Infected diabetic foot ulcers decision making

NewsBot · Jul 12, 2014

Cultures of Diabetic Foot Ulcers Without Clinical Signs of Infection Do Not Predict Outcomes.
Gardner SE, Haleem A, Jao YL, Hillis SL, Femino JE, Phisitkul P, Heilmann KP, Lehman SM, Franciscus CL.
Diabetes Care. 2014 Jul 10

OBJECTIVE:
We examined associations between ulcer bioburden and ulcer outcomes in neuropathic diabetic foot ulcers (DFUs) that lacked clinical signs of infection.

RESEARCH DESIGN AND METHODS: Three dimensions of bioburden (i.e., microbial load, microbial diversity, and the presence of likely pathogens) were measured at baseline using swab cultures obtained by Levine's technique. Subjects were assessed every 2 weeks for 26 weeks to determine the rate of healing and development of infection-related complications. Foot ulcers were offloaded using total-contact casts and routinely debrided. To establish associations between bioburden and rate of healing, Cox proportional hazards and least-squares regression were used after adjusting for ulcer depth, surface area, and duration.

RESULTS: A total of 77 subjects completed the study. Sixty-five (84.4%) had ulcers that healed during follow-up; weeks-to-closure ranged from 2 to 26 (median 4.0). Mean (± SD) percent reduction in surface area/week was 25.0% (± 23.33). Five (6.5%) of the DFUs developed an infection-related complication. None of the bioburden dimensions (i.e., microbial load, microbial diversity, or presence of likely pathogens) was significantly associated with weeks-to-closure or percent reduction in surface area per week. Weeks-to-closure was best predicted by ulcer duration, depth, and surface area (c-statistic = 0.75).

CONCLUSIONS: Culturing DFUs that showed no clinical signs of infection had no predictive value for outcomes of DFUs managed with total-contact casts and routine debridement. These findings support recommendations of the Infectious Disease Society of America that culturing and antibiotics should be avoided in treating DFUs that show no clinical signs of infection.
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NewsBot · Jul 16, 2014

Foot Injuries Among Hajj Pilgrims with and Without Diabetes Mellitus: Implications for Infection Management.
Alfelali M, Barasheed O, Alshehri J, Bokhary H, Alsaadi S, Alhamzi A, Aljohani N, Driscoll T, Rashid H.
Infect Disord Drug Targets. 2014 Jul 13.

Pilgrims attending Hajj in Makkah are at high risk of suffering from trauma and foot injury as they are required to make circuits barefooted on scorching marbles around the Holy Mosque, and march between two hillocks for long hours. No study has ever described the pattern of foot wounds among them. This observational study aimed to determine the spectrum of foot injuries among diabetic and non-diabetic Hajj pilgrims and the preventive measures adopted by them. Pilgrims who attended the Hajj 2013 and sought medical care for foot wounds at mobile podiatric clinics in Mina during the peak days of Hajj were invited to participate in the study and fill out a questionnaire while they were serviced. Podiatric carers noted down the significant signs of foot injuries. Out of 197 pilgrims from 21 different countries who participated in this study, 60 (31%) were diabetic. The two most common injuries observed were blisters (34%) and erythema (25%). Both diabetic and non-diabetic Hajj pilgrims were at high risk of developing infectious wounds, however a significantly higher proportion of diabetic pilgrims had callosities. Use of appropriately fitting protective footwear, and regularity in diets and drugs are highly recommended for pilgrims' optimum foot care. Tailored educational advice on foot hygiene before and during travel could be beneficial for Hajj pilgrims.
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NewsBot · Aug 9, 2014

Clinical Outcomes of Multidrug Resistant Pseudomonas aeruginosa Infection and the Relationship With Type III Secretion System in Patients With Diabetic Foot
Jinghang Zhang
International Journal of Lower Extremity Wounds August 8, 2014 1534734614545878

The objective was to analyze the clinical outcomes of multidrug resistant Pseudomonas aeruginosa (MDRPA) infection and determine the relationship between type III secretion system (TTSS) and MDRPA in diabetic foot (DF) patients. A total of 117 patients infected with P aeruginosa were recruited and grouped into MDRPA and non-MDRPA group according to antimicrobial susceptibility testing. TTSS genes were detected by polymerase chain reaction (PCR). Potential risk factors for MDRPA infection were examined using univariate and multivariate analyses. Clinical outcomes were compared on the basis of MDRPA or TTSS virulence gene. Previous antibiotic therapy, previous hospitalization and osteomyelitis were associated with MDRPA infection. MDRPA group had a higher amputation/toe rate (32.6% vs 16.2%) and lower healing rate (20.9% vs 41.9%) than non-MDRPA group (P = .032). A significantly higher proportion of exoU was present in MDRPA group (75.0% vs 25.0%, P < .05) than non-MDRPA group. Patients infected with exoU isolates had a lower healing rate and higher amputation/toe rate (25.0% vs 65.2%, 33.3% vs 8.7%, P < .05) than infected with exoS isolates. The exoU gene was predominance among MDRPA strains. The poor clinical outcomes of MDRPA infection in patients with DF were attributable to exoU gene.
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NewsBot · Sep 6, 2014

Diabetic foot infections in Zagazig University Hospital: bacterial etiology, antimicrobial resistance and biofilm formation
Abbas Hisham A, El-Sayed Mona A., Al-Kadi Laila M., Gad Amany I
Research Journal of Pharmacy and Technology Year : 2014, Volume : 7, Issue : 7

This study aimed to investigate the etiologic agents of diabetic foot infections, their antimicrobial resistance and biofilm formation ability. 50 non-repetitive samples were taken during a six-month period. Isolation and identification of pathogens were done according to standard procedures. The sensitivity to antimicrobial agents was determined by the disc diffusion method and the assessment of biofilm production was performed by the tube method.

Negative cultures were found in 4 (8%) samples. Polymicrobial infections were found in 22 (44%) samples. A total of 75 bacteria were isolated with an isolation ratio of 1.63 bacteria per patient. Gram-positive cocci were observed in 14.67% of isolates and Gram-negative bacilli in 85.33% of isolates. The most frequent organisms isolated were Proteus mirabilis (20%), E. coli (18.67%), Pseudomonas aeruginosa (16%), Klebsiella pneumoniae and Staphylococcus aureus (10.67% each). Fifty one strains were isolated in polymicrobial cultures. Proteus mirabilis (21.57%), Pseudomonas aeruginosa (19.61%), E. coli (15.69%), Klebsiella pneumoniae (11.76%), and Staphylococcus aureus (7.84%) were the most common organisms recovered in polymicrobial infections.

Imipenem was the most effective antibiotic against both Gram-negative and Gram-positive isolates. High resistance was shown by Acinetobacter baumanii (90.91%) followed by Klebsiella spp. (81.12%), Staphylococcus epidermidis (80%), E. coli (75.97%), Pseudomonas spp. (65.73%), Enterococcus faecalis (60%), Citrobacter freundii (54.55%), Proteus spp. (46.97%), while the least resistance was observed with Staphylococcus aureus (23.75%).

Biofilm production was positive in 70 isolates (93.33%). Among these isolates 44.29% were assessed as strong biofilm forming. Six gram-positive isolates (54.55%) and 31 isolates (48.44%) of gram-negative bacilli were strong biofilm forming. Among the common isolated pathogens, Proteus mirabilis was the predominant strong biofilm producer (80%), followed by Pseudomonas aeruginosa and staphylococcus aureus (50% each) and E.coli (28.57%). Resistance to antibiotics was higher among biofilm forming isolates than non-biofilm forming ones.

Multidrug resistance was found in 81.33% of isolates. Gram-negative bacilli showed higher multidrug resistance (89.06%) than gram-positive cocci (36.36%). The most frequent multidrug resistance pathogens were E. coli (21.31%), Pseudomonas aeruginosa and Proteus mirabilis (19.67% each) and Klebsiella pneumoniae (13.11%). Biofilm production was correlated with multidrug resistance. In 90.16% of MDR pathogens, biofilm formation was positive. The most common MDR biofilm producer pathogens were Pseudomonas aeruginosa and Proteus mirabilis (21.82% each), E. coli (18.18%) and Klebsiella pneumoniae (12.73%).

