IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023).

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the management and prevention of diabetes-related foot diseases since 1999. The present guideline is an update of the 2019 IWGDF guideline on the diagnosis and management of foot infections in persons with diabetes mellitus. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used for the development of this guideline. This was structured around identifying clinically relevant questions in the P(A)ICO format, determining patient-important outcomes, systematically reviewing the evidence, assessing the certainty of the evidence, and finally moving from evidence to the recommendation. This guideline was developed for healthcare professionals involved in diabetes-related foot care to inform clinical care around patient-important outcomes. Two systematic reviews from 2019 were updated to inform this guideline, and a total of 149 studies (62 new) meeting inclusion criteria were identified from the updated search and incorporated in this guideline. Updated recommendations are derived from these systematic reviews, and best practice statements made where evidence was not available. Evidence was weighed in light of benefits and harms to arrive at a recommendation. The certainty of the evidence for some recommendations was modified in this update with a more refined application of the GRADE framework centred around patient important outcomes. This is highlighted in the rationale section of this update. A note is also made where the newly identified evidence did not alter the strength or certainty of evidence for previous recommendations. The recommendations presented here continue to cover various aspects of diagnosing soft tissue and bone infections, including the classification scheme for diagnosing infection and its severity. Guidance on how to collect microbiological samples, and how to process them to identify causative pathogens, is also outlined. Finally, we present the approach to treating foot infections in persons with diabetes, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and bone infections; when and how to approach surgical treatment; and which adjunctive treatments may or may not affect the infectious outcomes of diabetes-related foot problems. We believe that following these recommendations will help healthcare professionals provide better care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes-related foot disease.

Diagnosis of infection in the foot of patients with diabetes: A systematic review.

BACKGROUND: Securing an early accurate diagnosis of diabetic foot infections and assessment of their severity are of paramount importance since these infections can cause great morbidity and potential mortality and present formidable challenges in surgical and antimicrobial treatment. METHODS: In June 2022, we searched the literature using PubMed and EMBASE for published studies on the diagnosis of diabetic foot infection (DFI). On the basis of pre-determined criteria, we reviewed prospective controlled, as well as non-controlled, studies in English. We then developed evidence statements based on the included papers. RESULTS: We selected a total of 64 papers that met our inclusion criteria. The certainty of the majority of the evidence statements was low because of the weak methodology of nearly all of the studies. The available data suggest that diagnosing diabetic foot infections on the basis of clinical signs and symptoms and classified according to the International Working Group of the Diabetic Foot/Infectious Diseases Society of America scheme correlates with the patient's likelihood of the need for hospitalisation, lower extremity amputation, and risk of death. Elevated levels of selected serum inflammatory markers such as erythrocyte sedimentation rate (ESR), C-reactive protein and procalcitonin are supportive, but not diagnostic, of soft tissue infection. Culturing tissue samples of soft tissues or bone, when care is taken to avoid contamination, provides more accurate microbiological information than culturing superficial (swab) samples. Although non-culture techniques, especially next-generation sequencing, are likely to identify more bacteria from tissue samples including bone than standard cultures, no studies have established a significant impact on the management of patients with DFIs. In patients with suspected diabetic foot osteomyelitis, the combination of a positive probe-to-bone test and elevated ESR supports this diagnosis. Plain X-ray remains the first-line imaging examination when there is suspicion of diabetic foot osteomyelitis (DFO), but advanced imaging methods including magnetic resonance imaging (MRI) and nuclear imaging when MRI is not feasible help in cases when either the diagnosis or the localisation of infection is uncertain. Intra-operative or non-per-wound percutaneous biopsy is the best method to accurately identify bone pathogens in case of a suspicion of a DFO. Bedside percutaneous biopsies are effective and safe and are an option to obtain bone culture data when conventional (i.e. surgical or radiological) procedures are not feasible. CONCLUSIONS: The results of this systematic review of the diagnosis of diabetic foot infections provide some guidance for clinicians, but there is still a need for more prospective controlled studies of high quality.

Interventions in the management of diabetes-related foot infections: A systematic review.

