support the choice of empirical antibiotic therapy in patients admitted with an acute infected DFI
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NewsBot · Nov 8, 2021

A comparative study of vancomycin loaded bone cement in the treatment of Wagner Ⅱ-Ⅳ diabetic foot
He Lyu et al
Zhongguo Gu Shang. 2021 Oct 25;34(10):947-52

Objective: To investigate the clinical effect of vancomycin bone cement in the treatment of diabetic foot ulcer (DFU) ruptured Wagner gradeⅡ-Ⅳ.

Methods: From March 2019 to April 2021, 32 patients with Wagner gradeⅡ-Ⅳ diabetic foot were divided into vacuum sealing drainage (VSD) group and bone cement group according to different treatment methods. There were 16 cases in VSD group, 8 males and 8 females;the age ranged from 66 to 81 (70.50±7.20) years, and the course of disease ranged from 8 to 40 (27.56±8.55) months;Wagner gradeⅡin 2 cases, grade Ⅲin 7 cases and grade Ⅳin 7 cases;debridement and VSD were used. There were 16 cases in the bone cement group, 9 males and 7 females;the age ranged from 63 to 79 (69.56±7.29) years, and the course of disease ranged from 11 to 39(22.75±11.43) months;Wagner gradeⅡ in 2 cases, grade Ⅲin 5 cases and grade Ⅳ in 9 cases;vancomycin loaded bone cement was used for treatment. The types of bacteria, negative time of bacterial culture, skin healing time, hospital stay, operation times and complications were observed and compared between two groups.

Results: All patients were followed up for 3 to 6 (4.00±1.07) months. The bacterial negative time, skin healing time and hospital stay in bone cement group were significantly lower than those in VSD group (P<0.05). The median number of operations in both groups was 2, and there was no significant difference (P>0.05). According to the analysis of pathogens in two groups, there were 13 cases of G+ patients, 14 cases of G- patients and 5 cases of mixed bacteria. The number of G+, G- and mixed bacteria in bone cement group was 6, 7 and 3 cases respectively, and the number of G+, G- and mixed bacteria in VSD group was 7, 7 and 2 cases respectively. The wounds of 32 patientsin two groups healed completely without complications.

Conclusion: Vancomycin loaded bone cement is effective in the treatment of Wagner grade Ⅱ-Ⅳ diabetic foot ulceration wounds. It can reduce the length of hospital stay, shorten the healing time of skin and kill pathogens as soon as possible. It is one of the effective methods to treat Wagner gradeⅡ-Ⅳdiabetic foot ulceration.
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NewsBot · Nov 9, 2021

Microbiological and Antimicrobial Pattern of Diabetic Foot Ulcers at a Tertiary Care Center in East China
Yaping Xie et al
Int J Low Extrem Wounds. 2021 Nov 6

Background: Diabetic foot infections (DFIs) are the most complex and challenging pathological state, characterized by high complexity of management, morbidity, and mortality. Empirical antimicrobial administration is needed before the identification of the causative organisms. Microbiological profile of the diabetic foot patients is the basis of the antibiotic choice for clinicians.

Methods: 76 patients visiting the Diabetic Foot Center of our Hospital for having ulcers with Wagner 3 to 5 were retrospectively surveyed for the bacterium infected. Antimicrobial susceptibility testing (AST) was implemented and the results were interpreted on the basis of the Clinical and Laboratory Standards Institute (CLSI) guidelines.

Results: A total of 92 isolates were obtained, of which 47 strains of gram-negative bacilli (GNB) accounted for 51.1%, 41 strains of gram-positive cocci (GPC) accounted for 44.6%, and 4 strains of fungi accounted for 4.3%. Species of Enterobacteriaceae and Staphylococcus are the two predominant strains. The top 4 most frequently isolated strains were Staphylococcus aureus (22.8%), enterococcus faecalis (9.8%), Pseudomonas aeruginosa (9.8%), Escherichia coli (5.4%). The rate of resistance to methicillin was 33.3% for S. aureus. The rate of extended-spectrum β-lactamases (ESBLs) production among E. coli was 60%. 50% of Klebsiella pneumoniae were resistant to carbapenems. P. aeruginosa showed high sensitivity to commonly used antibiotics. There was one isolate of Acinetobacter spp. resistant to most antimicrobials except tigecycline and aminoglycosides.

Conclusion: Enterobacteriaceae and Staphylococcus are the two predominant species. The resistance to antibiotics of S. aureus and P. aeruginosa showed optimistic results. However, the high prevalence of CRKP imposed a challenging issue for clinical physicians.
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NewsBot · Nov 10, 2021

Clinical and Microbiological Profile of Diabetic Foot Ulcers Infected With Staphylococcus aureus in a Regional General Hospital in Bahia, Brazil
Luciano Dias Nascimento et al
Int J Low Extrem Wounds. 2021 Nov 6

It is necessary to know the resistance profile of Staphylococcus aureus to better control diabetic foot ulcer infections, to establish rational antibiotic therapy, and to avoid the development of resistant strains. This cross-sectional study evaluated the clinical parameters, virulence, and antimicrobial resistance profiles of S aureus in patients with diabetic foot disease admitted to a public hospital. S aureus strains were identified in patients with diabetes with amputation indication. Infected tissue samples were collected, microbes were isolated and identified. The microbial resistance profile was determined. Samples were also analyzed for biofilm formation and other virulence markers. The 34 individuals examined were mostly men, black, aged 60 years on average, and generally had a low income and education level. Most individuals had type 2 diabetes, and the mean time since diagnosis was 13.9 years. On an SF-36 (the Medical Outcomes Study 36-item short-form health survey) quality-of-life questionnaire, 75% of individuals obtained a score equal to 0 for physical impairment. S aureus specimens from 17 patients were isolated, corresponding to 50% of samples. Five isolates were classified as methicillin-resistant S aureus (MRSA). Molecular typing revealed that 20% of MRSA strains were SCCmec type V and 80% were type I. All isolates were sensitive to doxycycline; 61.5% were resistant to erythromycin, 38.5% to cefoxitin, 30.7% to clindamycin and ciprofloxacin, 23% to meropenem, 15.3% to gentamicin, 38.5% to oxacillin, and 7.7% (one strain) to vancomycin. Regarding biofilm production, 53% of samples were able to produce biofilms, and 84.6% had icaA and/or icaD genes. Additionally, the following enterotoxin genes were identified in the isolates: seb, sec, seg, and sei (5.9%, 5.9%, 11.8%, and 23.9%, respectively) and agr types 1 (5.9%) and 2 (11.8%). Genotypic evaluation made it possible to understand the pathogenicity of S aureus strains isolated from the diabetic foot; laboratory tests can assist in the monitoring of patients with systemic involvement.
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NewsBot · Nov 22, 2021

Evaluation of Adherence to the Oral Antibiotic Treatment in Patients With Diabetic Foot Infection
Irene Sanz-Corbalán, DPM, PhD, Aroa Tardáguila-García, DPM, PhD, Yolanda García-Álvarez, DPM, PhD,
November 15, 2021

