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.

Diabetic Foot Infections in the Emergency Department.

Diabetic foot infection (DFI) is among the most common diabetic complications requiring hospitalization. Prompt emergency department diagnosis and evidence-based management can prevent eventual amputation and associated disability and mortality. Underlying neuropathy, arterial occlusion, immune dysfunction, and hyperglycemia-associated dehydration and ketoacidosis can all contribute to severity and conspire to make DFI diagnosis and management difficult. Serious complications include osteomyelitis, necrotizing infection, and sepsis. Practice guidelines are designed to assist frontline providers with correct diagnosis, categorization, and treatment decisions. Management generally includes a careful lower extremity examination and plain x-ray, obtaining appropriate tissue cultures, and evidence-based antibiotic selection tailored to severity.

Early outcomes and complications of surgically treated diabetic hallucal infection.

OBJECTIVE: Severely infected diabetic ulcers of the big toe often necessitate surgical treatment. Depending on the wound stage and presence of osteomyelitis, conservative surgery and amputation are the main surgical treatments. Few articles reported the outcomes and complications of such procedures. This study is a preliminary comparative report on the early outcomes and complications of hallucal DFI treated with either conservative surgery or amputation. SETTING AND DESIGN: This is a retrospective comparative study comprising a continuous series of patients admitted at our hospital. Initially, all DFU were infected and at advanced stage (Wagner Grade 3 or 4). All clinically suspected cases of osteomyelitis were confirmed by bone pathology and microbiology culture. METHODS: The study included 37 patients diagnosed with DFI. Infection profile was as follows: 23 DFU with osteomyelitis (Wagner Grade 3 or 4) and 14 infected DFU (Wagner Grade 2). Twenty-four conservative procedures and 13 amputation surgeries were performed initially. The primary outcome was defined as the frequency of subsequent surgery (deep infection recurrence treated with surgery). Statistical analysis was used to look for significant difference between both groups. RESULTS: Ten patients (27%) required additional surgeries because of deep infection recurrence. Four recurrences (16.7%) were observed in the conservative group and 6 (46%) in the amputation group (p = 0.054). Amputation rate as a subsequent procedure was 8.3% for the conservative group and the re-amputation rate for the amputation group was 23.1% (p = 0.2). CONCLUSION: The study findings would indicate that the more severe is the initial hallucal infection severity (higher Wagner grade), the higher is the frequency of early surgical complications mainly after an index amputation procedure. Our assessment tools of initial infection extent seems to be underperforming. A more aggressive treatment in the form of a more proximal cut with regard to MRI bone infection signal could be considered to minimize the risk of subsequent surgeries and re-amputations.

Diagnostic Performance of Atherogenic Index of Plasma for Predicting Diabetic Foot Osteomyelitis with Peripheral Artery Disease.

Background: This study aims to assess the atherogenic index of plasma (AIP) diagnostic value in detecting diabetic foot osteomyelitis (DFO) among patients with diabetic foot ulcers (DFUs). Methods: A prospective cohort study was conducted on 80 patients with DFUs and suspected DFO between January 2022 and December 2023. The primary outcome measures included the diagnosis of DFO, determined by positive microbiological analysis results from bone samples and its correlation with the AIP. Receiver operating characteristic (ROC) curves were utilized to select the optimal diagnostic cut-off points for AIP and post hoc analysis was performed to evaluate the difference in the AIP for diagnosing DFO in patients with and without peripheral arterial disease (PAD). Results: The diagnostic potential for DFO in PAD patients of AIP-1 (Log TC/HDL) showed an AUC of 0.914 (p < 0.001 [0.832-0.996]), leading to a sensitivity of 83% and a specificity of 85%. By contrast, AIP-2 (Log TG/HDL) demonstrated a slightly lower AUC of 0.841 (p < 0.001 [0.716-0.967]), leading to a sensitivity of 76% and a specificity of 74%. Conclusions: The AIP tool, with its ideal blend of sensitivity and specificity, aids in predicting DFO effectively. Therefore, clinicians should consider using AIP for patients suffering from PAD and associated DFO.