The optimal approaches to managing diabetic foot infections remain a challenge for clinicians. Despite an exponential rise in publications investigating different treatment strategies, the various agents studied generally produce comparable results, and high-quality data are scarce. In this systematic review, we searched the medical literature using the PubMed and Embase databases for published studies on the treatment of diabetic foot infections from 30 June 2018 to 30 June 2022. We combined this search with our previous literature search of a systematic review performed in 2020, in which the infection committee of the International Working Group on the Diabetic Foot searched the literature until June 2018. We defined the context of the literature by formulating clinical questions of interest, then developing structured clinical questions (Patients-Intervention-Control-Outcomes) to address these. We only included data from controlled studies of an intervention to prevent or cure a diabetic foot infection. Two independent reviewers selected articles for inclusion and then assessed their relevant outcomes and methodological quality. Our literature search identified a total of 5,418 articles, of which we selected 32 for full-text review. Overall, the newly available studies we identified since 2018 do not significantly modify the body of the 2020 statements for the interventions in the management of diabetes-related foot infections. The recent data confirm that outcomes in patients treated with the different antibiotic regimens for both skin and soft tissue infection and osteomyelitis of the diabetes-related foot are broadly equivalent across studies, with a few exceptions (tigecycline not non-inferior to ertapenem [±vancomycin]). The newly available data suggest that antibiotic therapy following surgical debridement for moderate or severe infections could be reduced to 10 days and to 3 weeks for osteomyelitis following surgical debridement of bone. Similar outcomes were reported in studies comparing primarily surgical and predominantly antibiotic treatment strategies in selected patients with diabetic foot osteomyelitis. There is insufficient high-quality evidence to assess the effect of various recent adjunctive therapies, such as cold plasma for infected foot ulcers and bioactive glass for osteomyelitis. Our updated systematic review confirms a trend to a better quality of the most recent trials and the need for further well-designed trials to produce higher quality evidence to underpin our recommendations.

Outpatient Foot-Sparing Surgery Is Safe in Selected Patients with Diabetic Foot Infections.

OBJECTIVE: To determine if outpatient foot-sparing surgery for patients with diabetic foot infections (DFIs) is associated with a higher rate of treatment failure or longer healing time. METHODS: In this prospective observational study, the authors consecutively recruited a cohort of 200 patients with moderate and severe DFIs from the Diabetic Foot Unit of Hospital San Juan de Dios, Caja Costarricense de Seguro Social, San José de Costa Rica, Costa Rica from October 15, 2020 to December 15, 2021. They compared outpatients with those admitted. Cox univariate analysis was performed, with time to treatment failure and time to healing as dependent variables and outpatient management as the independent variable. RESULTS: Seventy-one patients underwent surgery on an outpatient basis (35.5%), and 129 (64.5%) were admitted. Sixty of 111 patients (54.1%) with moderate infections were treated as outpatients versus 11 of 89 (12.4%) of those with severe infections. Twelve (16.9%) of the outpatients and 26 (20.2%) of those admitted presented failure (P = .57). The Cox univariate analysis with time to failure of treatment associated with outpatient management reported a hazard ratio of 1.26 (95% CI, 0.64-2.50; P = .50), and the analysis regarding healing time reported a hazard ratio of 0.91 (95% CI, 0.66-1.25; P = .56). CONCLUSIONS: Foot-sparing surgery on an outpatient basis was safe in more than half the cases of moderate DFIs, especially in patients with osteomyelitis. This approach is not associated with treatment failure or a longer healing time. Patients with severe infections, penetrating injuries, necrosis, or high inflammatory response and those with peripheral arterial disease who require revascularizations should be admitted to the hospital.

IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-related Foot Infections (IWGDF/IDSA 2023).

