Infected diabetic foot ulcers decision making

NewsBot · Feb 5, 2013

Utility of (99m)Tc-labelled antimicrobial peptide ubiquicidin (29-41) in the diagnosis of diabetic foot infection.
Saeed S, Zafar J, Khan B, Akhtar A, Qurieshi S, Fatima S, Ahmad N, Irfanullah J.
Eur J Nucl Med Mol Imaging. 2013 Jan 30.

PURPOSE:
Detection of osteomyelitis beneath a diabetic foot ulcer is imperative for proper management; however, accurate and noninvasive diagnosis of osteomyelitis remains a challenge. Ubiquicidin 29-41 (UBI 29-41) is a synthetic antimicrobial peptide fragment reported to be highly infection-specific. (99m)Tc-UBI 29-41 has recently been reported to be a promising radiotracer for infection imaging. The aim of this prospective study was to evaluate the utility of (99m)Tc-UBI 29-41 scintigraphy in diabetic patients with suspected osteomyelitis of the foot.

METHODS:
Included in the study were 65 patients with type 2 diabetes mellitus and foot ulcer and with clinical suspicion of osteomyelitis . Each patient had a three-phase bone scan and a (99m)Tc-UBI scan at 30 and 60 min after injection. The scan was considered to be consistent with osteomyelitis when the (99m)Tc-UBI 29-41 uptake was concordant with the (99m)Tc-MDP uptake. It was considered negative for osteomyelitis if there was no uptake of (99m)Tc-UBI 29-41 or if (99m)Tc-UBI 29-41 accumulated in an area not concordant with the abnormal uptake of (99m)Tc-MDP on the bone scan. In the latter case a diagnosis of soft-tissue infection was made. Bone infection was confirmed by bone biopsy/culture and by clinical and radiological follow-up.

RESULTS:
Final analysis was done in 55 patients. Osteomyelitis was confirmed in 37 patients, and 18 patients were free of bone infection. (99m)Tc-UBI 29-41 was positive in all 37 patients and with the bone scan as the reference for the bone identified all osteomyelitic foci (68 in total). (99m)Tc-UBI 29-41 was negative for osteomyelitis in all 18 patients, and 17 of these patients were diagnosed with soft-tissue infection ((99m)Tc-UBI 29-41 accumulation without concordant abnormal uptake on bone scintigraphy). The sensitivity, specificity and accuracy of (99m)Tc-UBI 29-41 scan in combination with three-phase bone scan for the diagnosis of osteomyelitis in diabetic foot was 100 %. Accuracy for soft-tissue infection was also 100 %. Maximum accumulation of the (99m)Tc-UBI 29-41 with maximum target to background activity was observed in the infectious foci at 30 min after injection.

CONCLUSION:
Tc-UBI 29-41 may be a useful agent for the accurate diagnosis of bone infection in diabetic foot because of the high accuracy demonstrated in this pilot study. It was able to differentiate between bone and soft-tissue involvement effectively in combination with a bone scan.
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NewsBot · Feb 5, 2013

Quality Assessment of Tissue Specimens for Studies of Diabetic Foot Ulcers
Olivera Stojadinovic et al
Experimental Dermatology (accepted article)

Diabetic Foot Ulcers (DFUs) represent an important clinical problem resulting in significant morbidity and mortality. Ongoing translational research studies strive to better understand molecular/cellular basis of DFU pathology that may lead to identification of novel treatment protocols. Tissue at the non-healing wound edge has been identified as one of major contributors to the DFU pathophysiology that provides important tool for translational and clinical investigations. To evaluate quality of tissue specimens and their potential use we obtained 81 DFU specimens from 25 patients and performed histological analyses, immunohistochemistry and RNA quality assessments. We found that depth of the collected specimen is important determinant of research utility, and only specimens containing a full-thickness epidermis could be utilized for immunohistochemistry and RNA isolation. We showed that only two-thirds of collected specimens could be utilized in translational studies. This attrition rate is important for designs of future studies involving tissue specimen collection from DFU.
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NewsBot · Mar 18, 2013

Relationship and susceptibility profile of Staphylococcus aureus infection diabetic foot ulcers with Staphylococcus aureus nasal carriage
Aza Bahadeen Taha
The Foot; Volume 23, Issue 1 , Pages 11-16, March 2013

Background
Staphylococcus aureus is the main cause of diabetic foot infection with the patient's endogenous flora as the principal source. Nasal carriage of S. aureus has been identified as an important risk factor for the acquisition of diabetic foot infections.

Objectives
The study assessment the associations of S. aureus with methicillin resistant S. aureus were isolation from diabetic foot infection and nasal carriage of the same patients and their antibiotic susceptibility profile.

Methods
Diagnosis of S. aureus and methicillin resistant S. aureus were carried out by using standard procedures. Antibiotic sensitivity profiles were determent by breakpoint dilution method.

Results
Out of 222 S. aureus isolation, 139 (62.61%) were isolated from the diabetic foot and 83 (37.39%) from the nasal carriage. Seventy one (30.87%) of the patients were S. aureus infection diabetic foot with nasal carriage. Among diabetic foot infection and nasal carriage patients, 40.85% of S. aureus were considered as methicillin resistant S. aureus. Rifampicin (96.40%) and Levofloxacin (91.44%) were active against S. aureus.

Conclusion
Patients at strong risk for methicillin resistant S. aureus nasal carriage and subsequent diabetic foot infection with high resistance to antibiotics.
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NewsBot · Mar 26, 2013

Molecular epidemiology of Staphylococcus aureus strains isolated from inpatients with infected diabetic foot ulcers in an Algerian University Hospital.
Djahmi N, Messad N, Nedjai S, Moussaoui A, Mazouz D, Richard JL, Sotto A, Lavigne JP.
Clin Microbiol Infect. 2013 Feb 26.