Peripheral Blood Eosinophilia in Patients with Diabetic Foot Infection Receiving Long-Term Antibiotic Therapy.

Background: The eosinophil level in peripheral blood increases in response to various conditions, the most common being medication use. Since the outcome of increased levels of eosinophils can range from a benign finding to extensive damage to host organs and systemic consequences, this finding raises concern among clinicians. We aimed to assess the prevalence of prolonged antibiotic-therapy-induced eosinophilia and possible outcomes. Methods: We conducted a retrospective cohort study of diabetic patients admitted to the orthopedic department from December 2016 through December 2020 due to a moderate to severe diabetic foot infection and who received at least 14 days of antibiotic therapy. Patients were identified retrospectively through the orthopedic department registry, and their files were reviewed, extracting demographics, laboratory test results, antibiotic treatment, and outcomes. Results: The cohort included 347 patients; a total of 114 (32.8%) developed eosinophilia during the follow-up period. Patients who developed eosinophilia had a significantly longer duration of antibiotic treatment (p < 0.001) and a significantly longer hospitalization (p = 0.001). For multivariable analysis, the independent risk factors predicting drug-induced eosinophilia included older age, higher eosinophil count on admission (per quantile) and higher platelet count on admission (per quantile) (p = 0.012, p < 0.001, p = 0.009, respectively). There was no evidence of complications in patients who developed eosinophilia compared to patients who did not. No significant association with a specific type of antibiotic was found. Conclusions: We found a higher incidence of drug-induced eosinophilia than expected or previously described. The factors associated with eosinophilia included age and higher baseline eosinophil and platelet levels but not antibiotic type.

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.

Vasculitis and infectious risk in a patient with type 2 diabetes mellitus: A case report.

The connection between vasculitis and infection is complex. The present study described a typical situation for a patient with unbalanced type 2 diabetes and chronic complications, in which a lack of adherence to the protection and care measures ultimately led to the appearance of some of the worst consequences of the condition, namely, ulceration, gangrene and amputation. In the context of an unstable condition with significant metabolic imbalance there was an impaired response to infections in the present patient, and the amputation resulted in wound persistence and ulcer development, followed by superinfection with methicillin-resistant Staphylococcus aureus according to the antibiogram performed. In this case, an episode of vasculitis was triggered without evidence of bacteraemia. The present case report highlighted the importance of proper hygiene and good metabolic control in patients with diabetes that suffer from amputations and conditions that expose them to certain complications, including vasculitis.

BedBiopsy: Diagnostic performance of bedside ultrasound-guided bone biopsies for the management of diabetic foot infection.

OBJECTIVE: We aimed to assess the feasibility and diagnostic performance of ultrasound-guided bone biopsies at the bedside of diabetic patients admitted for suspected foot osteitis not requiring surgery. RESEARCH DESIGN AND METHODS: In this retrospective monocentric study, we compared the performance of ultrasound-guided (n = 29 consecutive patients, Dec.2020-Oct.2022) versus surgical (n = 24 consecutive patients, Jan.2018-Nov.2020) bone biopsies at confirming or ruling out diabetic foot osteitis (primary outcome). RESULTS: Patient characteristics were similar in the two intervention groups, including arteritis prevalence (62.3 %), SINBAD score, and wound location (phalanges 36 %, metatarsus 43 %, and calcaneus 21 %). However, the ultrasound-guided group was older (67 ± 11 versus 60 ± 13 years respectively, P = 0.047) and had more type 2 diabetes (97 % versus 75 %, P = 0.038). Diagnostic performance (i.e., capacity to confirm or rule out suspected osteitis) was similar for ultrasound-guided (28/29 cases: 25 confirmations, 3 invalidations) and surgical (24 confirmations/24) biopsies, P = 0.358. No biopsy-related side effect or complication was observed for either intervention, even for patients on antiaggregation and/or anticoagulation therapy. The mean (± standard deviation) time necessary to perform the biopsy was shorter in the ultrasound-guided group (2.6 ± 3.0 versus 7.2 ± 5.8 days, respectively, P < 0.001) and wound evolution at three months was more favorable (83.3 versus 41.2 %, P = 0.005) (94.4 % versus 66.7 %, respectively, patients with new surgical procedure within six months excluded; P = 0.055). Even though not statistically significant, healing rates in terms of wound and osteitis at six months were also better in the ultrasound-guided group (wound: 40.9 % versus 36.8 %; P = 0.790, and osteitis: 81.8 vs 55.6 % P = 0.071). CONCLUSION: In diabetic patients with suspected foot osteitis not requiring surgery, bedside ultrasound-guided bone biopsies may constitute a promising alternative to surgical biopsies. This intervention provided excellent tolerance and microbiological documentation, short lead-times, and more favorable wound prognosis.

