Dietary Blueberry Ameliorates Vascular Complications in Diabetic Mice Possibly through NOX4 and Modulates Composition and Functional Diversity of Gut Microbes.

SCOPE: In diabetes, endothelial inflammation and dysfunction play a pivotal role in the development of vascular disease. This study investigates the effect of dietary blueberries on vascular complications and gut microbiome in diabetic mice. METHODS AND RESULTS: Seven-week-old diabetic db/db mice consume a standard diet (db/db) or a diet supplemented with 3.8% freeze-dried blueberry (db/db+BB) for 10 weeks. Control db/+ mice are fed a standard diet (db/+). Vascular inflammation is assessed by measuring monocyte binding to vasculature and inflammatory markers. Isometric tension procedures are used to assess mesenteric artery function. db/db mice exhibit enhanced vascular inflammation and reduced endothelial-dependent vasorelaxation as compared to db/+ mice, but these are improved in db/db+BB mice. Blueberry supplementation reduces the expression of NOX4 and IκKß in the aortic vessel and vascular endothelial cells (ECs) isolated from db/db+BB compared to db/db mice. The blueberry metabolites serum reduces glucose and palmitate induced endothelial inflammation in mouse aortic ECs. Further, blueberry supplementation increases commensal microbes and modulates the functional potential of gut microbes in diabetic mice. CONCLUSION: Dietary blueberry suppresses vascular inflammation, attenuates arterial endothelial dysfunction, and supports the growth of commensal microbes in diabetic mice. The endothelial-specific vascular benefits of blueberries are mediated through NOX4 signaling.

Gut Microbiota and Subclinical Cardiovascular Disease in Patients with Type 2 Diabetes Mellitus.

Type 2 diabetes (T2D) is associated with an increased risk of cardiovascular disease (CVD). The gut microbiota may contribute to the onset and progression of T2D and CVD. The aim of this study was to evaluate the relationship between the gut microbiota and subclinical CVD in T2D patients. This cross-sectional study used echocardiographic data to evaluate the cardiac structure and function in T2D patients. We used a quantitative polymerase chain reaction to measure the abundances of targeted fecal bacterial species that have been associated with T2D, including Bacteroidetes, Firmicutes, Clostridium leptum group, Faecalibacterium prausnitzii, Bacteroides, Bifidobacterium, Akkermansia muciniphila, and Escherichia coli. A total of 155 subjects were enrolled (mean age 62.9 ± 10.1 years; 57.4% male and 42.6% female). Phyla Bacteroidetes and Firmicutes and genera Bacteroides were positively correlated with the left ventricular ejection fraction. Low levels of phylum Firmicutes were associated with an increased risk of left ventricular hypertrophy. High levels of both phylum Bacteroidetes and genera Bacteroides were negatively associated with diastolic dysfunction. A high phylum Firmicutes/Bacteroidetes (F/B) ratio and low level of genera Bacteroides were correlated with an increased left atrial diameter. Phyla Firmicutes and Bacteroidetes, the F/B ratio, and the genera Bacteroides were associated with variations in the cardiac structure and systolic and diastolic dysfunction in T2D patients. These findings suggest that changes in the gut microbiome may be the potential marker of the development of subclinical CVD in T2D patients.

BuZangTongLuo decoction improved hindlimb ischemia by activating angiogenesis and regulating gut microbiota in diabetic mice.

