[Infectious diseases: what's new in 2023]. / Maladies infectieuses: ce qui a changé en 2023.

The year 2023 saw the publication of several studies in various areas of infectious diseases. The administration of corticosteroids decreased mortality in severe community-acquired pneumonia. Administration of doxycycline post-exposure prophylaxis reduced the risk of bacterial sexually transmitted infections at the risk of resistance selection. An herbal preparation decreased mortality in sepsis. A meta-analysis concludes that oseltamivir does not significantly reduce the risk of hospitalisation for influenza. Discontinuation of antibiotic prophylaxis during dental procedures in Sweden did not increase the incidence of viridans group Streptococcus endocarditis. Several studies have led to the introduction of RSV (Respiratory Syncytial Virus (RSV) vaccination. 2023 also saw the resurgence of invasive Group A Streptococcal infections, of which clinicians must be wary.

L'année 2023 est marquée par la publication d'études touchant des domaines variés de l'infectiologie. La mortalité de pneumonies communautaires sévères est diminuée par l'administration de corticostéroïdes. Lors de rapport sexuel à risque, l'administration de doxycycline en prophylaxie postexpositionnelle diminue le risque d'infections sexuellement transmissibles bactériennes, cependant au risque de sélectionner des bactéries résistantes. Une préparation de plantes diminue la mortalité du sepsis. Une méta-analyse conclut que l'oseltamivir ne diminue pas significativement le risque d'hospitalisation lors de grippe. L'arrêt de la prophylaxie antibiotique lors d'intervention dentaire en Suède n'a pas augmenté l'incidence d'endocardite à streptocoques du groupe viridans. Plusieurs études ont mené à l'introduction de la vaccination VRS (virus respiratoire syncytial humain). 2023 a aussi vu la résurgence d'infections invasives à streptocoques du groupe A dont le clinicien doit se méfier.

[Surgical antimicrobial prophylaxis : frequent questions in the perioperative setting]. / Antibioprophylaxie chirurgicale: questions fréquentes en périopératoire.

Surgical Site Infections account for 15-30% of healthcare-associated infections. Surgical antibiotic prophylaxis is one of well-documented measures to decrease the risk of infections. However, many situations threaten its proper application and thereby its effectiveness: patient already receiving antibiotics or carrying resistant germs, clinicians' misunderstanding about timing and duration of antibiotic prophylaxis or patient history of penicillin allergy. In this article we try to clarify these situations to favour good practice in perioperative antibiotic prophylaxis.

Les infections du site opératoire représentent 15-30 % des infections associées aux soins et l'antibioprophylaxie chirurgicale est l'une des mesures bien documentées pour en diminuer le risque. Cependant, de nombreuses situations prétéritent l'application adéquate de cette mesure et donc son efficacité : présence d'une antibiothérapie en cours, portage de germes résistants, incompréhensions sur le timing et la durée de l'antibioprophylaxie, notion d'allergie à la pénicilline. Dans cet article, nous tentons de clarifier ces situations afin de favoriser la bonne application de l'antibioprophylaxie.

Frequency and causes of antifungal treatment changes in allogeneic haematopoïetic cell transplant recipients with invasive mould infections.

BACKGROUND: Antifungal treatment duration and changes for invasive mould infections (IMI) have been poorly described. METHODS: We performed a 10-year cohort study of adult (≥18-year-old) allogeneic haematopoietic cell transplant recipients with proven/probable IMI to describe the duration and changes of antifungal treatment. All-cause-12-week mortality was described. RESULTS: Sixty-one patients with 66 IMI were identified. Overall treatment duration was 157 days (IQR: 14-675) and 213 (IQR: 90-675) days for patients still alive by Day 84 post-IMI diagnosis. There was at least one treatment change in 57/66 (86.4%) cases: median 2, (IQR: 0-6, range:0-8). There were 179 antifungal treatment changes due to 193 reasons: clinical efficacy (104/193, 53.9%), toxicity (55/193, 28.5%), toxicity or drug interactions resolution (15/193, 7.8%) and logistical reasons (11/193, 5.7%) and 15/193 (7.8%) changes due to unknown reasons. Clinical efficacy reasons included lack of improvement (34/104, 32.7%), targeted treatment (30/104, 28.8%), subtherapeutic drug levels (14/104, 13.5%) and other (26/104, 25%). Toxicity reasons included hepatotoxicity, nephrotoxicity, drug interactions, neurotoxicity and other in 24 (43.6%), 12 (21.8%), 12 (21.8%), 4 (7.4%) and 3 (5.5%) cases respectively. All-cause 12-week mortality was 31% (19/61), higher in patients whose antifungal treatment (logrank 0.04) or appropriate antifungal treatment (logrank 0.01) was started >7 days post-IMI diagnosis. All-cause 1-year mortality was higher in patients with ≥2 changes of treatment during the first 6 weeks post-IMI diagnosis (logrank 0.008) with an OR: 4.00 (p = .04). CONCLUSIONS: Patients with IMI require long treatment courses with multiple changes for variable reasons and potential effects on clinical outcomes, demonstrating the need more effective and safer treatment options. Early initiation of appropriate antifungal treatment is associated with improved outcomes.