Staphylococcus aureus is the most common pathogen cultured from diabetic foot infection (DFI). The consequence of its spread to soft tissue and bony structures is a major causal factor for lower-limb amputation. The objective of the study was to explore ecological data and epidemiological characteristics of S. aureus strains isolated from DFI in an Algerian hospital setting. Patients were included if they were admitted for DFI in the Department of Diabetology at the Annaba University Hospital from April 2011 to March 2012. Ulcers were classified according to the Infectious Diseases Society of America/International Working Group on the Diabetic Foot classification system. All S. aureus isolates were analysed. Using oligonucleotide arrays, S. aureus resistance and virulence genes were determined and each isolate was affiliated to a clonal complex. Among the 128 patients, 277 strains were isolated from 183 samples (1.51 isolate per sample). Aerobic Gram-negative bacilli were the most common isolated organisms (54.9% of all isolates). The study of ecological data highlighted the extremely high rate of multidrug-resistant organisms (MDROs) (58.5% of all isolates). The situation was especially striking for S. aureus [(85.9% were methicillin-resistant S. aureus (MRSA)], Klebsiella pneumonia (83.8%) and Escherichia coli (60%). Among the S. aureus isolates, 82.2% of MRSA belonged to ST239, one of the most worldwide disseminated clones. Ten strains (13.7%) belonged to the European clone PVL+ ST80. ermA, aacA-aphD, aphA, tetM, fosB, sek, seq, lukDE, fnbB, cap8 and agr group 1 genes were significantly associated with MRSA strains (p <0.01). The study shows for the first time the alarming prevalence of MDROs in DFI in Algeria.
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NewsBot · Apr 10, 2013

Antibiotic resistance rates in causative agents of infections in diabetic patients: rising concerns.
Boyanova L, Mitov I.
Expert Rev Anti Infect Ther. 2013 Apr;11(4):411-20.

The vicious cycle is that hyperglycemia (≥11.1 mmol/l) or other diabetes-associated factors facilitate or worsen the development of infections and vice versa, the infections deteriorate the glycemic control of the patients. Diabetic patients are prone to some infections, infection recurrences and poor outcomes. Immunocompromised state and frequent antibiotic use are associated with antibiotic resistance of the bacterial pathogens, such as Mycobacterium tuberculosis (in some studies), methicillin-resistant Staphylococcus aureus, Streptococcus pneumoniae, Gram-negative bacteria such as Pseudomonas aeruginosa and Acinetobacter baumannii, bacteria in diabetic foot infections and different opportunistic and rare pathogens or multidrug-resistant strains. Prompt diagnostics and susceptibility testing, early and aggressive surgical and/or antibiotic therapy, and, importantly, good glycemic control are of utmost importance for treatment of antibiotic-resistant infections in diabetic patients.
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Selwyn Firth · Apr 12, 2013

It is really quite disheartening to find such poor information about treating DFU's. My elderly mother lost a leg because of one which would not heal because her peripheral arteries were severely blocked. The doctor predicted how things would progress and they did.
Since poor circulation seems to be associated with non healing DFU's it is remarkable how few doctors lokk into looking for mechanical circulation enhancers. Our company markets one for DVT prevention but it has shown incredible promise as an adjunct for treating DFU's. I personally used one for my mother after she had lost her leg, to treat another one. To my knowledge it was the first time the device had been used for that purpose and it worked so well that a small group of 10 people were tested at MacMaster University in Hamilton, Ont. Canada.
Out of the ten all were completely healed within 30 days. A larger scale study is being planned but in the meantime the company is willing to refund the purchase price if there is no improvement after using the device for 4 hrs a day for 30 days. If anyone wants to find out more just send me an email. I would advertise the product if only PAYPAL would acceptt my credit card.

NewsBot · May 15, 2013

Revision Surgery for Diabetic Foot Infections: Giving Another Chance to the Patient.
Aragón-Sánchez J, Lázaro-Martínez JL, Molinés-Barroso R, García Álvarez Y, Quintana-Marrero Y, Hernández-Herrero MJ.
Int J Low Extrem Wounds. 2013 May 13.

Revision surgery (RS) is frequently needed to control diabetic foot infections. It is the aim of this retrospective observational study to analyze the variables associated with undergoing RS and the variables associated with undergoing a major amputation when RS was required. We conducted a retrospective study of patients with diabetes treated in our department during 10 years (January 1, 2000 to January 1, 2010) who had foot infections identifying those who required RS. In all, 167 out of 417 patients (40%) with diabetes who underwent surgery for foot infections underwent RS for persistent infection. The predictive variables related to undergoing revision surgery were erythrocyte sedimentation rate >70 mm/h (odds ratio [OR] = 1.6, 95% confidence interval [CI] = 1.1-2.6), leukocytosis (OR = 1.6, 95% CI = 1.1-2.5), peripheral arterial disease (OR = 1.5, 95% CI = 1.0-2.4), and isolation of gram-negative rods from tissue biopsy (OR = 2.2, 95% CI = 1.5-3.4). Seventy-nine out of 167 patients (47.3) who underwent RS required a higher level of surgery achieving a limb salvage rate of 70.7%. Predictive variables related to undergoing a major amputation after RS were persistent infection located in the bone (OR = 0.08, 95% CI = 0.03-0.22), ischemic heart disease (OR = 3.4, 95% CI = 1.4-8.5), 2 or more reoperations (OR = 3.0, 95% CI = 1.2-7.1), isolation of gram-negative rods from tissue biopsy (OR = 3.3, 95% CI = 1.3-8.4), and peripheral arterial disease (OR = 6.5, 95% CI = 1.9-22.8). Despite the fact that 40% of patients underwent reoperations for diabetic foot infections and 47.3% of them required a higher level of surgery, a high rate of limb salvage could be achieved.
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NewsBot · May 15, 2013