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the management and prevention of diabetes-related foot diseases since 1999. The present guideline is an update of the 2019 IWGDF guideline on the diagnosis and management of foot infections in persons with diabetes mellitus. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used for the development of this guideline. This was structured around identifying clinically relevant questions in the P(A)ICO format, determining patient-important outcomes, systematically reviewing the evidence, assessing the certainty of the evidence, and finally moving from evidence to the recommendation. This guideline was developed for healthcare professionals involved in diabetes-related foot care to inform clinical care around patient-important outcomes. Two systematic reviews from 2019 were updated to inform this guideline, and a total of 149 studies (62 new) meeting inclusion criteria were identified from the updated search and incorporated in this guideline. Updated recommendations are derived from these systematic reviews, and best practice statements made where evidence was not available. Evidence was weighed in light of benefits and harms to arrive at a recommendation. The certainty of the evidence for some recommendations was modified in this update with a more refined application of the GRADE framework centred around patient important outcomes. This is highlighted in the rationale section of this update. A note is also made where the newly identified evidence did not alter the strength or certainty of evidence for previous recommendations. The recommendations presented here continue to cover various aspects of diagnosing soft tissue and bone infections, including the classification scheme for diagnosing infection and its severity. Guidance on how to collect microbiological samples, and how to process them to identify causative pathogens, is also outlined. Finally, we present the approach to treating foot infections in persons with diabetes, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and bone infections; when and how to approach surgical treatment; and which adjunctive treatments may or may not affect the infectious outcomes of diabetes-related foot problems. We believe that following these recommendations will help healthcare professionals provide better care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes-related foot disease.

Residual osteomyelitis at the resection margin after conservative surgery is not associated with the recurrence of diabetic foot infection and may successfully be treated without postoperative antibiotic therapy.

AIMS: We hypothesize that microbiology- and pathology-confirmed positive bone margins after the resection of diabetes-related foot osteomyelitis are associated with worse outcomes. METHODS: We conducted a prospective study consisting of a cohort of 93 patients with diabetes-related foot osteomyelitis (histopathology confirmed) who underwent bone resection and where an additional bone biopsy was taken at the resection margin. The primary outcome was the recurrence of the infection. RESULTS: Pathology-confirmed positive margins were detected in 62 cases (66.7%), microbiology-confirmed positive margins were detected in 75 cases (80.6%) and recurrence was detected in 19 patients (20.4%). Chi-squared test failed to show the presence of an association between the recurrence of the infection with pathology-confirmed positive margins (p = 0.82), with microbiology-confirmed positive margins, (p = 0.34) and with the use of postoperative antibiotics (p = 0.70). Healing in patients with pathology-confirmed positive margins was achieved in a median of 12 weeks (95% CI 9.2-18) and those with pathology-confirmed negative margins in 14.9 weeks (95% CI 10.2-21.9), Log-rank test, p = 0.74. Thirty-four patients out of 61 available for follow-up (55.7%) with pathology-confirmed positive margins were treated without postoperative antibiotics. In that group, Chi-squared test failed to show the presence of an association between the recurrence of the infection with the use of postoperative antibiotics (p = 0.47). CONCLUSIONS: A positive margin was neither associated with the recurrence of the infection nor with the time to healing. More than half of patients with pathology-confirmed positive margins were treated without postoperative antibiotics and this approach was not associated with the recurrence of the infection.

Severe diabetic foot infections without systemic inflammatory response syndrome: Prospective validation of a new category.

We aimed to validate the prognostic value of subclassifying moderate diabetic foot infections into two categories: moderate and moderate/severe. We conducted a prospective study of a cohort of 200 patients with moderate and severe infections. Moderate infections were subclassified after applying a previously published score. Variables associated with prognosis were: need for any amputation, major amputation, need for hospitalisation, length of hospitalisation, length of antibiotic therapy, reinfection rate and infection-related mortality. Infections were moderate in 111 cases (55.5%) and severe in 89 (44.5%). Osteomyelitis (OM) was diagnosed in 114 cases (57%), 73 moderate (36.5%) and 41 severe (20.5%). Patients with severe OM had a higher rate of amputations, major amputations, hospitalisations and need for antibiotic therapy, and a longer duration of antibiotics when compared with moderate OM. After applying the score, moderate infections were subclassified into 73 moderate cases (65.7%) and 38 moderate/severe cases (34.3%). Moderate/severe had a higher rate of amputations, major amputations, hospitalisations and need for antibiotics than moderate ones. No differences regarding prognosis were found between moderate/severe and severe infections with systemic inflammatory response syndrome. Moderate/severe diabetic foot infections, which could also be known as severe infections without systemic inflammatory response syndrome, should be recognised as a new subgroup. We propose to merge severe diabetic foot infections with and without systemic inflammatory response syndrome into a unique category due to its prognostic value. Furthermore, OM should be added to both moderate and severe new categories of diabetic foot infections.