[Proper use of Quinolones in daily practice]. / Du bon usage des quinolones.

Quinolone's antibiotics, with their excellent biodisponibility, tissular penetration and broad spectrum of activity are commonly used in hospitals and outpatient settings. The properties of this class of antibiotics lead to overuse with inevitable selection of resistance, constantly rising in Switzerland. This article provides a summary of various elements useful to balance benefit/risk when using quinolones in daily clinical practice.

Les quinolones sont des antibiotiques fréquemment utilisés en pratique clinique en raison de leur bonne biodisponibilité, pénétration tissulaire et d'un spectre d'activité large, utile en milieu hospitalier comme en ambulatoire. Ces caractéristiques engendrent un risque élevé de surutilisation de cette classe d'antibiotiques avec, pour corollaire, une sélection de résistance large en progression constante en Suisse. Cet article propose une synthèse des caractéristiques permettant d'évaluer le rapport bénéfices/risques de leur utilisation en pratique quotidienne.

Subcutaneous tissue disinfection significantly reduces Cutibacterium acnes burden in primary open shoulder surgery.

BACKGROUND: Cutibacterium acnes is one of the major pathogens responsible for infection after shoulder surgery. Surgical dissection of the dermis may expose C acnes from sebum-producing hair follicles. Because of contact with the surgeon's gloves and instruments, further spread occurs throughout the surgical field. The purpose of this study was to determine whether subcutaneous tissue disinfection could reduce the C acnes culture rate in primary open shoulder surgery. METHODS: All patients eligible for primary open shoulder surgery by a deltopectoral approach were prospectively enrolled in our 2-arm, randomized, single-blinded clinical trial. In all patients, a skin swab of the operative field was taken prior to standard surgical skin preparation. After exposure of the deltoid fascia, the disinfection group received an additional preparation of the subcutaneous layer with povidone-iodine solution. Once the proximal humerus was completely exposed, 5 swabs from different sites were taken for microbiological examination according to a strict specimen collection protocol. All cultures were incubated in aerobic and anaerobic conditions for 14 days. RESULTS: Between February and December 2019, 108 patients were enrolled in the 2 groups: treatment (n = 70) and control (n = 38). The 2 groups did not show any significant difference in terms of sex, age, body mass index, or occurrence of diabetes. The subcutaneous disinfection protocol significantly reduced the positive culture rate of the operating field for all germs combined (P = .036) and specifically for C acnes (P = .013). The reduction of positive swabs for C acnes was significant for the surgeon's gloves (P = .041), as well as the retractors (P = .007). CONCLUSION: Disinfection of the subcutaneous tissue significantly reduced the C acnes culture rate during primary open shoulder surgery. We highly recommend this simple step as an adjunct to the current surgical practice to limit iatrogenic contamination of the surgical field. Future studies may observe a reduction in postoperative shoulder infection owing to this practice.

Performances and usefulness of Xpert MTB/RIF assay in low-incidence settings: not that bad?

