Clinical outcomes in people with diabetes-related foot infections: Analysis from a limb preservation service infection database.

BACKGROUND: Diabetes-related foot infections are common and represent a significant clinical challenge. There are scant data about outcomes from large cohorts. The purpose of this study was to report clinical outcomes from a large cohort of people with diabetes-related foot infections. METHODS: A tertiary referral hospital limb preservation service database was established in 2018, and all new episodes of foot infections were captured prospectively using an electronic database (REDCap). People with foot infections between January 2018 and May 2023, for whom complete data were available on infection episodes, were included. Infection outcomes were compared between skin and soft tissue infections (SST-DFI) and osteomyelitis (OM) using chi-square tests. RESULTS: Data extraction identified 647 complete DFI episodes in 397 patients. The data set was divided into two cohorts identifying each infection episode and its severity as either SST-DFI (N = 326, 50%) or OM (N = 321, 50%). Most infection presentations were classified as being moderate (PEDIS 3 = 327, 51%), with 36% mild (PEDIS 2 = 239) and 13% severe (PEDIS 4 = 81). Infection resolution occurred in 69% (n = 449) of episodes with failure in 31% (n = 198). Infection failures were more common with OM than SST-DFI (OM = 140, 71% vs. SST-DFI = 58, 29%, p < 0.00001). In patients with SST-DFI a greater number of infection failures were observed in the presence of peripheral arterial disease (PAD) compared to the patients without PAD (failure occurred in 30% (31/103) of episodes with PAD and 12% (27/223) of episodes without PAD; p < 0.001). In contrast, the number of observed infection failures in OM episodes were similar in patients with and without PAD (failure occurred in 45% (57/128) of episodes with PAD and 55% (83/193) of episodes without PAD; p = 0.78). CONCLUSIONS: This study provides important epidemiological data on the risk of poor outcomes for DFI and factors associated with poor outcomes in an Australian setting. It highlights the association of PAD and treatment failure, reinforcing the need for early intervention to improve PAD in patients with DFI. Future randomised trials should assess the benefits of revascularisation and surgery in people with DFI and particularly those with OM where outcomes are worse.

Type 2 diabetes mediates the causal relationship between obesity and osteomyelitis: A Mendelian randomization study.

Mendelian randomization (MR) analysis was used to determine the causal relationship between Type 2 diabetes (T2D) and osteomyelitis (OM). We performed MR analysis using pooled data from different large-scale genome-wide association studies (GWAS). Instrumental variables were selected based on genome-wide significance, instrumental strength was assessed using F-values, and thresholds for the number of exposed phenotypes were further adjusted by Bonferroni correction. univariable and multivariable MR analyses were performed to assess causal effects and proportions mediated by T2D. IVW (inverse variance weighting) showed a significant genetic effect of osteomyelitis on the following: After correction by Bonferroni, univariable analyses showed that childhood body mass index (BMI) was not significantly associated with genetic susceptibility to OM [odds ratio (OR), 1.26; 95% confidence interval (CI), 1.02, 1.55; P = .030], not significantly associated with adulthood BMI (OR, 1.28; 95% CI, 1.02, 1.61; P = .034), significantly associated with waist circumference (OR, 1.84; 95% CI, 1.51, 2.24; P < .001), and significantly associated with hip circumference (OR, 1.52; 95% CI, 1.31, 1.76; P < .001). Meanwhile, multivariable analyses showed no significant effect of childhood BMI on OM (OR, 1.16; 95% CI, 0.84, 1.62; P = .370), no significant effect of adulthood BMI on OM (OR, 0.42; 95% CI, 0.21, 0.84; P = .015), a significant association between waist circumference and OM (OR, 4.30; 95% CI, 1.89, 9.82; P = .001), T2D mediated 10% (95% CI, 0.02, 0.14), and no significant association between hip circumference and OM (OR, 1.01; 95% CI, 0.54, 1.90; P = .968). Our study provides evidence for a genetically predicted causal relationship among obesity, T2D, and OM. We demonstrate that increased waist circumference is positively associated with an increased risk of OM and that T2D mediates this relationship. Clinicians should be more cautious in the perioperative management of osteomyelitis surgery in obese patients with T2D. In addition, waist circumference may be a more important criterion to emphasize and strictly control than other measures of obesity.

MRSA infection, re-infection and clinical outcomes in diabetic foot infections.

