Anaerobes in diabetic foot infections: pathophysiology, epidemiology, virulence, and management.

SUMMARYDiabetic foot infections (DFI) are a public health problem worldwide. DFI are polymicrobial, biofilm-associated infections involving complex bacterial communities organized in functional equivalent pathogroups, all including anaerobes. Indeed, multiple pathophysiological factors favor the growth of anaerobes in this context. However, the prevalence, role, and contribution of anaerobes in wound evolution remain poorly characterized due to their challenging detection. Studies based on culture reviewed herein showed a weighted average of 17% of patients with anaerobes. Comparatively, the weighted average of patients with anaerobes identified by 16S rRNA gene sequencing was 83.8%. Culture largely underestimated not only the presence but also the diversity of anaerobes compared with cultivation-independent approaches but both methods showed that anaerobic Gram-negative bacilli and Gram-positive cocci were the most commonly identified in DFI. Anaerobes were more present in deeper lesions, and their detection was associated with fever, malodorous lesions, and ulcer depth and duration. More specifically, initial abundance of Peptoniphilus spp. was associated with ulcer-impaired healing, Fusobacterium spp. detection was significantly correlated with the duration of DFI, and the presence of Bacteroides spp. was significantly associated with amputation. Antimicrobial resistance of anaerobes in DFI remains slightly studied and warrants more consideration in the context of increasing resistance of the most frequently identified anaerobes in DFI. The high rate of patients with DFI-involving anaerobes, the increased knowledge on the species identified, their virulence factors, and their potential role in wound evolution support recommendations combining debridement and antibiotic therapy effective on anaerobes in moderate and severe DFI.

Assessment and management of diabetes-related foot infection according to the new International Working Group on the Diabetic Foot guidelines 2023-Multidisciplinary grand rounds.

Diabetes-related foot disease is a serious and common complication for people with diabetes mellitus. The gold standard care for a person with diabetes-related foot disease is the involvement of a multidisciplinary foot team engaged in evidence-based care. To date, there are seven International Working Group on the Diabetic Foot (IWGDF) guidelines published to assist healthcare providers in managing diabetes-related foot disease around the world. This review discusses the acute management of diabetes-related foot infection with insights from experts of various specialities (internal medicine, infectious disease, vascular surgery, radiology) with a discussion on the implementation of IWGDF guidelines in real life practice and the challenges that healthcare providers may face.

Selective Delivery of Clindamycin Using a Combination of Bacterially Sensitive Microparticle and Separable Effervescent Microarray Patch on Bacteria Causing Diabetic Foot Infection.

INTRODUCTION: Diabetic foot infection (DFI) is one of the complications of diabetes mellitus. Clindamycin (CLY) is one of the antibiotics recommended to treat DFI, but CLY given orally and intravenously still causes many side effects. METHODS: In this study, we encapsulated CLY in a bacteria sensitive microparticle system (MP-CLY) using polycaprolactone (PCL) polymer. MP-CLY was then delivered in a separable effervescent microarray patch (MP-CLY-SEMAP), which has the ability to separate between the needle layer and separable layer due to the formation of air bubbles when interacting with interstitial fluid in the skin. RESULT: The characterization results of MP-CLY proved that CLY was encapsulated in large amounts as the amount of PCL polymer used increased, and there was no change in the chemical structure of CLY. In vitro release test results showed increased CLY release in media cultured with Staphylococcus aureus bacteria and showed controlled release. The characterization results of MPCLY-SEMAP showed that the developed formula has optimal mechanical and penetration capabilities and can separate in 56 ± 5.099 s. An ex vivo dermatokinetic test on a bacterially infected skin model showed an improvement of CLY dermatokinetic profile from MP-CLY SEMAP and a decrease in bacterial viability by 99.99%. CONCLUSION: This research offers proof of concept demonstrating the improved dermatokinetic profile of CLY encapsulated in a bacteria sensitive MP form and delivered via MP-CLY-SEMAP. The results of this research can be developed for future research by testing MP-CLY-SEMAP in vivo in appropriate animal models.

Update of biomarkers to diagnose diabetic foot osteomyelitis: A meta-analysis and systematic review.