Xpert MTB/RIF assay, a real-time PCR assay designed to detect Mycobacterium tuberculosis, has proven sensitive and specific when performed on respiratory samples in a high prevalence setting. However, it was suggested as less accurate in a low-incidence environment. We evaluated the accuracy of the Xpert for the diagnosis of tuberculosis (TB) on pulmonary and extrapulmonary samples in Geneva (Switzerland), where the prevalence of active TB is very low. From March 2009 to February 2013, the Xpert was performed on clinical samples. All specimens were also processed using auramine, AFB staining, and mycobacterial culture with both solid and liquid media. The accuracy of both microscopy and Xpert was determined retrospectively using cultures as the reference method. A total of 732 clinical specimens were processed with the Xpert. The Xpert had a high specificity (97.5%; 95% confidence interval (CI), 95.8-98.5%) and revealed much more sensitive (82.7%; 95% CI, 74.1-89.0%) than microscopy (55.5%; 95% CI, 45.7-64.8%) for the diagnosis of TB, with a high negative predictive value (96.8%; 95% CI, 95.0-98.0%). The advantage of PCR over microscopy was even more pronounced for extrapulmonary specimens (sensitivity of 70% (95% CI, 50.4-84.6%) compared with 23.3% (95% CI, 10.6-42.7%)). Despite the low prevalence of TB in Switzerland, results performance for respiratory samples was similar to that reported in high prevalence countries. The high negative predictive value is clinically helpful in our setting, where pulmonary TB needs to be reasonably ruled out. When considering extrapulmonary samples, microscopy performed poorly compared with Xpert. This study shows that the Xpert remains accurate and useful in a low-incidence setting.

[Rapid microbiology and antimicrobial stewardship to combat antibiotic resistance]. / Microbiologie rapide et programmes d'épargne des antibiotiques pour combattre l'antibiorésistance.

The extraordinary development of medicine with the advent of solid organ and bone marrow transplants, chemotherapy and immunotherapy, as well as the explosion of invasive procedures (« foreign material ¼) has made our medicine dependant to the use of antibiotics. The overuse of « empirical ¼ antibiotics in breeding and medicine has favored the emergence and rapid dissemination of multidrug resistant pathogens (MDRs). This leaded clinicians today in a difficult situation. They should limit their empirical use of « broad-spectrum antibiotics ¼, although they face a higher risk of MDRs. To help them in this task, anti-microbial stewardship programs have been put in place, emphasizing the use of « hospital antibiograms ¼ and rapid and reliable microbiological diagnosis.

L'extraordinaire développement de la médecine, avec l'avènement des greffes d'organes, des chimiothérapies et immunothérapies, ainsi que l'explosion des gestes invasifs (matériel étranger) ont rendu notre médecine dépendante des antibiotiques. La surutilisation « empirique ¼ des antibiotiques dans l'élevage et la médecine a favorisé l'émergence et la dissémination rapide de bactéries multirésistantes (BMR). Cela a conduit les cliniciens d'aujourd'hui à une situation difficile. Ils doivent limiter leur utilisation d'« antibiotiques à large spectre ¼ bien qu'ils soient confrontés à un risque plus élevé de BMR. Des programmes d'antimicrobial stewardship ont été mis en place pour les soutenir, prônant l'utilisation d'« antibiogrammes hospitaliers ¼ et d'un diagnostic microbiologique rapide et fiable.

[Probiotics: benefits and harms]. / Probiotiques: bienfaits et méfaits.

Probiotics are a big food and pharmaceutical industry today. The most widely used probiotics are Lactobacillus spp, Bifidobacterium spp, strains of Enterococcus spp, Streptococcus spp and yeasts such as Saccharomyces pp. Among the best-known indications are Clostridioides difficile colitis and diarrhea due to antibiotics, but probiotics are also proposed as adjuvants for atopic syndromes, autoimmune diseases, prevention and treatment of obesity, diabetes and cystic fibrosis, where dysbiosis play an important role. However, their use remains debated due to a lack of powerful data proving their effectiveness and their often-overlooked side effects.

Les probiotiques constituent de nos jours une grande industrie alimentaire et pharmaceutique. Les plus utilisés sont des Lactobacillus spp, les Bifidobacterium spp., des souches d'Enterococcus spp., de Streptococcus spp. et des levures comme les Saccharomyces spp. La colite à Clostridioides difficile et les diarrhées dues aux antibiotiques sont des indications reconnues, mais les probiotiques sont aussi proposés comme adjuvants pour des syndromes atopiques, des maladies autoimmunes, la prévention et le traitement de l'obésité, du diabète et de la mucoviscidose, où la dysbiose joue un rôle important. Néanmoins, leur utilisation reste débattue en raison du manque de données puissantes prouvant leur efficacité et d'effets indésirables sous-estimés et mal étudiés.

Increase of invasive meningococcal serogroup W disease in Europe, 2013 to 2017.