Introduction: The knowledge about level of adherence to oral antibiotic treatment in diabetic patients with ulcer infection could be essential as a method of evaluation/monitoring of conservative treatment. Aim: To assess the adherence to oral antibiotic treatment in outpatients with diabetic foot infection (soft tissue vs. osteomyelitis) by 8-item structured, self-reported medication adherence scale. Methods: cross-sectional study was carried out with 46 consecutive patients who had diabetic foot infection (soft tissue or bone infection) and required antibiotic oral treatment at outpatient clinical setting. Medication adherence was tested using the Spanish version of the validated eight-item self-report MMAS-8. Results: patients with diabetic ulcer infection, had well level of adherence to antibiotic medication (7 ± 1.2 vs. 7.4 ± 1.5). Patients with lower level of adherence had lower level of satisfaction with the antibiotic medication. The profile of the patients with lower level of adherence were patients with primary level of education and patient who required more help to take the medication. Conclusion: Patients with diabetic foot infection demonstrated well level of adherence to antibiotic medication, independently of type of infection (soft tissue vs. osteomyelitis) by 8-item structured, self-reported medication adherence scale.
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NewsBot · Nov 26, 2021

Pathophysiology and Molecular Imaging of Diabetic Foot Infections
Katie Rubitschung et al
Int J Mol Sci. 2021 Oct 26;22(21):11552

Diabetic foot infection is the leading cause of non-traumatic lower limb amputations worldwide. In addition, diabetes mellitus and sequela of the disease are increasing in prevalence. In 2017, 9.4% of Americans were diagnosed with diabetes mellitus (DM). The growing pervasiveness and financial implications of diabetic foot infection (DFI) indicate an acute need for improved clinical assessment and treatment. Complex pathophysiology and suboptimal specificity of current non-invasive imaging modalities have made diagnosis and treatment response challenging. Current anatomical and molecular clinical imaging strategies have mainly targeted the host's immune responses rather than the unique metabolism of the invading microorganism. Advances in imaging have the potential to reduce the impact of these problems and improve the assessment of DFI, particularly in distinguishing infection of soft tissue alone from osteomyelitis (OM). This review presents a summary of the known pathophysiology of DFI, the molecular basis of current and emerging diagnostic imaging techniques, and the mechanistic links of these imaging techniques to the pathophysiology of diabetic foot infections.
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NewsBot · Dec 2, 2021

Phenotypic profile and antibiogram of biofilm-producing bacteria isolates from diabetic foot ulcers in Zaria, Nigeria
Yahaya Usman et al
Niger Postgrad Med J. Oct-Dec 2021;28(4):233-239

Background: Diabetic foot ulcers (DFUs) present with high morbidity and reduce patient's quality of life. There is a gross paucity of data on biofilm-producing bacteria in DFU Infection in North-Western Nigeria. The study sought to determine the biofilm-forming ability of bacteria isolates from DFUs and determine their antimicrobial susceptibility pattern in Zaria, North-Western Nigeria.

Materials and methods: This hospital-based cross-sectional study of patients with DFUs was conducted from June 2018 to February 2020. Consecutive biopsies were aseptically collected. Bacteria were isolated and identified using a Microgen kit. Biofilm forming ability and antibiogram of isolates were determined using microtitre plate and disk diffusion methods, respectively.

Results: Of the 225 participants enrolled, males constituted the majority, 144 (64.0%) with 88 (36.0%) females, the median age of participants was 54 (48-60) years, and the age range was 36-77 years. A total of 172 bacteria were isolated, and 123 (71.5%) were biofilm producers. Staphylococcus aureus (26.7%) was the highest biofilm producer, while Citrobacter freundii and Stenotrophomonas maltophilia were the least biofilm producers, 1 (0.6%) each. A disproportionate resistance pattern was demonstrated among the biofilm and non-biofilm producers against the cephalosporins tested, ceftazidime (68% vs. 18%), ceftriaxone (50% vs. 8.0%) and cefotaxime (21% vs. 0.0%). About 46% and 68% of the biofilm producers were resistant to gentamycin and ciprofloxacin, respectively. While only 2% of the non-biofilm producers were resistant to imipenem, 11% of the biofilm producers were resistant to it.

Conclusion: These findings revealed a high proportion of biofilm-producing bacteria and were more resistant than non-biofilm producers
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NewsBot · Dec 26, 2021

Association Between Dermcidin, Salusin-α, Salusin-β Molecules and Diabetic Foot Infections
Ayşe Sağmak Tartar, Kader Uğur, Kevser Tuncer Kara, ...
The International Journal of Lower Extremity Wounds December 20, 2021

Dermcidin, salusin-α, and salusin-β are three recently discovered molecules that confer antimicrobial properties. The present study aims to investigate the association between dermcidin, salusin-α, and salusin-β in the etiopathology of patients with diabetic foot infection. The study included three groups: Group 1 - diabetic foot infection; Group 2 - diabetes without history of diabetic foot; and Group 3 – the control group. Plasma dermcidin, salusin-α, and salusin-β levels were compared across the groups. Median (Q1-Q3) values of plasma dermcidin levels in Groups 1, 2, and 3 were 3.45 (0.8-4.4), 5.2 (3.7-6.4), and 5.8 (3.1-10) ng/mL, respectively. Diabetic foot infection group had significantly lower plasma dermcidin levels compared to diabetes only group and control group (P = .000, ANOVA), whereas there was no statistically significant difference between the Group 2 and Group 3 (P = .163, ANOVA). Salusin-α and salusin-β levels were significantly higher in the Group 3 compared to the other groups. Based on our findings, diabetic foot infection group had significantly lower plasma dermcidin levels and salusin-α and salusin-β levels were significantly higher in the control group. These molecules (dermcidin specifically) can be researched as an adjuvant therapeutic agent in addition to conventional treatments in diabetic foot diabetic foot infections. Also, it can be searched this may prevent many complications including amputation
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NewsBot · Jan 21, 2022

Physicochemical and Biological Study of 99m Tc and 68 Ga Radiolabelled Ciprofloxacin and Evaluation of [ 99m Tc]Tc-CIP as Potential Diagnostic Radiopharmaceutical for Diabetic Foot Syndrome Imaging
Przemysław Koźmiński et al
Tomography. 2021 Dec 1;7(4):829-842

This paper presents the application of ciprofloxacin as a biologically active molecule (vector) for delivering diagnostic radiopharmaceuticals to the sites of bacterial infection. Ciprofloxacin-based radioconjugates containing technetium-99m or gallium-68 radionuclides were synthesised, and their physicochemical (stability, lipophilicity) and biological (binding study to Staphylococcus aureus and Pseudomonas aeruginosa) properties were investigated. Both the tested radiopreparations met the requirements for radiopharmaceuticals, and technetium-99m-labelled ciprofloxacin turned out to be a good radiotracer for the tomography of diabetic foot syndrome using SPECT.
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NewsBot · Jan 24, 2022

Monitoring of amoxicilline and ceftazidime in the microdialysate of diabetic foot and serum by capillary electrophoresis with contactless conductivity detection
Petr Tůma et al
Electrophoresis. 2022 Jan 24.

Determination of the broad-spectrum antibiotics amoxicilline (AMX) and ceftazidime (CTZ) in blood serum and in microdialysates of the subcutaneous tissue of the lower limbs is performed using capillary electrophoresis (CE) with contactless conductivity detection (C4 D). Baseline separation of AMX is achieved in 0.5 M acetic acid as the background electrolyte and separation of CTZ in 3.2 M acetic acid with addition of 13% v/v methanol. The CE-C4 D determination is performed in a 25 μm capillary with suppression of the EOF using INST-coating on an effective length of 18 cm and the attained migration time is 4.2 min for AMX and 4.4 min for CTZ. The analysis was performed using 20 μL of serum and 15 μL of microdialysate, treated by the addition of acetonitrile in a ratio of 1/3 v/v and the sample is injected into the capillary using the large volume sample stacking technique. The LOQ attained in the microdialysate is 148 ng/mL for AMX and 339 ng/mL for CTZ, and in serum 143 ng/mL for AMX and 318 ng/mL for CTZ. The CE-C4 D method is employed for monitoring the passage of AMX and CTZ from the blood circulatory system into the subcutaneous tissue at the sites of diabetic ulceration in patients suffering from diabetic foot syndrome and also for measuring the pharmacokinetics following intravenous application of bolus antibiotic doses.
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NewsBot · Jan 26, 2022

The Infected Diabetic Foot: A Microbiological Analysis
Ute Waldecker, MD
Foot & Ankle Orthopaedics January 21, 2022

Introduction/Purpose:
Diabetic foot infections show increasing prevalence. Their therapy is time consuming and expensive. Standardized antibiotic treatments do not exist. Suboptimal antibiotic therapy increases the morbidity of the patient. The aim of the study was to evaluate the dominating bacterial colonization in the diabetic foot. Furthermore we evaluated the changes of the colonization during surgical and antibiotic treatment and the efficiency of the therapy.