The aim was to investigate methicillin-resistant Staphylococcus aureus (MRSA) incidence, conversion and outcomes in diabetic foot infections (DFIs). This is a pooled patient-level analysis of combined data sets from two randomised clinical trials including 219 patients admitted to the hospital with moderate or severe DFIs. Intraoperative bone and tissue cultures identified bacterial pathogens. We identified pathogens at index infections and subsequent re-infections. We identified MRSA conversion (MSSA to MRSA) in re-infections. MRSA incidence in index infections was 10.5%, with no difference between soft tissue infections (STIs) and osteomyelitis (OM). MRSA conversion occurred in 7.7% of the re-infections in patients who initially had MSSA in their cultures. Patients with re-infection were 2.2 times more likely to have MRSA compared to the first infection (10.5% vs. 25.8%, relative risk [RR] = 2.2, p = 0.001). Patients with MRSA had longer antibiotic treatment during the 1-year follow-up, compared to other pathogens (other 49.8 ± 34.7 days, MRSA 65.3 ± 41.5 days, p = 0.04). Furthermore, there were no differences in healing, time to heal, length of stay, re-infection, amputation, re-ulceration, re-admission, surgery after discharge and amputation after discharge compared to other pathogens. The incidence of MRSA at the index was 10.5% with no difference in STI and OM. MRSA incidence was 25.8% in re-infections. The RR of having MRSA was 2.2 times higher in re-infections. Patients with MRSA used more antibiotics during the 1-year follow-up. Furthermore, there were no differences in clinical outcomes compared to other bacterial pathogens.

Retention of Antibiotic Cement Delivery Implants in Orthopedic Infection Associated With United Fractures Does Not Increase Recurrence Risk.

OBJECTIVES: To evaluate whether retention of antibiotic cement delivery devices after resolution of orthopaedic infection is associated with recurrence. DESIGN: Retrospective cohort. SETTING: Academic medical center. PATIENT SELECTION CRITERIA: Patients with a fracture definitively treated with internal fixation that went on to unite and develop a confirmed fracture-related infection or osteomyelitis after a remote fracture surgery and had implantation of antibiotic-impregnated cement for infection management. OUTCOME MEASURES AND COMPARISONS: Patients were divided into whom the antibiotic implants were retained (Retained Cohort) and whom the antibiotic implants were removed (Removed Cohort). Outcome measures included clinical infection resolution, infection recurrence, time to resolution of infection signs, symptoms and laboratory values, reoperation and readmission rates, and need for soft tissue coverage (local flap vs. free tissue transfer) because of recurrence. RESULTS: Of 98 patients treated for fracture-related infection in united fractures or osteomyelitis after a remote fracture surgery, 39 (39.8%) underwent implantation of antibiotic-impregnated cement delivery devices: 21 (21.4%) beads, 7 (7.1%) rods, and 11 (11.2%) blocks. Twenty patients (51.3%) comprised the Retained Cohort and 19 patients (48.7%) comprised the Removed Cohort. There were few differences in demographics ([American Society of Anesthesiology Score, P = 0.026] and [diabetes, P = 0.047]), infection location, and pathogenic profiles. The cohorts demonstrated no difference in eventual resolution of infection (100% in the Retained Cohort, 95% in the Removed Cohort, P = 0.487) and experienced similar time to clinical infection resolution, based on signs, symptoms, and laboratory values ( P = 0.360). There was no difference in incidence of subsequent infection recurrence after clinical infection resolution (1 recurrence Retained vs. 2 recurrences Removed, P = 0.605) for those considered "cured." Compared with the Retained Cohort, the Removed Cohort underwent more reoperations (0.40 vs. 1.84 reoperations, P < 0.001) and admissions after implantation ( P < 0.001). CONCLUSIONS: Retention of antibiotic-impregnated cement delivery devices in patients with orthopaedic infection after fractured bones that have healed was not associated with infection recurrence. Additional surgical intervention with the sole purpose of removing antibiotic delivery devices may not be warranted. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Prevalence of radiographic findings in chronic osteomyelitis.