Due to the great involvement of diabetic foot ulcer in non-traumatic foot amputations, it is of significance to identify the causative pathogens of these ulcers, their antibiogram and biofilm formation in order to select the proper therapy.
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NewsBot · Sep 17, 2014

Clinical Outcomes of Multidrug Resistant Pseudomonas aeruginosa Infection and the Relationship With Type III Secretion System in Patients With Diabetic Foot
Jinghang Zhang et al
International Journal of Lower Extremity Wounds September 2014 vol. 13 no. 3 205-210

The objective was to analyze the clinical outcomes of multidrug resistant Pseudomonas aeruginosa (MDRPA) infection and determine the relationship between type III secretion system (TTSS) and MDRPA in diabetic foot (DF) patients. A total of 117 patients infected with P aeruginosa were recruited and grouped into MDRPA and non-MDRPA group according to antimicrobial susceptibility testing. TTSS genes were detected by polymerase chain reaction (PCR). Potential risk factors for MDRPA infection were examined using univariate and multivariate analyses. Clinical outcomes were compared on the basis of MDRPA or TTSS virulence gene. Previous antibiotic therapy, previous hospitalization and osteomyelitis were associated with MDRPA infection. MDRPA group had a higher amputation/toe rate (32.6% vs 16.2%) and lower healing rate (20.9% vs 41.9%) than non-MDRPA group (P = .032). A significantly higher proportion of exoU was present in MDRPA group (75.0% vs 25.0%, P < .05) than non-MDRPA group. Patients infected with exoU isolates had a lower healing rate and higher amputation/toe rate (25.0% vs 65.2%, 33.3% vs 8.7%, P < .05) than infected with exoS isolates. The exoU gene was predominance among MDRPA strains. The poor clinical outcomes of MDRPA infection in patients with DF were attributable to exoU gene.
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NewsBot · Oct 16, 2014

Antibiotic therapy for diabetic foot infections in a tertiary care hospital in Jakarta, Indonesia.
Radji M, Putri CS, Fauziyah S.
Diabetes Metab Syndr. 2014 Oct 10

AIMS:
The purpose of this study was to determine the microbiology of diabetic foot infections and to assess the antibiotic susceptibility patterns.
MATERIALS AND METHODS:
A cross sectional retrospective study of 35 patients with diabetic foot infections hospitalized at the internal medicine clinic of Dr. Mintohardjo Navy Hospital, Jakarta. The data were collected from patient medical records retrospectively. The classification of the diabetic foot infections was evaluated according to Meggit-Wagner's Classification. Identification of causative microorganisms was performed by standard microbiologic methods. Antibiotic susceptibility testing was performed using disk-diffusion method.
RESULTS:
During January to December 2012, a total of 288 of diabetic patients were admitted to hospital, and 35 patients had diabetic foot infections. According to Meggit-Wagner's classification the most common disease was grade 3 in 31.4% patients, followed by grade 2 in 25.7%, and grade 4 in 17.3% of patients. Conservative diabetic control care was carried out in 37.1% of patients, and surgical intervention was carried out in 62.9% of patients. A total of 59 pathogens were identified. The most common infecting microorganism isolated on pus cultures was Staphylococcus aureus (47.5%), followed by Pseudomonas spp (16.9%), E. coli (10.2%), Streptococcus spp. (8.5%), Enterobacter spp. (7.0%), Proteus spp. (6.7%), and Acinetobacter spp. (3.2%). Overall, 37.2% of the diabetic foot infection caused by a single microorganism, and 62.8% had polymicrobial infections. The most frequently administrated antibiotic was ceftriaxone (40.0%), followed by ciprofloxacin (11.4%), and meropenem (8.6%).
CONCLUSION:
Diabetic foot infections (62.8%) were polymicrobial. S. aureus was most commonly found in the foot infection. Most of the microorganisms isolated from diabetic foot infection were resistant to many types of antibiotics.
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NewsBot · Oct 22, 2014

Antimicrobial susceptibility pattern in diabetic foot ulcer: a pilot study.
Sekhar S, Vyas N, Unnikrishnan M, Rodrigues G, Mukhopadhyay C.
Ann Med Health Sci Res. 2014 Sep;4(5):742-5. doi: 10.4103/2141-9248.141541.

BACKGROUND:
Diabetic foot infections (DFIs) are major public health problems and knowledge of microbes that cause infections are helpful to determine proper antibiotic therapy.
AIMS:
The aim was to investigate the antimicrobial susceptibility pattern of microbes in DFIs.
SUBJECTS AND METHODS:
A cross-sectional study was conducted for a period of 6 months at the Department of General Surgery, KMC hospital, Manipal University, Manipal, India. During this period, 108 patients having DFIs admitted in the general surgery wards were tracked from the hospital data management system. These patients' pus samples were examined as Gram-stained smear and cultured aerobically on blood agar and MacConkey agar plates. Antimicrobial susceptibility test was performed by disc diffusion techniques according to Clinical and Laboratory Standards Institute guidelines.
RESULTS:
Of the 108 specimens of the diabetic foot lesions, culture showed polymicrobial growth in 44.4% (48/108). Prevalence of Gram-negative organisms (56%, 84/150) was found to be more than Gram-positive organisms (44%, 66/150). However, Staphylococcus aureus was the most frequent pathogen (28%, 42/150). All Gram-positive aerobes were sensitive to doxycycline. All Gram-negative isolates, including extended spectrum beta lactamase producing strains of Proteus mirabilis and Klebsiella oxytoca except Acinetobacter were highly sensitive to amikacin, cefoperazone/sulbactam, and meropenem. Acinetobacter was completely resistant to all the common antibiotics tested.
CONCLUSION:
Prevalence showed Gram-negative bacteria was slightly more than Gram-positive bacteria in diabetic foot ulcers. This study recommends doxycycline should be empirical treatment of choice for Gram-positive isolates and amikacin, cefoperazone/sulbactam, and meropenem should be considered for most of the Gram-negatives aerobes.
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NewsBot · Nov 26, 2014

Ceftaroline fosamil for treatment of diabetic foot infections: the CAPTURE study experience
B. A. Lipsky, C. M. Cannon, A. Ramani, A. Jandourek, A. Calmaggi, H. D. Friedland and E. J. C. Goldstein
Diabetes/Metabolism Research and Reviews

Background
To ascertain which demographic, clinical and microbiological factors might affect clinical outcomes of patients with diabetic foot infections, excluding known osteomyelitis, by analysing CAPTURE registry study data of patients treated with ceftaroline fosamil.

Methods
At participating study centres, we collected data by randomised selection and chart review, including patient demographics, co-morbidities, infecting pathogens, antibiotic use, surgical interventions and clinical response. Evaluable patients were those with data sufficient to determine clinical outcome. Clinical success was defined as clinical cure with no use of other antibiotics, or clinical improvement with a switch to oral antibiotic therapy at the end of intravenous ceftaroline fosamil treatment.

Results
Among 201 patients (mean age 61.7 years, mean body mass index 33.2, 57% males), 40% had peripheral vascular disease (PVD). Prior antibiotic therapy had been given to 161 (80%) of the patients, most commonly with vancomycin and/or piperacillin-tazobactam. Patients received ceftaroline fosamil for a mean duration of 6.1 (range 1 – 30) days, as monotherapy in 130 (65%) patients and concurrently with other antibiotics in 71 (35%). Bacterial pathogens were identified in 114 (57%) of the patients; methicillin-resistant Staphylococcus aureus (MRSA) and methicillin-sensitive S. aureus were isolated from 56 (49%) and 28 (25%) of culture-positive patients, respectively. Clinical success was noted in 81% of patients and was not significantly associated with co-morbidities, pathogen type, or need for surgical intervention.

Conclusions
Ceftaroline fosamil treatment of diabetic foot infections was associated with high clinical success, including in patients with obesity, co-morbidities, MRSA or mixed infections, or requiring surgical intervention.
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NewsBot · Dec 16, 2014

Clinico microbiological profile of Pseudomonas
aeruginosa isolated from diabetic foot ulcer
Rajesh Kamtikar, Nagaraj Mitra
Journal of Scientific and Innovative Research 2014; 3(5): 478-481

Diabetes mellitus is a major health problem, rapidly expanding worldwide. In India, it is projected that
around 80 million will be affected by DM. Asia contributes to >60% of the world's population with
diabetes, of which two nations; India and China contribute the largest. In developing countries like India,
diabetic foot ulcerations and infections are one of the most common causes of hospitalization and often
resulting in amputation, osteomyelitis, mortality and morbidity. Infection is most often a consequence of
foot ulceration, which typically follows trauma to a neuropathic foot. The present study was conducted
to know the prevalence and sensitivity pattern of P. aeruginosa from diabetic foot infections and to
assess their susceptibility to the commonly used antibiotics. This was a retrospective study conducted at
a tertiary care hospital in South India conducted from January 2013 to August 2013. Culture materials
from all the wounds were obtained, either by washing the wound with sterile physiological saline and
then making a puncture-aspiration from the base of the wound or by applying a sterile cotton swab to the
wound. A total of 77 patients were included in the study. 104 bacteria were isolated from 77 patients.
Out of 104 bacteria, 39 (37.5%) were P. aeruginosa. Infection was polymicrobial is some cases and
Gram negative bacteria were the most common organisms isolated. P. aeruginosa showed resistnce to
most commonly used antibiotics, highest resistance was seen with Ciprofloxacin and Ofloxacin and least
with Aztreonam an Imipenem. Other studies have reported similar findings. The major concern is
emergence of resistance to third and fourth generation of Cephalosporins and even more alarming is
Carbapenem resistance surfacing nowadays. The increasing prevalence of multi drug resistance in P.
aeruginosa is a cause for concern. The selection of the antibiotic treatment should be based on the
predominant organisms which are isolated and their antimicrobial susceptibility patterns.
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NewsBot · Jan 8, 2015

New Molecular Techniques to Study the Skin Microbiota of Diabetic Foot Ulcers.
Lavigne J, Sotto A, Dunyach-Remy C, Lipsky BA.
Adv Wound Care (New Rochelle). 2015 Jan 1;4(1):38-49.