Tissue and Swab Culture in Diabetic Foot Infections: Neuropathic Versus Neuroischemic Ulcers.
Demetriou M, Papanas N, Panopoulou M, Papatheodorou K, Bounovas A, Maltezos E.
Int J Low Extrem Wounds. 2013 May 9[/UR]

We evaluated the diagnostic performance of swabs versus tissue cultures in 28 diabetic patients with neuropathic (group A) and 22 diabetic patients with neuroischemic foot ulcer (group B) and the differences in bacterial isolates between the 2 groups. In group A, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of swab cultures for the diagnosis of infection were 100%, 40%, 88.5%, and 100%, respectively. In group B, the corresponding values were 100%, 22.2%, 65%, and 100%. In group A, sensitivity, specificity, PPV, and NPV of swab cultures for the identification of pathogens were 100%, 14.3%, 53.8%, and 100%, respectively. In group B, the corresponding values were 100%, 18.2%, 55%, and 100%. In each group, Staphylococcus aureus and Pseudomonas aeruginosa were the most common isolates. The number of isolates was significantly higher on swab versus tissue cultures only in group A (P = .033). No differences were observed between groups in number of isolates and colony forming units. In conclusion, swab cultures are highly sensitive but less specific and have an excellent NPV both in diabetic patients with neuropathic and in those with neuroischemic foot ulcer. There are no differences between the groups in microbial load.
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NewsBot · May 18, 2013

The diabetic foot infections: Biofilms and antimicrobial resistance.
Malik A, Mohammad Z, Ahmad J.
Diabetes Metab Syndr. 2013 Apr-Jun;7(2):101-7.

AIM:
To study the difference in antimicrobial resistance profile among biofilm producing and non-producing microorganisms isolated from diabetic foot ulcer in a tertiary care hospital in North India.

METHODOLOGY:
We performed a prospective study on 162 DFU in patients treated in a multidisciplinary based diabetes and endocrinology center of JNMCH, AMU, Aligarh, India during the period of December 2008-March 2011. Detailed history and physical examination was carried out for every subject. Patient's profile, grade of DFU, co-morbidities and complications, laboratory data and final outcome were collected. Standard methods of sample collection and identification of microorganism were adopted. Risk factors for biofilm producing infections were determined by univariate analysis with 95% of CI. P value <0.05 were considered as significant.

RESULTS:
The overall biofilm producing infection rate among DFU was 67.9%. On univariate analysis, significant risk factors for biofilm producing infection were male sex [P=0.015, OR 2.35, RR 1.71], duration of diabetes [P<0.006, OR 4.0, RR 2.7], duration of ulcer >1 month [P<0.02, OR 2.26, RR 1.72], size of ulcer >4cm(2) [P<0.05, OR 2.03, RR 1.54], Grade II ulcer [P<0.06, OR 1.87, RR 1.63], necrotic ulcer [P<0.002, OR 5.79, RR 3.59], previous antibiotic use [P<0.007, OR 4.24, RR 2.74], subcutaneous infection [P<0.06, OR 1.87, RR 1.63], HbA1c >7% [P<0.04, OR 3.19, RR1.87] and polymicrobial infection [P<0.001, OR 6.64, RR 3.21] were significant risk factors.

CONCLUSIONS:
Treating the DFU by shifting from the planktonic model of microbiology to the biofilm model was recommended. With this new scientific approaches along with coordination of clinical and laboratory efforts, education, and research, it is possible to imagine overcoming much of biofilm disease.
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NewsBot · May 25, 2013

Epidemiology of Diabetic Foot Infections in an Eastern Caribbean Population: A Prospective Study.
Islam S, Harnarayan P, Cawich SO, Budhooram S, Bheem V, Mahabir V, Ramsewak S, Aziz I, Naraynsingh V.
Perm J. 2013 Spring;17(2):37-40.

INTRODUCTION:
This study evaluates the epidemiology of diabetic foot infections in an Eastern Caribbean nation in order to direct public health preventive measures.

METHODS:
We prospectively identified all patients with diabetic foot infections who were admitted to tertiary care hospitals across Trinidad and Tobago from July 2011 to June 2012. A questionnaire was used to collect data on demographics, patient knowledge, avoidance of risk factors for chronic diseases (a proxy to unhealthy lifestyles), and glycosylated hemoglobin measurements on admission as an index of blood glucose control. The data were analyzed with statistical software.

RESULTS:
There were 446 patients with diabetic foot infections (mean age = 56.9 years, standard deviation = 12.4 years). Most patients had Type 2 diabetes (93.3%) and were of Indo-Trinidadian (49.1%) or Afro-Trinidadian (41.7%) descent. There were preexisting complications of diabetes in 82.9% of patients with Type 2 diabetes: foot infections requiring hospitalization (70.2%), ischemic heart disease (32.5%), renal impairment (13.7%), and retinopathy (22.1%). Despite most patients claiming compliance with treatment, 75% had glycosylated hemoglobin levels above 7.1% at presentation, and 49.3% continued unhealthy lifestyles. Despite the high prevalence of diabetic complications at admission, and despite 70% having had previous hospitalization for treatment of foot infections, only 57.4% of patients reported ever being counseled or taught about foot care by medical personnel.