BACKGROUND: Simple radiography in conjunction with pertinent medical history and a comprehensive physical examination is typically adequate for diagnosing chronic osteomyelitis (CO). However, radiographic manifestations of CO lack specificity; therefore, the concordance among specialists in this regard has not been systematically assessed. This study aimed to compare and evaluate the proficiency of orthopedic surgeons and radiologists in identifying radiographic indicators present in simple radiographs for diagnosing CO. METHODS: This cross-sectional study was a correlational investigation utilizing plain radiographs obtained from a cohort of 60 patients diagnosed with CO. Comprehensive assessments of the demographic and clinical characteristics, comorbidities, and microbiological parameters were conducted. Additional variables included the anatomical location of the CO, existence of fistulas, disease duration, and presence of pseudoarthrosis. This study meticulously documented the presence or absence of six specific findings: bone destruction, which incorporates erosion and radiolucencies around implants; bone sclerosis; cortical thinning concomitant with erosion; cortical thickening; sequestrum formation; and soft-tissue swelling. RESULTS: Most patients were men (75%), with a mean age of 45.1 years. Hematogenous etiology of CO represented 23%. Bone sclerosis (71.3%) and cortical thickening (67.7%) were the most common radiographic findings, followed by soft-tissue swelling (51.3%), sequestration (47.3%), bone destruction (33.3%), and cortical erosion (30.3%). The mean agreement was 74.2%, showing a marked disagreement rate of 25.8% among all radiographic findings. The presence or absence of soft tissue edema, a prominent radiographic finding that was more important than the other findings, showed the greatest disagreement. CONCLUSIONS: Radiographic findings in CO were universally observed in all patients, demonstrating a high degree of concordance among specialists, with the exception of soft tissue swelling.

Treatment Effect of Zoledronic Acid in Chronic Non-bacterial Osteomyelitis of the Jaw: A Case Series.

Chronic non-bacterial osteomyelitis (CNO) is an autoinflammatory, osteolytic bone disorder sometimes localized to a unifocal site in the jaw, causing long-term pain and reduced function. The aim of this study was to describe the patients with CNO of the jaw, focusing on treatment with zoledronic acid for pain relief. An analysis of medical records of 24 patients with CNO of the jaw, including treatment with zoledronic acid and effects on pain relief. Descriptive statistics and nonparametric tests were used to describe the population and compare treatment effects, respectively. The average treatment period was 33.4 months (median 23; Q1 11.5; Q3 42.0) with an average of 4.1 infusions (median 3; Q1 2; Q3 5) of zoledronic acid. The average pain VAS score (visual analogue scale) was significantly reduced from 7.7 (median 8; Q1 6.5; Q3 8.5) to 2.5 points (median 2; Q1 0.5; Q3 4.5) (p < 0.001). At final visit, 46% of patients reported no pain and 38% reported a reduction of pain. At least 67% of patients had at least one episode of pain recurrence, and most patients experienced the first recurrence within a year of initial treatment. Four patients (16%) had no pain relief from the treatment. In this group of patients with CNO of the jaw, there was a positive response to treatment with zoledronic acid on pain relief, averaging 5.2 points on a pain VAS score, with 84% of patients treated experiencing either a partial or a total reduction in pain after about 2.5 years.

Risk Factors and Outcomes of Hematogenous Vertebral Osteomyelitis in Patients With Staphylococcus aureus Bacteremia.

BACKGROUND: Hematogenous vertebral osteomyelitis (HVOM) is an incompletely understood complication of Staphylococcus aureus bacteremia (SAB). METHODS: Eligible SAB patients with and without HVOM were prospectively enrolled from 1995 through 2019 at Duke University Health System. HVOM was diagnosed either radiographically or microbiologically. Multivariable logistic regression analysis was performed to identify clinical and microbial factors associated with HVOM risk. All bloodstream S. aureus isolates were genotyped using spa typing. RESULTS: Of 3165 cases of SAB, 127 (4.0%) developed HVOM. Patients who experienced HVOM were more likely to have community-acquired SAB (30.7% vs 16.7%, P < .001), have a longer time to diagnosis of SAB (median, 5 days; interquartile range [IQR], 2-10.5 vs median, 2 days; IQR, 0-4; P < .001), and to exhibit persistent bacteremia (48.8% vs 20.6%, P < .001). A significant number of HVOM patients developed infective endocarditis (26% vs 15.2%, P = .002). Overall, 26.2% (n = 33) of SAB patients with HVOM underwent surgical intervention. Methicillin resistance (46.6% vs 41.7%, P = .318) and bacterial genotype were not associated with the development of HVOM. At the 12-month follow-up, 22% of patients with HVOM had died. Of the surviving patients, 20.4% remained on antibiotic therapy, and 29.6% had recurrence of either HVOM or SAB. CONCLUSIONS: Among patients with SAB, HVOM risk was associated with clinical factors and not bacterial genotype. Despite being a rare complication of SAB, patients with HVOM had high all-cause mortality rates and healthcare resource requirements up to 1 year after their HVOM diagnosis. Close clinical monitoring is indicated in this vulnerable population.

