The bacteriostatic effect of controlled-flux electrolyzed acidic solution on healthy hallucal skin.

BACKGROUND: There are various treatment protocols to manage the increased bacterial load in plantar ulcers. Recently, Controlled-Flux Electrolyzed Acidic Solution (CFEAS), with a pH less than 3, has appeared to be an effective option since its antimicrobial effect could help in the healing of those ulcers. In order to evaluate its potential in this sense, the aim of the present study was to compare bacterial growth on healthy hallucal skin using two types of bandaging (control and Controlled-Flux Electrolysed Acidic Solution). MATERIAL AND METHODS: In a sample of 19 healthy subjects, two experiments were performed. In the first, for each subject, two identical hallux bandages were applied in the early morning. At random between left and right foot, either physiological saline (wetting every 2 h) was applied or nothing (control). In the second, two days later, new bandages were applied as before, but now either wetting with Controlled-Flux Electrolysed Acidic Solution (experimental, again wetting every 2 h) or nothing (control). In each experiment, the bacterial load in the nail fold was assessed at the first moment and after 10 h from standard counts of bacterial colony forming units (CFU). RESULTS: In the first experiment, the CFU counts had increased significantly (p < 0.05) in both toes after the 10-h period. In the second experiment, while the bacterial load increased significantly (p = 0.001) from 0.68 ±â€¯0.8 × 104 CFU/cm2 (the "pre" sample) to 1.3 ±â€¯0.9 × 104 CFU/cm2 (the "post" sample) in the control toe, in the experimental CFEAS toe, the pre sample bacterial load was 0.61 ±â€¯0.6 × 104 CFU/cm2, and the post sample 0.9 ±â€¯0.8 × 104 CFU/cm2, with no significant difference between them (p = 0.221). Negative cultures were obtained in 3 cases (15.78%) of the experimental toe post sample, and equal post and pre counts in 2 cases (10.5%). CONCLUSION: Controlled-Flux Electrolyzed Acidic Solution has an effect on healthy hallucal skin that is bacteriostatic, and in some cases bactericidal. This effect could be very helpful in treating plantar ulcers when there is a greatly increased bacterial load in the wound, thus potentially favoring the normal formation of granulation tissue in the skin and normal healing and closure of the ulcer.

Additional Risk Stratification Using Local and Systemic Factors for Patients with Critical Limb Ischaemia Undergoing Endovascular Therapy in the WIfI Era.

OBJECTIVES: While current guidelines describe the importance of assessing limb characteristics for predicting limb prognosis in patients with critical limb ischaemia (CLI), several reports have also suggested that systemic factors are associated with limb prognosis. The aim of this study was to evaluate whether systemic factors have the same impact on wound healing as limb characteristics in CLI patients undergoing endovascular therapy. METHODS: A total of 735 patients who were treated for the first time for CLI with tissue loss between April 2010 and December 2015 were extracted from a prospective registry and data for the Wound, Ischaemia, and foot Infection (WIfI) classification were searched retrospectively. The predictors of wound healing were explored with Cox proportional hazards regression. RESULTS: The one year wound healing rate was 60.2% in WIfI stage 1-3 patients and 53.6% in WIfI stage 4 (p = .01). In WIfI stage 1-3, no systemic factors were significantly associated with wound healing, whereas, in WIfI stage 4 patients, non-ambulatory status [hazard ratio (HR) 1.98; 95% confidence interval (CI) 1.37-2.84], haemodialysis (HR 1.90; 95% CI 1.33-2.72) and an albumin level under 3.0 g/dL (HR 1.53; 95% CI 1.02-2.31), were identified as independent risk factors for failure to achieve wound healing. If none or one of these risk factors were present, wound healing was comparable with WIfI 4 and WIfI 1-3 patients (67.7% vs. 63.6%, p = .89), whereas in patients with two or more risk factors wound healing was worse in WIfI 4 than in WIfI 1-3 patients (35.7% vs. 49.5%, p = .01). CONCLUSION: Non-ambulatory status, haemodialysis, and a low albumin level were additional systemic risk factors for impaired wound healing in patients with WIfI stage 4. The wound healing rate in WIfI stage 4 patients with one or fewer of these risk factors was comparable to that in WIfI stage 1-3.

Development of predictive nomograms for clinical use to quantify the risk of isolating resistance prone organisms in patients with infected foot ulcers.

Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA) have been considered prevalent pathogens in foot infections. However, whether empiric therapy directed against these organisms is necessary, and in whom to consider treatment, is rather unclear. The aim of this study was to develop predictive algorithms for forecasting the probability of isolating these organisms in the infected wounds of patients in a population where the prevalence of resistant pathogens is low. This was a retrospective study of regression model-based risk factor analysis that included 140 patients who presented with infected, culture positive foot ulcers to two urban hospitals. A total of 307 bacteria were identified, most frequently MRSA (11.1%). P. aeruginosa prevalence was 6.5%. In the multivariable analysis, amputation (odds ratio (OR) 5.75, 95% confidence interval (CI) 1.48-27.63), renal disease (OR 5.46, 95% CI 1.43-25.16) and gangrene (OR 2.78, 95% CI 0.82-9.59) were identified as risk factors associated with higher while diabetes (OR 0.07, 95% CI 0.01-0.34) and Infectious Diseases Society of America infection severity >3 (OR 0.18, 95% CI 0.03-0.65) were associated with lower odds of P. aeruginosa isolation (C statistic 0.81). Similar analysis for MRSA showed that amputation was associated with significantly lower (OR 0.29, 95% CI 0.09-0.79) risk, while history of MRSA infection (OR 5.63, 95% CI 1.56-20.63) and osteomyelitis (OR 2.523, 95% CI 1.00-6.79) was associated with higher odds of isolation (C statistic 0.69). We developed two predictive nomograms with reasonable to strong ability to discriminate between patients who were likely of being infected with P. aeruginosa or MRSA and those who were not. These analyses confirm the association of some, but also question the significance of other frequently described risk factors in predicting the isolation of these organisms.

The Management of Critically Colonized and Locally Infected Leg Ulcers with an Acid-Oxidizing Solution: A Pilot Study.

OBJECTIVE: Critical colonization or local infection is very common in chronic wounds, but clinically problematic. Because therapeutic options for these conditions are limited in number and efficacy, the study authors tested a new acid-oxidizing solution (AOS [Nexodyn]; APR Applied Pharma Research S.A., Balerna, Switzerland) to determine its ancillary antimicrobial properties and potential support for wound healing. DESIGN AND SETTING: This open-label clinical case series was conducted with a prospective, single-arm design at the Federal County Hospital in Bregenz, Austria. PATIENTS: In the study, 30 patients with critically colonized or locally infected chronic leg ulcers of any origin were included. INTERVENTIONS: The AOS was applied on each leg ulcer at every dressing change for 35 days. MAIN OUTCOME MEASURES: The tolerability and performance of the AOS were assessed by evaluating the ulcer characteristics and comparing them with those at baseline. The clinical course of wounds was analyzed using standard measures for bioburden, local infection, pain, pH, and wound healing. MAIN RESULTS: Application of the solution was well tolerated, and no adverse events were recorded. In all patients, local infection was overcome, and wound bed pH and wound area decreased significantly. In addition, patient pain levels decreased to a level where interventions were not required after study day 7. In 37% of all patients, a complete resolution of chronic ulcers was achieved by the end of the study period. CONCLUSION: According to these results, the AOS seems to be a valid and highly tolerable treatment to support wound healing in locally infected ulcers. Nevertheless, larger controlled cohort studies are needed to substantiate these findings.

Implications of Antimicrobial Combinations in Complex Wound Biofilms Containing Fungi.

Diabetic foot ulcer treatment currently focuses on targeting bacterial biofilms, while dismissing fungi. To investigate this, we used an in vitro biofilm model containing bacteria and fungi, reflective of the wound environment, to test the impact of antimicrobials. Here we showed that while monotreatment approaches influenced biofilm composition, this had no discernible effect on overall quantity. Only by combining bacterium- and fungus-specific antibiotics were we able to decrease the biofilm bioburden, irrespective of composition.

Nonsurgical Treatment of Osteomyelitis of the Hallux Sesamoids: A Case Series and Literature Review.

The aim of the present study was to determine the effectiveness of nonsurgical treatment for osteomyelitis of the hallucal sesamoids. Osteomyelitis of the hallucal sesamoids in young and healthy patients is rare and might originate from hematogenous spread or after a puncture wound. In diabetic patients with peripheral neuropathy, it often results from direct contiguous seeding from adjacent ulceration. The superiority of surgical versus nonsurgical therapy is still debated. In our institution, all patients presenting with osteomyelitis of the hallucal sesamoids are first treated nonsurgically but eventually usually require a surgical procedure. We reviewed 18 patients with a clinical and radiologic diagnosis of osteomyelitis of the hallucal sesamoids treated in our institution during a 13-year period (from January 2000 to December 2012). The inclusion criteria were a signal alteration on magnetic resonance imaging or bone lesions on computed tomography or conventional radiographs, combined with a deep ulcer with a positive probe-to-bone test. Nonsurgical therapy consisted of frequent wound treatment, immobilization, offloading in a cast or other orthotic device, and oral antibiotics. Of the 18 patients, 11 had diabetes, 16 had peripheral neuropathy, 11 had peripheral arterial disease, and 5 had immunosuppression. After a period of nonsurgical therapy ranging from 4 weeks to 9 months, 15 of 18 patients required surgical excision, internal resection, or amputation. In this patient population, we no longer consider nonsurgical therapy a viable option. Patients should be advised, before starting nonsurgical treatment, that the therapy will be long and demanding and very often results in a surgical procedure.