An Atypical Manifestation of Necrotizing Fasciitis in a Patient With Type II Diabetes.

In this case report, we discuss a 32-year-old diabetic male patient who presented with right foot pain three days following a spider bite. The foot progressively became swollen, preventing the patient from bearing weight on it. After admission to the emergency department, the examination showed discoloration of the dorsum of the proximal phalanx of the first toe with an open wound and pus. The patient received fluid resuscitation along with a course of metronidazole and levofloxacin. Subsequently, the patient was referred to an orthopedic and podiatric team where he underwent a complete foot fasciotomy. The procedure was successful, and the patient recovered well. This case showcases a rare manifestation of necrotizing fasciitis (NF) and highlights the importance of future research regarding NF and its association with diabetes mellitus.

Validation of spectrophotometric and colorimetric methods to quantify clindamycin in skin tissue: application to in vitro release and ex vivo dermatokinetic studies from separable effervescent microarray patch loaded bacterially sensitive microparticle.

Diabetes mellitus can cause diabetic foot infection (DFI) complications. DFI is generally caused by infection from bacteria and Methicillin-Resistant Staphylococcus aureus (MRSA) which is resistant to several antibiotics. Application therapy of clindamycin (CLY) administration with the oral route has low bioavailability and non-selective distribution of antibiotics towards bacteria intravenously. In this research, CLY was developed into bacterially sensitive microparticles (MPs) which were further incorporated into a separable effervescent microarray patch (SEMAP) system to increase the selective and responsive to DFI-causing bacteria of CLY. To support this formulation, we explore the potential of silver nanoparticles (AgNPs) towards the UV-Vis spectrophotometry method. The analytical method was validated in phosphate-buffered saline (PBS), tryptic soy broth (TSB), and skin tissue to quantify CLY, CLY loaded in microparticle, and SEMAP system. The developed analytical method was suitable for the acceptance criteria of ICH guidelines. The results showed that the correlation coefficients were linear ≥ 0.999. The values of LLOQ towards PBS, TSB, and skin tissue were 2.02 µg/mL, 4.29 µg/mL, and 2.31 µg/mL, respectively. These approaching methods were also found to be accurate and precise without being affected by dilution integrity. The presence of Staphylococcus aureus bacteria culture can produce lipase enzymes that can lysing the microparticle matrix. Drug release studies showed that bacterial infection in the high drug release microparticle sensitive bacteria and high drug retention in ex vivo dermatokinetic in rat skin tissue media. In addition, in vivo studies were required to quantify the CLY inside in further analytical validation methods.

Epalrestat is effective in treating diabetic foot infection and can lower serum inflammatory factors in patients.