ETHNOPHARMACOLOGICAL RELEVANCE: Seven traditional medicinal plants (including Astragalus membranaceus, Dioscorea hemsleyi, Salvia miltiorrhiza, Scrophularia ningpoensis, Ophiopogon japonicus, Panax ginseng and Fritillariae cirrhosae) and one insect leech (Whitmania pigra Whitman) were combined into BuZangTongLuo formula (BZTLF) under the guidance of traditional Chinese medicine. BZTLF is potentially effective against diabetic vascular complications. AIM OF THE STUDY: Previous studies failed to clarify the molecular mechanism through which BZTLF suppressed diabetic ischemia. In this study, we aimed to explore whether BZTLF treatment could prevent the occurrence of type 2 diabetic (T2D) hindlimb ischemia in mice. Further, we investigated the regulatory effect of BZTLF on angiogenesis-related VEGF signaling pathway and gut microbiota dysfunction in diabetic ischemia mice. MATERIALS AND METHODS: C57BL/6J mice fed with high-fat diet (HFD) received STZ injection and femoral artery ligation to build T2D diabetic hindlimb ischemia model. Mice were gavaged with BZTLF (5 g [raw materials]/kg/d) or with metformin plus atorvastatin for three weeks. Laser doppler imaging system was utilized for the visualization of blood flow. Histochemistry analysis was performed for microvascular vessel staining. Western blot was applied to detect the protein changes of signaling molecules responsible for VEGF pathway. Finally, 16S rDNA gene sequencing was conducted for analysis of gut microbiota structure. RESULTS: BZTLF treatment remarkably restored blood flow and capillary density of diabetic hindlimb ischemia. And the protein changes of VEGF signaling molecules were reversed in BZTLF-treated diabetic ischemia mice, including the decreased VEGF and HIF-1α, and the increased NO, eNOS and p-ERK1/2. The gut microbiota analysis suggests that BZTLF treatment increased the abundances of several beneficial bacteria (Akkermansia, Bifidobacterium and Bacteroides), while decreased the populations of some harmful bacteria(Blautia, Weissella, Escherichia Shigella and Kurthia). By using Spearman's correlation analysis, these changed gut flora were positively/negatively correlated with VEGF signaling pathway or glycometabolic parameters. CONCLUSION: BZTLF displayed beneficial effects on diabetic hindlimb ischemia by reshaping the gut microbiota structure and stunning the VEGF/HIF-1α pathway.

The Role of the Microbiota in the Diabetic Peripheral Artery Disease.

Vascular complications of diabetes mellitus represent a major public health problem. Although many steps forward have been made to define the causes and to find the best possible therapies, the problem remains crucial. In recent years, more and more evidences have defined a link between microbiota and the initiation, promotion, and evolution of atherosclerotic disease, even in the diabetic scenario. There is an urgency to develop the knowledge of modern medicine about the link between gut microbiota and its host's metabolic pathways, and it would be useful to understand and justify the interindividual diversity of clinical disease presentation of diabetic vascular complication even if an optimization of pharmacological treatment has been made or in the case of young patients where hypertension, dyslipidemia, and diabetes are not able to justify a very quick progress of atherosclerotic process. The aim of the present review is to gather all the best available evidence in this regard and to define a new role of the microbiota in this field, from biomarker to possible therapeutic target.

The role of the microbiome in nonhealing diabetic wounds.

Wound healing is a highly coordinated and complex process, and there can be devastating consequences if it is interrupted. It is believed that, in combination with host factors, microorganisms in a wound bed can not only impair wound healing but can lead to stalled, chronic wounds. It is hypothesized that the wound microbiota persists in chronic wounds as a biofilm, recalcitrant to antibiotic and mechanical intervention. Cultivation-based methods are the gold standard for identification of pathogens residing in wounds. However, these methods are biased against fastidious organisms, and do not capture the full extent of microbial diversity in chronic wounds. Thus, the link between specific microbes and impaired healing remains tenuous. This is partially because local infection and, more specifically, the formation of a biofilm, is difficult to diagnose. This has led to research efforts aimed at understanding if biofilm formation delays healing and leads to persistent and chronic infection. Circumventing challenges associated with culture-based estimations, advances in high-throughput sequencing analysis has revealed that chronic wounds are host to complex, diverse microbiomes comprising multiple species of bacteria and fungi. Here, we discuss how the use of genomic methodologies to study wound microbiomes has advanced the current understanding of infection and biofilm formation in chronic wounds.

SGLT2 inhibition via dapagliflozin improves generalized vascular dysfunction and alters the gut microbiota in type 2 diabetic mice.