Clinical, microbiological and inflammatory markers of severe diabetic foot infections.

AIMS: In addition to systemic inflammatory response syndrome (SIRS), various clinical signs, microbiological findings and inflammatory markers could be associated with severe diabetic foot infections (DFI). METHODS: This study included a retrospective cohort of 245 patients with DFI treated at San Juan de Dios Hospital in San José de Costa Rica. Erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), CRP/albumin ratio, peripheral blood leucocyte ratios and the Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) scoring system were evaluated. Univariate analysis was carried out between moderate and severe infections. ROC curves were plotted. Cut-off value of inflammatory markers for diagnosing severe infections was established and then dichotomized to be included in a logistic regression model. A score was designed based on its results. RESULTS: Skin necrosis (p < 0.01, OR = 8.5, 95% CI = 3.5-20.9), ESR > 94 mm/h (p < 0.01, OR = 2.5, 95% CI = 1.2-5.1), albumin < 2.8 g/dl (p = 0.04, OR = 2.0, 95% CI = 1.0-4.1) and neutrophil-to-lymphocyte ratio (NLR) > 4.52 (p < 0.01, OR = 3.3, 95% CI = 1.6-6.5) were found to be predictive of severe infections. Score >5 had a good diagnosis performance for classifying severe infections. Moderate infections with a score >5 had a worse prognosis than moderate ones. CONCLUSIONS: We found an association of necrosis, serum albumin, ESR and NLR values with severe DFI. The presence of these predictive factors of severity in cases of moderate infections was significantly associated with a higher rate of amputations and recurrences, longer duration of antibiotic treatment and longer hospital stays. DFI could be classified as mild, moderate, severe without SIRS and severe.

Interventions in the management of infection in the foot in diabetes: a systematic review.

The optimal approaches to managing diabetic foot infections remain a challenge for clinicians. Despite an exponential rise in publications investigating different treatment strategies, the various agents studied generally produce comparable results, and high-quality data are scarce. In this systematic review, we searched the medical literature using the PubMed and Embase databases for published studies on the treatment of diabetic foot infections as of June 2018. This systematic review is an update of previous reviews, the first of which was undertaken in 2010 and the most recent in 2014, by the infection committee of the International Working Group of the Diabetic Foot. We defined the context of literature by formulating clinical questions of interest, then developing structured clinical questions (PICOs) to address these. We only included data from controlled studies of an intervention to prevent or cure a diabetic foot infection. Two independent reviewers selected articles for inclusion and then assessed their relevant outcomes and the methodological quality. Our literature search identified a total of 15 327 articles, of which we selected 48 for full-text review; we added five more studies discovered by means other than the systematic literature search. Among these selected articles were 11 high-quality studies published in the last 4 years and two Cochrane systematic reviews. Overall, the outcomes in patients treated with the different antibiotic regimens for both skin and soft tissue infection and osteomyelitis of the diabetic foot were broadly equivalent across studies, except that treatment with tigecycline was inferior to ertapenem (±vancomycin). Similar outcomes were also reported in studies comparing primarily surgical and predominantly antibiotic treatment strategies in selected patients with diabetic foot osteomyelitis. There is insufficient high-quality evidence to assess the effect of various adjunctive therapies, such as negative pressure wound therapy, topical ointments or hyperbaric oxygen, on infection related outcomes of the diabetic foot. In general, the quality of more recent trial designs are better in past years, but there is still a great need for further well-designed trials to produce higher quality evidence to underpin our recommendations.

Diagnosis of infection in the foot in diabetes: a systematic review.