The aim of this study was to evaluate the diagnostic characteristics of biomarker for diabetic foot osteomyelitis (DFO). We searched PubMed, Scopus, Embase and Medline for studies who report serological markers and DFO before December 2022. Studies must include at least one of the following diagnostic parameters for biomarkers: area under the curve, sensitivities, specificities, positive predictive value, negative predictive value. Two authors evaluated quality using the Quality Assessment of Diagnostic Accuracy Studies tool. We included 19 papers. In this systematic review, there were 2854 subjects with 2134 (74.8%) of those patients being included in the meta-analysis. The most common biomarkers were erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) and procalcitonin (PCT). A meta-analysis was then performed where data were evaluated with Forrest plots and receiver operating characteristic curves. The pooled sensitivity and specificity were 0.72 and 0.75 for PCT, 0.72 and 0.76 for CRP and 0.70 and 0.77 for ESR. Pooled area under the curves for ESR, CRP and PCT were 0.83, 0.77 and 0.71, respectfully. Average diagnostic odds ratios were 16.1 (range 3.6-55.4), 14.3 (range 2.7-48.7) and 6.7 (range 3.6-10.4) for ESR, CRP and PCT, respectfully. None of the biomarkers we evaluated could be rated as 'outstanding' to diagnose osteomyelitis. Based on the areas under the curve, ESR is an 'excellent' biomarker to detect osteomyelitis, and CRP and PCT are 'acceptable' biomarkers to diagnose osteomyelitis. Diagnostic odds ratios indicate that ESR, CRP and PCT are 'good' or 'very good' tools to identify osteomyelitis.

Microbiological characterization of neuropathic diabetic foot infection: a retrospective study at a Portuguese tertiary hospital.

Diabetic foot infection imposes a significant burden and is the major cause of nontraumatic limb amputation. Adequate patient management with effective antibiotic therapy is crucial.This retrospective cohort study aimed to characterize the microbiology and resistance patterns of moderate to severe neuropathic diabetic foot infection in patients hospitalized at a tertiary referral hospital between January 2020 and June 2023. Deep tissue specimens from ulcers were collected for culture.Sixty inpatients were included (62% male, mean age 59.1 ± 11.5 years). Osteomyelitis was present in 90% of the patients. Among 102 microorganisms (average of 1.91 ± 1.25 pathogens per patient), 60.8% were gram-positive bacteria, 31.4% were gram-negative, 3.92% were anaerobic bacteria, and 3.92% were fungi. Staphylococcus aureus (19%) and Enterococcus faecium (17%) were the most common. Pseudomonas aeruginosa (8%) and bacteria of the Enterobacterales family (24%) accounted for all the isolated gram-negative bacteria. Sixteen percent of Staphylococcus aureus and 67% of coagulase-negative Staphylococci were resistant to methicillin. Resistance to ampicillin was found in 11% of Enterococci. All Pseudomonas aeruginosa isolates were sensitive to piperacillin-tazobactam, ceftazidime, or cefepime. Among the Enterobacterales, resistance rates were 35% for piperacillin-tazobactam, 38% for ceftazidime, 21% for cefepime, and 13% for carbapenems.Although the prevalence of methicillin-resistant staphylococci was lower than that in other studies, carbapenem resistance among gram-negative bacteria warrants attention. This study highlights the importance of understanding local epidemiology for effective diabetic foot infection management and resistance mitigation.

The diabetic sausage toe: Prevalence, presentation and outcomes.