The role of procalcitonin as a marker of diabetic foot ulcer infection.

Foot ulcers are frequent in diabetic patients and are responsible for 85% of amputations, especially in the presence of infection. The diagnosis of diabetic foot ulcer infection is essentially based on clinical evaluation, but laboratory parameters such as erythrocyte sedimentation rate (ESR), white blood count (WBC), C-reactive protein (CRP) and, more recently, procalcitonin (PCT) could aid the diagnosis, especially when clinical signs are misleading. Fifteen diabetic patients with infected foot ulcers were admitted to our department and were compared with an additional group of patients with non-infected diabetic foot ulcers (NIDFUs). Blood samples were collected from all patients in order to evaluate laboratory markers. In the current study, the diagnostic accuracy of PCT serum levels was evaluated in comparison with other inflammatory markers such as CRP, ESR and WBC as an indicator to make the distinction between infected diabetic foot ulcers (IDFUs) and NIDFUs. CRP, WBC, ESR and especially PCT measurements represent effective biomarkers in the diagnosis of foot infections in diabetic patients particularly when clinical signs are misleading.

Burden of Infected Diabetic Foot Ulcers on Hospital Admissions and Costs.

BACKGROUND: Costs related to diabetic foot ulcer (DFU) care are greater than $1 billion annually and rising. We sought to describe the impact of diabetes mellitus (DM) on foot ulcer admissions in the United States, and to investigate potential explanations for rising hospital costs. METHODS: The Nationwide Inpatient Sample (2005-2010) was queried using International Classification of Diseases, 9th Revision (ICD-9) codes for a primary diagnosis of foot ulceration. Multivariable analyses were used to compare outcomes and per-admission costs among patients with foot ulceration and DM versus non-DM. RESULTS: In total, 962,496 foot ulcer patients were admitted over the study period. The overall rate of admissions was relatively stable over time, but the ratio of DM versus non-DM admissions increased significantly (2005: 10.2 vs. 2010: 12.7; P < 0.001). Neuropathy and infection accounted for 90% of DFU admissions, while peripheral vascular disease accounted for most non-DM admissions. Admissions related to infection rose significantly among DM patients (2005: 39,682 vs. 2010: 51,660; P < 0.001), but remained stable among non-DM patients. Overall, DM accounted for 83% and 96% of all major and minor amputations related to foot ulcers, respectively, and significantly increased cost of care (DM: $1.38 vs. non-DM: $0.13 billion/year; P < 0.001). Hospital costs per DFU admission were significantly higher for patients with infection compared with all other causes ($11,290 vs. $8,145; P < 0.001). CONCLUSIONS: Diabetes increases the incidence of foot ulcer admissions by 11-fold, accounting for more than 80% of all amputations and increasing hospital costs more than 10-fold over the 5 years. The majority of these costs are related to the treatment of infected foot ulcers. Education initiatives and early prevention strategies through outpatient multidisciplinary care targeted at high-risk populations are essential to preventing further increases in what is already a substantial economic burden.

Severe forefoot infection complicated by Fusobacterium russii.

We present the first case of a complicated foot infection caused by Fusobacterium russii in Austria. F. russii is highly associated with mammals such as cats and dogs. Our case underlines the difficulties in isolation and identification of anaerobes and the pitfalls in antimicrobial treatment of polymicrobial infections.

[Cutaneous diphtheria after a minor injury in Sri Lanka]. / Kutane Diphtherie nach Bagatellverletzung in Sri Lanka.

Cutaneous dipththeria is an infectious bacterial disease endemic in tropical regions, but rarely diagnosed in Germany. Following travel in Sri Lanka, a 60-year-old German presented to our dermatological clinic with a skin ulcer and extensive erythematous erosive edema of his left foot. Corynebacterium diphtheriae was isolated from a swab of the lesion. There were no clinical signs of toxic diphtheria. The patient was treated with penicillin G and erythromycin, followed by a slow healing of the lesion. The isolated strain could be identified as toxigenic C. diphtheriae mitis. Due to increased travel activity, dermatologists should have uncommon infections like cutaneous diphtheria in mind.