This study was designed to determine the efficacy of epalrestat on patients with diabetic foot infection (DFI) and its effects on serum inflammatory factors in the patients. METHODS: The data of 80 patients with DFI treated in the First Affiliated Hospital of Jiangxi Medical College from May 2020 to May 2022 were analyzed retrospectively. Among them, patients who received routine comprehensive treatment were enrolled into the control group (n=37), and those who received epalrestat on the basis of routine comprehensive treatment were enrolled into the study group (n=43). The changes of serum inflammatory factors before and after treatment, granulation tissue grading and efficacy in the two groups were analyzed and compared, and the wound healing time, hospitalization time and adverse reactions (including nausea and vomiting, dizziness, headache, pruritus, etc.) of the two groups were statistically analyzed. The prognosis of the patients within 1 year after treatment was analyzed, and the independent risk factors of poor prognosis were analyzed through logistic regression. RESULTS: Before treatment, the two groups were not significantly different in the levels of tumor necrosis factor-α (TNF-α), high sensitivity C-reactive protein (hs-CRP), and interleukin-6 (IL-6), while after treatment, the levels decreased significantly in both groups, with significantly lower levels in the study group than those in the control group. The study group had a significant lower proportion of patients with grade 0/grade 1 granulation tissue than the control group, and had a significantly higher proportion of patients with grade 2/grade 4 granulation tissue than the control group, but the proportion of patients with grade 3 granulation tissue in the two groups was not greatly different. The study group experienced notably shorter wound healing time and hospitalization time than the control group. A notably higher overall response rate was found in the study group than that in the control group. In addition, the total incidence of adverse reactions was not greatly different between the two groups. BMI, diabetes mellitus type, Wagner grading and classification of diabetic foot infection were found to be the risk factors affecting the prognosis of patients, and Wagner grading was an independent risk factor affecting the prognosis of patients. CONCLUSION: Epalrestat is effective in treating DFI, because it can lower the levels of serum inflammatory factors, shorten the time of wound healing and hospitalization, and promote the growth and recovery of granulation, without increasing adverse reactions. Therefore, it is worthy of clinical promotion.

Population pharmacokinetics of vancomycin in patients with diabetic foot infection: a comparison of five models.

Purpose: This study aimed to compare individual pharmacokinetic (PK) parameters of vancomycin with predicted values from five population PK models in patients with diabetic foot infections (DFIs). Methods: Patients with a diagnosis of DFI and an estimated glomerular filtration rate (eGFR) ≥ 30 mL/min were included in the study. Individual PK data was carried on by collecting three vancomycin serum concentrations in a steady-state condition. Five published population-based nomograms were assumed to predict PK parameters. Optimal vancomycin exposure was considered as a trough level of 15-20 mg/L or the area under the curve over 24 h/minimum inhibitory concentration (AUC24/MIC) ≥ 400. Results: A total of 48 samples from 16 patients were analyzed. There was a statistically significant difference between the volume of distribution (Vd) obtained from population methods and the individual estimations (P ≤ 0.001 in Ambrose and Burton, P = 0.010 and 0.006 in Bauer and Burton revised models, respectively). AUC/MIC ≥ 400 was achieved in 68.7% of patients while 50% had a trough level of less than 15 mg/L. Conclusions: Vancomycin PK parameters, particularly individualized Vd, may not be predictable by population nomograms in patients with DFI and stable renal function. Moreover, the weak correlation between AUC24 values and trough concentrations underlines the starting practice of vancomycin AUC24-based monitoring and dosing in the clinical setting.

Enhancing open clinical trials through blinded evaluations: an exploration with diabetic foot infections.