BACKGROUND: Type 2 diabetes (T2D) is associated with generalized vascular dysfunction characterized by increases in large artery stiffness, endothelial dysfunction, and vascular smooth muscle dysfunction. Sodium glucose cotransporter 2 inhibitors (SGLT2i) represent the most recently approved class of oral medications for the treatment of T2D, and have been shown to reduce cardiovascular and overall mortality. Although it is currently unclear how SGLT2i decrease cardiovascular risk, an improvement in vascular function is one potential mechanism. The aim of the current study was to examine if dapagliflozin, a widely prescribed STLT2i, improves generalized vascular dysfunction in type 2 diabetic mice. In light of several studies demonstrating a bi-directional relation between orally ingested medications and the gut microbiota, a secondary aim was to determine the effects of dapagliflozin on the gut microbiota. METHODS: Male diabetic mice (Db, n = 24) and control littermates (Con; n = 23) were randomized to receive either a standard diet or a standard diet containing dapagliflozin (60 mg dapagliflozin/kg diet; 0.006%) for 8 weeks. Arterial stiffness was assessed by aortic pulse wave velocity; endothelial function and vascular smooth muscle dysfunction were assessed by dilatory responses to acetylcholine and sodium nitroprusside, respectively. RESULTS: Compared to untreated diabetic mice, diabetic mice treated with dapagliflozin displayed significantly lower arterial stiffness (Db = 469 cm/s vs. Db + dapa = 435 cm/s, p < 0.05), and improvements in endothelial dysfunction (area under the curve [AUC] Db = 57.2 vs. Db + dapa = 117.0, p < 0.05) and vascular smooth muscle dysfunction (AUC, Db = 201.7 vs. Db + dapa = 285.5, p < 0.05). These vascular improvements were accompanied by reductions in hyperglycemia and circulating markers of inflammation. The microbiota of Db and Con mice were distinctly different, and dapagliflozin treatment was associated with minor alterations in gut microbiota composition, particularly in Db mice, although these effects did not conclusively mediate the improvements in vascular function. CONCLUSIONS: Dapagliflozin treatment improves arterial stiffness, endothelial dysfunction and vascular smooth muscle dysfunction, and subtly alters microbiota composition in type 2 diabetic mice. Collectively, the improvements in generalized vascular function may represent an important mechanism underlying the cardiovascular benefits of SGLT2i treatment.

Classification of diabetic foot ulcers.

It is known that the relative importance of factors involved in the development of diabetic foot problems can vary in both their presence and severity between patients and lesions. This may be one of the reasons why outcomes seem to vary centre to centre and why some treatments may seem more effective in some people than others. There is a need therefore to classify and describe lesions of the foot in patients with diabetes in a manner that is agreed across all communities but is simple to use in clinical practice. No single system is currently in widespread use, although a number have been published. Not all are well validated outside the system from which they were derived, and it has not always been made clear the clinical purposes to which such classifications should be put to use, whether that be for research, clinical description in routine clinical care or audit. Here the currently published classification systems, their validation in clinical practice, whether they were designed for research, audit or clinical care, and the strengths and weaknesses of each are explored.

Tissue and swab culture in diabetic foot infections: neuropathic versus neuroischemic ulcers.

We evaluated the diagnostic performance of swabs versus tissue cultures in 28 diabetic patients with neuropathic (group A) and 22 diabetic patients with neuroischemic foot ulcer (group B) and the differences in bacterial isolates between the 2 groups. In group A, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of swab cultures for the diagnosis of infection were 100%, 40%, 88.5%, and 100%, respectively. In group B, the corresponding values were 100%, 22.2%, 65%, and 100%. In group A, sensitivity, specificity, PPV, and NPV of swab cultures for the identification of pathogens were 100%, 14.3%, 53.8%, and 100%, respectively. In group B, the corresponding values were 100%, 18.2%, 55%, and 100%. In each group, Staphylococcus aureus and Pseudomonas aeruginosa were the most common isolates. The number of isolates was significantly higher on swab versus tissue cultures only in group A (P = .033). No differences were observed between groups in number of isolates and colony forming units. In conclusion, swab cultures are highly sensitive but less specific and have an excellent NPV both in diabetic patients with neuropathic and in those with neuroischemic foot ulcer. There are no differences between the groups in microbial load.