Bordetella trematum in chronic ulcers: report on two cases and review of the literature.

We report on two new cases Bordetella trematum in chronic ulcers. Literature shows that this species is infrequently isolated from clinical samples. Only a few cases have been reported so far. B. trematum may be underdiagnosed because of its problematic identification. Today, MALDI-TOF MS allows for an accurate discrimination of these bacteria. Overall, B. trematum was typically associated with severe skin and soft tissue infections, particularly in diabetic patients. The intrinsic resistance to some antibiotics commonly used to treat these infections makes the isolation of B. trematum significant.

Leprosy ulcers in a rural hospital of Ethiopia: pattern of aerobic bacterial isolates and drug sensitivities.

BACKGROUND: Plantar ulcers, which commonly occur in leprosy patients, tend to recur increasing physical disability. The aim of this study is to identify both the bacteriological profile of these ulcers and the antibiotic susceptibility of the isolated bacteria. MATERIALS AND METHODS: 68 leprosy patients with chronic ulcers attending the in-patient department of Gambo General Hospital, West Arsi, were included in this study. Proper sample collection, inoculation on culture media, and final identification using biochemical methods were undertaken. RESULTS: 66 patients (97.1%) had a positive culture. A total of 81 microorganisms were isolated. Multiple organisms (two or more) were isolated in 15 (22.7% out of positive culture) patients. The main isolation was Proteus spp (30.9%), followed by Escherichia coli (21.0%), Staphylococcus aureus (18.5%) and Pseudomonas aeruginosa (9.9%). In the total number of the isolated bacteria, the antibiotics with less resistance were gentamicin (18.5%), fosfomycin (22.2%) cefoxitin (24.7%), ceftriaxone (25.9%) ciprofloxacin (25.9%), and amoxicillin-clavulanic acid (28.49%). CONCLUSION: The bacteriological study of plantar ulcers of leprosy patients revealed Enterobacteriaceae and S. aureus as the main pathogens involved in such infections. The results of this study may guide empirical therapy in a rural area hospital where culture and susceptibility testing facilities are scarce.

Community acquired multi drug resistant Staphylococcus aureus in a rural setting of North Western Ethiopia: a tough challenge.

Commnunity acquired Methicillin Resistant Staphylococcus aureus species are common causes of skin and soft tissue infections. Foot ulcer of former leprosy patients can be invaded by a multi-microbial infection. Cervicitis is usually caused by certain sexually transmitted agents. Here we report a series of cases of methicillin-resistant Staphylococcus aureus, isolated from two patients presenting with foot ulcer and cervicitis respectively, both in an outpatient or community setting (community onset) in rural North Western Ethiopia. The strains were resistant to all commonly available drugs such as trimethoprim-sulfamethoxazole, ciprofloxacin, erythromycin, chloramphenicol and tetracycline but sensitive to clindamycin. This is the first report of CA-MRSA in the study area.

De-epithelialized fasciocutaneous turnover flap for recurrent calcaneal wound with osteomyelitis.

Recurrent ulcerations of the foot and ankle almost always present a challenge to lower extremity surgeons. Recalcitrant heel ulcerations with osteomyelitis are especially difficult to treat because of the lack of soft tissue coverage. The turnover flap is a simple, fast, and effective treatment method for lower extremity wounds. It is a de-epithelialized fasciocutaneous flap harvested from the adjacent area of the wound. We believe it is an underused technique for advanced wound closure in the lower extremity. It offers several advantages compared with traditional, more difficult to perform, flaps. We have seen an excellent result 18 months after using the turnover flap in a patient with recurrent posterior heel ulceration with calcaneal osteomyelitis.

In-office distal Symes lesser toe amputation: a safe, reliable, and cost-effective treatment of diabetes-related tip of toe ulcers complicated by osteomyelitis.