BACKGROUND: Blinding drugs through simulation techniques is an important means to control the subjective bias of investigators and subjects. However, clinical trials face significant challenges in the placebo production of drugs, and many trials cannot be double-blinded. OBJECTIVE: This study was conducted to ascertain the consistency between non-blind and blind evaluation results in clinical trials and to pioneer strategies to control information bias, particularly in trials where double-blinding is not feasible. METHODS: In this investigation, a randomized controlled trial (RCT) studying diabetic foot infections (DFIs) was utilized as a representative case. In this trial, the grading of DFIs, as per guidelines by the Infectious Disease Society of America (IDSA) and International Working Group on Diabetic Foot (IWGDF), was used as the primary efficacy indicator. A sample of sixteen patients was randomly chosen from the RCT, and DFI grading was assessed jointly by both non-blinded investigators and blinded center-reading investigators. A consistency test was then deployed to compare the evaluation results, forming the basis for our proposed strategies for effective blinded evaluation. In addition, other perspectives were collected at the end of this study, including with those involved in designing and conducting the recent blinded evaluation trial. RESULTS: Five subjects were excluded due to the quality of photos or the lack of post-treatment visits. The post-treatment IDSA/IWGDF grading results were compared in 11 subjects (experimental group=6, control group=5), and the consistency test showed inconsistent results between the non-blinded and center reading blinded evaluations (Kappa=0.248, p=0.384). In the experimental group, three cases were judged as grade 1 in the non-blinded evaluation and grade 2 in the central reading blinded evaluation; in the control group, three cases were judged as grade 2 in the non-blinded evaluation and grade 1 in the central reading blinded evaluation. The sum of these two cases in 22 post-treatment determinations was 27% (6/22). Furthermore, researchers propose several strategies for implementing blinded evaluations in clinical trials after this trial, which encompass aspects such as staff allocation, training, participant management, trial drug administration, efficacy indicator collection, and safety event management. CONCLUSIONS: The study highlighted that evaluations from non-blinded site investigators may potentially exaggerate the efficacy of the experimental group and that deep wounds can present challenges for observation via center-reading photos. These findings underline the vital necessity for objective assessment in open clinical trials, especially those where wound observation serves as the primary efficacy indicator. The study suggests the adoption of independent blinded investigators at each site, complemented by a comprehensive set of standard operating procedures for blinding evaluation. These measures could serve as an effective counterbalance to subjective bias, thereby augmenting the credibility and consistency of results in open clinical trials. The implications of these findings and recommendations could be of great significance for the design and execution of future open clinical trials, potentially bolstering the quality of clinical research in this area. TRIAL REGISTRATION: ChiCTR2000041443. Registered on December 2020.

Predictive Value of C-Reactive Protein to Albumin Ratio for Amputation Risk in Diabetic Foot Infection.

Diabetic foot infections are one of the complications of diabetes mellitus resulting in extremity amputation and mortality. This study aimed to examine the predictive value of the C-reactive protein (CRP) to albumin ratio (CAR) for amputation risk in diabetic foot infection. Data from 178 patients were retrospectively examined. We found the cut point value of 15.45 according to the receiver operating characteristic (ROC) curve to show the predictive value of CAR for amputation risk in the overall population. We then divided the patients into two groups low (<15.45, n = 96) and high risk (≥15.45, n = 82) according to their CAR value. Matching based on propensity scores produced 64 patients in each group and showed that the amputation rate was high in the high-risk groups (50 vs 25%, P = .003). In the multivariate analysis in the matching group, previous amputation, antibiotic therapy in the last 3 months, and CAR (Odds ratio [OR]: 1.30, 95%Confidence interval [CI]: 1.01-1.45, P < .001) were independent predictors of amputation. These parameters may be useful to predict amputation risk in these patient groups.

Limited Clinical Utility of Routine Mycobacterial Cultures for the Management of Diabetic Foot Infections.

Mycobacterial infections of the foot and ankle are uncommon. In a cohort of 2340 patients with diabetic foot infection (DFI) in a region with increased prevalence of mycobacterial disease, we identified no clinically significant positive cultures over a 3-year period. Routine mycobacterial culture of DFIs is of limited clinical utility.

Outcome of Modified Pirogoff Amputation for Diabetic Foot Infection: A Single-Center Case Series.