CONCLUSIONS:
There is room for improvement in public health strategies to prevent diabetic foot complications in this setting. Such strategies should focus on patient education with emphasis on lifestyle modification and compliance with medical therapy.
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NewsBot · Jun 8, 2013

Microbial profile of diabetic foot infections in Trinidad and Tobago
Shariful Islam et al
Primary Care Diabetes (in press)

Aims

To examine the microbiologic profile of diabetic foot infections in order to guide empiric antibiotic choices.
Methods

All patients with moderate–severe diabetic foot infections at a tertiary care facility were identified from July 2011 to June 2012. Culture samples were routinely collected before empiric antibiotics were commenced. Retrospective chart review was performed to extract the following data: demographics, clinical details, empiric antibiotic choice and microbiologic data. Descriptive analyses were performed using SPSS 12.0.
Results

There were 139 patients at a mean age of 56.9 ± 12.4 years. Mixed poly-microbial infections were present in 56.8% of cases. Of 221 organisms isolated, 64.7% were gram-negative aerobes, 32.1% were gram-positive aerobes and 3.2% were obligate anaerobes. Multidrug resistant organisms were encountered in 25.9% of cases and included ESBL producers (11.3%), MRSA (4.5%) and VRE (1.4%). Both ciprofloxacin and ceftazidime had good overall anti-microbial activity against gram-negative (68% and 62%, respectively) and gram-positive pathogens (69% and 48%, respectively). Obligate anaerobes were uncommonly isolated due to institutional constraints.
Conclusion

In this environment, both ciprofloxacin and ceftazidime provide good broad-spectrum anti-microbial activity against the commonly isolated pathogens. Either agent can be used as single agent empiric therapy in patients with moderate/severe diabetic infections in our setting. Although institutional limitations precluded isolation of anaerobes in most cases, there is sufficient evidence for anti-anaerobic agents to be recommended as a part of empiric therapy.
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NewsBot · Jun 11, 2013

The management of diabetic foot infections in a busy district hospital: an audit report
Chioma J Iwu, Becky Mersh, Michael Parkin, Samson O Oyibo
The Online Journal of Clinical Audits, Vol 5, No 2 (2013)

Aims – We audited the management of diabetic foot infections in our District General Hospital after adopting the guidelines produced by the National Institute for Clinical Excellence.

Methods – The admission notes for patients admitted with a diabetic foot infection between January 2011 and September of 2012 were used to fill out the audit questionnaire.

Results – We reviewed 42 patient-admission notes. A majority were male patients with a moderately infected fore-foot ulcer and were referred from their general practitioner. More than three-quarter of patients had investigations and treatment in accordance with the guidelines. However, there was less than adequate documentation of evidence of feet examination and less than adequate documentation of reasons for non-adherence to the antibiotic policy. Ninety percent of patients were seen by a member of the multidisciplinary foot team during admission. The median length of stay in hospital for the patient group was 5.5 days.

Conclusions – There was reasonably good adherence to guidelines in important areas of management. Continued staff education and involvement of the multidisciplinary foot team is essential for improving adherence to guidelines, so as to reduce morbidity, mortality and long hospital stay in patients with diabetic foot infections.
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Selwyn Firth · Jun 11, 2013

NewsBot said: ↑

A series of systematic reviews to inform a decision analysis for sampling and treating infected diabetic foot ulcers.
Health Technol Assess. 2006 Apr;10(12):1-238
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The analysis and the conclusions demonstrate how difficult it is for Podiatrists to choose the best course of action for their diabetic patients, who are at the greatest risk of losing limbs. The majority of Doctors agree that poor circulation is the main problem in fighting infection and healing. Infections can be controlled by topical agents to some degree, but the wound environment provides plenty of food for the bacteria. The poor circulation prevents oxygen, nutrients, growth factors and antibiotics from reaching the wound site.

The company i work for manufactures the Venowave. A small portable calf compression device which byits action forces blood back to the heart. As venous blood flows back the arterial flow must increase to compensate for the venous return. This simple action ensures that since the flow moves through the cappillary bed then more blood must get to the wound site.
The few results of a proof of concept study had a hundred percent recovery in 10 patients who had long standing non healing wounds. More can be found on Youtube by searching for Venowave. This device is able to increase circulation by .1 l perminute or 6 liters an hour to the foot. Since there is very little blood flow to the foot this may be as much as a 5- 10 fold increase depending on the severity of the blockages involved.

NewsBot · Jun 13, 2013

Press Release:
Dual Agent Scan Differentiates Diabetic Foot Disorders

Novel approach to a molecular imaging technique helps doctors identify diabetic foot infection and rule out a non-infectious complication that develops in nerve-damaged joints

Vancouver, British Columbia – Researchers are kick-starting better diabetic foot care and promoting reduced radiation dose with a new take on a hybrid molecular imaging technique. By targeting both bone cell activity and immune response and improving imaging data interpretation, doctors can better distinguish diabetic foot infection from another common foot condition that often requires an additional bone-marrow scan for definitive diagnosis, say researchers presenting a study at the Society of Nuclear Medicine and Molecular Imaging’s 2013 Annual Meeting.

Diabetes, if not well managed, can damage blood vessels and nerves, causing poor circulation, reduced healing, a condition called neuropathy and loss of sensation, especially in sufferers’ feet. In time, infection can develop in soft tissues and spread to bone (osteomyelitis), and weight-bearing joints can degenerate in a condition called Charcot joint, named after the discoverer of the disease. This study reveals that with enhanced visual and data analysis of standard hybrid imaging that combines agents targeting bone cell activity and white blood cell immune response, physicians can accurately diagnose diabetic foot disorders and avoid second-day bone marrow imaging.