Diabetes-related tip of lesser toe ulcers have typically been associated with both underlying hammertoe contracture and peripheral neuropathy. The combination of digital deformity and neuropathy commonly results in non-healing, deep sores that frequently become complicated by osteomyelitis. We report on a well-known, but poorly reported, technique for surgical management of non-healing tip of lesser toe ulcers. After approval by the institutional review board, a review was performed of consecutive patients who had undergone office-based distal Symes toe amputation for a non-healing tip of lesser toe ulcer from January 2007 to December 2012. A variety of clinical, laboratory, and radiographic data were collected. A total of 48 consecutive patients (48 toe ulcers) were identified for inclusion in the present study. All patients had ulcers at the time of surgery, and no patient developed repeat ulceration of the involved digit postoperatively. Of the 48 patients, 44 (92%) had hammertoe deformity preoperatively. Also, 30 patients (63%) had positive probe-to-bone results, and 29 (97%) of these patients had culture or histologic findings positive for osteomyelitis. Of the 48 patients (48 ulcers), 73% had positive bone cultures, 69% had positive pathologic findings demonstrating osteomyelitis, and 100% had clean margins. Methicillin-resistant Staphylococcus epidermidis was the most common pathogen isolated (13 of 48, 27%). No patient required additional amputation related to the operative digit. The mean follow-up period was 28.79 months. Our results have shown that in-office distal Symes lesser toe amputation is a safe, reliable, and likely cost-effective treatment of non-healing tip of lesser toe ulcers complicated by osteomyelitis. This office-based procedure allows bone biopsy diagnosis, removes the non-healing ulcer, confirms clear margins regarding the osteomyelitis, and addresses the underlying toe deformity to minimize the chances of repeat ulceration.

[Treatment of trophic ulsers of different etiology].

The research included 40 patients with chronic trophic ulcers of lower extremities of different etiology (arterial insufficiency - 14 patients, venous insufficiency - 20 patients, diabetic foot syndrome - 6 people). According to the data of prime bacteriological inoculation, the main pathogens were: gram-positive coccus (Staphylococcus spp., Staphylococcus aureus - 75%, Staphylococcus epidermidis - 7,5%) and yeast-like fungi (Candida albicans - 7,5%). Microbial semination in plentiful quantity (more than 106 KOE) was detected at first inoculation in 85% of the patients. The ointment was applied for the patients. After 20 days, the lack of growth and the decrease of contamination level (lower than critical (less than 102 KOE) were noted. A visual analog scale estimated an intensity of pain in patients and it consisted of 39,8% before the treatment, 27,1% - after 10 days, 14,6% - after 20 days. The "Oflomelid" application allowed the reduction of the terms of wound cleansing from nonviable tissues in majority of patients and gained the fast transition from the granulation to epithelization phase. The principle of wound management with the application of ointment "Oflomelid" should be followed in a moist environment. A modern wound dressing must be used after the ointment. This shortened the terms of separate-phase wound repair and decreased the terms of the whole period of trophic ulcers repair in patients with vascular and endocrine pathology.

Clinical antimicrobial photodynamic therapy: phase II studies in chronic wounds.

Microbiologically based diseases continue to pose serious global health problems. Effective alternative treatments that are not susceptible to resistance are sorely needed, and the killing of photosensitized bacteria through photodynamic therapy (PDT) may ultimately emerge as such an option. In preclinical research and early in vivo studies, PDT has demonstrated the ability to kill an assortment of microorganisms. Antimicrobial PDT has the potential to accelerate wound healing and prevent clinical infection, particularly in patients with chronic leg ulcers. Larger trials are needed to confirm its early promise and suggest its ultimate role in caring for chronic wounds.

Treatment of lepromatous ulcers using citric acid as a sole antimicrobial agent.

A prospective study was carried out to assess the role of citric acid as a sole antimicrobial agent in the management of lepromatous ulcers. Thirty-four known cases of lepromatous ulcers not responding to conventional antibiotic therapies for long duration were investigated for culture and susceptibility studies. Staphylococcus aureus (25·00%) and Klebsiella spp. (23·43%) were found to be the most common isolates. Amikacin (68·75%) and ciprofloxacin (67·18%) were found to be the most effective antimicrobial agents. Topical application of citric acid ointment resulted in complete healing in 25 (73·52%) cases. In eight cases (26·48%), there was elimination of infective agent from ulcer site and formation of healthy granulation, but no complete healing of ulcer was seen. Results indicate that citric acid is the best alternative for the effective management of lepromatous ulcers when other therapies are exhausted.

Shewanelia putrefaciens: a rare microbial agent associated with a non-healing ulcer in a leprosy patient.

Female aged 55 years presented with signs and symptoms of borderline lepromatous leprosy and presence of a non-healing ulcer and multiple haemorrhagic blisters over dorsum of both feet. Discharge from the various lesions was subjected to microbiological examination and an unusual organism Shewanella purtefaciens was isolated which was sensitive to most routine antibiotics. Patient responded well to cephadroxil therapy with uneventful and complete healing of ulcer and blisters.