Methods:
The study included 100 patients with a diabetic foot syndrome and a pedal ulcer. Ulcers were classified according to Wagner Classification. HbA1c, CRP and patients BMI were documented. All patients underwent an angiologic investigation with arterial doppler ultrasonography and TcpO2 measurement. An MRI of the affected foot was performed to rule out osteomyelitis. All patients underwent surgical and antibiotic treatment. Surgery included debridement, abscess drainage, VAK therapy, bony resection, minor amputation, resection arthroplasty, Helal osteotomies. Osteomyelitis was pathologically verified. Microbiological results of superficial and deep smears, which were taken during the surgical therapy were analyzed. The antibiotic treatment was adapted to the bacterial resistance.

Results:
The duration of antibiotic treatment varied from 1 to 136 days (Mean:19.6 days, SD:17.3 ). The mean number of surgical interventions was 2.6. The dominating initial antibiotic treatment was Clindamycin/ Cefuroxim (48%) followed by Clindamycin (11%),Cefuroxim (7%), Clindamycin/ Ciprofloxacin (6%), Tazobactam (3%). The dominating bacteria were gram +. The difference of the percentage distribution compared to the gram- bacteria was statistically significant. The only significant percentage change of the antibiotic treatment was seen after the first surgical intervention, when the initial antibiotic treatment was significantly more effective against gram - bacteria. A change of the antibiotic treatment was seen with 1. Clindamycin / Ciprofloxacin in 66%, 2. Tazobactam in 67%, 3.Clindamycin in 36% and Clindamycin/ Cefuroxim in 35%.

Conclusion:
The dominating bacteria of the infected diabetic feet were gram +. The initial i.v. antibiotic treatment with Clindamycin/ Cefuroxim was effective in 66%. An optimization of the initial antibiotic treatment with greater focus on the gram + bacteria seems to be necessary.
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NewsBot · Mar 7, 2022

Is It Really Infected? Recognizing Infection in Diabetic Foot Ulcers Based on the Evidence

NewsBot · Apr 5, 2022

The impact of the length of total and intravenous systemic antibiotic therapy for the remission of diabetic foot infections
Florian Haug et al
Int J Infect Dis. 2022 Mar 28

Objective: We investigated the impact of the total length of systemic antibiotic therapy (ABT) and its initial intravenous (IV) part, on clinical and microbiological failures (CF and MF) in diabetic foot infections (DFI).

Methods: Single-centre, retrospective, unmatched case-control study; including DFI episodes treated with a combined surgical-antibiotic approach.

Results: We included 721 DFI episodes; 537 with osteomyelitis (DFO). CF occurred in 191 (26.5%) and MF in 42 episodes (5.8%). Multivariate Cox regression analysis showed that a short ABT of 8-21 days (hazard ratio (HR) 0.4; 95%CI 0.2-0.7) was inversely associated with CF. This same applied for IV ABT with relatively short durations of 2-7 days (HR 0.5; 0.3-0.8) or 8-14 days (HR 0.6; 0.4-0.9). We failed to detect a minimal threshold of total or IV ABT predictive for CF or MF.

Conclusion: Compared to total ABT of more than 84 days and IV therapy of more than 14 days, shorter total and IV ABT yielded no enhanced risk of CF or MF. Considering the "bias by indication" inherent to retrospective DFI studies, the best study design concerning the duration of ABT would be a stratified, prospective-randomized trial, which is currently under way in our medical centre.
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NewsBot · Apr 7, 2022

A Systematic Review of Randomized Controlled Trials of Antibiotic Use in Diabetic Foot Ulcer Infections: Focus on Clinical Cure
Vincent Pratama et al
Infect Chemother. 2022 Mar;54(1):125-139

Background: The use of antibiotics in diabetic foot ulcer infections (DFUI) is essential in reducing morbidity. Optimal administration of antibiotics can improve clinical outcomes and reduce the risk of antibiotic resistance. This study aims to review the efficacy, in terms of clinical cure, of various regimens and the duration of antibiotic administration in DFUI patients, based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The efficacy based on microbiological response is also reviewed as the secondary outcome.

Materials and methods: We used three databases, namely PubMed, Scopus, and ScienceDirect, to search for randomized controlled trials (RCTs) in patients with DFUI who required antibiotics.

Results: A total of 16 studies were included in the systematic review. The study locations and bacterial patterns varied, with the most common pathogen being Staphylococcus aureus. Most studies did not demonstrate a significant difference in clinical cure and pathogen eradication, either in the comparison between systemic and topical antibiotics or in the duration of administration. Some studies had similar characteristics and were analyzed to conclude. These studies showed that ertapenem had comparable efficacy to piperacillin/tazobactam. Similar results were also conducted from studies of piperacillin-tazobactam+amoxicillin-clavulanic acid vs. moxifloxacin.

Conclusion: Most studies have heterogeneous characteristics, possibly due to differences in research location. Therefore, there is no strong evidence to recommend a specific antibiotic with the highest efficacy. However, since all included studies are RCTs, this review provides a good summary in considering antibiotic choices when treating DFUI patients.
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NewsBot · Apr 11, 2022

Characteristics and Microbiological Profile of Patients
with Diabetic Foot Infections in Kuantan, Pahang
Kow RY et al
Malaysian Orthopaedic Journal 2022 Vol 16 No 1

Introduction: The number of people suffering from diabetic
foot infection (DFI) has increased precipitously over the
years in Malaysia, owing to increased population,
urbanisation, the surge of number of people with obesity and
physical inactivity. As one of the most dreaded
complications of diabetes mellitus, DFI is associated with
high morbidity and mortality. We aim to study the
microbiological profile of patients with DFI at a university
hospital in Kuantan, Pahang.
Materials and methods: This retrospective study was
carried out at at Sultan Ahmad Shah Medical Centre @IIUM
(SASMEC @IIUM) from 1 January 2018 to 30 April 2019.
Patients’ demographic data, types of infection and surgical
intervention, and the microbiological profile were obtained
from the medical records.
Results: A total of 142 causative pathogens were cultured
from 130 tissue samples, with an average of 1.09 pathogens
per lesion. Majority of the pathogens were gram-negative
pathogens (52.8%). Staphylococcus sp. was the most
common pathogen isolated (22.5%). This was followed by
Streptococcus sp. (10.6%), Pseudomonas sp. (9.2%),
Morganella sp. (5.6%), Klebsiella sp. (4.9%), Enterobacter
sp. (4.9%), and others. Among the 142 pathogens, there were
9 multidrug-resistant strains observed. Most of the
antibiotics were effective against the gram-positive
pathogens except benzylpenicillin, tetracyclin, fusidic acid
and ciprofloxacin. Meanwhile, cefotaxime, amoxicillin and
ampicillin-sulbactam were also not suitable against gramnegative pathogens. Oxacillin and sulfamethoxazole/
trimethoprim can be used as empirical antibiotics against
gram-positive pathogens, while vancomycin should be
reserved for patients with septic shock or suspected multidrug resistant strain infection. Piperacillin/tazobactam and
ceftazidime can be usConclusion: Early initiation of empirical antibiotic(s) is
paramount to stymie the infection from getting worse while
waiting for the identification of causative pathogens in the
management of DFI. This study provides a guide for treating
physicians to initiate the most appropriate empirical
antibiotic in DFI.
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NewsBot · Apr 11, 2022

Microbiome Characterization of Infected Diabetic Foot Ulcers in Association With Clinical Outcomes: Traditional Cultures Versus Molecular Sequencing Methods
Hadar Mudrik-Zohar et al
Front Cell Infect Microbiol. 2022 Mar 24

Background: Infected diabetic foot ulcers (IDFU) are a major complication of diabetes mellitus. These potentially limb-threatening ulcers are challenging to treat due to impaired wound healing characterizing diabetic patients and the complex microbial environment of these ulcers.