Risk factors of deep vein thrombosis in children with osteomyelitis.

OBJECTIVE: To investigate the risk factors for deep vein thrombosis (DVT) in children with osteomyelitis and provide diagnostic and treatment strategies for the prevention, early detection and treatment of DVT. STUDY DESIGN: The clinical data of nine children diagnosed with osteomyelitis and DVT between July 2012 and March 2021 were collected at our hospital, including age, sex, clinical manifestations, body temperature, coagulation function and other data, as well as the clinical data of 27 children diagnosed with osteomyelitis without DVT during the same period. Thirty-six children were divided into thrombus and thrombus-free groups. The clinical characteristics and risk factors for DVT in children with osteomyelitis were analysed. RESULTS: Among the 36 children in this study, nine cases of thrombus formation mainly occurred in the femoral vein, popliteal vein and iliac vein, all near the infection site. The main clinical manifestations were lower extremity pain, swelling and pulmonary embolism in three cases. Among them, intensive care unit (ICU) admission, sepsis, higher D-dimer, higher body temperature during hospitalization, and pathogen culture showed that methicillin-resistant Staphylococcus aureus (MRSA) was associated with DVT. MRSA was the independent risk factor for DVT. CONCLUSIONS: Admission to ICU, sepsis, higher D-dimer, higher body temperature during hospitalization, and MRSA are risk factors for thrombosis. MRSA is the independent risk factor for DVT. For patients with related risk factors, timely ultrasound examination of the infected site should be considered to achieve early detection and treatment.

Characterization of an Emerging Enterococcus cecorum Outbreak Causing Severe Systemic Disease with Concurrent Leg Problems in a Broiler Integrator in the Southern United States.

Enterococcus cecorum has been associated mainly with osteomyelitis of the free thoracic vertebra in chickens. However, there are reports of E. cecorum producing septicemic lesions and having tropism for cartilages, resulting in the presentation of femoral head necrosis and synovitis. This paper discusses the presentation of E. cecorum as it relates to an outbreak in one vertical integrator where the main lesions were related to septicemia. Using a convenience sampling method, 100 broiler chicken cases received at the Poultry Research and Diagnostic Laboratory of Mississippi State University from April to December of 2021 were analyzed. The peak in cases was observed from June to August. The average age of broilers was 21 days with a range of 15-31 days. Most of these cases were related to systemic disease and leg problems, with gross lesions including characteristic pericarditis along with perihepatitis, osteomyelitis, and arthritis. In six of the 100 cases, E cecorum was isolated from the free thoracic vertebra, with the remaining being recovered from various other locations including liver, pericardium, hock/joint, femoral head, and bone marrow. Enterococcus cecorum identification was performed by using Vitek matrix-assisted laser desorption/ionization time-of-flight mass spectrometry. These results were then sent to the research-use only SARAMIS database for analysis. Once the spectra of the isolates were imported, the relative and absolute taxonomy were analyzed. Two super spectrums and three clusters by homology were identified. The minimal inhibitory concentrations obtained by antimicrobial sensitivity tests were analyzed using WHONET Microbiology Laboratory Database Software. No isolates were pan-susceptible, 80% of isolates were noted to be resistant to ≥3 classes of antibiotics and, in general, isolates exhibited a high degree of variability when examining antimicrobial resistance patterns.

Reporte de caso- Caracterización de un brote reciente de Enterococcus cecorum causante de una enfermedad sistémica grave simultáneamente con problemas en las patas en un integrador de pollo de engorde en el sur de los Estados Unidos. La bacteria Enterococcus cecorum se ha asociado principalmente con osteomielitis de la vértebra torácica móvil de los pollos. Sin embargo, existen reportes de E. cecorum produciendo lesiones septicémicas y presentando tropismo por los cartílagos, resultando en la presentación de necrosis de la cabeza femoral y sinovitis. Este artículo analiza la presentación de E. cecorum relacionada con un brote en un integrador vertical donde las principales lesiones estaban relacionadas con septicemia. Utilizando un método de muestreo de conveniencia, se analizaron 100 casos de pollos de engorde recibidos en el Laboratorio de Investigación y Diagnóstico Avícolas de la Universidad Estatal de Mississippi de abril a diciembre del 2021. El mayor número de casos se observó de junio a agosto. La edad promedio de los pollos de engorde fue de 21 días con un rango de 15 a 31 días. La mayoría de estos casos estaban relacionados con enfermedad sistémica y problemas en las patas, con lesiones macroscópicas que incluían pericarditis característica junto con perihepatitis, osteomielitis y artritis. En seis de los 100 casos, E cecorum se aisló de la vértebra torácica móvil, y el resto de los casos se recuperó de otros lugares, incluyendo el hígado, el pericardio, articulación del corvejón, la cabeza femoral y la médula ósea. La identificación de E. cecorum se realizó utilizando la plataforma Vitek de espectrometría de masas MALDI-TOF. Posteriormente, estos resultados se enviaron a la base de datos SARAMIS de uso exclusivo para investigación para su análisis. Una vez importados los espectros de los aislados, se analizó la taxonomía relativa y absoluta. Se identificaron dos superespectros y tres grupos mediante homología. Las concentraciones inhibitorias mínimas obtenidas mediante pruebas de sensibilidad antimicrobiana se analizaron utilizando el software de base de datos de laboratorio de microbiología de WHONET. Ningún aislamiento fue pan-susceptible, se observó que el 80% de los aislamientos eran resistentes a tres o más clases de antibióticos y en general, los aislamientos exhibieron un alto grado de variabilidad al examinar los patrones de resistencia a los antimicrobianos.