Significance: Diabetic foot ulcers (DFU) are a major and growing public health problem. They pose difficulties in clinical practice in both diagnosis and management. Bacterial interactions on the skin surface are important in the pathophysiology of DFU and may contribute to a delay in healing. Fully identifying bacteria present in these wounds is difficult with traditional culture methods. New molecular tools, however, have greatly contributed to our understanding of the role of the cutaneous microbiota in DFU.
Recent Advances: Molecular technologies revealed new information concerning how bacteria are organized in DFU. This has led to the concept of "functionally equivalent pathogroups," meaning that certain bacterial species which are usually nonpathogenic (or at least incapable of maintaining a chronic infection on their own) may coaggregate symbiotically in a pathogenic biofilm and act synergistically to cause a chronic infection. The distribution of pathogens in multispecies biofilms is nonrandom. The high bacterial diversity is probably related to the development of a microbial biofilm that is irreversibly attached to the wound matrix.
Critical Issues: Using molecular techniques requires a financial outlay for high-cost equipment. They are still too time-consuming to perform and reporting is too delayed for them to be used in routine practice. Finally, they do not differentiate live from dead or pathogenic from nonpathogenic microorganisms. Future Directions: Molecular tools have better documented the composition and organization of the skin flora. Further advances are required to elucidate which among the many bacteria in the DFU flora are likely to be pathogens, rather than colonizers.
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NewsBot · Jan 25, 2015

Population pharmacokinetics and target attainment analysis of moxifloxacin in patients with diabetic foot infections
Sebastian G. Wicha et al
The Journal of Clinical Pharmacology; Accepted Article

The objective of this study was to provide a pharmacokinetic/pharmacodynamic analysis of moxifloxacin in patients with diabetic foot infections (DFI).

The plasma concentration-time courses were determined in 50 DFI patients on day 1 and 3 after intravenous moxifloxacin 400 mg once-daily. A two-compartment population pharmacokinetic model was developed, identifying as covariates total body weight on central and peripheral volume of distribution (V1, V2) and ideal body weight on clearance (CL), respectively. For a 70 kg patient V1 was 68.1 L (interindividual variability, CV: 27.4%), V2 44.6 L and CL 12.1 L/h (25.6%). Simulations were performed to calculate the probability of target attainment (PTA) for Gram-positive and Gram-negative pathogens with fAUC/MIC targets of ≥30 and ≥100, respectively. PTA was 0.68-1 for susceptible (MIC ≤0.5 mg/L according to EUCAST) Gram-positive, but <0.25 for Gram-negative pathogens with MIC ≥0.25 mg/L. With the exception of the first 24 hours of therapy, obesity affected PTA only marginally.

Pharmacokinetic parameters in DFI patients were similar to those reported for healthy volunteers, indicating the appropriateness of the standard dose of moxifloxacin. Overall clinical efficacy has been shown previously, but PTA is limited in a subpopulation infected with formally susceptible Gram-negative pathogens close to the EUCAST breakpoint.
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NewsBot · Feb 1, 2015

Microbiology of diabetic foot ulcer with special reference to
ESBL infections
Mohammad Zubair, Abida Malik, Jamal Ahmad.
American Journal of Clinical and Experimental Medicine. Vol. 3, No. 1, 2015, pp. 6-23.

Chronic foot wounds represent an increasing burden to healthcare systems as the age of the population increases.
The deep dermal tissues of all chronic wounds harbor microorganisms, however, the precise interaction between microbes in the
wounds and impaired healing is unknown. With regard to antibiotic therapy, there is a lack of evidence concerning its
effectiveness, optimal regimens or clinical indications for treatment. Despite this lack of evidence, antibiotics are frequently a
feature of the management of chronic wounds and these patients receive significantly more antibiotic prescriptions (both
systemic and topical) than age and sex-matched patients. Current guidelines for antibiotic prescribing for such diabetic foot
wounds are often based on expert opinion rather than scientific fact and may present difficulties in interpretation and
implementation to the clinician. Although the increasing prevalence of antibiotic resistance is widely recognized, the
relationships between antibiotic resistance, chronic wound microbiology and rationales for antibiotic therapy have yet to be
determined. This review discusses the role of microbes in chronic diabetic foot wounds from a clinical perspective with particular
focus on the occurrence of type bacteria and their impact on such wounds and resistance pattern, Extended Spectrum Beta
Lactamases [ESBL] studies with special reference to Indian studies. The evidence and role of antibiotics in the treatment of such
wounds are outlined and current practice of antibiotic usage for chronic wounds in the primary care setting described. The
implications of antibiotic usage with regard to antibiotic resistance are also considered.
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NewsBot · Mar 11, 2015

Changes in Bacterial Profiles and Antibiotic Sensitivity Before and After Wound Bed Preparation for Diabetic Foot Ulcers
Guangyu Wang et al
International Journal of Lower Extremity Wounds March 9, 2015

We aimed to investigate the characteristics of bacterial profiles and antibiotic sensitivity in diabetic foot ulcers before and after wound bed preparation. This study involved 423 diabetic patients with Wagner grades 1 to 4 foot ulcers. Secretion culture was performed before wound bed preparation. The observation endpoint was when the wound showed a tendency toward healing and a specialist determined that stopping antibiotic treatment would not affect wound healing. A second secretion culture was performed after the observation endpoint. We obtained results from both secretion cultures from 411 patients. The proportion of multi-drug-resistant (MDR) gram-positive bacteria was 22.0% and 47.8% before and after treatment, respectively; that for gram-negative bacteria was 3.5% and 19.2%, respectively (P < .05). Pretreatment antibiotic sensitivity of staphylococci and other gram-positive bacteria was 48.7% and 44.8%, respectively; the rates decreased significantly after treatment to 36.8% (P = .031) and 34.8% (P = .027), respectively. Pretreatment antibiotic sensitivity of common and nonfermenting rare gram-negative bacteria was 55.4% and 54.6%, respectively, which decreased substantially after treatment to 33.2% (P = .002) and 32.9% (P = .003), respectively. Wound healing was achieved in 92.7% of patients. Pretreatment and posttreatment C-reactive protein levels were 124.759 ± 71.58 mg/dL and 82.8 ± 53.61 mg/dL, respectively (P < .05). In conclusion, following wound bed preparation for diabetic foot ulcers, MDR bacteria numbers were increased and antibiotic sensitivity was decreased; inflammation was decreased. These findings warrant future studies for confirmation.
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NewsBot · Mar 20, 2015

Staphylococcus aureus small colony variants in diabetic foot infections.
Cervantes-García E, García-Gonzalez R, Reyes-Torres A, Resendiz-Albor AA, Salazar-Schettino PM.
Diabet Foot Ankle. 2015 Mar 17;6:26431

Background : Staphylococcus aureus (S. aureus) is one of the major pathogens causing chronic infections. The ability of S. aureus to acquire resistance to a diverse range of antimicrobial compounds results in limited treatment options, particularly in methicillin-resistant S. aureus (MRSA). A mechanism by which S. aureus develops reduced susceptibility to antimicrobials is through the formation of small colony variants (SCVs). Infections by SCVs of S. aureus are an upcoming problem due to difficulties in laboratory diagnosis and resistance to antimicrobial therapy.
Methods : A prospective study was performed on 120 patients diagnosed with both type 2 diabetes mellitus and infected diabetic foot ulcers. The study was carried out from July 2012 to December 2013 in Hospital General de Mexico. The samples were cultured in blood agar, mannitol salt agar, and MacConkey agar media, and incubated at 37°C in aerobic conditions.
Results : We describe the first known cases of diabetic foot infections caused by MRSA-SCVs in patients diagnosed with type 2 diabetes mellitus and infected diabetic foot ulcers. In all of our cases, the patients had not received any form of gentamicin therapy.
Conclusions : The antibiotic therapy commonly used in diabetic patients with infected diabetic foot ulcers fails in the case of MRSA-SCVs because the intracellular location protects S. aureus-SCVs from the host's defenses and also helps them resist antibiotics. The cases studied in this article add to the spectrum of persistent and relapsing infections attributed to MRSA-SCVs and emphasizes that these variants may also play a relevant role in diabetic foot infections.
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NewsBot · Apr 4, 2015

Klebsiella oxytoca with reduced sensitivity to chlorhexidine isolated from a diabetic foot ulcer.
Vali L, Dashti AA, El-Shazly S, Jadaon MM
Int J Infect Dis. 2015 Mar 30

In most hospitals, chlorhexidine is used as skin antiseptic prior to clinical procedures, in dressings and when bathing patients. We hereby report, for the first time, the isolation of a clinical Klebsiella oxytoca isolate with reduced sensitivity to chlorhexidine from a foot ulcer of a diabetic patient, which is a common and serious complication associated with diabetes. The Minimum Inhibitory Concentration of the K. oxytoca isolate to chlorhexidine was found to be 30mg/L and the Minimum Bactericidal Concentration was 60mg/L. An increased resistance to ethidium bromide (MIC 200mg/L) was also observed. Molecular tests revealed that the isolate contained blaCTXM15, blaTEM-1 and blaSHV. The other resistant genes detected were qnrB1 and aac(6')-Ib-cr. The resistant determinants were located on a class I integron integrase (intI1) containing qacE gene. DNA sequencing showed homology to K. oxytoca plasmid pACM1. Identification of K. oxytoca with reduced sensitivity to chlorhexidine raises concern regarding dilution standards in hospitals. Adherence to the hospitals' infection control policies should be strictly monitored to avoid continuous low level exposure of bacteria to biocides, specifically in the developing countries.
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NewsBot · Apr 7, 2015