Aim: To analyze the microbiome of IDFU in association with clinical outcomes.

Methods: Wound biopsies from IDFU were obtained from hospitalized patients and were analyzed using traditional microbiology cultures, 16S rRNA sequencing and metagenomic sequencing. Patients' characteristics, culture-based results and sequencing data were analyzed in association with clinical outcomes.

Results: A total of 31 patients were enrolled. Gram-negative bacteria dominated the IDFU samples (79%, 59% and 54% of metagenomics, 16S rRNA and cultures results, respectively, p<0.001). 16S rRNA and metagenomic sequencing detected significantly more anaerobic bacteria, as compared to conventional cultures (59% and 76%, respectively vs. 26% in cultures, p=0.001). Culture-based results showed that Staphylococcus aureus was more prevalent among patients who were treated conservatively (p=0.048). In metagenomic analysis, the Bacteroides genus was more prevalent among patients who underwent amputation (p<0.001). Analysis of metagenomic-based functional data showed that antibiotic resistance genes and genes related to biofilm production and to bacterial virulent factors were more prevalent in IDFU that resulted in amputation (p<0.001).

Conclusion: Sequencing tools uncover the complex biodiversity of IDFU and emphasize the high prevalence of anaerobes and Gram-negative bacteria in these ulcers. Furthermore, sequencing results highlight possible associations among certain genera, species, and bacterial functional genes to clinical outcomes.
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NewsBot · Apr 12, 2022

Multifaceted Strategy Improves Outcomes of Patients Hospitalized with a Diabetic Foot Infection
Elad Keren et al
Int J Low Extrem Wounds. 2022 Apr 11

Diabetic foot infections (DFIs) are associated with major morbidity, reduced quality of life and increased mortality. Osteomyelitis is a leading cause of lower-extremity amputation in diabetic patients. We aimed to examine whether a multifaceted strategy for treating hospitalized patients with a DFI effectively influenced microbiological culture results and outcomes. A retrospective cohort-study in a 1100-bed, tertiary-care university hospital was conducted. Adult patients with a DFI admitted to the orthopedics department between 2015 and 2019 were included. During the pre-intervention period (2015-2016), one general orthopedic department was in operation. In the post-intervention period (2017-2019), a second department was created with a designated "complicated wound unit". The multifaceted strategy included revising local guidelines for DFI culturing emphasizing bone cultures, correct sample handling, and adjusting antibiotic treatment to culture results. Additionally, a weekly multidisciplinary-team grand round was instigated and post-discharge outpatient follow-up was scheduled. 652 patients with DFIs were included; 101 during the pre-intervention period and 551 during the post-intervention period. Compared to the pre-intervention, during the post-intervention period mainly bone or deep-tissue cultures were performed (9.7% vs. 98.2%, P < 0.001). Bacteriology cultures in the pre-intervention versus post-intervention period revealed: among staphylococcus isolates, fewer methicillin-resistant Staphylococcus aureus detected (20.4% vs. 9.8%, P = 0.010); within Enterobacteriaceae isolates, fewer extended-spectrum β-lactamase producing bacteria detected (51.6% vs. 23.6%, P < 0.001); a decrease in Pseudomonas aeruginosa isolates (28% vs. 10.6%, P < 0.001) and an increase in anaerobic bacterial isolates (0 vs. 11.1%, P < 0.001). On multivariate regression, the post-intervention period (ie multifaceted strategy) was a protective measure against readmissions (P = 0.007 OR 0.50 95% CI 0.30-0.82). We conclude that our interventive multifaceted strategy led to accurate bacterial diagnosis, de-escalation of antibiotic treatment and readmission reduction.
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NewsBot · Apr 14, 2022

Short and oral antimicrobial therapy for diabetic foot infection: a narrative review of current knowledge
Steven M Maurer et al
J Bone Jt Infect. 2022 Mar 25;7(2):61-70

Diabetic foot infection is a frequent complication in long-standing diabetes mellitus. For antimicrobial therapy of this infection, both the optimal duration and the route of administration are often based more on expert opinion than on published evidence. We reviewed the scientific literature, specifically seeking prospective trials, and aimed at addressing two clinical issues: (1) shortening the currently recommended antibiotic duration and (2) using oral (rather than parenteral) therapy, especially after the patient has undergone debridement and revascularization. We also reviewed some older key articles that are critical to our understanding of the treatment of these infections, particularly with respect to diabetic foot osteomyelitis. Our conclusion is that the maximum duration of antibiotic therapy for osteomyelitis should be no more than to 4-6 weeks and might even be shorter in selected cases. In the future, in addition to conducting randomized trials and propagating national and international guidance, we should also explore innovative strategies, such as intraosseous antibiotic agents and bacteriophages.
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NewsBot · Apr 18, 2022

A Systematic Review of Randomized Controlled Trials of Antibiotic Use in Diabetic Foot Ulcer Infections: Focus on Clinical Cure
Vincent Pratama et al
Infect Chemother. 2022 Mar;54(1):125-139

Background
The use of antibiotics in diabetic foot ulcer infections (DFUI) is essential in reducing morbidity. Optimal administration of antibiotics can improve clinical outcomes and reduce the risk of antibiotic resistance. This study aims to review the efficacy, in terms of clinical cure, of various regimens and the duration of antibiotic administration in DFUI patients, based on Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. The efficacy based on microbiological response is also reviewed as the secondary outcome.

Materials and Methods
We used three databases, namely PubMed, Scopus, and ScienceDirect, to search for randomized controlled trials (RCTs) in patients with DFUI who required antibiotics.

Results
A total of 16 studies were included in the systematic review. The study locations and bacterial patterns varied, with the most common pathogen being Staphylococcus aureus. Most studies did not demonstrate a significant difference in clinical cure and pathogen eradication, either in the comparison between systemic and topical antibiotics or in the duration of administration. Some studies had similar characteristics and were analyzed to conclude. These studies showed that ertapenem had comparable efficacy to piperacillin/tazobactam. Similar results were also conducted from studies of piperacillin-tazobactam+amoxicillin-clavulanic acid vs. moxifloxacin.

Conclusion
Most studies have heterogeneous characteristics, possibly due to differences in research location. Therefore, there is no strong evidence to recommend a specific antibiotic with the highest efficacy. However, since all included studies are RCTs, this review provides a good summary in considering antibiotic choices when treating DFUI patients.
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NewsBot · Apr 21, 2022

Clinico-Microbiological Profile and Culture Sensitivity Pattern of Micro-Organisms Isolated from Diabetic Foot Ulcers: Study from a Tertiary Care Centre
Andavarapu Gouri ShankarRao et al
J Assoc Physicians India. 2022 Apr;70(4):11-12.