BACKGROUND: Securing an early accurate diagnosis of diabetic foot infections and assessment of their severity are of paramount importance since these infections can cause great morbidity and potentially mortality and present formidable challenges in surgical and antimicrobial treatment. METHODS: In June 2018, we searched the literature using PuEbMed and EMBASE for published studies on the diagnosis of diabetic foot infection. On the basis of predetermined criteria, we reviewed prospective controlled, as well as noncontrolled, studies in any language, seeking translations for those not in English. We then developed evidence statements on the basis of the included papers. RESULTS: From the 4242 records screened, we selected 35 papers that met our inclusion criteria. The quality of all but one of the evidence statements was low because of the weak methodology of nearly all of the studies. The available data suggest that diagnosing diabetic foot infections on the basis of clinical signs and symptoms and classified according to the International Working Group of the Diabetic Foot scheme correlates with the patient's likelihood of ulcer healing, of lower extremity amputation, and risk of death. Elevated levels of selected serum inflammatory markers are supportive, but not diagnostic, of soft tissue or bone infection. In patients with suspected diabetic foot osteomyelitis, both a positive probe-to-bone test and an elevated erythrocyte sedimentation rate are strongly associated with its presence. Culturing tissue samples of soft tissues or bone, when care is taken to avoid contamination, provides more accurate microbiological information than culturing superficial (swab) samples. Plain X-ray remains the first-line imaging examination when there is suspicion of diabetic foot osteomyelitis, but advanced imaging methods help in cases when either the diagnosis or the localization of infection is uncertain. CONCLUSION: The results of this first reported systematic review on the diagnosis of diabetic foot infections provide some guidance for clinicians, but there is a need for more prospective controlled studies of high quality.

Guidelines on the diagnosis and treatment of foot infection in persons with diabetes (IWGDF 2019 update).

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the diagnosis and treatment of foot infection in persons with diabetes and updates the 2015 IWGDF infection guideline. On the basis of patient, intervention, comparison, outcomes (PICOs) developed by the infection committee, in conjunction with internal and external reviewers and consultants, and on systematic reviews the committee conducted on the diagnosis of infection (new) and treatment of infection (updated from 2015), we offer 27 recommendations. These cover various aspects of diagnosing soft tissue and bone infection, including the classification scheme for diagnosing infection and its severity. Of note, we have updated this scheme for the first time since we developed it 15 years ago. We also review the microbiology of diabetic foot infections, including how to collect samples and to process them to identify causative pathogens. Finally, we discuss the approach to treating diabetic foot infections, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and for bone infections, when and how to approach surgical treatment, and which adjunctive treatments we think are or are not useful for the infectious aspects of diabetic foot problems. For this version of the guideline, we also updated four tables and one figure from the 2016 guideline. We think that following the principles of diagnosing and treating diabetic foot infections outlined in this guideline can help clinicians to provide better care for these patients.

Platelet-rich plasma for the treatment of diabetic foot ulcers: A meta-analysis.

Foot ulcer is a major complication of diabetes mellitus and often precedes leg amputation. Among the different methods to achieve ulcer healing, the use of platelet-rich plasma, which is rich in multiple growth factors and cytokines and may have similarities to the natural wound healing process, is gaining in popularity. A systematic review with meta-analyses was performed to evaluate the safety and clinical effectiveness of platelet-rich plasma for the treatment of diabetic foot ulcers compared to standard treatment or any other alternative therapy. The electronic databases Medline, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials were consulted in March 2017 with no restrictions placed on the publication date. Predefined criteria were used to determine inclusion of studies and to assess their methodologic quality. Eight randomized clinical trials and two prospective longitudinal-observational studies with control group were included. Platelet-rich plasma treatment increased the likelihood of chronic wound healing (RR = 1.32; 95% CI: 1.11, 1.57, I2 = 15%) while the volume of the ulcer (MD = 0.12 cm2 ; 95% CI: 0.08, 0.16; p < 0.01; I2 = 0%) and time to complete wound healing (MD = -11.18 days; 95% CI: -20.69, -1.68; I2 = 53%) decreased. Regarding safety profile, platelet-rich plasma did not differ from standard treatment in terms of probability of occurrence of wound complications (RR = 0.57; 95% CI: 0.25, 1.28; I2 = 0%) or recurrences (RR = 2.76; 95% CI: 0.23, 33.36; p = 0.43; I2 = 82%) but it decreased the rate of adverse events (RR = 0.80; 95% CI: 0.66, 0.96; p = 0.02; I2 = 0%). Cumulative meta-analysis revealed that there is enough evidence to demonstrate a statistically significant benefit. However, studies included presented serious methodologic flaws. According to the results, platelet-rich plasma could be considered a candidate treatment for nonhealing of diabetic foot ulcers.