BackgroundThe total incidence of invasive meningococcal disease (IMD) in Europe has been declining in recent years; however, a rising incidence due to serogroup W (MenW), predominantly sequence type 11 (ST-11), clonal complex 11 (cc11), was reported in some European countries.AimThe aim of this study was to compile the most recent laboratory surveillance data on MenW IMD from several European countries to assess recent trends in Europe.MethodsIn this observational, retrospective study, IMD surveillance data collected from 2013-17 by national reference laboratories and surveillance units from 13 European countries were analysed using descriptive statistics.ResultsThe overall incidence of IMD has been stable during the study period. Incidence of MenW IMD per 100,000 population (2013: 0.03; 2014: 0.05; 2015: 0.08; 2016: 0.11; 2017: 0.11) and the proportion of this serogroup among all invasive cases (2013: 5% (116/2,216); 2014: 9% (161/1,761); 2015: 13% (271/2,074); 2016: 17% (388/2,222); 2017: 19% (393/2,112)) continuously increased. The most affected countries were England, the Netherlands, Switzerland and Sweden. MenW was more frequent in older age groups (≥ 45 years), while the proportion in children (< 15 years) was lower than in other age groups. Of the culture-confirmed MenW IMD cases, 80% (615/767) were caused by hypervirulent cc11.ConclusionDuring the years 2013-17, an increase in MenW IMD, mainly caused by MenW cc11, was observed in the majority of European countries. Given the unpredictable nature of meningococcal spread and the epidemiological potential of cc11, European countries may consider preventive strategies adapted to their contexts.

[Update on the use of steroids in infectious diseases]. / Utilisation des stéroïdes dans les pathologies infectieuses†: mise à jour.

It is well established in daily clinical practice, on the basis of randomized studies, to add corticosteroïds to the antibiotherapy in cases of S. pneumoniae H. influenzae meningitis, tuberculous meningitis and Pneumocystis jiroveci pneumonia in HIV patients. Clear benefits have been demonstrated for these infectious disease. This litterature review aims at updating the use of corticosteroids, adding them to antibiotic treatments, in cases of bacterial community-acquired pneumonia, septic shock, septic arthritis and ENT infectious syndromes. We also highlight the infections at high risk of reactivation when giving a corticotherapy with ≥20 mg/d for more than a month, that should be screened for and discussed in terms of the need for prophylaxis.

Il est bien établi dans la pratique clinique quotidienne sur la base d'études randomisées d'adjoindre un traitement de corticostéroïdes dans les cas de méningite à S. pneumoniae et H. influenzae, méningite tuberculeuse et les pneumonies à Pneumocystis jiroveci chez les patients VIH. Des bénéfices ont été clairement mis en évidence pour ces syndromes infectieux. Cette revue de la littérature vise à mettre à jour leur utilisation, en adjonction aux antibiotiques, dans les pneumonies communautaires bactériennes, le choc septique, les arthrites septiques et les syndromes ORL. Nous rappelons également quelles sont les infections à haut risque de réactivation lors d'une corticothérapie de plus d'un mois à raison de ≥ 20 mg/jour, qui devraient être dépistées et faire l'objet d'une discussion sur l'introduction de certaines prophylaxies.

[Oral antibiotics for severe infections†: an update]. / Antibiothérapie orale en cas d'infection sévère: mise à jour.

Antibiotic resistance, good resource management and health care costs drive us to think about our practice. In this update we take into consideration therapeutical guidelines for the most frequently encountered serious infections in a hospital setting, and respective non-inferiority studies supporting early switch to an oral form of antibiotic. This strategy generally leads to a shorter hospital stay, with the same effect in terms of mortality, relapse, complications or treatment failure. Too often still, doctors and patients believe that intravenous antibiotics only are effective enough for severe infections, whereas in many cases, oral antibiotics are as effective.

La résistance aux antibiotiques, la bonne gestion des ressources ainsi que les coûts du système de santé, nous poussent à réfléchir à nos pratiques. Dans cet article, nous prenons en considération les recommandations thérapeutiques des infections sévères les plus souvent rencontrées dans la pratique médicale hospitalière ainsi que les études respectives de non-infériorité de l'antibiothérapie orale précoce. Cette dernière permet en général un séjour hospitalier plus court tout en ayant le même effet en termes de mortalité, récidive, complications ou échec de traitement. Trop souvent encore, médecins et patients pensent que seule une antibiothérapie intraveineuse est efficace lors d'infections sévères, alors qu'une administration per os s'avère tout aussi efficace.