Worldwide, diabetic foot lesions are a major medical, social and economic problem and are the leading cause of hospitalization for patients with diabetes. The organisms causing the ulcers vary from different geographical regions and initiation of empiric antibiotics depends on the prevalence of the local pathogens and their sensitivity pattern, With this background the present study was carried out to evaluate the bacterial diversity and their culture sensitivity patterns in diabetic foot ulcers.

Material: Medical records of 65 cases of diabetes mellitus with diabetic foot ulcer admitted to hospital during the period from January 2019 to December 2020 were retrieved from the Medical Records Department. Demographic, clinical profile and microbiological profile with antibiotic sensitivity pattern were analyzed.

Observation: Out of 65 cases (n=65), 54 (83.07%) were male and 11 (16.92%) were female. Age range of the patients was from 39 years to 80 years with mean age of 59=/-9.65years. The mean duration of diabetes was 9.4=/-5.7 years and 52.4% had diabetes for more than 10 years. Hypertension was present in 84.5% of the cases. Nearly 62.5% had lesions for 3 months before presenting to the hospital. Peripheral neuropathy was present in all the cases. More than 60% cases were surgically treated with debridement. Osteomyelitis was present in 44.5% cases. Out of 65 cases, 64 were culture positive. Pseudomonas aeruginosa was the leading pathogen in 23.3% cases (n=15), Staphylococcus aureus, E.coli, Acinetobacter baumannii and Klebsiella pneumoniae were isolated in 15.38% cases each followed by Burkholderia cepacia which constituted 10% of all cases. Multiple organisms were isolated in 11 cases (16.92%).

Conclusion: Burkholderia cepacia, which was earlier an uncommon infection in Diabetic foot ulcer, was found in significant (10%) number of cases. This may be due to improper waste management and change in environmental conditions.
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NewsBot · May 10, 2022

Diabetic foot infections: how to investigate more efficiently? A retrospective study in a quaternary university center
Aisin Ibrahim et al
Insights Imaging. 2022 May 10;13(1):88

Background: Diabetic foot infections are frequent and associated with substantial morbidity and substantial cost to the healthcare system. Up to 34% of diabetic patients will develop an ulcer potentially leading to osteomyelitis. Imaging plays a crucial role in the diagnostic process. Imaging modalities to investigate the diabetic foot infection are many and imaging prescription habits remain heterogeneous across physicians. We aimed to improve the appropriateness of imaging examination requested, and performed, for diabetic foot osteomyelitis and we aimed to reduce the overall imaging-related cost.

Methods: Local committee was created to develop an algorithm for suspected diabetic foot osteomyelitis. Best practices were defined by the local algorithm. The algorithm was shared with our physicians. Pre- and post-intervention analysis was conducted retrospectively. All adult diabetic patients with suspected foot osteomyelitis were included. Adherence to best practices was measured. Statistical analysis with Chi-Square and two tailed unpaired t-test was performed.

Results: Pre-intervention cohort had 223 patients (mean age: 63; 168 men). Adherence to best practice was 43%. Scintigraphy (48%) preferred over MRI (44%) and performed simultaneously in 15 patients. Post-intervention cohort had 73 patients (mean age: 66; 62 men). Adherence to best practice was 78%, improved by 35% (p < 0.001). MRI (51%) preferred over scintigraphy (23%) and performed simultaneously in three patients. Scintigraphy examinations decreased by 25% (p < 0.001). MRI examinations increased by 7% (p = 0.32). Hospital imaging related fees decreased by 22% per patient (p = 0.002).

Conclusion: Interval improvement in adequate adherence while reducing unnecessary examinations for patients and decreasing costs for the healthcare system was observed.
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NewsBot · May 17, 2022

Measuring the minimum biofilm eradication concentration for bacterial isolates from diabetic foot infections
Manal Ismail et al
09 May 2022

Background: Diabetic foot infection (DFI) is considered the most common cause of diabetes-related hospitalization. Diabetic foot ulcers are subjected to bacterial colonization with biofilm forming organisms which are difficult to eradicate. The aim of this study was to identify the spectrum of bacteria associated with DFI and their ability to form biofilm, to evaluate differences in antibiotic susceptibility pattern between planktonic and biofilm phases, and to determine the antibiotics which are active on the organism in the biofilm phase. Methods: The study comprised 50 patients with DFI. A deep swab was collected from each patient and cultured. All isolates were identified and screened for biofilm formation. Biofilm forming isolates were further subjected to minimum biofilm eradication concentration (MBEC) assays to determine resistance to different antimicrobials while in the biofilm phase. Results: Seventy-one isolates were identified, (14.1%) were Gram positive cocci, (83.1%) were Gram negative bacilli, and (2.8%) were Candida species. The most frequently isolated organism was Klebsiella spp. (18/71, 25.4%), followed by Proteus spp. (14/71, 19.7%). The prevalence of biofilm forming isolates was 38%. All the studied isolates showed MBEC higher than the MIC for all tested antimicrobials. Conclusions: The substantial discrepancy between MIC and MBEC results observed in this study emphasizes the lack of reliability of the routine antimicrobial susceptibility testing in case of biofilm formation. Among all tested antimicrobials; cefoperazone/sulbactam, gentamicin, and vancomycin demonstrated activity against bacteria in the biofilm phase.
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NewsBot · May 30, 2022

Moderate to Severe Soft Tissue Diabetic Foot Infections: A Randomized, Controlled, Pilot Trial of Post-Debridement Antibiotic Treatment for 10 versus 20 days
Truong-Thanh Pham et al
Ann Surg. 2021 Sep 15

Background: The optimal duration of antibiotic therapy for soft-tissue infections of the diabetic foot (ST-DFI) remains unknown.

Objective: We determine if antibiotic therapy after debridement for a short (10 days), compared with a long (20 days), duration for ST-DFI results in similar rates of clinical remission and adverse events (AE).

Summary background data: The optimal duration of systemic antibiotic therapy, after successful debridement, for soft tissue infections of diabetic patients is unknown. Because of the high recurrence risk, overuse is commonplace.

Methods: This was a randomized, controlled, non-inferiority pilot trial of cases of diabetic foot infection (excluding osteomyelitis) with the primary outcome of "clinical remission at two-months follow-up".

Results: Among 66 enrolled episodes (17% females; median age 71 years), we randomized 35 to the 10-day arm and 31 to the 20-day arm. The median duration of the parenteral antibiotic therapy was 1 day, with the remainder given orally. In the intention-to-treat (ITT) population, we achieved clinical remission in 27 (77%) patients in the 10-day arm compared to 22 (71%) in the 20-days arm (p = 0.57). There were a similar proportion in each arm of AE (14/35 versus 11/31; p = 0.71), and remission in the per-protocol (PP) population (25/32 vs. 18/27; p = 0.32). Overall, eight soft tissue DFIs in the 10-day arm and five cases in the 20-day arm recurred as a new osteomyelitis (8/35 [23%] versus 5/31 [16%]; p = 0.53). Overall, the number of recurrences limited to the soft tissues was 4 (6%). By multivariate analysis, rates of remission (ITT population, hazard ratio 0.6, 95%CI 0.3-1.1; PP population 0.8, 95%CI 0.4-1.5) and AE were not significantly different with a 10-day compared to 20-day course.