Risk factors associated with pressure ulcer recurrence after reconstruction: Analysis of a national database.

In this study, we sought to clarify the patient traits and comorbidities that are associated with pressure injury recurrence following pressure injury reconstruction. An insurance claims database, PearlDiver, was used to conduct a retrospective cohort study. The two cohorts included patients who underwent pressure injury reconstruction without recurrence and patients who experienced recurrence with subsequent reconstruction. Multiple logistic regression analysis was used to identify risk factors for recurrence after reconstruction. Recurrence was associated with hypoalbuminemia (p < 0.05), paraplegia (p < 0.05), and osteomyelitis (p < 0.05). In patients with osteomyelitis, primary closure was associated with recurrence (p < 0.05) while flap reconstruction was not (p > 0.05). Osteomyelitis was not associated with recurrence after flap reconstruction. Prior to reconstruction, patients with osteomyelitis and hypoalbuminemia should have their nutrition and infection optimised.

Update on treatment responses and outcome measure development in chronic nonbacterial osteomyelitis.

PURPOSE OF REVIEW: To review recent trends in treatment and recent progress in developing outcome measures needed for chronic nonbacterial osteomyelitis (CNO) clinical trials. RECENT FINDINGS: CNO is an autoinflammatory bone disease. In a minority of patients, the disease is genetically driven, and diagnosis can be made by DNA sequencing. However, for nonsyndromic CNO there is no diagnostic test. The number of children with CNO appears to be increasing and damage is common. Increases in CNO diagnosis is due to raised awareness, increased availability of whole-body magnetic resonance imaging and rising incidence. Treatment remains empiric and it is unclear which second line treatment is superior. Tumor necrosis factor inhibitors (TNFi) and bisphosphonates continue to be used as second line agents for nonsteroidal anti-inflammatory drugs (NSAID) refractory CNO; newer immune modulatory medications are used if this fails. Validated classification criteria, clinical outcome measures and imaging scoring standards are needed for successful clinical trials. SUMMARY: Best treatment for NSAID refractory CNO remains unclear. Classification criteria, clinical outcomes measures and standardized imaging scoring have been developed or are near completion. This will facilitate robust clinical trials in CNO with the goal of having approved medications for this painful disease.

The bacteriology of diabetic foot ulcers and infections and incidence of Staphylococcus aureus Small Colony Variants.

Introduction. Uninfected diabetes-related foot ulcer (DFU) progression to diabetes-related foot infection (DFI) is a prevalent complication for patients with diabetes. DFI often progresses to osteomyelitis (DFI-OM). Active (growing) Staphylococcus aureus is the most common pathogen in these infections. There is relapse in 40-60 % of cases even when the initial treatment at the DFI stage apparently clears infection.Hypothesis. S. aureus adopts the quasi-dormant Small Colony Variant (SCV) state during DFU and consequently infection, and when present in DFI cases also permits survival in non-diseased tissues as a reservoir to cause relapse.Aim. The aim of this study was to investigate the bacterial factors that facilitate persistent infections.Methodology. People with diabetes were recruited from two tertiary hospitals. Clinical and bacterial data was taken from 153 patients with diabetes (51 from a control group with no ulcer or infection) and samples taken from 102 patients with foot complications to identify bacterial species and their variant colony types, and then compare the bacterial composition in those with uninfected DFU, DFI and those with DFI-OM, of whom samples were taken both from wounds (DFI-OM/W) and bone (DFI-OM/B). Intracellular, extracellular and proximal 'healthy' bone were examined.Results. S. aureus was identified as the most prevalent pathogen in diabetes-related foot pathologies (25 % of all samples). For patients where disease progressed from DFU to DFI-OM, S. aureus was isolated as a diversity of colony types, with increasing numbers of SCVs present. Intracellular (bone) SCVs were found, and even within uninfected bone SCVs were present. Wounds of 24 % of patients with uninfected DFU contained active S. aureus. All patients with a DFI with a wound but not bone infection had previously had S. aureus isolated from an infection (including amputation), representing a relapse.Conclusion. The presence of S. aureus SCVs in recalcitrant pathologies highlights their importance in persistent infections through the colonization of reservoirs, such as bone. The survival of these cells in intracellular bone is an important clinical finding supporting in vitro data. Also, there seems to be a link between the genetics of S. aureus found in deeper infections compared to those only found in DFU.