Validation of an algorithm to predict reulceration in amputation patients with diabetes.

The aim of this article was to assess the ability to predict reulceration in people with diabetes and a history of minor amputation according to the formula proposed by Miller et al. A retrospective study was performed on 156 consecutive records of patients with a recent history of simple or multiple forefoot amputation. The sample was divided according to Miller's formula into patients at low risk of reulceration and those at high risk; those were further divided into two subgroups according to whether or not the first segment of the forefoot had been amputated. Forty-eight (47·1%) individuals suffered forefoot reulceration, showing a median reulceration-free survival time of 8 months [interquartile range (IR) 3·6-14·8]. Nephropathy (P = 0.005) and Miller's formula (P = 0.028) were risk factors for reulceration-free survival time in the univariate analysis. The pattern relating to the first segment amputated [hazard ratio (HR) 2·853; P = 0·004; 95% confidence interval (CI) 1·391-5·849] and nephropathy (HR 2·468; P = 0.004; 95% CI 1.328-4.587) showed a significant hazard ratio in the multivariate Cox model. Participants with first segment amputation and one other amputation showed an association with the probability of reulceration in comparison with any other specific type of minor amputation.

Two-Step Conservative Surgery for Complicated Forms of Diabetes-Related Foot Osteomyelitis.

Diabetes-related foot osteomyelitis (DFO) is a common yet complex condition, often complicated by concurrent soft tissue infections (STIs). This study evaluates the efficacy of a two-step conservative surgical approach, hypothesizing that it offers comparable outcomes to a one-step procedure. Conducted on a cohort of 93 patients with DFO, the study categorized cases into two types: OM1 (osteomyelitis without STI) and OM2 (osteomyelitis with STI). OM2 was further subdivided into OM2a (early diagnosis) and OM2b (late diagnosis), with OM2 patients undergoing initial soft tissue debridement followed by elective bone surgery. The results indicated no significant differences in infection recurrence or amputation rates between the two surgical approaches, with recurrence observed in 20.7% of cases and amputations in 10.8%. The two-step procedure was associated with higher inflammatory responses and greater need for antibiotics and hospital admissions. However, these factors did not translate into increased recurrence or amputation compared to the one-step procedure. The study supports the two-step approach as a safe and effective method for managing complicated DFO cases, providing a viable alternative to immediate amputation or single-stage surgery. Despite some limitations, including regional specificity and potential underdiagnosis in late-diagnosed cases, the findings offer valuable insights for clinical management and suggest further research to refine treatment protocols. The study's strengths include confirmed histopathological diagnoses and consistent follow-up, reinforcing the validity of the two-step surgical approach for complex DFO treatment.

Handgrip Strength But Not Malnutrition According to Global Leadership Initiative on Malnutrition Criteria Is a Risk Factor for Mortality in Hospitalized Patients with Ischemic Diabetic Foot Ulcers.