Osteomyelitis (OM) in diabetic foot infection could have many presentations such as an infected ulcer spreading to the bone or superimposed to Charcot neuroarthropathy. However, the sausage toe as a diabetic OM presentation was very rarely investigated; therefore, this study aims to assess the prevalence and signs of this presentation along with treatment modalities and outcomes. This is a retrospective series of patients presenting a sausage toe on admission. Several methods were conducted to diagnose OM, and three treatment modalities were applied. Two groups were compared: acute and chronic sausage toes. Outcomes were defined as sausage toe prevalence, ulcer location, OM prevalence, and comparative treatment results. Out of 82 diabetic toe infection cases, 24 (30%) presented as 'sausage toe'. The side of the proximal interphalangeal joint of the lateral toes was the most frequent ulcer location (50%), mostly on the dorsal aspect followed by the side aspect. There were 15 (62.5%) acute cases and 9 (37.5%) chronic cases. MRI showed signs of OM in 21 (87.5%) cases and signs of septic arthritis in 3 (12.5%) cases. At the final follow-up, a successful treatment was recorded in five (20%) cases with antibiotics alone. Out of the 19 (42%) procedures, conservative surgery was performed successfully in 8 (58%) cases while amputation was needed in 11 (45.8%) cases. There was no significant difference in amputation frequency between acute and chronic groups. This is the first study documenting the sausage toe as a prevalent presentation of diabetic toe infection. The deformity is conclusive of deep infection with a very high osteomyelitis frequency. Surgery is often required for infection control and healing, mainly for chronic cases, and treatment outcomes did not differ between acute and chronic sausage toe groups. It could be beneficial to include this entity in the diabetic wound classification systems.

Basic haematological tests as inflammatory performance markers of patients treated either by conservative surgery or minor amputation for infected diabetic foot ulcers.

Basic inflammatory markers have been extensively studied to differentiate between non-infected and infected diabetic foot ulcers (DFUs). Very rarely, basic haematological tests such as white cell count (WCC) and platelet counts were used as performance markers for DFU infection severity. The aim is to investigate these biomarkers in patients with DFU treated exclusively with surgery. In this retrospective comparative study, we included 154 procedures comparing a conservative surgery group (n = 66 for infected DFU) and a minor amputation group (n = 88 for infected DFU with osteomyelitis). Outcomes were set as the preoperative values of: WCC, neutrophils (N), lymphocytes (L), Monocytes (M), Platelets (P), red cell distribution width (RDW) and the ratios N/L, L/M and P/L. Area under curve (AUC) of the receiver operating characteristic (ROC) was calculated based on the diagnosis of minor amputation as a positive result. Cutoff point values with the highest sensitivity and specificity were obtained for each outcome. The highest AUC values were for WCC (0.68), neutrophils (0.68), platelets (0.7) and P/L ratio (0.69) with corresponding cut-off values of 10,650/mm3 , 76%, 234,000/mcL and 265, respectively. The highest sensitivity was for the platelet count (81.5%) while the highest specificity was for L/M (89%) and P/L ratios (87%). Postoperative values showed similar results. Simple routine blood tests could serve as inflammatory performance markers to help predict the severity of infection in patients treated surgically for infected DFU.

The association between bacteria and outcome and the influence of sampling method, in people with a diabetic foot infection.

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.

Improving the Management and Treatment of Diabetic Foot Infection: Challenges and Research Opportunities.

Diabetic foot infection (DFI) management requires complex multidisciplinary care pathways with off-loading, debridement and targeted antibiotic treatment central to positive clinical outcomes. Local administration of topical treatments and advanced wound dressings are often used for more superficial infections, and in combination with systemic antibiotics for more advanced infections. In practice, the choice of such topical approaches, whether alone or as adjuncts, is rarely evidence-based, and there does not appear to be a single market leader. There are several reasons for this, including a lack of clear evidence-based guidelines on their efficacy and a paucity of robust clinical trials. Nonetheless, with a growing number of people living with diabetes, preventing the progression of chronic foot infections to amputation is critical. Topical agents may increasingly play a role, especially as they have potential to limit the use of systemic antibiotics in an environment of increasing antibiotic resistance. While a number of advanced dressings are currently marketed for DFI, here we review the literature describing promising future-focused approaches for topical treatment of DFI that may overcome some of the current hurdles. Specifically, we focus on antibiotic-impregnated biomaterials, novel antimicrobial peptides and photodynamic therapy.

Predictive Value of MRSA Nares Colonization in Diabetic Foot Infections: A Systematic Review and Bivariate Random Effects Meta-Analysis.