The role of anaerobes in diabetic foot infections
Patrick GP. Charles, Ilker Uçkay, Benjamin Kressmann, Stéphane Emonet, Benjamin A. Lipsky
Anaerobe; 2 April 2015

Diabetic foot infections (DFI) are a common cause of morbidity and, on occasion, even mortality. Infection can be either mono- or polymicrobial, with a wide variety of potential pathogens. Anaerobes may be involved, particularly in wounds that are deeper or more chronic, and are more frequently identified when using modern molecular techniques, such as 16s PCR and pyrosequencing. It remains unclear whether the presence of anaerobes in DFI leads to more severe manifestations, or if these organisms are largely colonizers associated with the presence of greater degrees of tissue ischemia and necrosis. Commonly used empiric antibiotic therapy for diabetic foot infections is generally broad-spectrum and usually has activity against the most frequently identified anaerobes, such as Peptostreptococcus and Bacteroides species. Adequate surgical debridement and, when needed, foot revascularization may be at least as important as the choice of antibiotic to achieve a successful treatment outcome.
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NewsBot · Apr 10, 2015

Outcomes and cost minimisation associated with Outpatient Parenteral Antimicrobial Therapy (OPAT) for foot infections in people with diabetes.
Malone M, West D, Xuan W, Lau NS, Maley M, Dickson HG.
Diabetes Metab Res Rev. 2015 Apr 7

OBJECTIVE:
To determine clinical outcomes in patients with diabetic foot infections (DFI) receiving outpatient parenteral antimicrobial therapy (OPAT), to evaluate cost savings from the use of OPAT, and to analyse demographic, clinical and laboratory data that may predict OPAT failure.
RESEARCH DESIGN AND METHODOLOGY:
A retrospective cohort analysis was conducted between 1 January 2007 and 7th July 2012 at a tertiary referral hospital in metropolitan Sydney. Patients with DFI were identified from the OPAT database. Demographic, clinical, laboratory, and operative report data were obtained from patient charts and electronic medical records (EMR). Potential cost savings were calculated on the estimated cost of expenditure versus the expected savings. Linear regression was used to explore outcomes associated with OPAT failure.
RESULTS:
59 patients were identified over the 5-year study period. The OPAT success rate for DFI was 88%. Following the resolution of the primary episode of infection, new infective episodes within the study period were high (n=26, 44%). Regression analysis of variables for OPAT failure failed to indicate any factors reaching statistical significance. A total of 1569 days were saved by using OPAT for an estimated total cost saving of $983,645 or $16,672 per patient.
CONCLUSION:
Outpatient intravenous therapy for diabetic foot infections is an effective mode of treatment that can contribute to significant healthcare savings. High re-infection rates associated with diabetes foot ulceration in this population underline the need for close monitoring and management of these patients in multidisciplinary high-risk foot setting.
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NewsBot · Apr 21, 2015

Clinicians' perceptions of prescribing antibiotics for infections in the diabetic foot
Debbie Sharman
Journal of Foot and Ankle Research 2015, 8(Suppl 1):A5 doi:10.1186/1757-1146-8-S1-A5

Introduction
Responsible use of antibiotics is high on the public health agenda. The management of infection within the diabetic foot is variable, partly due to a lack of consensus and evidence to guide management choices. Study aims: To explore and describe experiences and views regarding the clinical management of diabetic foot infections among specialist secondary care clinicians involved in the management of diabetic foot infections; to explore perceptions and awareness of antibiotic resistance; to explore whether there are any unknown factors that may contribute to the ‘non-pharmacological’ prescribing of antibiotics. Study design and methods: A phenomenological approach was used, with data collected in face to face interviews with specialist hospital clinicians including Consultant Physicians, Specialist Registrars, Consultant Microbiologist, Specialist Podiatrists and Consultant Vascular Surgeons within two acute hospital foundation trusts in the south of England.

Results
A total of 152 themes were identified and clustered into ten different groups including: resistance issues, appropriate use of antibiotics, when to prescribe / stop antibiotics, influences on prescribing, complications / areas of concern, microbiology, duration of treatment, the multi-disciplinary team (MDT), training / experience and other factors. There was generally a strong consensus of opinion among clinicians, despite the lack of availability of strong evidence to guide practice.

Conclusion
Responsible use of antibiotics is high on the public health agenda. This study presents a new way to understand how specialist clinicians perceive antibiotic prescribing in the management of diabetic foot infection. Clinicians report the value of the multi-disciplinary foot care team and the importance of shared decision making. There is acknowledgement that antibiotics may be prescribed for longer durations than may be absolutely indicated, but a belief that current practices do not lead to excessive harm in terms of antibiotic resistance and significant adverse effects.

Antibiotics do not appear to be used indiscriminately, and careful consideration is given to their use. There is consensus regarding the limited value of superficial wound swabs, and a desire for improved diagnostic measures to guide treatment choices. Experience and clinical judgement are seen as the major tools available in terms of managing diabetic infection.
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NewsBot · Apr 21, 2015

CODIFI (Concordance in Diabetic Foot Infection): Agreement in reported presence of likely pathogens in swabs and tissue samples from infected diabetic foot ulcers
Michael Backhouse, Andrea Nelson, Alexandra Wright-Hughes, Moninder Bhogal, Sarah Brown, Catherine Reynolds, Benjamin Lipsky, Christopher Dowson, Jane Nixon and The Codifi Study Group
Journal of Foot and Ankle Research 2015, 8(Suppl 1):A2 doi:10.1186/1757-1146-8-S1-A2

Aim
Wound infection is common in diabetic foot ulcers with potentially life changing sequelae. Targeted treatment of infective organisms requires accurate identification of pathogens to enable refinement of antibiotic protocols to improve outcomes and reduce antibiotic resistance. Wound sampling is routinely conducted using swabs although some guidelines recommend use of tissue samples. To date there is a lack of robust evidence to inform clinical practice regarding sampling technique.

This study aimed to evaluate the extent to which results from wound swab and tissue samples taken from the same patient agree with each other; one might report pathogens more than the other, they might both report the same pathogens consistently, or they might disagree with a more complex pattern of disagreement. Here we report agreement and disagreement between the techniques based upon reported presence of likely pathogens.

Methods
In this multi-centre, cross-sectional study, 401 patients with a suspected infected diabetic foot ulcer were recruited from 25 sites across England. All patients had both a swab and tissue sample taken from same ulcer for plating and culture. Agreement between techniques in the reported presence of likely pathogens was assessed by overall prevalence and bias adjusted Kappa (PABAK). McNemar’s test was used to investigate patterns of disagreement.

Results
401 patients were recruited between 2011 and 2013 with a median age of 63 years; 79% were male; 85.5% had type 2 diabetes; 27.5% presented with a recurrent ulcer; and 45.5% had a neuro-ischaemic ulcer, 50.5% neuropathic, and 3.5% ischaemic.

Both swab and tissue reports were available for 395 patients, and at least one pathogen was reported in 70.1% of swab samples and 86.1% of tissue samples. In 58% of patients the two samples resulted in a difference in the reported pathogens, with: 13.2% both reporting different pathogens; 36.7% reporting additional pathogens in the tissue sample; and 8.1% reporting additional pathogens in the swab sample.

In the most prevalent pathogens (those present in >8%), there were significantly higher rates of reporting of the following pathogens from tissue samples than swabs (McNemar’s p-value <0.05): Gram Positive Cocci, Gram Negative Bacilli, Enterobacteriacea, Anaerobes, Streptococcus, Enterococcus, Coagulase-Negative Staphylococcus, Gram Positive Bacilli, Corynebacterium; with differences ranging between 3.3% (Streptococcus) and 13.7% (Gram Positive Cocci). There was no evidence of a difference in reporting for Methicillin-resistant S. Aureus (MRSA) (p=0.22); Staphylococcus Aureus and Pseudomonas (the latter two both had p=1.00). In terms of agreement, the PABAK ranged from 0.58 (Gram Positive Cocci) to 0.97 (MRSA).

Investigation of the influence of baseline factors on agreement of the number of reported pathogens found, despite large centre variation, significant evidence (p=0.02) of an association with ulcer duration, such that older ulcers ( ≥56 days old) had a reduced odds (0.64 95% CI (0.45, 0.95)) of the tissue sample reporting more pathogens than the swab.

Conclusions
Overall, there were significant differences in the pathogens reported from swab and tissue samples in patients with suspected infected diabetic foot ulcers. This has potential implications for choice of sampling technique in clinical practice.
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NewsBot · May 22, 2015

Pseudomonas as trespassers in diabetic foot infections: More questions and fewer answers.
Najjad MK, Idrees Z, Zamir M, Zeeshan S, Shah SA
J Pak Med Assoc. 2014 Dec;64(12 Suppl 2):S112-5.