“Optimizing imaging protocol for detection and localization of diabetic foot conditions aids attending physicians in distinguishing between true bone infection and bone marrow overgrowth associated with Charcot joint,” says Sherif Heiba, MD, director of nuclear medicine residency program and associate professor of radiology at Mount Sinai School of Medicine, New York, NY. “This helps patients considerably by not only eliminating unnecessary scans but also reducing imaging time and the total radiation dose required to make that determination.”

Current imaging standards advise an additional bone marrow scan if initial scanning comes back positive for white blood cell activity in foot bone, indicating osteomyelitis but also possibly caused by hyperplasia, a proliferation of cells in the bone marrow of patients with Charcot joint. In this study, researchers investigated new data analysis for single photon emission computed tomography (SPECT) and computed tomography (CT), which together provide both biological and anatomical information about diabetic food disorders. The combination of imaging agents technetium-99mhydroxymethylene diphosphonate (HDP)—an expert biomarker for targeting bone—and a white blood cell or leukocyte biomarker that seeks out hot spots of infection can provide new comparative imaging data that make accurate diagnosis possible with a single scan.

A total of 22 diabetic patients were imaged with dual-isotope SPECT/CT for suspected diabetic foot infection. Scanning detected 27 lesions, 10 of which were confirmed as osteomyelitis. Osteomyelitis correlated with adjacent deep soft tissue infection in white blood cell SPECT/CT scan in nine of the 10 lesions. Researchers also analyzed patterns of wash-out of the white blood cell imaging agent to differentiate actual osteomyelitis from Charcot joint. Initial scans for 15 of the 17 lesions that were confirmed to represent Charcot joints showed white blood cell wash-out. Results were confirmed by an additional bone marrow scan, proving that dual-isotope bone and white blood cell SPECT/CT scan can positively identify osteomyelitis from Charcot joint without an additional bone marrow scan.

This study shows that accurate detection, differentiation and localization of foot disease with this molecular imaging technique can improve the lives of diabetic patients while simplifying the current imaging standard and reducing overall radiation exposure. Further investigation is needed to replicate these results in order to implement a change in standard imaging practice for diabetics with suspected foot infection.

An estimated 347 million people worldwide are currently living with diabetes, according to 2013 diabetes statistics from the World Health Organization. The highest rates of hospitalization due to diabetes complications relate tofoot infections that refuse to heal.

Scientific Paper 654: Sherif Heiba, Panagiotis Sideras, Lale Kostakoglu, Ina Savitch, Josef Machac, Radiology, Nuclear Medicine Division, Mount Sinai School of Medicine, New York, NY, “The beneficial influence of dual isotope SPECT/CT use on management of patients with suspected diabetic foot infection,” SNMMI’s 60th Annual Meeting, June 8–12, 2013, Vancouver, British Columbia.
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NewsBot · Jun 15, 2013

Full text:
Antibiotic Susceptibility Patterns of Pathogens Isolated From Diabetic Foot Ulcers

NewsBot · Jun 15, 2013

Tissue and Swab Culture in Diabetic Foot Infections Neuropathic Versus Neuroischemic Ulcers
Maria Demetriou et al
International Journal of Lower Extremity Wounds June 2013 vol. 12 no. 2 87-93

We evaluated the diagnostic performance of swabs versus tissue cultures in 28 diabetic patients with neuropathic (group A) and 22 diabetic patients with neuroischemic foot ulcer (group B) and the differences in bacterial isolates between the 2 groups. In group A, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of swab cultures for the diagnosis of infection were 100%, 40%, 88.5%, and 100%, respectively. In group B, the corresponding values were 100%, 22.2%, 65%, and 100%. In group A, sensitivity, specificity, PPV, and NPV of swab cultures for the identification of pathogens were 100%, 14.3%, 53.8%, and 100%, respectively. In group B, the corresponding values were 100%, 18.2%, 55%, and 100%. In each group, Staphylococcus aureus and Pseudomonas aeruginosa were the most common isolates. The number of isolates was significantly higher on swab versus tissue cultures only in group A (P = .033). No differences were observed between groups in number of isolates and colony forming units. In conclusion, swab cultures are highly sensitive but less specific and have an excellent NPV both in diabetic patients with neuropathic and in those with neuroischemic foot ulcer. There are no differences between the groups in microbial load.
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NewsBot · Jun 15, 2013

Revision Surgery for Diabetic Foot Infections
Giving Another Chance to the Patient
Javier Aragón-Sánchez, et al
International Journal of Lower Extremity Wounds June 2013 vol. 12 no. 2 146-151

Revision surgery (RS) is frequently needed to control diabetic foot infections. It is the aim of this retrospective observational study to analyze the variables associated with undergoing RS and the variables associated with undergoing a major amputation when RS was required. We conducted a retrospective study of patients with diabetes treated in our department during 10 years (January 1, 2000 to January 1, 2010) who had foot infections identifying those who required RS. In all, 167 out of 417 patients (40%) with diabetes who underwent surgery for foot infections underwent RS for persistent infection. The predictive variables related to undergoing revision surgery were erythrocyte sedimentation rate >70 mm/h (odds ratio [OR] = 1.6, 95% confidence interval [CI] = 1.1-2.6), leukocytosis (OR = 1.6, 95% CI = 1.1-2.5), peripheral arterial disease (OR = 1.5, 95% CI = 1.0-2.4), and isolation of gram-negative rods from tissue biopsy (OR = 2.2, 95% CI = 1.5-3.4). Seventy-nine out of 167 patients (47.3) who underwent RS required a higher level of surgery achieving a limb salvage rate of 70.7%. Predictive variables related to undergoing a major amputation after RS were persistent infection located in the bone (OR = 0.08, 95% CI = 0.03-0.22), ischemic heart disease (OR = 3.4, 95% CI = 1.4-8.5), 2 or more reoperations (OR = 3.0, 95% CI = 1.2-7.1), isolation of gram-negative rods from tissue biopsy (OR = 3.3, 95% CI = 1.3-8.4), and peripheral arterial disease (OR = 6.5, 95% CI = 1.9-22.8). Despite the fact that 40% of patients underwent reoperations for diabetic foot infections and 47.3% of them required a higher level of surgery, a high rate of limb salvage could be achieved.
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NewsBot · Jul 11, 2013