Conclusions: In this randomized, controlled pilot trial, post-debridement antibiotic therapy for soft tissue DFI for 10 days gave similar (and non-inferior) rates of remission and AEs to 20 days. A larger confirmatory trial is under way.
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NewsBot · May 31, 2022

Clinical and Histological Outcomes of Negatively Charged Polystyrene Microspheres Applied Daily Versus Three Times per Week in Hard-to-Heal Diabetic Foot Ulcers: A Randomized Blinded Controlled Trial
José Luis Lázaro-Martínez et al
Int J Low Extrem Wounds. 2022 May 29

Negatively charged polystyrene microspheres (NCMs) have been demonstrated as a novel and effective therapy for managing hard-to-heal diabetic foot ulcers (DFUs). However, one limitation of this therapy is that the protocol is based on daily application, which sometimes does not fit local protocols of wound care. Thus, we aimed to analyze the safety and efficacy of a new dose regimen. We conducted a randomized blinded controlled trial in a specialized diabetic foot unit between May 2019 and February 2021 with a total of 30 patients who had neuropathic or neuroischemic DFUs that had not responded after four weeks of standard treatment. Patients were randomized consecutively into a group that received daily application (control) or one that received applications three times per week (experimental). The clinical outcomes were evaluated using the Wollina score and wound-area reduction (WAR) weekly during a treatment period of 28 days. The histological outcomes were assessed using a soft-tissue punch biopsy (3 mm) at 0, 14, and 28 days to evaluate cellular proliferation. The Wollina scores were higher at the end of treatment by week 4 in both groups, but the differences were not significant between groups. The averages were 6 (5, 7) points in Experimental group (EG) and 6 (6,7) points in Control group (CG) (p = 0.848). Wound area reduction at day 28 was 53.57 [37.43, 79.16] % in the CG and 79.37 [42.74, 93.57] % in the EG, without differences among groups (p = 0.305). Cellular proliferation was similar in both groups at day 28. Application three times per week showed similar clinical and histological outcomes to those of daily application, both dose regimens demonstrated significant improvement of granulation tissue formation and WAR during the treatment.
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NewsBot · May 31, 2022

Pseudomonal Diabetic Foot Infections: Vive la Différence?
Ilker Uçkay et al
Mayo Clin Proc Innov Qual Outcomes. 2022 May 23;6(3):250-256

Objective: To assess the outcomes of diabetic foot infections (DFIs) due to Pseudomonas aeruginosa.

Patients and methods: From April 24, 2013 to July 31, 2016, we analyzed data from patients prospectively enrolled in our clinical pathway of DFIs, comparing those with infection due to Pseudomonas with those without infection due to Pseudomonas.

Results: Overall, we assessed 1018 cases of DFIs: 392 with osteomyelitis and 626 with only soft tissue infections. The prevalence of P aeruginosa in deep wound cultures was 10% (104/1018); of the 1018 cultures, 22 were monomicrobial, 82 were polymicrobial, and 46 were with osteomyelitis. Overall, the patients were treated with a median of 1 surgical debridement and a total of 20 days of antibiotic therapy. In a comparison of crude groups, the proportion of clinical failures was significantly higher with Pseudomonas than with other pathogens (36/104 [35%] vs 218/914 [24%], respectively; P=.02). A multivariate analysis showed that pseudomonal DFIs did not recur more often than nonpseudomonal DFIs (hazard ratio, 1.0; 95% confidence interval, 0.6-1.7). Among the 104 cases of pseudomonal DFIs, there was no association between failure of treatment and the total duration of antibiotic therapy, duration of intravenous therapy, duration of combined antibiotic therapy with more than 1 agent, or duration of oral (fluoroquinolone) therapy. Among 15 cases of pseudomonal recurrence, 2 (13%) developed resistance to the antibiotic agent used for the index episode.

Conclusion: For DFIs caused by P aeruginosa, other than choosing an antibiotic agent that is active against the organism, it does not appear necessary to treat with a different therapeutic regimen compared with the treatment of nonpseudomonal DFIs. There is no difference!
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NewsBot · Jun 5, 2022

Use of Rifampicin in the treatment of non healing Diabetic Foot Ulcer- an observational study
Satish Banka, MS et al
https://doi.org/10.1016/j.eprac.2022.03.088

Nonhealing diabetic foot ulcer with osteomyelitis is difficult to treat & the majority of cases lead to amputation or foot deformity along with long-term physical and psychological morbidity. Multidrug-resistant polymicrobial infection is the commonest cause. In addition to glycemic control, offloading & debridement of ulcers is necessary. In this observational study, we looked at the outcome of treatment with Rifampicin on such ulcers.
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NewsBot · Jun 8, 2022

Diabetic foot infection caused by bacteria of the Burkholderia cepacia complex: report of an unusual case and a scoping literature review
Rodrigo Cuiabano Paes Leme et al
Rev Inst Med Trop Sao Paulo. 2022 Jun 6

Burkholderia cepacia complex (BCC) is group of widespread gram-negative bacillus organized in over 20 phylogenetically distinct bacterial species. According to previous studies, BCC species pathogens are widely reported in patients with cystic fibrosis (CF), but not in individuals with diabetes mellitus (DM). In this case report, a 42-year-old male patient with DM and a foot infection caused by BCC is presented. The patient was hospitalized after antibiotic treatment failure and improved after two surgical debridement procedures and a high-dose extended infusion (EI) of meropenem. The team of vascular surgeons and the infectious disease specialists worked fervently to solve the case. Finally, a scoping review was conducted to map BCC infections in patients with DM.
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NewsBot · Jul 2, 2022

Clinical usefulness of quantifying microbial load from diabetic foot ulcers: a multicenter cohort study
Laura Soldevila-Boixader et al
Diabetes Res Clin Pract. 2022 Jun 28

Aims: To evaluate if microbial load from diabetic foot ulcers (DFUs) can help in predicting outcomes.

Methods: A multicenter prospective cohort study was performed in an outpatient setting (September 1, 2017-January 31, 2019) in diabetic patients with DFU.Quantitative cultures from DFU tissue biopsies at a baseline visit were obtained; high and low microbial loads were defined as ≥6logCFU/mL and <6logCFU/mL, respectively. Diagnosis of DFU infection was made and managed according to established guidelines. The outcome was evaluated at 6 month-visit as failure (persistence/new infection/amputation) or cure.

Results: Out of 65 patients, 52 (80%) had long-standing DFUs (≥4 weeks), with high microbial load in 19 (29%).DFU infection (n=24, 37%) was not associated with high microbial load in all patients but those with shorter DFU duration.Treatment failure occurred in 20/57 (35%) patients; high DFU microbial load was associated with worse outcome (n=9/20, 45% failure rate, adjusted OR4.69; 95% CI, 1.22-18.09; p=0.03),mainly due to the subgroup of patients with high microbial load and long-stand DFUs.

Conclusions: Since patients with high microbial load had a worse outcome, quantitative cultures from DFUs can identify patients who would benefit from antibiotic therapy.
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NewsBot · Jul 3, 2022

Isolation and characterization of bacteriophages active against Pseudomonas aeruginosa strains isolated from diabetic foot infections
W. F Mohamedet al
Source

Diabetic foot infection has become one of the most important public health concerns and is a growing problem. Pseudomonas aeruginosa is an important opportunistic multi-drug resistant bacterium in diabetic foot infections. In absence of antibiotics active against MDR strains of P. aeruginosa, phage therapy become a key way to deal with P. aeruginosa infections.

Out of 185 samples collected from diabetic foot ulcers, 50 (27.02%) isolates were identified as P. aeruginosa. The incidence increases with older ages and males (n=34, 68%) predominated in all age groups.