OBJECTIVE:
To assess microbiological isolates from diabetic foot ulcers presented at a tertiary care teaching hospital.
METHODS:
The prospective observational study was conducted at department of Orthopaedics, Liaquat National Hospital Karachi, from January 2009 to October 2011, and comprised patients with diabetic foot ulcers (Wagner grading 1-4). Grade 0 and 5 were excluded. Wound swabs or tissue biopsies were taken before the induction of antibiotic prophylaxis according to the standard aseptic protocols. SPSS 16 was used for statistical analysis.
RESULTS:
Of the 250 patients in the study, 151(60.4%) were male with an overall mean age of the subjects of 46±8.1 years. Mean duration of diabetes was 14±6.7 years. Based on Wagner's grading, 90(36%) patients had grade 1, 58(23.2%) grade 2, 97(38.8%) grade 3, and 5(2%) grade 4. The most common isolates were polymicrobial in 90(36%) patients and pseudomonas aeruginosa in 87(34.8%). Resistance antibiogram for pseudomonas aeruginosa showed sensitivity against Imipenem, Aztreonam, Ceftazidime, Ciprofloxacin and Gentamicin.
CONCLUSIONS:
The isolation of pseudomonas aeruginosa gives an idea about the recent microbial spectra from our region and should prompt the need for multi-centre studies from South Asia to devise treatment guidelines for this part of the world.
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NewsBot · Jul 18, 2015

Changes in Bacterial Profiles and Antibiotic Sensitivity Before and After Wound Bed Preparation for Diabetic Foot Ulcers
Guangyu Wang et al
International Journal of Lower Extremity Wounds June 2015 vol. 14 no. 2 160-167

We aimed to investigate the characteristics of bacterial profiles and antibiotic sensitivity in diabetic foot ulcers before and after wound bed preparation. This study involved 423 diabetic patients with Wagner grades 1 to 4 foot ulcers. Secretion culture was performed before wound bed preparation. The observation endpoint was when the wound showed a tendency toward healing and a specialist determined that stopping antibiotic treatment would not affect wound healing. A second secretion culture was performed after the observation endpoint. We obtained results from both secretion cultures from 411 patients. The proportion of multi-drug-resistant (MDR) gram-positive bacteria was 22.0% and 47.8% before and after treatment, respectively; that for gram-negative bacteria was 3.5% and 19.2%, respectively (P < .05). Pretreatment antibiotic sensitivity of staphylococci and other gram-positive bacteria was 48.7% and 44.8%, respectively; the rates decreased significantly after treatment to 36.8% (P = .031) and 34.8% (P = .027), respectively. Pretreatment antibiotic sensitivity of common and nonfermenting rare gram-negative bacteria was 55.4% and 54.6%, respectively, which decreased substantially after treatment to 33.2% (P = .002) and 32.9% (P = .003), respectively. Wound healing was achieved in 92.7% of patients. Pretreatment and posttreatment C-reactive protein levels were 124.759 ± 71.58 mg/dL and 82.8 ± 53.61 mg/dL, respectively (P < .05). In conclusion, following wound bed preparation for diabetic foot ulcers, MDR bacteria numbers were increased and antibiotic sensitivity was decreased; inflammation was decreased. These findings warrant future studies for confirmation.
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NewsBot · Jul 28, 2015

Set Phages to Stun: Reducing the Virulence of Staphylococcus aureus in Diabetic Foot Ulcers
David G. Armstrong, Bonnie L. Hurwitz and Benjamin A. Lipsky

Full text editorial in Diabetes

NewsBot · Aug 7, 2015

Can We Stop Antibiotic Therapy When Signs and Symptoms Have Resolved in Diabetic Foot Infection Patients?
Yuejie Chu et al
International Journal of Lower Extremity Wounds August 6, 2015

The study aimed to investigate whether we can stop antibiotic therapy when signs and symptoms have resolved in diabetic foot infection (DFI) patients with different grades of peripheral arterial disease (PAD) and those without PAD, and to determine whether the severity of PAD and infection has an effect on antibiotic therapy duration. A prospective randomized controlled trial of DFI patients was carried out. Patients were randomized into 2 groups when signs and symptoms had resolved: continuing antibiotics group (CAG) and discontinuing antibiotics group (DAG). The recurrence and clinical outcomes were recorded. The recurrence rate of mild infection with mild/moderate PAD was similar in the 2 groups. Compared with CAG, the recurrence rate of mild infection with severe PAD was higher in DAG (P = .030), also for moderate/severe infection with PAD (mild/moderate [P = .032]; severe [P = .008]). No difference was found in the 2 groups (either mild or moderate/severe) for those without PAD. The clinical outcomes of mild infection in patients were similar in the 2 groups. For moderate/severe infection, the healing rate was higher (73.3% vs 48.3%), and the rate of minor/major amputation and death was lower (23.8% vs 49.4%; 6.9% vs 20.7%; 2.0% vs 13.8%) in the CAG. When the clinical signs and symptoms of infection have resolved, it might be appropriate to stop antibiotics for DFI patients without PAD, and also for patients with mild infection with mild/moderate PAD. For patients with mild infection with severe PAD and moderate/severe infection with PAD, we should perhaps continue antibiotic treatment. Continuing antibiotic therapy could improve clinical outcomes for patients with moderate/severe infection.
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NewsBot · Aug 8, 2015

Clinical presentation and microorganisms sensitivity profile for diabetic foot ulcers: a pilot study.
Nur Hilda Hanina AW et al
Med J Malaysia. 2015 Jun;70(3):182-7.

INTRODUCTION:
Patients suffering from diabetes mellitus (DM) frequently present with infected diabetic foot ulcers (DFU). This study was done to record the anatomical site and the grade of ulcers according to Wagner's classification and to culture the microorganisms from the ulcers and determine their antibiotic sensitivity.
MATERIALS AND METHODS:
Prospective study was conducted on 77 diabetic patients who were admitted with DFU from June until December 2011. Patients with end stage renal failure, those who had previous vascular surgery on the involved limb, or hyperbaric oxygen or maggot therapy for the ulcers, or had unrelated skin diseases around the involved foot were excluded from the study. Specimens for culture were obtained by a sterile swab stick or tissue sample was taken from the wound with sterile surgical instruments.
RESULTS:
Wagner's grade III and IV ulcers were most common. Majority of the ulcers involved toes (48%). Gram negative microorganisms were predominantly isolated (71.1%). Gram positive microorganisms were less frequently cultured (27.7%). Fungus was cultured from one sample (1.2%). Gram negative microorganisms were sensitive to aminoglycosides, cephalosporins or β-lactamase inhibitors. More than 40% were resistant to ampicillin. Gram positive microorganisms were sensitive to cloxacillin. MRSA were sensitive to vancomycin.
CONCLUSION:
Empirical use of antibiotics should be curtailed to prevent development of drug resistant strains of microorganisms and MRSA. We suggest use of antiseptic solutions to clean the ulcers until antibiotic sensitivity report is available. Results of our altered treatment regimen we plan to publish in a later study.
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NewsBot · Aug 15, 2015

Evaluation and Management of Cellulitis and its Local Complications in Diabetic Lower Limb using the New Amit Jain?s Staging System for Cellulitis ? A Retrospective study
Amit Kumar C Jain, Viswanath S.
SEAJCRR. 2015; 4(2): 1392-1401

Introduction: Cellulitis affecting the lower limb is a common type 1 diabetic foot complication, yet there are very few studies done on it over last few decades.
Aim: To study cellulitis in diabetic lower limb through Amit Jain?s staging system, the first specific focussed classification system for cellulitis and its local complications in diabetic lower limb.
Methods: A retrospective analysis was carried out in a single surgical unit of department of surgery of St John?s medical college, Bangalore, India.
Results: A total of 26 patients were included in this study. 76.92% were males. Stage 2 was the commonest stage of presentation. 23.07% of the patients had history of known preceding trauma. Debridement was the commonest procedure done in cellulitis.
Conclusion: Cellulitis in lower limb in diabetes is a common condition that can lead to serious complication. Stage 2 is the commonest presentation to a hospital. This is the first study on cellulitis in diabetic lower limb through the new Amit Jain?s staging system from Indian subcontinent.
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NewsBot · Oct 7, 2015

Systemic antibiotics for treating diabetic foot infections.
Selva Olid A, Sol? I, Barajas-Nava LA, Gianneo OD, Bonfill Cosp X, Lipsky BA.
Cochrane Database Syst Rev. 2015 Sep 4;9