The primary objective of this study was to assess the negative predictive value of methicillin-resistant Staphylococcus aureus (MRSA) nasal swabs in MRSA diabetic foot infections. MEDLINE and Cochrane Library were searched from inception to May 1, 2020. The following search string was used: (methicillin-resistant S. aureus OR MRSA) AND (nasal OR nares) AND (diabetic OR foot OR diabetic foot infections). All studies that contained data comparing MRSA nasal swab positivity to wound cultures from diabetic foot infections and met the inclusion criteria were included. Among the 86 relevant studies, 6 studies with 8706 diabetic patients were included. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guideline extension for Diagnostic Test Accuracy reviews was followed. The primary meta-analysis outcomes were the negative and positive predictive values of MRSA nasal swabs for MRSA diabetic foot infections. The pooled specificity and pooled sensitivity were determined by generating hierarchical summary receiver characteristic operating curves. In the bivariate meta-analysis, involving the 6 studies, pooled sensitivity and specificity was 41.7% (95% confidence interval = 32.9, 51) and 94.1% (95% confidence interval = 89.5, 96.8), respectively. In low-moderate MRSA prevalence levels (<15%), negative predictive value of MRSA nasal swab was >90% and positive predictive value was <55%. This meta-analysis suggests that in patients with diabetic foot infections, the nasal swab MRSA screen has a poor positive predictive value but an excellent negative predictive value in regions of low to moderate prevalence of MRSA diabetic foot infections.

[Characteristics of Inflammatory Markers in Diabetic Foot Patients and Their Relationship With Prognosis of Diabetic Foot Ulcers]. / ç³–å°¿ç— è¶³æ‚£è€ ç‚Žç—‡æ ‡å¿—ç‰©ç‰¹å¾åŠå ¶ä¸Žè¶³æºƒç–¡é¢„åŽå ³ç³».

Objective: To explore the characteristics of baseline inflammatory markers in diabetic foot patients and their relationship with the prognosis of diabetic foot ulcers. Methods: The clinical data of diabetic foot patients (n=495) admitted to West China Hospital, Sichuan University since 2016 were retrospectively collected through the hospital electronic medical record system to analyze the characteristics of inflammatory markers and their relationship with the prognosis of diabetic foot ulcers. Results: White blood cell count (WBC), erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), procalcitonin (PCT), and interleukin-6 (IL-6) levels were significantly higher in patients defined as grade 4 on the Wagner Scale than those in patients defined as grade 0-3 on the Wagner Scale. Neutrophil percentage (NE%) was higher in Wagner grade-4 patients than those in Wagner grade-0 and grade-1 patients and higher in Wagner grade-3 patients than those in Wagner grade-0 patients. NE%, CRP, PCT, and IL-6 levels were positively correlated with the severity of diabetic foot, with the respective odds ratio (OR) at 95% confidence interval (CI) being 1.038 (1.019-1.056), 1.019 (1.012-1.026), 8.225 (2.015-33.576), and 1.017 (1.008-1.025). Using Wagner grade-0 patients as the reference, patients with higher WBC were more likely to progress to Wagner grade 2, 3, and 4, with the respective OR (95% CI) values being 1.260 (1.096-1.447), 1.188 (1.041-1.356), and 1.301 (1.137-1.490); patients with higher ESR were more likely to progress to Wagner grade 3 and 4, with the respective OR (95% CI) values being 1.030 (1.006-1.054) and 1.045 (1.019-1.071). Baseline ESR (P=0.008), CRP (P=0.039), and IL-6 (P=0.033) levels were lower in patients who had received antibiotics prior to their admission than those in patients who had not received antibiotics before admission. The levels of WBC, NE%, ESR, PCT, and IL-6 were lower in the full recovery group than those in the group of patients who did not respond to treatment. The higher the levels of NE% and IL-6, the worse the prognosis of diabetic foot ulcers became, with the respective OR (95% CI) values being 1.030 (1.010-1.051) and 1.008 (1.002-1.013). Conclusion: The severity of diabetic foot ulcers increased with the rise in baseline levels of inflammatory markers. Elevated baseline NE% and IL-6 levels suggest a poor prognosis. Our findings suggest that early assessment of diabetic foot infection and standardized antibiotic therapy should be implemented to improve the prognosis.