Antibiotic Duration Following Abdominal Gunshot Injuries With Associated Pelvis or Spine Involvement: A 20-Year Single-Center Experience.

INTRODUCTION: Optimal antimicrobial prophylaxis duration following gunshot wounds (GSW) to the abdomen with an associated orthopedic fracture is unknown. This study evaluated the safety and efficacy of short versus long courses of prophylactic antibiotics following penetrating hollow viscus injury with communicating orthopedic fracture. METHODS: This retrospective study included adult patients admitted to the trauma service over a 20-y period who sustained an abdominal GSW with hollow viscus injury and communicating spine or pelvic fractures. Patients were stratified into cohorts based on prophylactic antibiotic duration: short course (SC, ≤48 h) and long course (>48 h). The primary outcome was the incidence of osteomyelitis and meningitis up to 1-y postinjury. Secondary outcomes included hospital length of stay and the incidence of multidrug-resistant organisms and Clostridioides difficile infections. Risk factors for osteomyelitis and meningitis were determined. RESULTS: A total of 125 patients were included with 45 (36%) in the SC group. Median prophylactic antibiotic durations were SC, 1 (interquartile range [IQR], 1-2) versus long course, 7 (IQR, 5-7) d (P < 0.001). There was no difference in osteomyelitis and meningitis incidence (2 [4.4%] versus 4 [5%], P = 0.77). Median hospital length of stay (7 [IQR, 6-11] versus 9 [IQR, 6-15] d, P = 0.072) and incidence of multidrug-resistant organisms (6 [13.3%] versus 13 [16.3%], P = 0.86) and Clostridioides difficile infections (0 [0%] versus 1 [1.3%], P = 0.77) were similar between groups. There were no independent risk factors identified for osteomyelitis or meningitis. CONCLUSIONS: A shorter course of antibiotic prophylaxis ≤48 h may be adequate following abdominal GSW that traverses a hollow viscus and results in pelvic fracture or spinal column injury.

An Update on Pediatric Acute Hematogenous Osteomyelitis in New Zealand - A Decade on.

INTRODUCTION: New Zealand (NZ) has high rates of pediatric acute hematogenous osteomyelitis (AHO) with males and children of Pasifika and Maori ethnicity overrepresented. AIMS: To update the incidence of Pediatric AHO over 10 years, identifying trends in presentation, organisms, treatment, and outcomes. METHODS: A 10-year retrospective review of children aged 6 weeks to 15 years admitted with Pediatric AHO across two centers from 2008 to 2017. Demographic data, features of presentation, investigations, management, and complications were collected. Incidence was calculated from census data. Data were compared with our osteomyelitis database from the previous decade. (1). RESULTS: 796 cases were identified. The incidence was 18 per 100,000 per annum. The average age was 7.7 years. Pasifika and Maori children are overrepresented (57%). 370 children (51%) came from low socioeconomic areas. Methicillin-sensitive Staphylococcus aureus was the most common pathogen (87%). Methicillin-resistant Staphylococcus aureus (MRSA) rates are low (4.4%). Forty-four (5.5%) children were admitted to the Pediatric Intensive Care Unit (PICU) with 9% mortality. The mean duration of antibiotics was 40 days. 325 children (41%) had surgery. Chronic infection has increased from 1.7% to 5.7%. CONCLUSIONS: NZ has high rates of AHO, however, the incidence has decreased from the previous decade. Males, those in low socioeconomic areas, Pasifika and Maori have high disease burden. The use of MRI as a diagnostic modality has increased. Future studies should focus on improving treatment via prospective analysis and reporting long-term morbidity to improve outcomes for children with severe disease and reduce rates of chronic infection.