Dual-isotope SPECT/CT impact on hospitalized patients with suspected diabetic foot infection: saving limbs, lives, and resources.
Heiba S, Kolker D, Ong L, Sharma S, Travis A, Teodorescu V, Ellozy S, Kostakoglu L, Savitch I, Machac J.
Nucl Med Commun. 2013 Jul 7.

BACKGROUND:
Foot ulcer with suspected infection is one of the most common reasons for hospitalization and a major factor contributing to morbidity and high healthcare-related expenses among diabetic patients. Many patients will require amputation; however, major amputation is associated with an alarmingly high 5-year mortality rate. In this study, we assess the diagnosis and management of suspected foot infection in diabetic patients using dual-isotope (DI) single-photon emission computed tomography/computed tomography (SPECT/CT) compared with conventional imaging.
METHODS:
The diagnostic accuracy in and management of 227 patients who had undergone DI SPECT/CT was compared with that of 232 similar patients who had undergone conventional imaging including plain radiography, CT, planar bone scanning, planar indium-111 white blood cell scanning, and MRI. The duration of hospitalization was additionally compared between these two groups of patients after excluding patients with other active comorbidities.
RESULTS:
Soft-tissue infection, osteomyelitis with or without soft-tissue infection, and other bony pathologies were more accurately and confidently identified with DI SPECT/CT than with conventional imaging. DI SPECT/CT use was associated with significantly fewer major amputations and more selective bony resection as well as with shorter duration of hospitalization when compared with conventional imaging.
CONCLUSION:
In this large population of diabetic patients with suspected foot infection DI SPECT/CT was more accurate in diagnosing and localizing infection compared with conventional imaging. In addition, DI SPECT/CT provided clear guidance and promoted many limb salvage procedures. Of equal importance to health economics, DI SPECT/CT use was associated with considerably reduced length of hospitalization compared with conventional imaging.
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NewsBot · Jul 20, 2013

Detection of Escherichia coli and Associated β-Lactamases Genes from Diabetic Foot Ulcers by Multiplex PCR and Molecular Modeling and Docking of SHV-1, TEM-1, and OXA-1 β-Lactamases with Clindamycin and Piperacillin-Tazobactam.
Shahi SK, Singh VK, Kumar A.
PLoS One. 2013 Jul 4;8(7):e68234. doi: 10.1371/journal.pone.0068234. Print 2013.

Diabetic foot ulcer (DFU) is a common and devastating complication in diabetes. Antimicrobial resistance mediated by extended-spectrum β-lactamases (ESBLs) production by bacteria is considered to be a major threat for foot amputation. The present study deals with the detection of Escherichia coli and the prevalence of bla TEM, bla SHV and bla OXA genes directly from biopsy and swab of foot ulcers of diabetic patients. In total, 116 DFU patients were screened, of which 42 suffering with severe DFUs were selected for this study. Altogether 16 E. coli strains were successfully isolated from biopsy and/or swab samples of 15 (35.71%) patients. ESBL production was noted in 12 (75%) strains. Amplification of β-lactamase genes by multiplex PCR showed the presence of bla CTX-M like genes in 10 strains, bla TEM and bla OXA in 9 strains each, and bla SHV in 8 of the total 16 strains of E. coli. Out of the ten antibiotics tested, E. coli strains were found to be resistant to ampicillin (75%), cefoxitin (56.25%), cefazolin (50%), meropenem (37.5%), cefoperazone (25%), cefepime (31.25%), ceftazidime (56.25%), and cefotaxime (68.75%) but all showed sensitivity (100%) to clindamycin and piperacillin-tazobactam. 3D models of the most prevalent variants of β-lactamases namely TEM-1, SHV-1, OXA-1, and ESBL namely CTX-M-15 were predicted and docking was performed with clindamycin and piperacillin-tazobactam to reveal the molecular basis of drug sensitivity. Docking showed the best docking score with significant interactions, forming hydrogen bond, Van der Waals and polar level interaction with active site residues. Findings of the present study may provide useful insights for the development of new antibiotic drugs and may also prevent ESBLs-mediated resistance problem in DFU. The novel multiplex PCR assay designed in this study may be routinely used in clinical diagnostics of E. coli and associated bla TEM, bla SHV, and bla OXA like genes.
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NewsBot · Jul 23, 2013

Tissue penetration and antimicrobial activity of standard- and high-dose trimethoprim/sulfamethoxazole and linezolid in patients with diabetic foot infection.
Stein GE, Throckmorton JK, Scharmen AE, Weiss WJ, Prokai L, Smith CL, Havlichek DH.
J Antimicrob Chemother. 2013 Jul 19.