Epidemiology and prevalence of methicillin-resistant Staphylococcus aureus and Staphylococcus epidermidis in patients with diabetic foot ulcers: focus on the differences between species isolated from individuals with ischemic vs. neuropathic foot ulcers.

We examined whether foot ischemia or neuropathy with diabetic foot ulcer (DFU) promote selection of staphylococci species, evaluated frequency of MRSA and MRSE among strains yielded from patients with DFU and assessed multidrug resistance of isolates. Patients with DFU and foot osteomyelitis were divided into ischemic foot ulcer (IFU, n=21) and neuropathic foot ulcer (NFU, n=29) groups. Frequency of Staphylococcus epidermidis yielded from curettage of IFU was higher compared with NFU (P<0.05). S. epidermidis was also more frequently isolated from the toe web surface of patients with IFU compared with NFU (55% vs. 17.9%, respectively) and healthy volunteers (HV, n=20) (17.6%, P<0.05). These mostly MRSE strains (83.3-100%) originating from DFU patients were multidrug resistant (88.8%). Also, most of MRSA isolates were multidrug resistant (70.3%). Higher rates of MSSA from DFU patients than HV showed resistance to antimicrobials. This is the first report indicating that diabetic patients with IFU differ with NFU patients in higher frequency of S. epidermidis skin colonization and ulcer infection. We suggest that IFU should be defined as separate disease state of DFU and S. epidermidis should be appreciated as a nosocomial pathogen.

Enterococcus gallinarum endocarditis in a diabetic patient.

Recent studies pointed out the increasing rate of infective endocarditis (IE) in diabetic patients. As diabetes mellitus (DM) prevalence is expected to increase in the coming years, infective endocarditis could be more frequently reported in these patients. We here describe a rare case of Enterococcus gallinarum endocarditis developing on normal native heart valve in an elderly diabetic woman. Therapeutic options were restricted due to resistance factors of the microorganism, limited guidance in the medical literature, and the patient's history and underlying condition. Despite these challenges, adequate antibiotic therapy led to the patient's recovery.

Vascular risks and complications in diabetes mellitus: the role of helicobacter pylori infection.

Patients with diabetes mellitus (DM) are at risk for Helicobacter pylori infection. This infection has been linked to atherosclerosis and its vascular complications. The aim of this study was to evaluate the: (1) prevalence of H pylori infection in patients with DM; (2) association between diabetic vascular complications and H pylori infection; and (3) influence of H pylori infection on atherosclerosis and inflammatory biomarkers. In this study, we evaluated 80 patients with DM for atherosclerosis; cardiac, cerebral, and peripheral vascular diseases; retinopathy; neuropathy; and nephropathy. We estimated the blood levels of glucose, glycosylated hemoglobin, complete blood cell count, erythrocytic sedimentation rate, lipid profile, tumor necrosis factor-alpha, interleukin (IL)-6, and anti-H pylori IgG antibodies. H pylori infection was detected in 85% of patients versus 76.7% for control subjects. Carotid artery intima-media thickness was significant in H pylori-infected patients. IL-6 and tumor necrosis factor-alpha were significantly associated with H pylori infection. In multivariate analysis, blood glucose, triglycerides, erythrocytic sedimentation rate, IL-6, and tumor necrosis factor-alpha increased the odds for atherothrombotic cause of cerebral ischemia in H pylori infection. We concluded that H pylori infection is common in DM and seems to be linked to the presence of atherosclerosis and ischemic cerebrovascular stroke. This effect could be mediated by increasing cytokine levels.