[Acute pyelonephritis in adults: for a unified patient care]. / La pyélonéphrite aiguë chez l'adulte: pour une prise en charge unifiée.

Pyelonephritis is a frequent infection mostly found in women. Urine must be collected for culture before beginning antibiotherapy. The predominant pathogen identified is E coli. Ciprofloxacin may be used right away if the E. coli susceptibility to this antibiotic is at least 90% in the local population. Otherwise, a dose of ceftriaxone or amikacin (outside pregnancy) should be administered. For inpatient care, initial treatment is different according to clinical severity. In case of complication, specialists of urology and infectiology should be consulted. An antibiotic de-escalation should be considered if permitted by the clinical evolution and the antibiogram; in favor of amoxicillin in women and ciprofloxacin in men. In case of history of ESBL infection or carriage, the empirical treatment should be adapted.

La pyélonéphrite est une infection fréquente principalement présente chez la femme. Une culture d'urine doit être prélevée avant de débuter l'antibiothérapie. Le germe le plus identifié est l'E. coli La ciprofloxacine peut être prescrite d'emblée si l'E. coli est sensible, soit chez 90 % ou plus de la population locale. Dans le cas contraire, une dose de ceftriaxone ou d'amikacine (sauf grossesse) devrait être administrée. En cas hospitalisation, le traitement initial diffère selon la gravité clinique. Lors de complication, un urologue et un infectiologue devraient être consultés. Une désescalade antibiotique est à envisager si l'évolution clinique et l'antibiogramme le permettent ; pour l'amoxicilline chez la femme et la ciprofloxacine chez l'homme. En cas d'antécédent d'infection ou de portage BLSE, le traitement devrait être adapté.

[Septic arthritis diagnosis : the role of microbiology]. / Diagnostic microbiologique des arthrites septiques.

Septic arthritis is a medical and surgical emergency. It is therefore essential to promptly differentiate an infectious from a non-infectious origin in order to improve the prognostic (mortality and morbidity). To do so the clinician needs not only to know which tests are available but also how to adequately use them and interpret their results. In this article, we review the various tests in use for the evaluation of acute arthritis, highlighting the most useful ones for the diagnosis of septic arthritis. We will also have a quick look at the use of intra-articular injection of corticosteroid.

L'arthrite septique est une urgence médicale et souvent chirurgicale. Dès lors, il est essentiel de rapidement distinguer une arthrite infectieuse d'une arthrite d'autre étiologie afin d'améliorer le pronostic en termes de morbidité et même de mortalité. Pour ce faire, de nombreux tests biologiques et microbiologiques sont à disposition du clinicien. Encore faut-il choisir le bon et l'interpréter correctement. Dans cet article, nous passons en revue les différents examens utiles (et moins utiles) au diagnostic d'arthrite septique. Nous évoquons également la question de l'utilisation de corticostéroïdes intra-articulaires en cas d'arthrite aiguë.

[Meningococcal infections in Switzerland : changes in epidemiology, clinical manifestations and prophylaxis]. / Infections à méningocoques en Suisse : changements épidémiologiques, cliniques et de prophylaxie.

In the last decade, the epidemiology of meningococcal infections in Switzerland and Europe has changed. The prevalence of Y and W serogroups augmented, with more atypical clinical manifestations such as pharyngitis, pneumonia and arthritis. A hypervirulent clonal serogroup W strain of Neisseria meningitidis has emerged in Europe and Switzerland, with a noticeable potential for epidemics as evidenced by its clonality. In this context, vaccinal recommendations for risk groups have and will continue to evolve towards the use of novel conjugated vaccines.

Depuis quelques années, l'épidémiologie des infections sévères à méningocoques évolue en Europe et en Suisse. La prévalence des sérogroupes Y et W a augmenté, avec des tableaux cliniques moins classiques qu'auparavant : pneumonies, pharyngites, arthrites. Une souche hypervirulente de Neisseria meningitidis du sérogroupe W s'est propagée en Europe et en Suisse, avec un potentiel épidémique non négligeable comme en témoigne son caractère clonal. Dans ce contexte, les recommandations vaccinales pour les groupes à risque ont et vont encore évoluer vers l'utilisation de nouveaux vaccins conjugués.

Detection of Bacterial Pathogens from Broncho-Alveolar Lavage by Next-Generation Sequencing.