Epidemiological updates of post-traumatic related limb osteomyelitis in china: a 10 years multicentre cohort study.

BACKGROUND: Post-traumatic related limb osteomyelitis (PTRLO) is a complex bone infection. Currently, there are no available microbial data on a national scale that can guide appropriate antibiotic selection, and explore the dynamic changes in dominant pathogens over time. This study aimed to conduct a comprehensive epidemiological analysis of PTRLO in China. METHODS: The study was approved by the Institutional Research Board (IRB), and 3526 PTRLO patients were identified from 212 394 traumatic limb fracture patients at 21 hospitals between 1 January 2008 and 31 December 2017. A retrospective analysis was conducted to investigate the epidemiology of PTRLO, including changes in infection rate (IR), pathogens, infection risk factors and antibiotic resistance and sensitivity. RESULTS: The IR of PTRLO increased gradually from 0.93 to 2.16% (Z=14.392, P <0.001). Monomicrobial infection (82.6%) was significantly higher than polymicrobial infection (17.4%) ( P <0.001). The IR of Gram-positive (GP) and Gram-negative (GN) pathogens showed a significant increase from the lowest 0.41% to the highest 1.15% (GP) or 1.62% (GN), respectively. However, the longitudinal trend of GP vs. GN's composition did not show any significance (Z=±1.1918, P >0.05). The most prevalent GP strains were Methicillin-sensitive Staphylococcus aureus (MSSA) (17.03%), Methicillin-resistant Staphylococcus aureus (MRSA) (10.46%), E. faecalis (5.19%) and S. epidermidis (4.87%). In contrast, the dominant strains GN strains were Pseudomonas Aeruginosa (10.92%), E. cloacae (10.34%), E. coli (9.47%), Acinetobacter Baumannii (7.92%) and Klebsiella Pneumoniae (3.33%). In general, the high-risk factors for polymicrobial infection include opened-fracture (odds ratio, 2.223), hypoproteinemia (odds ratio, 2.328), and multiple fractures (odds ratio, 1.465). It is important to note that the antibiotics resistance and sensitivity analysis of the pathogens may be influenced by complications or comorbidities. CONCLUSIONS: This study provides the latest data of PTRLO in China and offers trustworthy guidelines for clinical practice. (China Clinical Trials.gov number, ChiCTR1800017597).

Clinical Spectrum and Microbial Etiology of Bone and Joint Infections in Children: A Retrospective Analysis from South India.

Acute infections of bone and joints are medical emergencies. Early diagnosis and treatment are essential for limb salvage and prevention of deformities. Data from developing countries are essential to develop region-specific treatment guidelines including choice of empiric antibiotics. We reviewed electronic medical records of children (≤ 12 years old) admitted to the pediatrics or orthopedics department of a tertiary care hospital in South India from 2013 to 2017 with a diagnosis of septic arthritis and/or osteomyelitis. Clinical, microbiological, and follow-up data were collected and analyzed. The median (interquartile range, IQR) age of the children (N = 207) was 48 (7.5-105) months. Acute infections were more common in infants, whereas chronic cases were common in children > 5 years of age. Staphylococcus aureus (71%) was the most common organism identified. Gram-negative organisms were more frequently isolated in infants compared with older children. Blood and/or wound culture positivity was 78% (N = 161) overall and 78% (N = 31) in chronic cases. The median (IQR) duration of antibiotics was 7 (5-8) weeks. Sequelae and readmissions occurred in 47% (N = 81) of the 172 patients followed for a year. Culture positivity rates especially of wound were high even after receiving antibiotics.

Racial and Ethnic Differences in Length of Stay for US Children Hospitalized for Acute Osteomyelitis.