[Serological markers of chronic Chlamydia pneumoniae and cytomegalovirus (CMV) infection in patients with peripheral occlusive artery disease--an initial report]. / Serologiczne wykladniki przewleklego zakazenia Chlamydia pneumoniae i Cytomegalowirusem (CMV) u chorych na miazdzyce zarostowa--doniesienie wstepne.

Involvement of infection agents in pathogenesis of atherosclerosis was described in several studies, particularly in patients with acute coronary syndrome or ischemic stroke. However, in very few studies an association of serological markers of chronic infection with peripheral occlusive artery disease was analysed. The prevalence and concentration of immunoglobulin G and A to Chlamydia pneumoniae and immunoglobulin G to CMV were measured in sera of 31 participants suffering from peripheral occlusive artery disease. Significant difference in the prevalance of immunoglobulin G to C. pneumoniae and CMV between study and control groups was documented. There was no such association in reference to immunoglobulin A to C. pneumoniae index. Serum concentration of all measured antibodies were significantly higher in the study group than in control.

Increased incidence of cytomegalovirus but not Chlamydia pneumoniae in atherosclerotic lesions of arteries of lower extremities from patients with diabetes mellitus undergoing amputation.

AIMS: To evaluate the association between cytomegalovirus (CMV) or Chlamydia pneumoniae infection and the development of accelerated atherosclerotic lesions in patients with diabetes who are known to have an impaired immune response to infection and a high incidence of atherosclerosis. METHODS: Two hundred arterial samples from patients with diabetes who had undergone surgical amputation for gangrenous lower limbs were selected to assess the presence of CMV or C pneumoniae nucleic acid by means of the polymerase chain reaction. RESULTS: CMV nucleic acid sequences were detected in 64 of 200 (32%) samples and C pneumoniae in seven of 200 (3.5%) arterial samples with severe atherosclerosis. Of those positive for C pneumoniae, six were also positive for CMV. CONCLUSION: The significantly higher incidence of CMV nucleic acid sequences in the arterial samples of patients with diabetes supports the hypothesis that this organism is involved in the pathogenesis of atherosclerosis in patients with diabetic mellitus. It is possible that the potential role of different infectious agents in the pathogenesis of atherosclerosis might rely on their biological properties and their infectivity in hosts with varying immunological status.

[The MRSA patient in technical orthopaedics and rehabilitation]. / Das Problem der MRSA-Infektionen bei der Behandlung des Diabetischen Fusssyndroms. Teil 1: Charakterisierung eines Patientenkollektivs.

Colonisation and infection of humans by methicillin-resistant Staphylococcus aureus (MRSA) was examined retrospectively at the Clinic of Technical Orthopedics and Rehabilitation of the University Clinic at Münster (Germany). The cohort consisted of 28 patients who over the period were microbiologically shown to harbour MRSA from January 1997 to June 2000. Out of these, only 16 patients were colonised and only 12 patients developed MRSA infection. The inpatient stay was longer for MRSA subjects than for non-MRSA subjects. All patients had chronic wound healing disorders of the lower extremities which were due to peripheral neuropathies, diabetes mellitus and/or obstructive disease of the arteries. All patients were at risk for colonisation with MRSA.

Bacterial population of chronic crural ulcers: is there a difference between the diabetic, the venous, and the arterial ulcer?