Should we resect more proximally? Outcomes of toe amputation versus ray resection in patients with infected diabetic ulcers and osteomyelitis. A preliminary study and new treatment algorithm.

BACKGROUND: The treatment of severe diabetic toe infection complicated with osteomyelitis is often surgical. The decision on the level of amputation, when required, is difficult. Very few articles reported comparative outcomes between toe amputation and ray resection, and only in relation to the hallux. The aim of this preliminary report is to record the results of these procedures when performed on all toes. METHODS: This is a comparative retrospective study where the charts of a continuous series of 44 patients (48 procedures) with diabetic forefoot infection were analyzed. Only cases of severe infection with confirmed osteomyelitis were included. Two groups were compared based on the level of amputation: the toe amputation group (at and distal to the metatarsophalangeal joint) and the ray resection group (distal to tarsometatarsal joint). The primary outcomes were defined as osteomyelitis recurrence and re-amputation. RESULTS: Outcome comparison between toe amputation and ray resection; 47.3 % vs. 51.7 % had a recurrence of their osteomyelitis (p = 0.8), 36.8 % vs. 34.5 % had a re-amputation (p = 0.02). Re-amputation was needed in 25 % of cases following hallux/first ray index procedure while the same was required in 39 % of cases following lateral toes/rays index procedures (p = 0.4). Both primary outcomes were correlated to CDK, smoking and creatinine level. CONCLUSIONS: Bone infection recurrence and re-amputation are highly prevalent in patients undergoing initial amputation for severe diabetic toe infection. A more aggressive approach in the form of a more proximal level of index amputation might be needed when treating severe toe infections with osteomyelitis in patients with diabetes.

Association between the duration of diabetes and gram-negative bacterial infection in diabetic foot infections: a case-control study.

This retrospective case-control study was designed to explore the association between the duration of diabetes and gram-negative bacterial infection in diabetic foot infections (DFIs). All DFI patients hospitalized in the Department of Endocrinology in the Sixth Affiliated Hospital of Sun Yat-sen University between 2013 and 2019 with positive microbial culture results were included. Cases were defined as DFI patients whose microbial cultures grew gram-negative bacteria (including polymicrobial flora). Controls were defined as DFI patients whose positive microbial cultures did not grow gram-negative bacteria. Clinical data were extracted from the hospital information system. Stabilized inverse probability weighting was used to balance between-group differences at baseline. Confounders were selected using a directed acyclic graph. Missing data were imputed with the multiple imputation of chained equations method. Odds ratios (ORs) with 95% confidence intervals (CIs) and Ptrend for associations between the duration of diabetes and gram-negative bacterial infection were obtained using binomial logistic regression models. The weighted OR of gram-negative bacterial infection for DFI patients with a moderate duration of diabetes (8~19 years) compared with those with a short duration (0~7 years) was 3.87 (95% CI: 1.15 to 13.07), and the OR for those with a longer duration (20~30 + years) was 7.70 (95% CI: 1.45 to 41.00), and there was a dose-response trend with increasing duration of diabetes (weighted Ptrend = 0.007). The results demonstrated that a long duration of diabetes might be associated with an increased risk of gram-negative bacterial infection in type 2 diabetes patients with DFI.

Identification of the rare yeast Cutaneotrichosporon (Trichosporon) debeurmannianum from diabetic foot infection.

BACKGROUND: Diabetic foot infection is the most common complications of diabetes mellitus. Although most of the diabetic foot infections has been known to be caused by aerobic and anaerobic bacteria, mycotic diabetic foot infection caused by Candida species has also been reported recently. Here, we present the first case of diabetic foot infection caused by Cutaneotrichosporon debeurmannianum (previously known as Trichosporon debeurmannianum). METHODS: A 68-year-old diabetic male patient was admitted for management of the necrosis of the big toe. Wound swab culture was performed three times, and each time after 5 days of incubation, beige-colored, wrinkled, and rough colonies were observed on chocolate agar plate. RESULTS: The isolate was identified as C. debeurmannianum with the matrix-assisted laser desorption ionization-time of flight mass spectrometry system (MicroIDSys, ASTA corp.). For confirmation, the sequencing for ITS1/ITS2 and D1/D2 ribosomal DNA was also performed, and the isolate was confirmed as C. debeurmannianum with 100% identity. The isolate exhibited low minimum inhibitory concentrations (MICs) for azoles and high MICs for all echinocandins. CONCLUSION: Considering that usual incubation time for bacterial culture of open wound specimens is only 48 h, it is important to include the request for fungus culture to detect pathogen in diabetic foot lesion.