OBJECTIVE: To examine the associations between race and ethnicity and length of stay (LOS) for US children with acute osteomyelitis. STUDY DESIGN: Using the Kids' Inpatient Database, we conducted a cross-sectional study of children <21 years old hospitalized in 2016 or 2019 with acute osteomyelitis. Using survey-weighted negative binomial regression, we modeled LOS by race and ethnicity, adjusting for clinical and hospital characteristics and socioeconomic status. Secondary outcomes included prolonged LOS, defined as LOS of >7 days (equivalent to LOS in the highest quartile). RESULTS: We identified 2388 children discharged with acute osteomyelitis. The median LOS was 5 days (IQR, 3-7). Compared with White children, children of Black race (adjusted incidence rate ratio [aIRR] 1.15; 95% CI, 1.05-1.27), Hispanic ethnicity (aIRR 1.11; 95% CI, 1.02-1.21), and other race and ethnicity (aIRR 1.12; 95% CI, 1.01-1.23) had a significantly longer LOS. The odds of Black children experiencing prolonged LOS was 46% higher compared with White children (aOR, 1.46; 95% CI, 1.01-2.11). CONCLUSIONS: Children of Black race, Hispanic ethnicity, and other race and ethnicity with acute osteomyelitis experienced longer LOS than White children. Elucidating the mechanisms underlying these race- and ethnicity-based differences, including social drivers such as access to care, structural racism, and bias in provision of inpatient care, may improve management and outcomes for children with acute osteomyelitis.

Effect of diabetic foot ulcers and other risk factors on the prevalence of lower extremity amputation: A meta-analysis.

A meta-analysis study was conducted to measure the consequence of diabetic foot ulcers (DFUs) and other risk factors (RFs) on the prevalence of lower extremity amputation (LEA). A comprehensive literature inspection till February 2023 was applied and 2765 interrelated studies were reviewed. Of the 32 chosen studies enclosed, 9934 subjects were in the chosen studies' starting point, and 2906 of them were with LEA. Odds ratio (OR) in addition to 95% confidence intervals (CIs) were used to compute the value of the effect of DFUs and other RFs on the prevalence of LEA by the continuous and dichotomous approaches and a fixed or random effect model. Male gender (OR, 1.30; 95% CI, 1.17-1.44, P < .001), smoking (OR, 1.24; 95% CI, 1.01-1.53, P = .04), previous foot ulcer (OR, 2.69; 95% CI, 1.93-3.74, P < .001), osteomyelitis (OR, 3.87; 95% CI, 2.28-6.57, P < .001), gangrene (OR, 14.45; 95% CI, 7.03-29.72, P < .001), hypertension (OR, 1.17; 95% CI, 1.03-1.33, P = .01), and white blood cells count (WBCC) (MD, 2.05; 95% CI, 1.37-2.74, P < .001) were significantly shown to be an RF in LEA in subjects with DFUs. Age (MD, 0.81; 95% CI, -0.75 to 2.37, P = .31), body mass index (MD, -0.55; 95% CI, -1.15 to 0.05, P = .07), diabetes mellitus type (OR, 0.99; 95% CI, 0.63-1.56, P = .96), and glycated haemoglobin (MD, 0.33; 95% CI, -0.15 to 0.81, P = .17) were not shown to be an RF in LEA in subjects with DFUs. Male gender, smoking, previous foot ulcer, osteomyelitis, gangrene, hypertension, and WBCC were significantly shown to be an RF in LEA in subjects with DFUs. However, age and diabetes mellitus type were not shown to be RF in LEA in subjects with DFUs. However, caused of the small sample sizes of several chosen studies for this meta-analysis, care must be exercised when dealing with its values.

Ten-year Review of Acute Pediatric Hematogenous Osteomyelitis at a New Zealand Tertiary Referral Center.

BACKGROUND: Acute hematogenous osteomyelitis (AHO) remains a cause of severe illness among children with the possibility of long-term consequences for growth and development. Recent research has highlighted an unusually high burden of disease in the New Zealand population compared with other Western regions. We have sought to identify trends in presentation, diagnosis, and management of AHO, with added focus on ethnicity and access to health care. METHODS: A 10-year retrospective review of all patients <16 years with presumed AHO presenting to a tertiary referral center between 2008 and 2018 was performed. RESULTS: One hundred fifty-one cases met inclusion criteria. The median age was 8 years with a male predominance (69.5%). Staphylococcus aureus was the most common pathogen using traditional laboratory culture method (84%). The number of cases per year decreased from 2008 to 2018. Assessment using New Zealand deprivation scores showed Maori children were most likely to experience socioeconomic hardship ( P ≤0.01). Median distance traveled by families to first hospital consult was 26 km (range 1 to 178 km). Delayed presentation was associated with need for prolonged antibiotic therapy. Incidence of disease varied by ethnicity with 1:9000 cases per year for New Zealand European, 1:6500 for Pacific, and 1:4000 for Maori. Overall recurrence rate was 11%. CONCLUSIONS: The incidence of AHO in New Zealand is concerningly high within Maori and Pacific populations. Future health interventions should consider environmental, socioeconomic, and microbiological trends in the burden of disease. LEVEL OF EVIDENCE: Retrospective study, Level III.