BACKGROUND:
Foot infection is the most common cause of non-traumatic amputation in people with diabetes. Most diabetic foot infections (DFIs) require systemic antibiotic therapy and the initial choice is usually empirical. Although there are many antibiotics available, uncertainty exists about which is the best for treating DFIs.
OBJECTIVES:
To determine the effects and safety of systemic antibiotics in the treatment of DFIs compared with other systemic antibiotics, topical foot care or placebo.
SEARCH METHODS:
In April 2015 we searched the Cochrane Wounds Group Specialised Register; The Cochrane Central Register of Controlled Trials (CENTRAL; The Cochrane Library); Ovid MEDLINE, Ovid MEDLINE (In-Process & Other Non-Indexed Citations); Ovid EMBASE, and EBSCO CINAHL. We also searched in the Database of Abstracts of Reviews of Effects (DARE; The Cochrane Library), the Health Technology Assessment database (HTA; The Cochrane Library), the National Health Service Economic Evaluation Database (NHS-EED; The Cochrane Library), unpublished literature in OpenSIGLE and ProQuest Dissertations and on-going trials registers.
SELECTION CRITERIA:
Randomised controlled trials (RCTs) evaluating the effects of systemic antibiotics (oral or parenteral) in people with a DFI. Primary outcomes were clinical resolution of the infection, time to its resolution, complications and adverse effects.
DATA COLLECTION AND ANALYSIS:
Two review authors independently selected studies, assessed the risk of bias, and extracted data. Risk ratios (RR) were estimated for dichotomous data and, when sufficient numbers of comparable trials were available, trials were pooled in a meta-analysis.
MAIN RESULTS:
We included 20 trials with 3791 participants. Studies were heterogenous in study design, population, antibiotic regimens, and outcomes. We grouped the sixteen different antibiotic agents studied into six categories: 1) anti-pseudomonal penicillins (three trials); 2) broad-spectrum penicillins (one trial); 3) cephalosporins (two trials); 4) carbapenems (four trials); 5) fluoroquinolones (six trials); 6) other antibiotics (four trials).Only 9 of the 20 trials protected against detection bias with blinded outcome assessment. Only one-third of the trials provided enough information to enable a judgement about whether the randomisation sequence was adequately concealed. Eighteen out of 20 trials received funding from pharmaceutical industry-sponsors.The included studies reported the following findings for clinical resolution of infection: there is evidence from one large trial at low risk of bias that patients receiving ertapenem with or without vancomycin are more likely to have resolution of their foot infection than those receiving tigecycline (RR 0.92, 95% confidence interval (CI) 0.85 to 0.99; 955 participants). It is unclear if there is a difference in rates of clinical resolution of infection between: 1) two alternative anti-pseudomonal penicillins (one trial); 2) an anti-pseudomonal penicillin and a broad-spectrum penicillin (one trial) or a carbapenem (one trial); 3) a broad-spectrum penicillin and a second-generation cephalosporin (one trial); 4) cephalosporins and other beta-lactam antibiotics (two trials); 5) carbapenems and anti-pseudomonal penicillins or broad-spectrum penicillins (four trials); 6) fluoroquinolones and anti-pseudomonal penicillins (four trials) or broad-spectrum penicillins (two trials); 7) daptomycin and vancomycin (one trial); 8) linezolid and a combination of aminopenicillins and beta-lactamase inhibitors (one trial); and 9) clindamycin and cephalexin (one trial).Carbapenems combined with anti-pseudomonal agents produced fewer adverse effects than anti-pseudomonal penicillins (RR 0.27, 95% CI 0.09 to 0.84; 1 trial). An additional trial did not find significant differences in the rate of adverse events between a carbapenem alone and an anti-pseudomonal penicillin, but the rate of diarrhoea was lower for participants treated with a carbapenem (RR 0.58, 95% CI 0.36 to 0.93; 1 trial). Daptomycin produced fewer adverse effects than vancomycin or other semi-synthetic penicillins (RR 0.61, 95%CI 0.39 to 0.94; 1 trial). Linezolid produced more adverse effects than ampicillin-sulbactam (RR 2.66; 95% CI 1.49 to 4.73; 1 trial), as did tigecycline compared to ertapenem with or without vancomycin (RR 1.47, 95% CI 1.34 to 1.60; 1 trial). There was no evidence of a difference in safety for the other comparisons.
AUTHORS' CONCLUSIONS:
The evidence for the relative effects of different systemic antibiotics for the treatment of foot infections in diabetes is very heterogeneous and generally at unclear or high risk of bias. Consequently it is not clear if any one systemic antibiotic treatment is better than others in resolving infection or in terms of safety. One non-inferiority trial suggested that ertapenem with or without vancomycin is more effective in achieving clinical resolution of infection than tigecycline. Otherwise the relative effects of different antibiotics are unclear. The quality of the evidence is low due to limitations in the design of the included trials and important differences between them in terms of the diversity of antibiotics assessed, duration of treatments, and time points at which outcomes were assessed. Any further studies in this area should have a blinded assessment of outcomes, use standardised criteria to classify severity of infection, define clear outcome measures, and establish the duration of treatment.
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NewsBot · Oct 10, 2015

Diabetic foot infections: current treatment and delaying the "post-antibiotic era".
Lipsky BA
Diabetes Metab Res Rev. 2015 Oct 9

BACKGROUND:
Treatment for diabetic foot infections requires properly diagnosing infection, obtaining an appropriate specimen for culture, assessing for any needed surgical procedures and selecting an empiric antibiotic regimen. Therapy will often need to be modified based on results of culture and sensitivity testing. Because of excessive and inappropriate use of antibiotics for treating diabetic foot infections, resistance to the usually employed bacteria has been increasing to alarming levels.
REVIEW:
This paper reviews recommendations from evidence-based guidelines, informed by results of systematic reviews, on treating diabetic foot infections. Data from the pre-antibiotic era reported rates mortality of about 9% and of high-level leg amputations of about 70%. Outcomes have greatly improved with appropriate antibiotic therapy. While there are now many oral and parenteral antibiotic agents that have demonstrated efficacy in treating diabetic foot infections, the rate of infection with multidrug-resistant pathogens is growing. This problem requires a multi-focal approach, including providing education to both clinicians and patients, developing robust antimicrobial stewardship programs and using new diagnostic and therapeutic technologies. Recently, new methods have been developed to find novel antibiotic agents and to resurrect old treatments, like bacteriophages, for treating these difficult infections.
CONCLUSION:
Medical and political leaders have recognized the serious global threat posed by the growing problem of antibiotic resistance. By a multipronged approach that includes exerting administrative pressure on clinicians to do the right thing, investing in new technologies, and encouraging the profitable development of new antimicrobials we may be able to stave off the coming "post-antibiotic era."
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NewsBot · Oct 17, 2015

Spectrum of bacteria associated with diabetic foot ulcer and biofilm formation: A prospective study.
Banu A, Noorul Hassan MM, Rajkumar J, Srinivasa S
Australas Med J. 2015 Sep 30;8(9):280-5. doi: 10.4066/AMJ.2015.2422. eCollection 2015.

BACKGROUND:
India has the world's largest number of diabetics. Non-traumatic lower limb amputation is the most common devastating complication of diabetes, primarily due to diabetic foot ulcers (DFU) and diabetic foot infections (DFI). In India, the incidence of foot ulcers ranges from 8-17 per cent. DFIs are predominantly polymicrobial and multidrug-resistant (MDR) with the ability to form biofilm, which is an important virulence factor and results in treatment failure.
AIMS:
The main objectives of the study are to identify the spectrum of multidrug-resistant bacteria associated with these infections, their antibiotic sensitivity pattern, and to detect the biofilm formation.
METHODS:
This was a prospective study at a tertiary care hospital. One hundred patients over the age of 18, having chronic diabetic foot ulcer, and attending the surgery outpatient department were included. Samples of pus were collected from deep wounds and processed using standard techniques for culture and sensitivity. Biofilm detection was done. Results were compiled and statistically analysed.
RESULTS:
One hundred samples were processed and 82 yielded positive cultures. Staphylococcus aureus was the predominant organism, followed by Pseudomonas aeruginosa. Biofilm formation was seen in 38 (46.34 per cent) of the organisms. Biofilms were formed predominantly by Staphylococcus aureus (20 per cent).
CONCLUSION:
The organisms causing chronic diabetic foot ulcers were commonly multidrug-resistant; this was also observed among biofilm formers. Therefore, screening for biofilm formation, along with the usual antibiogram, needs to be performed as a routine procedure in chronic diabetic ulcers to formulate effective treatment strategies for these patients.
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NewsBot · Oct 24, 2015

Rapid Bacteria Identification Using Multivariate Classifier on Diabetic Foot Infection
Yusuf, N.; Omar, M. I.; Zakaria, A.; Masnan, M. J.; Abdullah, A. A.; Kamarudin, L. M.; Shakaff, A. Y. M.; Thriumani, R.; Yeap, E. J.; Othman, A.; Yasin, M. S.
Journal of Medical Imaging and Health Informatics, Volume 5, Number 6, November 2015, pp. 1251-1254(4)

Identification of bacteria species on diabetic foot infection at the early stage is very crucial especially to reduce the major surgery for diabetic patients. An attempt to resolve this problem is to conduct an experiment by investigating the nature of bacterial morphology from the perspective of sensor technology. Therefore, the aim of this study is to investigate the aerobic gram positive bacteria (S. aureus, S. pyogenes) and aerobic gram negative bacteria (E. coli, P. aeruginosa, P. mirabilis and K. pneumoniae) at the early growth of bacteria at 6 hours followed by 12 hours, 18 hours to 24 hours bacteria culture in the incubator. All the bacteria were cultured in a blood agar medium by using a swabbing technique. The bacteria samples then were sniffed using Cyranose320 (e-nose) to collect the data samples and analysed using three various classifier techniques, Linear Discriminant Analysis (LDA), Probabilistic Neural Network (PNN) and k Nearest Neighbors (kNN). The preliminary results obtained in this study have shown that the e-nose was better able to identify and classify the bacteria pathogen with up to 90% accuracy using that classifier. Based on the overall classifier performance, kNN achieved higher accuracy compare to both LDA and PNN which imply that kNN is a good model to interpret the data analysis.
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NewsBot · Nov 19, 2015

Microbiological Features and Risk Factors in Patients With Diabetic Foot Ulcers.
Parsa H, Samani S
Wounds. 2015 Nov;27(11):308-312.