The value of administering intravenous antibiotics during haemodialysis in the treatment of diabetic foot infections.

OBJECTIVE: People with diabetes who are on haemodialysis (HD) are at a high risk of diabetic foot infections (DFI) and related complications. We explored the value of treating DFI with intravenous (IV) antibiotics during HD. METHOD: This was an observational study of consecutively treated patients with DFIs with IV antibiotics during HD. Data collected included baseline characteristics, IV antibiotics used, details of multidisciplinary interventions and DFI treatment outcome. RESULTS: A cohort of 11 patients, mean (±standard deviation) age 62.4±12.7 years, had 15 episodes of treatment with IV antibiotics during HD. Of the patients, six (54.5%) were male and nine (81.8%) had type 2 diabetes. The estimated mean glomerular filtration rate (eGFR) was 11.4±3.9ml/minute. All patients had infected foot ulceration, soft tissue infection, six (54.5%) patients had osteomyelitis, and two (18.2%) had wet gangrene. The commonest IV antibiotic used was vancomycin (10/15 episodes, 66.7%). Other IV antibiotics used were daptomycin and meropenem. In three episodes, oral ciprofloxacin was used with IV antibiotics. The mean duration of antibiotic treatment was 9.2±4.9 weeks. Of the episodes, 11 (73.3%) were treated successfully with IV antibiotics alone and two (13.3%) episodes required minor surgical debridement/amputation. Some 10 (90.9%) members of the cohort had peripheral arterial disease and of those, five (50%) underwent angioplasty during IV antibiotic treatment. CONCLUSION: HD provides a good opportunity for treatment with IV antibiotics in DFI. This mode of administration of IV antibiotics, along with multidisciplinary intervention, is associated with ulcer healing and resolution of infection in over three-quarters of patients with DFI. DECLARATION OF INTEREST: The authors have no conflicts of interest to declare.

Are Transmetatarsal Amputations a Durable Limb Salvage Option? A Single-Institution Descriptive Analysis.

In limb and life-threatening diabetic foot infections, transmetatarsal amputations are often indicated as a limb salvage procedure. The aim of this study is to analyze the long-term durability of initially successful transmetatarsal amputations in the diabetic population. We defined a successful transmetatarsal amputation as one which had clinical healing 1 year after surgery. A retrospective review of transmetatarsal amputations completed at our institution over an 11-year period was performed. We identified 83 amputations that met inclusion criteria. The mean follow-up was 4 years. The mean time to surgical healing was 109.8 days. After successfully healing the transmetatarsal amputation the long-term outcomes were analyzed. Re-ulcerations occurred in 44% of the transmetatarsal amputations a mean of 15 months after surgical healing. Patients who re-ulcerated were noted to be significantly younger (p value 0.02) with a significantly higher preprocedure hemoglobin A1c (p value < .001). Additional procedures after successful healing included 13 (15.66%) revision surgeries and 12 (14.46%) more proximal amputations. While transmetatarsal amputations remain a viable and durable limb preserving surgery, all patients who have undergone a transmetatarsal amputation should be monitored lifelong as they remain at risk for re-ulceration and more proximal amputation.

Oral Versus Intravenous Antibiotics for Residual Osteomyelitis After Amputation in the Diabetic Foot.