BACKGROUND: At the Surgical Department of Surgery of the University Hospital Würzburg microbiological examinations were performed of the ulcer grounds from patients with diabetic-neuropathic, diabetic-ischemic, venous, and arterial leg ulcers. The aim of the examination was to evaluate possible differences in the healing process of these ulcers based on the knowledge of their bacterial populations. PATIENTS AND METHODS: In a period of four months, 63 patients were consecutively examined by taking a bacteriological swab of their ulcer area. The healing process of their wounds was followed and related to the impact of bacterial colonisation and clinical signs of infection. RESULTS: 95% of the venous and arterial leg ulcers had a positive smear, whereas only 70% of diabetic ulcers were positive for bacterial growth. Bacterial population of the three ulcer entities, however did not differ significantly. 100% of the clinically infected venous and arterial ulcers but only 80% of the diabetic wounds revealed a positive smear. On the other hand, only 22% of the venous ulcers with a positive smear developed a clinical infection in contrast to 70% of the arterial and diabetic. Venous ulcers showed only in a few patients prolonged healing, even in cases of marked bacterial contamination. Despite of clinical signs of infection however, diabetic wounds sometimes did not reveal a positive wound smear (20%). All infected venous, but only 20% of the infected ischemic ulcers healed satisfactorily. Arterial wounds with no bacterial growth healed significantly better than contaminated wounds. This difference was not significant in the other entities. Radical removal of the infection by minor amputation increased the healing rate in diabetic ulcers over 80%, whereas ischemic wounds did not profit from this therapy. CONCLUSIONS: A positive bacterial wound smear is not inevitably correlated with a protracted leg ulcer healing. Nevertheless a fulminant infection often developed in diabetic ulcers despite the initial inability to demonstrate bacterial growth. In order to start antibiotic treatment as early as possible, a wound smear should be obtained routinely from patients with diabetic ulcers. In chronic venous ulcers, a routine swab does not appear to be indicated as it bears no clinical consequences. The same applies to patients with surgically fully treated peripheral arterial occlusive disease. As ischemia presents the limiting factor, antibiotic therapy in case of infection will not prevent imminent amputation.

Association of Helicobacter pylori infection with cardiovascular and cerebrovascular disease in diabetic patients.

OBJECTIVE: Infection by Helicobacter pylori has been epidemiologically linked to some extradigestive conditions, including ischemic heart disease. Diabetic patients are an at-risk population for cardiovascular and thrombo-occlusive cerebral disease. The aim of the study was to examine a possible relationship between H. pylori infection and cardiovascular or cerebrovascular disease in diabetic patients. RESEARCH DESIGN AND METHODS: This was a cross-sectional case-control study with 127 diabetic patients (both IDDM and NIDDM). Special emphasis was placed on the detection of clinical macro- and microvascular complications, cardiovascular risk factors, acute phase reactants, and serological markers of increased cardiovascular disease risk. H. pylori infection was assessed through the determination of specific Ig-G titers, measured by a commercial enzyme-linked immunosorbent assay. RESULTS: Coronary heart disease was more prevalent in diabetic patients with than without H. pylori (odds ratio [OR] 4.07; 95% CI 1.21-13.6; P < 0.05). A history of thrombo-occlusive cerebral disease was also more frequent in H. pylori-positive diabetic patients (OR 4.8; 95% CI 1.24-18.51; P < 0.05). Other complications such as peripheral arteriopathy, advanced nephropathy, neuropathy, or retinopathy were no differently distributed according to serological status. Alterations in the levels of the following acute-phase reactants and blood chemistry determinations were significantly more profound in H. pylori-positive diabetic patients: high fibrinogen (P < 0.05), high erythrocyte sedimentation rate (P < 0.001), high triglycerides (P < 0.001), and low HDL cholesterol (P < 0.001). There values were also more deeply altered in H. pylori-positive diabetic patients with a history of coronary heart disease, thrombo-occlusive cerebral disease, or both, when compared with H. pylori-positive diabetic patients without those complications. CONCLUSIONS: Our data indicate a possible association of H. pylori infection and the development of coronary heart disease, thrombo-occlusive cerebral disease, or both, in diabetic patients. The importance of this link is highlighted by the possibility of an effective intervention against H. pylori infection.

Cardiovascular mortality and morbidity in type-2 diabetes mellitus.