INTRODUCTION: Diabetic-related foot condition is one of the most debilitating complications with a higher rate of failure in limb correction, reconstruction, or salvage surgery. Amputation is the final option after other surgical treatments have failed. Major amputation increases energy consumption, resulting in high dependency, decreased mobility, and poor prognosis. Consequently, minor amputation is preferred to resolve these problems but elevated wound complications leading to inadequate prosthesis fit, became a detriment to minor amputation. Strict selection of patients is crucial to ensure success and good functional outcomes as demonstrated in this retrospective study of this case series. Methods: This case series included six patients who underwent Pirogoff amputation with the modification described by Nather and reported the procedure's outcome. The inclusion criteria for subjects were the presence of palpable posterior tibial artery (PTA) or at least biphasic Doppler signal and ankle-brachial systolic index (ABSI) more than 0.70. Other demographic data as well as hematological, inflammatory, and biochemical parameters that may affect wound healing such as Hb, HbA1c, ESR, CRP, WBC, and albumin were recorded as well. The rate and time for wound healing and bone union, presence of complications, and final ambulatory status of patients were determined as the outcome of this study. RESULTS: All of the patients had diabetic foot infections involving only the forefoot region with the presence of either palpable PTA or biphasic Doppler signal. Although the majority of the cases had deranged blood parameters, soft tissue and bone healing were achieved at variable times. Four had good outcomes as they were able to ambulate. One case was complicated with chronic wound dehiscence and another one had Pirogoff stump infection and required transtibial amputation. CONCLUSION: With strict selection criteria, Pirogoff amputation may provide a good functional outcome with a lesser degree of complications compared to major amputation.

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.

Parenteral Vancomycin in the Treatment of MRSA-Associated Diabetic Foot Infections: An Unnecessary Risk.

Diabetic foot infections (DFIs) are a common and costly complication of diabetes. Soft tissue and bone infections in DFIs frequently lead to amputation and/or sepsis which can be costly for both the patient and the healthcare system. Staphylococcus aureus is the most commonly identified causative agent in DFIs, and people with diabetes may have an increased risk of infection with methicillin-resistant Staphylococcus aureus (MRSA). In addition to increased susceptibility to severe infection, MRSA in DFIs is associated with high rates of treatment failure, morbidity, and hospitalization costs meaning appropriate treatment is a high priority. While hospitalized patients are usually treated with intravenous (IV) vancomycin, this can be costly in terms of inpatient stays, staffing costs, and adverse events. For example, vancomycin-associated acute kidney injury not only delays hospital discharge and increases costs but is also a particular concern for patients with diabetes who already have an increased risk of kidney problems. Vancomycin-resistant strains of S. aureus have also been identified, which means that alternative treatment options may need to be explored. Treatment alternatives to IV vancomycin, including oral antibiotics, have been shown to provide similar efficacy, with reduced costs, outpatient or home-based administration, and with fewer serious adverse effects. Although infectious disease specialists often use IV vancomycin alone, or in combination, as a first-line therapeutic option, they are increasingly seeing the value of outpatient or at-home oral antibiotics as an alternative. This manuscript reviews the evidence for true costs of vancomycin therapy for MRSA-associated DFIs and examines the alternatives.

A Narrative Review on the Role of Dalbavancin in the Treatment of Bone and Joint Infections.

Bone and joint infections (BJI) require prolonged antimicrobial treatment, leading to lengthy hospitalizations, high costs, the risk of nosocomial infections, and the development of antimicrobial resistance. Dalbavancin is a novel semisynthetic lipoglycopeptide approved for the treatment of adults and children with acute bacterial skin and skin structure infections. This narrative review aims to summarize the characteristics of dalbavancin and the current scientific evidence regarding its clinical efficacy and safety in the treatment of BJI. A literature search until June 2023 was performed to identify all published research about the role of dalbavancin in the management of BJI. Due to its unique pharmacokinetics characterized by prolonged half-life, high bactericidal activity against most Gram-positive bacteria, a good safety profile, and high tissue penetration, dalbavancin can be a valuable alternative to the treatment of BJI. Clinical studies have shown its non-inferiority compared to conventional therapies in BJI, offering potent activity against key pathogens and an extended dosing interval that may shorten hospitalization. In conclusion, dalbavancin represents a promising treatment option for BJI with a favorable safety profile, but further research in both adults and particularly children, who are ideal candidates for long-acting antibiotics, is necessary to evaluate the role of dalbavancin in BJI.