OBJECTIVES:
The purpose of this study was to conduct a pharmacokinetic and pharmacodynamic evaluation of high (320/1600 mg) and standard (160/800 mg) doses of trimethoprim/sulfamethoxazole and linezolid in outpatients with mild diabetic foot infections (DFIs).
METHODS:
Both viable skin/soft tissue from the infection site and serum were obtained at various times after antibiotic administration from 18 patients (6 per study group) being treated with linezolid, standard doses of trimethoprim/sulfamethoxazole or high doses of trimethoprim/sulfamethoxazole during a follow-up clinic visit. These samples were assayed for drug concentrations by liquid chromatography in tandem with mass spectrometry. Patient sera were also utilized in time-kill assays against two strains of Staphylococcus aureus and three strains of β-haemolytic streptococci.
RESULTS:
The mean tissue/serum ratio for linezolid was 0.46 (range, 0.18-0.71). The mean tissue/serum ratio for trimethoprim was 1.2 (range, 0.3-4.5) for both standard and high doses, and 0.23 (range, 0.1-0.46) and 0.36 (range, 0.14-1.28) for standard and high doses of sulfamethoxazole, respectively. Linezolid exhibited inhibitory activity in time-kill assays against strains of S. aureus (0.45 ± 0.5 log10 cfu/mL) and β-haemolytic streptococci (2.2 ± 0.6 log10 cfu/mL), while trimethoprim/sulfamethoxazole exhibited bactericidal (>3 log kill) activity against all of these isolates. These findings were consistent for each sampling time and for high as well as standard doses of trimethoprim/sulfamethoxazole.
CONCLUSIONS:
This pharmacokinetic/pharmacodynamic study found that trimethoprim/sulfamethoxazole exhibits good skin/soft tissue penetration in patients with DFIs as well as bactericidal activity in serum against strains of S. aureus and β-haemolytic streptococci.
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NewsBot · Jul 24, 2013

Determinants of microbial load in infected diabetic foot ulcers: a pilot study.
Demetriou M, Papanas N, Panopoulou M, Papatheodorou K, Maltezos E.
Int J Endocrinol. 2013;2013:858206.

We examined the determinants of microbial load in infected diabetic foot ulcers in 62 patients (38 men and 24 women, mean age: 65.63 ± 12.71 years) with clinically infected diabetic foot ulcers. Tissue cultures were taken from ulcers by 4 mm punches. Ulcer grade (University of Texas classification), neuropathy disability score (NDS), neuropathy symptom score (NSS), ankle-brachial index (ABI), perfusion, extent, depth, infection, and sensation (PEDIS) grade of diabetic foot infection, and laboratory parameters were evaluated in all patients. Total microbial load was positively correlated with the number of isolates on tissue cultures (r s = 0.544, P < 0.001), white blood cell count (WBC) (r s = 0.273, P = 0.032), and platelet count (PLT) (r s = 0.306, P = 0.015). It also exhibited a borderline insignificant positive correlation with PEDIS infection grade (r s = 0.246, P = 0.053). In stepwise linear regression analysis, the number of isolates on tissue cultures and WBC were identified as the only two significant parameters accounting for 38% of the variation in the log of total microbial load (adjusted R (2) = 0.380, P < 0.001). In conclusion, patients with infected diabetic foot ulcer exhibit a positive correlation of total microbial load with the number of isolates on tissue cultures, WBC and PLT.
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NewsBot · Sep 25, 2013

SIRS Is Valid in Discriminating Between Severe and Moderate Diabetic Foot Infections
Dane K. Wukich, Kimberlee B. Hobizal, Katherine Marie Raspovic, Bedda L. Rosario
Diabetes Care September 23, 2013

OBJECTIVE This retrospective, single-center study was designed to distinguish severe diabetic foot infection (DFI) from moderate DFI based on the presence or absence of systemic inflammatory response syndrome (SIRS).

RESEARCH DESIGN AND METHODS The database of a single academic foot and ankle program was reviewed and 119 patients were identified. Severe DFI was defined as local infection associated with manifestation of two or more objective findings of systemic toxicity using SIRS criteria.

RESULTS Patients with severe DFI experienced a 2.55-fold higher risk of any amputation (95% CI 1.21–5.36) and a 7.12-fold higher risk of major amputation (1.83–41.05) than patients with moderate DFI. The risk of minor amputations was not significantly different between the two groups (odds ratio 1.02 [95% CI 0.51–2.28]). The odds of having a severe DFI was 7.82 times higher in patients who presented with gangrene (2.03–44.81) and five times higher in patients who reported symptoms of anorexia, chills, nausea, or vomiting (2.22–11.25). The mean length of stay for patients with severe DFI was ∼4 days longer than for patients with moderate DFI, and this difference was statistically significant.

CONCLUSIONS SIRS is valid in distinguishing severe from moderate DFI in hospitalized patients. Patients with severe DFI, as by manifesting two or more signs of systemic inflammation or toxicity, had higher rates of major amputation and longer hospital stays and required more surgery and more subsequent admissions than patients who did not manifest SIRS.
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thekwie · Sep 25, 2013

As I was viewing this thread, an ad appeared with a link to this site:

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Oh dear.....