A representative number of prospective studies clearly indicate that cardiovascular morbidity and mortality is significantly increased in type-2 diabetic patients in comparison with non-diabetic control subjects. The cardiovascular death rate is 4.4 fold increased in those diabetic patients presenting none of the classical risk factors (hypertension, hypercholesterinemia or smoking) compared with age-matched control subjects (MRFIT). A decreased survival rate after myocardial infarction, congestive heart failure and an increased occurrence of silent ischemia are responsible for the poor prognosis of type-2 diabetic patients. Recent studies indicate that haemostatic abnormalities and endothelial dysfunction are important risk factors for coronary events in diabetic as well as in nondiabetic patients. In newly diagnosed type-2 diabetic patients a similar prevalence of myocardial infarction and angina compared to previously known type-2 diabetes was found. The long prediabetic period and clustering of risk factors may be very relevant for the high prevalence of cardiovascular disease already at diagnosis of type-2 diabetes. More recent studies performed in Scotland and Verona demonstrated a mortality risk approximately only 50% higher than in nondiabetic subjects. The reduction in the mortality risk could reflect an improvement in diabetes prognosis from the 1960s to the 1980s. Recent observations in type-2 diabetic patients from Finland indicate that glycemic control is an important predictor for coronary heart disease morbidity and mortality. However incidence of coronary heart disease is only low in those patients presenting with a HbAlc value below 6.0%. More information will be available after analysis of the United Kingdom prospective diabetes study. (UKPDS).

Treatment of lower extremity infections in diabetics.

Despite recent medical advances in the treatment of diabetes mellitus, foot infection remains a major cause of morbidity and mortality in patients with this disorder. Three main factors are responsible for this: neuropathy, angiopathy and immunopathy. Neuropathy is probably the most important factor: minor irritations and trauma can lead to limb-threatening infections without the patient feeling the changes. Angiopathy plays only a minor role, while immunopathy has implications for antibiotic treatment, in that bactericidal agents are needed. A classification scheme that incorporates clinical and laboratory findings can direct the selection of empirical antibiotic therapy in patients with foot infections. These infections may be defined as mild, moderate and severe. In less severe cases, there are effective oral agents that can stop the progress of the infection and obviate the need for patient hospitalisation. Moderate to severe infections require hospitalisation with the use of parenteral agents. With some of the new broad spectrum drugs, single agent therapy is now possible, eliminating the need for expensive, potentially toxic combinations. Antibiotics, however, are only part of the cure. Aggressive surgical debridement followed by conscientious local wound care plays an equal role. The ultimate goal is foot salvage, and the clinical judgement of the practitioner is paramount in determining the treatment strategies needed to achieve this objective.

Therapy of lower extremity infections with ciprofloxacin in patients with diabetes mellitus, peripheral vascular disease, or both.

PURPOSE: Lower extremity infections in the presence vascular insufficiency are difficult and costly to treat. Few well-controlled clinical trials evaluating the management of these infections exist. We decided to investigate the ability of a new fluoroquinolone, ciprofloxacin, to reduce the morbidity associated with these infections and the amount of in-hospital time required for the administration of antibiotic therapy. PATIENTS AND METHODS: Forty-eight patients with peripheral vascular disease (46 with diabetes mellitus) who presented to the hospital for treatment of lower extremity infections were randomized in a blinded fashion to receive oral ciprofloxacin at a dosage of either 750 mg or 1,000 mg twice daily. Patients with osteomyelitis received three months of therapy and those with infections limited to soft tissues, three weeks of ciprofloxacin treatment. All subjects were followed for one year. RESULTS: One patient received an amputation 24 hours after enrollment, and two patients discontinued therapy after 20 and 34 days because of adverse effects and were not evaluable. At the one-year follow-up, 27 of the 45 (60 percent) evaluable patients had a fully successful outcome defined as not requiring either repeat antimicrobial therapy for their initial infection or amputation of the involved extremity. In the group of 18 patients in whom therapy failed, a total of only nine amputations were required. In the 15 patients whose lesion closed during therapy, 93% (14 patients) experienced a long-term successful outcome. CONCLUSION: Treatment with this new fluoroquinolone offers promise for the improved outcome of patients with the serious infectious complication of infected lower extremity ulcerations in peripheral vascular disease, diabetes mellitus, or both.