The tested isolates showed maximum susceptibility towards colistin (80%), imipenem (72%), amikacin (66%), and piperacillin/tazobactam (62%), while these isolates showed moderate susceptibility towards ceftazidime (58%), cefepime (52%) and gentamicin (46%). However, it showed complete resistance (100%) to ampicillin, cefaclor, and sulphamethoxazole/trimethoprim and highly resistance to clindamycin (90%) and amoxicillin/clavulanic acid (84%).

Two bacteriophages (ϕPAE1 and ϕPAE2) isolated from sewage samples showed a broad host range against P. aeruginosa clinical strains. ϕPAE2 infected 74% (37/50) and ϕPAE2 58% (29/50). Furthermore, both phages were found to be host specific, infecting only P. aeruginosa strains and could not infect other bacterial species in the cross infectivity studies.

Both phages were found to be relatively heat stable as over a period of 1 h, after exposure to temperature range of 37–50°C, not a significant loss in phage activity was observed. On the other hand, the lowest activity was observed at 70°C (39.15%) for ϕPAE1 where as it was totally inactivated at 75°C while, the lowest activity was observed at 75°C (38.01%) for ϕPAE2 where as it was totally inactivated at 80°C.

Isolated phages were able to survive and lyse host bacteria over a wide pH range. The optimum pH range for infection was from 6 to 8. Furthermore, ϕPAE1 lost its ability to lyse at pH 2, 3, 11 and 12 whereas; ϕPAE2 lost its infectivity at pH 2, 3 and 12
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NewsBot · Jul 13, 2022

Empirical Antibiotic for Diabetic Foot Infection in Indonesian Tertiary Hospital, Is It Time to Rethink the Options?
Hikmat Permana, Aluisha Saboe, Nanny Nm Soetedjo, Dewi Kartika, Bachti Alisjahbana
Acta Med Indones. 2022 Apr;54(2):247-254.

Background: The choice of empiric antibiotics in Diabetic Foot Infection (DFI) is a key to successful therapy. Meanwhile, the management of DFI in Indonesia is based on guideline originating from western countries which have different bacteriological patterns. Therefore, this study aimed to describe the bacterial and antibiotic susceptibility pattern on DFI which potentially contribute to better antibiotics selection guidelines.

Methods: This was a cross-sectional descriptive study conducted using consecutive sampling with DFI patients admitted in the emergency room and wards of Hasan Sadikin Hospital between February and July 2020. Tissue samples were obtained from all wounds, while antibiotic susceptibility tests were carried out on the culture results.

Results: A total of 65 bacterial growths were obtained from 45 enrolled patients. Gram-negative bacteria dominated with 54 growths (83.07%) including Klebsiela pneumonia 13 (20%) as the most common. Furthermore, antibiotics with good susceptible (> 80%) against Gram-negative bacteria are the carbapenemes (meropenem and ertapenem) and amikacin. The multi drug resistant bacteria were found in 18 growths (27.7%), which include ESBL, Carbapenemase producing bacteria, and MRSA. However, there were no susceptibility pattern differences between patients with ulcer duration above or below 2 months, higher grade wound (Wagner 4 and 5) and lower, as well as patients with previous or no antibiotic history.

Conclusion: The growth of Gram-negative bacteria dominated DFI with limited susceptibility to the empirical first-line antibiotics in the known international guidelines. Therefore, there is a need to reconsider the algorithm for selecting empirical antibiotics and management of DFI which is appropriate in our current condition.
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NewsBot · Jul 16, 2022

Retrospective Cohort Evaluating the Comparative Effectiveness of Ceftaroline and Daptomycin as First-Line Therapies for Inpatient Treatment of Diabetic Foot Infection in the United States Veterans Health Care System
Alyssa C Eaves et al
Drugs Real World Outcomes. 2022 Jul 15

Background: Both ceftaroline and daptomycin are possible therapeutic options for diabetic foot infection (DFI) and both are active against methicillin-resistant Staphylococcus aureus (MRSA) infection; however, no previous studies have evaluated their effectiveness head-to-head.

Objective: This study compared hospital readmission and mortality proportions among patients receiving ceftaroline fosamil or daptomycin for DFI.

Patients and methods: This was a retrospective cohort, comparative effectiveness study of adults (aged ≥ 18 years) admitted to United States Veterans Health Care System hospitals with a diagnosis code for DFI between 1 October 2010 and 30 September 2014 with an electronic order for ceftaroline or daptomycin as first-line therapy within 14 days of admission. Baseline characteristics were compared using Chi-square, Fisher's exact, and Wilcoxon rank-sum tests. Hospital readmission and patient mortality proportions were compared through multivariable logistic regression models with Hispanic ethnicity, prior hospitalization, dyslipidemia, and Charlson comorbidity score as covariates.

Results: In total, 223 patients were included (ceftaroline, n = 71; daptomycin n = 152). At baseline, ceftaroline patients were more likely to be Hispanic (18 vs. 6%, p < 0.01) and have been hospitalized in the past 90 days (34 vs. 19%, p = 0.02). Unadjusted 90-day hospital readmission proportions for ceftaroline versus daptomycin were 34 vs. 49%, and unadjusted 90-day mortality proportions were 1% vs. 8%. In multivariable models, ceftaroline patients were less likely to experience 90-day hospital readmission (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.25-0.85) and 90-day mortality (OR 0.14, 95% CI 0.01-0.77).

Conclusions: In this population, ceftaroline was associated with lower 90-day hospital readmission and 90-day mortality compared with daptomycin when used as first-line therapy for DFI.
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NewsBot · Jul 25, 2022

The association between bacteria and outcome and the influence of sampling method, in people with a diabetic foot infection
Meryl Cinzía Tila Tamara Gramberg et al
Infection. 2022 Jul 22

Purpose: Different bacteria lead to divers diabetic foot infections (DFIs), and some bacteria probably lead to higher amputation and mortality risks. We assessed mortality and amputation risk in relation to bacterial profiles in people DFI and investigated the role of sampling method.

Methods: We included people (> 18 years) with DFI in this retrospective study (2011-2020) at a Dutch tertiary care hospital. We retrieved cultures according to best sampling method: (1) bone biopsy; (2) ulcer bed biopsy; and (3) swab. We aggregated data into a composite determinant, consisting of unrepeated bacteria of one episode of infection, clustered into 5 profiles: (1) Streptococcus and Staphylococcus aureus; (2) coagulase-negative Staphylococcus, Cutibacterium, Corynebacterium and Enterococcus; (3) gram-negative; (4) Anaerobic; and (5) less common gram-positive bacteria. We calculated Hazard Ratio's (HR's) using time-dependent-Cox regression for the analyses and investigated effect modification by sampling method.

Results: We included 139 people, with 447 person-years follow-up and 459 episodes of infection. Sampling method modified the association between bacterial profiles and amputation for profile 2. HR's (95% CI's) for amputation for bacterial profiles 1-5: 0.7 (0.39-1.1); stratified analysis for profile 2: bone biopsy 0.84 (0.26-2.7), ulcer bed biopsy 0.89 (0.34-2.3), swab 5.9*(2.9-11.8); 1.3 (0.78-2.1); 1.6 (0.91-2.6); 1.6 (0.58-4.5). HR's (95% CI's) for mortality for bacterial profiles 1-5: 0.89 (0.49-1.6); 0.73 (0.38-1.4); 2.6*(1.4-4.8); 1.1(0.58-2.2); 0.80(0.19-3.3).