INTRODUCTION:
Approximately 25% of people with diabetes will experience diabetic foot ulcers (DFUs) during their lifetime. The present study was designed to evaluate the prevalence of diabetic foot infection among patients with DFUs and to identify the microorganisms isolated from the DFUs. This study also aimed to determine predisposing factors contributing to these infections at the authors' wound care clinic at the Rajaii and Velayat University Hospitals in Qazvin, Iran.
METHODS:
This cross-sectional descriptive study included 500 patients with diabetes mellitus between May 2011 and April 2013 at the authors' wound care clinic in Qazvin, Iran. All demographic, clinical, and laboratory data such as age, sex, duration of diabetes (years), duration of DFUs before inclusion in the study, size of ulcer (cm2), glycosylated hemoglobin (HbA1c), and results of ulcer culture were collected for each case. The collected data were analyzed using SPSS software (SPSS Inc, Chicago, IL). A P value less than 0.05 was considered significant.
RESULTS:
Overall, 54 (11%) patients with infected ulcers were found in the present study. Among patients with infected DFUs, the most commonly isolated microorganism was Pseudomonas aeruginosa, which infected 35% of patients, followed by Staphylococcus aureus in 19% of patients, and methicillin-resistant S. aureus in 6% of patients. Additionally, in the multivariable logistic regression model, age > 65 years, ulcer size > 2 cm2, and HbA1c > 7% were associated with the occurrence of an infection in DFUs.
CONCLUSION:
Periodic examination of the feet of patients with diabetes is necessary. In addition, to decrease the prevalence of infected DFUs, more attention to the described risk factors is recommended.
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NewsBot · Dec 29, 2015

Factors Affecting Penetration of Ciprofloxacin in Lower Extremity Ischemic Tissues
Janis Vella et al
International Journal of Lower Extremity Wounds December 28, 2015

The aims of this study were to evaluate factors influencing the distribution of ciprofloxacin in tissue of patients suffering from varying degrees of peripheral arterial disease (PAD). Blood and tissue samples were collected from patients undergoing debridement or amputation procedures and the amount of ciprofloxacin in them was determined using high-performance liquid chromatography. All patients were administered a 200-mg dose of intravenous ciprofloxacin prior to the debridement or amputation procedure. Data, including patient gender, age, type of diabetes, presence of neuropathy, medications taken, and severity of PAD were collected. These data were then analyzed to determine factors influencing the concentrations of ciprofloxacin in tissue of the lower limbs. The Kruskal-Wallis test, Spearman correlation, and chi-square test were used to relate covariates and fixed factors with the concentration of ciprofloxacin in tissue. Following bivariate analysis, a 3-predictor regression model was fitted to predict tissue concentrations of ciprofloxacin given information about these predictors. Blood and tissue samples were collected from 50 patients having an average age of 68 years. Thirty-three patients were males and 35 patients suffered from type 2 diabetes. The average number of medications that these patients were taking was 10. The majority of patients (n = 35) were suffering from severe PAD. Tissue concentrations of ciprofloxacin were mainly related to plasma concentrations of ciprofloxacin, number of medications that the patients were taking and severity of PAD.
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NewsBot · Jan 9, 2016

First Report of Yokenella regensburgei Isolated from the Wound Exudate after Disarticulation Due to Diabetic Foot Infection in Korea
Sae-Mi Lee, Young-Jin Kang, Hee Jae Huh, Chang-Seok Ki and Nam Yong Lee
Ann Clin Microbiol. 2015 Dec;18(4):135-139

Yokenella regensburgei, a member of the family Enterobacteriaceae, is rarely isolated in humans. Here, we report a 71-year-old man with diabetic foot infection from which Y. regensburgei was isolated. Following debridement and disarticulation of the foot, an exudate specimen was obtained, from which Gramnegative bacilli were recovered. The organism was identified as Y. regensburgei using the Vitek 2 system (bioM?rieux, USA) and 16S rRNA and gyrB gene sequencing. To our knowledge, this is the first case of Y. regensburgei isolation in Korea.
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NewsBot · Jan 20, 2016

Isolation and Genetic Analysis of Multidrug Resistant Bacteria from Diabetic Foot Ulcers.
Shahi SK, Kumar A
Front Microbiol. 2016 Jan 5;6:1464

Severe diabetic foot ulcers (DFUs) patients visiting Sir Sunderlal Hospital, Banaras Hindu University, Varanasi, were selected for this study. Bacteria were isolated from swab and deep tissue of 42 patients, for examining their prevalence and antibiotic sensitivity. DFUs of majority of the patients were found infected with Enterococcus spp. (47.61%), Escherichia coli (35.71%), Staphylococcus spp. (33.33%), Alcaligenes spp. (30.95%), Pseudomonas spp. (30.95%), and Stenotrophomonas spp. (30.95%). Antibiotic susceptibility assay of 142 bacteria with 16 antibiotics belonging to eight classes showed the presence of 38 (26.76%) isolates with multidrug resistance (MDR) phenotypes. MDR character appeared to be governed by integrons as class 1 integrons were detected in 26 (68.42%) isolates. Altogether six different arrays of genes (aadA1, aadB, aadAV, dhfrV, dhfrXII, and dhfrXVII) were found within class 1 integron. Gene cassette dhfrAXVII-aadAV (1.6 kb) was present in 12 (3 Gram positive and 9 Gram negative) isolates and was conserved across all the isolates as evident from RFLP analysis. In addition to the presence of class 1 integron, six β-lactamase resistance encoding genes namely bla TEM, bla SHV, bla OXA, bla CTX-M-gp1, bla CTX-M-gp2, and bla CTX-M-gp9 and two methicillin resistance genes namely mecA and femA and vancomycin resistance encoding genes (vanA and vanB) were identified in different isolates. Majority of the MDR isolates were positive for bla TEM (89.47%), bla OXA (52.63%), and bla CTX-M-gp1 (34.21%). To our knowledge, this is the first report of molecular characterization of antibiotic resistance in bacteria isolated from DFUs from North India. In conclusion, findings of this study suggest that class-1 integrons and β-lactamase genes contributed to the MDR in above bacteria.
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NewsBot · Jan 20, 2016

Diabetic foot infections: recent literature and cornerstones of management.
U?kay I, Gariani K, Dubois-Ferri?re V, Suv? D, Lipsky BA.
Curr Opin Infect Dis. 2016 Jan 15

PURPOSE OF REVIEW:
Diabetes mellitus has reached pandemic levels and will continue to increase worldwide. Physicians and surgeons should know to manage one of its most prevalent complications, the diabetic foot infection (DFI), in a scientifically based and resource-sparing way. We performed a nonsystematic review of recent scientific literature to provide guidance on management of DFIs.
RECENT FINDINGS:
Studies in the past couple of years provide data on which recommendations for diagnosing and treating DFI are based, especially with validated guidelines and reviews of the microbiology and selected aspects of the complex DFI problem. Recent literature provides approaches to prevention and studies support more conservative surgical treatment. Unfortunately, there have been virtually no new therapeutic molecules, antibiotic regimens, randomized trials, or surgical techniques introduced in the recent past; we briefly discuss how this may change in the future.
SUMMARY:
Recent scientific evidence on DFI strongly supports the value of multidisciplinary and some new care models, guideline-based management, more preventive approaches, and confirms several established therapeutic concepts. In contrast, there has been almost no new substantial information regarding the optimal antibiotic or surgical management in recent literature.
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NewsBot · Jan 29, 2016

Pitfalls in diagnosing diabetic foot infections.
Peters EJ
Diabetes Metab Res Rev. 2016 Jan;32 Suppl 1:254-60.

Although the diagnosis of a diabetic foot infection is made based on clinical symptoms and signs, we also use blood laboratory, microbiological and radiological studies to make treatment decisions. All of these diagnostic studies have pitfalls that can lead to a delay in diagnosis. Such delays will likely lead to further tissue damage and to a higher chance of amputation. One of these pitfalls is that some clinicians rely on microbiological, rather than clinical data, to diagnose infection. Though subjective by nature, clinical signs predict outcome of foot infections accurately. Another pitfall is that microbiological data can be misleading. All wounds harbour microorganisms; therefore, a positive wound culture does not mean that a wound is infected. Furthermore, the outcome of cultures of wound swabs does not correlate well with culture results of tissue biopsies. Therapy guidance by wound swab will likely lead to overtreatment of non-pathogenic organisms. Genotyping might have a role in identifying previously unrecognized (combinations of) pathogens in diabetic foot infection, bacteria in sessile phenotype and non-culturable pathogens, e.g. in cases where antibiotics have already been administered. One more pitfall is that the diagnosis of osteomyelitis remains difficult. Although the result of percutaneous bone biopsy is the reference standard for osteomyelitis, some other diagnostic modalities can aid in the diagnosis. A combination of several of these diagnostic tests is probably a good strategy to achieve a higher diagnostic accuracy. Relying on a single test will likely lead to misidentification of patients with osteomyelitis with associated overtreatment and undertreatment.
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NewsBot · Feb 3, 2016