The standard management for residual osteomyelitis following amputation in a diabetic foot infection includes a prolonged course of intravenous antibiotic agents. The purpose of this analysis was to investigate whether oral antibiotic therapy led to treatment failure more than intravenous antibiotic therapy for this indication. The primary endpoint was treatment failure within one year of the initial amputation, defined by re-operation for residual osteomyelitic infection or a remaining nonhealing wound at the surgical site. All patients received at least 4 weeks of antibiotics and were chosen for oral or intravenous route of administration by infectious disease specialists. Characteristics including age, sex, hemoglobin A1c, BMI, tobacco use, PVD, homelessness and IDSA classification were also assessed for influence on antibiotic success and failure. Of the 65 patients meeting inclusion criteria, treatment failure occurred in 32 and treatment success occurred in 33. Of the treatment failures, 17 (53%) were in the intravenous group, and 15 (47%) were in the oral group. The differences between the modalities of antibiotic administration and their failure rates were not found to be statistically significant (p = .28 (proportional difference: -14%, 95% confidence interval [CI]:-36% to 10%)).

Empirical Antibiotic for Diabetic Foot Infection in Indonesian Tertiary Hospital, Is It Time to Rethink the Options?

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.

Comparison of efficacy of systemic antibiotics alone and combination of systemic antibiotics with gentamicin cream in diabetic foot infections.

Objective: To compare efficacy of systemic antibiotics alone and combination of systemic antibiotics with gentamicin cream in diabetic foot infections. Methods: Prospective Observational Study was conducted at Department of Surgery, Pakistan Ordinance Factories (POF) Hospital, Wah Cantt for duration of two years (January 2018-December 2019). A sample size of 140 diabetic foot infection patients (70 patients in each group) was calculated using WHO calculator. DFI patients were selected through non probability (consecutive) sampling technique. All patients signed consent forms before participation into study. Patients were randomly divided into two group (computer generated random number table); Group-A patients were given systemic antibiotics alone while Group-B was given combination of gentamicin cream and systemic antibiotics. SPSS version 24 was utilized for analysis purpose. Chi-square test was applied in our study. Results with p value ≤0.05 found significant. Results: Total 140 patients were included in study. There were 87(62.1%) male and 53(37.9%) females in our data. Mean age of patients was 46 years±11.3SD. Group-B (combination of gentamicin and systemic antibiotics) showed significant reduction in inflammation (p=0.03), culture negativity(p=0.001), increase clinical cure (p=0.02) and pathological eradication (p=0.03) as compared to Group-A (systemic antibiotics alone). Gender, age and duration of diabetes mellitus had insignificant association with outcomes (p>0.05). Conclusion: Diabetic foot infections are significant contributors of morbidity in our country. Combination of gentamicin cream with systemic antibiotics is highly effective in inflammation reduction, increasing clinical cure rate and pathological eradication as compared to systemic antibiotics alone in diabetic foot infections. Early identification of risk factors, proper patients care and multidisciplinary approach for diabetic foot infections prevention is required.

The internal pedal amputation as a salvage procedure in diabetic and ischemic foot infection. A meta-analysis.

BACKGROUND: Osteomyelitis of the diabetic foot is a very challenging condition and amputation is often indicated. In some cases where the infection is localized and the surrounding soft tissue is mildly involved, an internal pedal amputation (IPA) based on resection and limited excision of the infected bone have been suggested as a viable option. This systematic review aims to look for the effectiveness of this technique in treating selected cases of diabetic foot osteomyelitis. METHODS: A systematic literature search was conducted using multiple electronic databases from inception. Eight studies met the inclusion criteria; one retrospective comparative study, six retrospective observational studies and one prospective observational study. RESULTS: Based on a pooled sample of 545 patients followed over a mean period of 27.7 ± 15.2 months, the weighted results were as follows: (a) healing rate was 87.7% (95% CI = 0.757-0.959), (b) time for healing was 7.1 ± 2.9 weeks, (c) wound infection rate was 5.6% (95% CI = 0.030-0.089), (d) wound dehiscence rate was 8% (95% CI = 0.010-0.204), (e) ulcer recurrence rate was of 10% (95% CI = 0.037-0.188), and (f) amputation rate was 2.8% (95% CI = 0.001-0.085) whilst all were minor amputations. CONCLUSION: The findings support the selection of toe/ray sparing surgery via IPA as a viable surgical option for selected cases of focal osteomyelitis secondary to diabetic foot infection. The results would indicate that when the ulcer size could be adequately reduced, removing the infected bone while preserving the soft tissue envelope could yield high chance of success with few serious complications.