The applications of whole-metagenome shotgun sequencing (WMGS) in routine clinical analysis are still limited. A combination of a DNA extraction procedure, sequencing, and bioinformatics tools is essential for the removal of human DNA and for improving bacterial species identification in a timely manner. We tackled these issues with a broncho-alveolar lavage (BAL) sample from an immunocompromised patient who had developed severe chronic pneumonia. We extracted DNA from the BAL sample with protocols based either on sequential lysis of human and bacterial cells or on the mechanical disruption of all cells. Metagenomic libraries were sequenced on Illumina HiSeq platforms. Microbial community composition was determined by k-mer analysis or by mapping to taxonomic markers. Results were compared to those obtained by conventional clinical culture and molecular methods. Compared to mechanical cell disruption, a sequential lysis protocol resulted in a significantly increased proportion of bacterial DNA over human DNA and higher sequence coverage of Mycobacterium abscessus, Corynebacterium jeikeium and Rothia dentocariosa, the bacteria reported by clinical microbiology tests. In addition, we identified anaerobic bacteria not searched for by the clinical laboratory. Our results further support the implementation of WMGS in clinical routine diagnosis for bacterial identification.

Use of Treponema pallidum PCR in testing of ulcers for diagnosis of primary syphilis.

Treponema pallidum PCR (Tp-PCR) has been noted as a valid method for diagnosing syphilis. We compared Tp-PCR to a combination of darkfield microscopy (DFM), the reference method, and serologic testing in a cohort of 273 patients from France and Switzerland and found the diagnostic accuracy of Tp-PCR was higher than that for DFM.

Performance of the 47-kilodalton membrane protein versus DNA polymerase I genes for detection of Treponema pallidum by PCR in ulcers.

Treponema pallidum PCR (Tp-PCR) is a direct diagnostic method for primary and secondary syphilis, but there is no recommendation regarding the best choice of target gene. In this study, we sequentially tested 272 specimens from patients with sexually transmitted ulcers using Tp-PCR targeting the tpp47 and then polA genes. The two methods showed similar accuracies and an almost-perfect agreement.

Characteristics of multidrug-resistant Acinetobacter baumannii strains isolated in Geneva during colonization or infection.

This study determined the antibiotic susceptibility profile and genetic mechanisms of ß-lactam resistance in 27 clinical strains of Acinetobacter baumannii isolated at the University Hospitals of Geneva, Switzerland. The antimicrobial susceptibility testing was performed using Etest and the disc diffusion method in accordance with CLSI guidelines. All of the strains were defined as multi-drug resistant (MDR) and were susceptible to colistin and moderately susceptible to tigecycline. Uniplex PCR assays were used to detect the following ß-lactamase genes: four class D carbapenem-hydrolysing oxacillinases (blaOXA-51, blaOXA-23, blaOXA-24 and blaOXA-58), four class B metallo-ß-lactamases genes (blaIMP, blaVIM, blaSPM and blaNDM) and two class A carbapenemases (blaKPC and blaGES). All of the strains were positive for blaOXA-51 (intrinsic resistance), 14/27 strains carried blaOXA-23, 2/27 strains carried a blaOXA-24-like gene, and 4/27 strains had a blaOXA-58 gene. blaGES-11 was found in three strains, and NDM-1-harbouring strains were identified in three patients. All of the A. baumannii isolates were typed by rep-PCR (DiversiLab) and excluded any clonality. Altogether, this analysis suggests a very high genetic diversity of imported MDR A. baumannii.

The role of anaerobes in diabetic foot infections.

Diabetic foot infections (DFI) are a common cause of morbidity and, on occasion, even mortality. Infection can be either mono- or polymicrobial, with a wide variety of potential pathogens. Anaerobes may be involved, particularly in wounds that are deeper or more chronic, and are more frequently identified when using modern molecular techniques, such as 16s PCR and pyrosequencing. It remains unclear whether the presence of anaerobes in DFI leads to more severe manifestations, or if these organisms are largely colonizers associated with the presence of greater degrees of tissue ischemia and necrosis. Commonly used empiric antibiotic therapy for diabetic foot infections is generally broad-spectrum and usually has activity against the most frequently identified anaerobes, such as Peptostreptococcus and Bacteroides species. Adequate surgical debridement and, when needed, foot revascularization may be at least as important as the choice of antibiotic to achieve a successful treatment outcome.