PRESCRIBING PATTERN OF DIFFERENT ANTIBIOTICS AND ANALGESICS USED IN PATIENT WITH DIABETIC FOOT ULCER
Elahe Elhami, Kiran Nagaraju
IAJPR. 2016; 6(1): 3987-3995

The present study was to investigate the antimicrobial susceptibility pattern of microbes in DFIs. We used the patient database to conduct a retrospective observational study of hospitalized patients with diabetic foot infections. Patient record system, which contains patient demographics, diagnoses, diagnostic studies, treatments received and patient outcomes. Diabetes mellitus with foot ulcer was observed to be higher in patients with the age group of 40-50 years, affecting (59.33%) male and (40.66%) females. The most common comorbid conditions observed by us were Nephropathy. In our study antibiotic drugs were prescribed as monotherapy in 26 (17.33%) patients. Two drug combinations were prescribed to 46 (30.66%) patients and 3 drug combinations were prescribed to 100 (66.66%) patients. In the present study S.aureus 39(26%) was predominantly isolated. As regards the aerobic Gram negative bacilli, 56(37.33%) were E.coli, 21(14%) were Ps.aeruginosa, 12(8%) were k.pneumoniae, 10(6.66%) were c.koseri, 7(4.66%) were Citrobacter spp, 5 (3.33%) was p.vulgaris. Out of 396 antibiotic drugs prescribe the most commonly used antibiotic drugs are amino glycoside (21.46%), Quinolones (20.2%) and cephalosporin?s (19.44%).In our study analgesic drugs were prescribed as monotherapy in 45 (30%) patients. Two drug combinations were prescribed to 79 (52.66%) patients and 3 drug combinations were prescribed to 26 (17.33%) patients. Out of 281 analgesic drugs the most common drugs were, 17.79% lidocaine Hcl and Tramadol follow by 17.08% Aceclofenac and14.23% Paracetamol. The percentage of generics prescribed in our study (9.33%) is very low.
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NewsBot · Feb 22, 2016

Causative Pathogens and Antibiotic Resistance in Diabetic Foot Infections: A prospective multi-center study
Mustafa Hatipoglu, Mesut Mutluoglu, Vedat Turhan, Gunalp Uzun, Benjamin A. Lipsky, Turk-Day Study Group
Journal of Diabetes and its Complications; Article in Press

Aim
Clinical practice guidelines for the management of diabetic foot infections developed by the Infectious Diseases Society of America (IDSA) are commonly used worldwide. The issue of whether or not these guidelines need to be adjusted for local circumstances, however, has seldom been assessed in large prospective trials.

Methods
The Turk-DAY trial was a prospective, multi-center study in which infectious disease specialists from centers across Turkey were invited to participate.

Results
A total of 35 centers throughout Turkey enrolled patients in the trial. Overall, investigators collected a total of 522 specimens from infected diabetic foot wounds for culture from 447 individual patients. Among all isolates, 36.4% were gram-positive organisms, with Staphylococcus aureus the most common among these (11.4%). Gram-negative organisms constituted 60.2% of all the isolates, and the most commonly isolated gram-negative was Escherichia coli (15%). The sensitivity rates of the isolated species were remarkably low for several antimicrobials used in the mild infection group.

Conclusions
Based on our findings, several of the antimicrobials frequently used for empirical treatment, including some also recommended in the IDSA guidelines, would not be optimal for treating diabetic foot infections in Turkey. Although the IDSA guideline recommendations may be helpful to guide empiric antimicrobial therapy of DFIs, they should be adjusted to local conditions.
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NewsBot · Feb 27, 2016

Causative Pathogens and Antibiotic Resistance in Diabetic Foot Infections: A prospective multi-center study
Mustafa Hatipoglu, Mesut Mutluoglu, Vedat Turhan, Gunalp Uzun, Benjamin A. Lipsky, Turk-Day Study Group
Journal of Diabetes and its Complications; Article in Press

Aim
Clinical practice guidelines for the management of diabetic foot infections developed by the Infectious Diseases Society of America (IDSA) are commonly used worldwide. The issue of whether or not these guidelines need to be adjusted for local circumstances, however, has seldom been assessed in large prospective trials.

Methods
The Turk-DAY trial was a prospective, multi-center study in which infectious disease specialists from centers across Turkey were invited to participate.

Results
A total of 35 centers throughout Turkey enrolled patients in the trial. Overall, investigators collected a total of 522 specimens from infected diabetic foot wounds for culture from 447 individual patients. Among all isolates, 36.4% were gram-positive organisms, with Staphylococcus aureus the most common among these (11.4%). Gram-negative organisms constituted 60.2% of all the isolates, and the most commonly isolated gram-negative was Escherichia coli (15%). The sensitivity rates of the isolated species were remarkably low for several antimicrobials used in the mild infection group.

Conclusions
Based on our findings, several of the antimicrobials frequently used for empirical treatment, including some also recommended in the IDSA guidelines, would not be optimal for treating diabetic foot infections in Turkey. Although the IDSA guideline recommendations may be helpful to guide empiric antimicrobial therapy of DFIs, they should be adjusted to local conditions.
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NewsBot · Mar 16, 2016

Diabetic Foot Infection in Morocco: Microbiological Profile.
Belefquih B, Frikh M, Benlahlou Y, Maleh A, Jadid L, Bssaibis F, Ghazouani M, Chagar B, Lamsaouri J, Lemnouer A, Elouennass M.
Wounds. 2016 Mar;28(3):89-98.

OBJECTIVE:
The objective of this work is to describe the microbiology of diabetic foot infections (DFIs).
MATERIALS AND METHODS:
The authors included all samples of infected diabetic foot ulcers between January 2009 and June 2014 at the Mohammed Vth Military Teaching Hospital of Rabat, Morocco.
RESULTS:
The researchers collected 199 samples corresponding to 157 patients. The mean age of the patients was 59 years ? 12 years. Of the collected samples, deep samples represented 41% and swab samples 59%. Direct examination indicated anaerobic infection in 32% of the cases. There were 307 bacteria isolates from both deep and swab samples. There was no statistically significant association between the sampling method and isolate species (P = 0.237). Enterobacteriaceae, Staphylococcus aureus, Streptococcus sp, nonfermenting gram-negative bacilli (NFGNB), and Enterococcus sp represented 31.8%, 12.6 %, 12.3%, 11.7%, and 8.7% of the isolates, respectively. Methicillin-resistant S. aureus represented 4.7% of S. aureus isolates. Enterobacteriaceae and NFGNB-producing extended spectrum β-lactamases represented 14.1% and 5.1%, respectively, with isolates producing carabapenemase representing 3.8% and 38.5%. Piperacillin-tazobactam, imipenem, and ciprofloxacin resistance concerned 7.5%, 4.7%, and 25.5%, respectively, of isolated Enterobacteriaceae, and 35.9%, 30.7%, and 35.9% of NFGNB. Low susceptibility to β-lactams was found in 4.9% of Streptococcus sp isolates and 4.9% of Streptococcus sp isolates were resistant to moxifloxacin.
CONCLUSION:
Gram-negative bacilli are responsible for 43% of DFIs, and multidrug-resistant GNB is a challenging issue in DFI management. The sampling method doesn't seem to impact the bacteriological profile; however, this finding must be confirmed with further study.
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NewsBot · Mar 23, 2016

Clinico-microbiological study and antibiotic resistance profile of mecA and ESBL gene prevalence in patients with diabetic foot infections.
Chaudhry WN et al
Exp Ther Med. 2016 Mar;11(3):1031-1038.

Diabetic foot infections (DFIs) constitute a major complication of diabetes mellitus. DFIs contribute to the development of gangrene and non-traumatic lower extremity amputations with a lifetime risk of up to 25%. The aim of the present study was to identify the presence of neuropathy and determine the ulcer grade, microbial profile and phenotypic and genotypic prevalence of the methicillin-resistance gene mecA and extended spectrum β-lactamase (ESBL)-encoding genes in bacterial isolates of DFI in patients registered at the Pakistan Institute of Medical Sciences (Islamabad, Pakistan). The results indicated that 46/50 patients (92%), exhibited sensory neuropathy. The most common isolate was Staphylococcus aureus (25%), followed by Pseudomonas aeruginosa (P. aeruginosa; 18.18%), Escherichia coli (16.16%), Streptococcus species (spp.) (15.15%), Proteus spp. (15.15%), Enterococcus spp. (9%) and Klebsiella pneumoniae (K. pneumoniae; 3%). The prevalence of the mecA gene was found to be 88% phenotypically and 84% genotypically. K. pneumoniae was shown to have the highest percentage of ESBL producers with a prevalence of 66.7% by double disk synergy test, and 100% by the cefotaxime + clavulanic acid/ceftazidime + clavulanic acid combination disk test. P. aeruginosa and K. pneumoniae had the highest (100%) proportion of metallo β-lactamase producers as identified by the EDTA combination disk test. The overall prevalence of β-lactamase (bla)-CTX-M, bla-CTX-M-15, bla-TEM, bla-OXA and bla-SHV genes was found to be 76.9, 76.9, 75.0, 57.7 and 84.6%, respectively, in gram-negative DFI isolates. The prevalence of mecA and ESBL-related genes was found to be alarmingly high in DFIs, since these genes are a major cause of antibiotic treatment failure.
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