Objective: This study aimed to test the hypothesis that patients with malnutrition and impaired muscle function determined by hand grip strength (HGS) will have adverse outcomes. Approach: We conducted a prospective observational study of 77 patients admitted for ischemic diabetic foot ulcers (IDFU). Global Leadership Initiative on Malnutrition (GLIM) criteria were used to diagnose malnutrition. Values obtained with a dynamometer were dichotomized into values < and ≥ mean according to the values obtained in both sexes. The Cox proportional hazards model and the Kaplan-Meier method were applied. STROBE guidelines for cohorts were met in the present study. Results: In total, 55 patients (71.4%) were malnourished. Malnutrition according to GLIM criteria was not associated with adverse outcomes. HGS < mean was associated with patient age, duration of diabetes mellitus, body mass index, brachial circumference, plasma albumin, prealbumin, hemoglobin, transferrin, and HbA1c levels. Predictive variables of mortality after applying multivariate Cox model were age >69years (hazard ratio [HR] 4.0, 95% confidence interval [CI] 1.3-12.0, p = 0.01), and HGS < mean (HR 3.7, 95% CI 1.2-11.3, p = 0.01). Survival time in patients with HGS < mean was shorter than in those with HGS ≥ mean, p < 0.01. Innovation: HGS is an easy and useful tool associated with nutritional parameters and with prognosis in patients admitted for IDFU. Conclusions: Neither malnutrition nor muscle function impairment were associated with limb loss or a need for readmission. Patients with HGS < mean presented shorter survival times. As HGS is a simple and cost-effective tool, it should be implemented as part of the nutritional admission evaluation.

Risk Factors Associated with Failure of Toe Amputation in Diabetic Foot Infections.

We aim to identify the factors associated with the failure of amputation of one to three toes (index toe amputation) in patients with diabetes and foot infection. We conducted a retrospective cohort of 175 patients with diabetes who were hospitalized for moderate to severe foot infection and underwent amputation of one to three toes. A Poisson regression model was used to determine the prevalence ratio (PR) as a measure of association. The mean age was 63.3 ± 11.4 years. Fifty-three patients presented failure after undergoing toe amputation (30.3%). Multivariate analysis, adjusted for age and sex, showed the following significant variables: severe infection (PR: 1.78; 95% confidence interval [CI]: 1.14-2.78; P = 0.011), infection by Escherichia coli (PR: 2.21; 95% CI: 1.42-3.43; P < 0.001), infection by Pseudomonas aeruginosa (PR: 2.11; 95% CI: 1.29-3.43; P = 0.003) and prothrombin time (PR: 1.13; 95% CI: 1.05-1.21; P = 0.001), obesity (PR: 0.58; 95% CI: 0.37-0.93; P = 0.024), and haemoglobin value (PR: 0.92; 95% CI: 0.86-0.99; P = 0.023). About one-third of patients who underwent amputation of one to three toes for diabetic foot infection presented a failure and required a more proximal surgery. Severe infections, isolation of Pseudomonas aeruginosa and Escherichia coli, and prolonged prothrombin time were associated with a higher prevalence of failure. However, obesity and an elevated haemoglobin level were associated with a lower prevalence of failure.

Onychomycosis and Tinea Pedis in the Feet of Patients With Diabetes.

This study aimed to determine the prevalence of onychomycosis and interdigital tinea pedis in a cohort of Spanish patients with diabetes in whom onychomycosis was clinically suspected (n = 101). Samples from a first toenail scraping and the fourth toe clefts were subjected to potassium hydroxide direct vision and incubated in Sabouraud and dermatophyte test medium. Fifty-eight samples were also analyzed by a pathologist using periodic acid-Schiff staining and Calcofluor white direct fluorescence microscopy. Onychomycosis was only confirmed in 41 patients (40.6%). The most frequent aetiological agent was Trichophyton rubrum, isolated in 10 patients (36%), followed by Candida parapsilosis in 7 patients (25%). Tests on the fourth toe cleft samples were only positive in 11 patients (10.9%), and in all cases, onychomycosis was also diagnosed. Neuroischemic foot was the only significant variable associated with onychomycosis in the univariate analysis (P < .01). A positive result for mycosis in the fourth toe cleft was found in 11 cases (10.9%) and was associated with a history of myocardial infarction (P< .01; odds ratio [OR]: 84.2, confidence interval [CI]: 6.8-1036.4) and neuroischemic foot (P< .01; OR: 13.7, CI: 12.6-71.6) in the multivariate model. In conclusion, the prevalence of onychomycosis and tinea pedis in patients with diabetes in whom onychomycosis was clinically suspected was 40.6% and 10.9%, respectively. In addition, onychomycosis was not always associated with tinea pedis. These results show that clinical diagnosis has low accuracy in people with diabetes mellitus, and that diagnosis should not be based on clinical toenail characteristics alone.