Conclusions: In people with DFI, there was no association between bacterial profiles in ulcer bed and bone biopsies and amputation. Only in swab cultures, low-pathogenic bacteria (profile 2), were associated with a higher amputation risk. Infection with gram-negative bacteria was associated with a higher mortality risk. This study underlined the possible negative outcome of DFI treatment based on swabs cultures
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NewsBot · Jul 25, 2022

Prevalence and Predictors of Pseudomonas aeruginosa Among Hospitalized Patients With Diabetic Foot Infections
Michael P Veve et al
Open Forum Infect Dis. 2022 Jun 17;9(7)

Background: Diabetic foot infections (DFIs) are commonly associated with antibiotic overuse. Empiric DFI treatment often includes coverage for Pseudomonas aeruginosa (PsA), but the frequency of PsA DFIs is poorly understood. The study objectives were to quantify the prevalence of and determine predictors for PsA DFIs.

Methods: This multicenter, retrospective cohort included hospitalized patients with DFI from 2013 through 2020 who were age ≥18 years; diabetes mellitus diagnosis; and DFI based on International Classification of Diseases, Tenth Revision coding, antibiotic treatment, and DFI culture with organism growth. Osteomyelitis was excluded. Patient characteristics were described and compared; the primary outcome was presence of PsA on DFI culture. Predictors of PsA DFI were identified using multivariable logistic regression.

Results: Two hundred ninety-two patients were included. The median age was 61 (interquartile range [IQR], 53-69) years; the majority were men (201 [69%]) and White (163 [56%]). The most commonly isolated organisms were methicillin-susceptible Staphylococcus aureus (35%) and streptococci (32%); 147 (54%) cultures were polymicrobial. Two hundred fifty-seven (88%) patients received empiric antibiotics active against PsA, but only 27 (9%) patients had PsA DFI. Immunocompromised status (adjusted odds ratio [aOR], 4.6 [95% confidence interval {CI}, 1.3-16.7]) and previous outpatient DFI antibiotic treatment failure (aOR, 4.8 [95% CI, 1.9-11.9]) were associated with PsA DFI.

Conclusions: PsA DFI is uncommon, but most patients receive empiric antipseudomonal antibiotics. Empiric broad-spectrum antibiotics are warranted given the frequency of mixed infections, but patient-specific risk factors should be considered before adding antipseudomonal coverage.
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NewsBot · Jul 27, 2022

The association between bacteria and outcome and the influence of sampling method, in people with a diabetic foot infection
Meryl Cinzía Tila Tamara Gramberg, Shaya Krishnaa Normadevi Mahadew, Birgit Ilja Lissenberg-Witte, Marielle Petra Bleijenberg, Jara Rebekka de la Court, Jarne Marijn van Hattem, Louise Willy Elizabeth Sabelis, Rimke Sabine Lagrand, Vincent de Groot, Martin Den Heijer & Edgar Josephus Gerardus Peters
Infection (2022)

Purpose
Different bacteria lead to divers diabetic foot infections (DFIs), and some bacteria probably lead to higher amputation and mortality risks. We assessed mortality and amputation risk in relation to bacterial profiles in people DFI and investigated the role of sampling method.

Methods
We included people (> 18 years) with DFI in this retrospective study (2011–2020) at a Dutch tertiary care hospital. We retrieved cultures according to best sampling method: (1) bone biopsy; (2) ulcer bed biopsy; and (3) swab. We aggregated data into a composite determinant, consisting of unrepeated bacteria of one episode of infection, clustered into 5 profiles: (1) Streptococcus and Staphylococcus aureus; (2) coagulase-negative Staphylococcus, Cutibacterium, Corynebacterium and Enterococcus; (3) gram-negative; (4) Anaerobic; and (5) less common gram-positive bacteria. We calculated Hazard Ratio’s (HR’s) using time-dependent-Cox regression for the analyses and investigated effect modification by sampling method.

Results
We included 139 people, with 447 person-years follow-up and 459 episodes of infection. Sampling method modified the association between bacterial profiles and amputation for profile 2. HR’s (95% CI’s) for amputation for bacterial profiles 1–5: 0.7 (0.39–1.1); stratified analysis for profile 2: bone biopsy 0.84 (0.26–2.7), ulcer bed biopsy 0.89 (0.34–2.3), swab 5.9*(2.9–11.8); 1.3 (0.78–2.1); 1.6 (0.91–2.6); 1.6 (0.58–4.5). HR’s (95% CI’s) for mortality for bacterial profiles 1–5: 0.89 (0.49–1.6); 0.73 (0.38–1.4); 2.6*(1.4–4.8); 1.1(0.58–2.2); 0.80(0.19–3.3).

Conclusions
In people with DFI, there was no association between bacterial profiles in ulcer bed and bone biopsies and amputation. Only in swab cultures, low-pathogenic bacteria (profile 2), were associated with a higher amputation risk. Infection with gram-negative bacteria was associated with a higher mortality risk. This study underlined the possible negative outcome of DFI treatment based on swabs cultures.
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NewsBot · Aug 5, 2022

Usefulness of the delta neutrophil index in predicting surgery in patients with foot and ankle infection
Ji Eun Shin et al
PLoS One. 2022 Aug 4;17(8):e0272574

Background: In foot and ankle infections, cases with apparent soft-tissue necrosis or purulent fluid collections definitely require surgical treatments. However, clinicians often have difficulty in determining whether to perform surgery in ambiguous cases without these findings. This study aimed to investigate the impact of the delta neutrophil index as a predictor of surgical treatment in patients with foot and ankle infections.

Methods: In total, 66 patients diagnosed with foot and ankle infections who underwent the delta neutrophil index test were retrospectively investigated. Medical records, including data on diabetes mellitus status, delta neutrophil index values, white blood cell count, polymorphonuclear leukocyte count, erythrocyte sedimentation rate, and C-reactive protein level, were retrospectively investigated. Logistic regression models were analyzed for the correlation between biomarkers, such as the delta neutrophil index and surgical treatment. The area under the curve was investigated to evaluate the cut-off value of the logistic model in predicting surgery.

Results: The relationship between the delta neutrophil index and surgical treatment was analyzed. The delta neutrophil index, adjusted for diabetes mellitus, was the best predictor of future surgical intervention. Based on the Youden index, the cutoff point (the equation's adjusted by diabetes mellitus) for the prediction of surgical treatment was defined as a probability of 0.3, with sensitivity and specificity of 82.4% and 77.6%, respectively.

Conclusions: Based on the present study, the delta neutrophil index can help clinicians decide the appropriate surgical treatment for foot and ankle infections at the right time.
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NewsBot · Aug 14, 2022

Bacterial Infections Associated with Diabetic Foot Ulcers: A Review
Ji Chang Woog
Clin Res Foot Ankle 2022, 10:7

Diabetic bottom ulcers (DFUs) and diabetic bottom infections (DFIs) are associated with reduced patient quality
of life, lower- extremity amputation, hospitalization, and high morbidity and mortality. Different bacterial communities
have been linked in DFUs DFIs, playing a significant part in infection prognostic. still, due to the high diversity of
bacterial communities settled in DFUs DFIs, culture- grounded styles may not insulate all of the bacterial population
or unanticipated microorganisms. Lately, high perceptivity and particularity of DNA (metagenomics) and RNA
(metatranscriptomics) technologies have addressed limitations of culture- grounded styles and have taken a step
beyond bacterial identification. As a consequence, new advances attained from DNA- and RNA- grounded ways for
bacterial identification can ameliorate remedial approaches. This review estimated the current state of play in aetiology
of DFUs DFIs on culture and molecular approaches, and bandied the impact of metagenomic and metatranscriptomic
styles in bacterial identification approaches.
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Infected diabetic foot ulcers decision making

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