NewsBot · Sep 28, 2013

Are clindamycin and ciprofloxacin appropriate for the empirical treatment of diabetic foot infections?
M. G. de Vries, M. B. Ekkelenkamp, E. J. G. Peters
European Journal of Clinical Microbiology & Infectious Diseases; September 2013

The objective of this study was to determine if specific species of microorganisms are associated with severe infection and amputation in patients with a diabetic foot infection and to evaluate the effectiveness of clindamycin and ciprofloxacin in this population. A retrospective cohort study was performed at the University Medical Center Utrecht, The Netherlands, for the period January 1st 2005 to January 1st 2010. Patients with ICD-9 codes ‘diabetic foot’ were selected from the hospital database. We evaluated the association of Staphylococcus aureus and Gram-negative species (GNS) with severity of infection, number of amputations, and healing rates. No significant association was found between the different microorganisms and infection severity. Coinfections of GNS and S. aureus were significantly associated with amputation compared to infections with only S. aureus [p = 0.016, odds ratio (OR) 4.9, confidence interval (CI) 1.4–16.9]. The empiric antibiotic regimen of clindamycin and ciprofloxacin covered only 85 % of S. aureus and 78 % of GNS diabetic foot infections. In mild diabetic foot infection in the studied population, where methicillin-sensitive S. aureus and streptococci are the most likely pathogens, a beta-lactam antibiotic such as flucloxacillin would likely be more effective than clindamycin. In moderate and severe infections, where GNS as a causative organism cannot be safely excluded, broad-spectrum antibiotic therapy may be more adequate.
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NewsBot · Oct 8, 2013

Bacteriocin from Bacillus subtilis as a novel drug against diabetic foot ulcer bacterial pathogens.
Joseph B, Dhas B, Hena V, Raj J.
Asian Pac J Trop Biomed. 2013 Dec;3(12):942-946.

OBJECTIVE:
To isolate and identify Bacillus subtilis (B. subtilis) from soil and to characterize and partially purify the bacteriocin. To evaluate the antimicrobial activity against four diabetic foot ulcer bacterial pathogens.
METHODS:
Genotypic identification was done based on Bergey's manual of systemic bacteriology. Antimicrobial susceptibility test was done by Kirby-Bauer disc diffusion method. Colonies were identified by colony morphology and biochemical characterization and also compared with MTCC 121 strain. Further identification was done by 16S rRNA sequencing. Inhibitory activities of partially purified bacteriocin on all the DFU isolates were done by agar well diffusion method. The strain was identified to produce bacteriocin by stab overlay assay. Bacteriocin was extracted by organic solvent extraction using chloroform, further purified by HPLC and physical, and chemical characterization was performed.
RESULTS:
The four isolates showed high level of resistance to amoxyclav and sensitivity to ciprofloxacin. HPLC purification revealed that the extracts are bacteriocin. The phylogenetic tree analysis results showed that the isolate was 99% related to B. subtilis BSF01. The results reveled activity to all the four isolates and high level of activity was seen in case of Klebsiella sp.
CONCLUSIONS:
Partially purified bacteriocin was found to have antimicrobial activity against the four diabetic foot ulcer bacterial pathogens, which can thus be applied as a better drug molecule on further studies. The strain B. subtilis are found to be safe for use and these antimicrobial peptides can be used as an antimicrobial in humans to treat DFU bacterial pathogens.
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NewsBot · Oct 17, 2013

Increasing incidence of Gram-negative organisms in bacterial agents isolated from diabetic foot ulcers.
Turhan V, Mutluoglu M, Acar A, Hatipoglu M, Onem Y, Uzun G, Ay H, Oncul O, Gorenek L.
J Infect Dev Ctries. 2013 Oct 15;7(10):707-712.

INTRODUCTION:
In the present study, we sought to identify the bacterial organisms associated with diabetic foot infections (DFIs) and their antibiotic sensitivity profiles.
METHODOLOGY:
We retrospectively reviewed the records of wound cultures collected from diabetic patients with foot infections between May 2005 and July 2010.
RESULTS:
We identified a total of 298 culture specimens (165 [55%] wound swab, 108 [36%] tissue samples, and 25 [9%] bone samples) from 107 patients (74 [69%] males and 33 [31%] females, mean age 62 ± 13 yr) with a DFI. Among all cultures 83.5% (223/267) were monomicrobial and 16.4% (44/267) were polymicrobial. Gram-negative bacterial isolates (n = 191; 61.3%) significantly outnumbered Gram-positive isolates (n = 121; 38.7%). The most frequently isolated bacteria were Pseudomonas species (29.8%), Staphylococcus aureus (16.7%), Enterococcus species (11.5%), Escherichia coli (7.1%), and Enterobacter species (7.1%), respectively. While 13.2% of the Gram-negative isolates were inducible beta-lactamase positive, 44.2% of Staphylococcus aureus isolates were methicillin resistant. Conclusions: Our results support the recent view that Gram-negative organisms, depending on the geographical location, may predominate in DFIs.
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NewsBot · Nov 16, 2013

Diagnosing diabetic foot infection: the role of imaging and a proposed flow chart for assessment.
Israel O, Sconfienza LM, Lipsky BA.
Q J Nucl Med Mol Imaging. 2013 Nov 14.

Diabetes mellitus, a major current epidemic, is frequently complicated by foot infections that are associated with high morbidity. Diagnosing these infections, especially whether or not underlying bone is involved, poses clinical challenges, but is crucial to making proper decisions regarding therapeutic strategies. The most effective means of managing patients with a diabetic foot infection is within the framework of a multidisciplinary team. Present diagnostic efforts are aimed at developing better methods to differentiate uninfected from infected soft tissue wounds, to determine when bone infection is present, and to more clearly define when infection has resolved with treatment. Imaging studies play a major role in diagnosis. This usually begins with plain radiographs, but when advanced imaging is needed, magnetic resonance imaging (MRI) is considered the modality of choice. Newer techniques, such as molecular hybrid imaging, positron emission tomography (PET)/computed tomography (CT) and single photon emission (SPECT)/CT using various radiotracers, play an increasing role. These tests may redefine the non-invasive diagnostic work-up of diabetic foot wounds, potentially leading to substantial improvements in patient management. As experts in infectious diseases, radiology and nuclear medicine, we reviewed the available literature on diagnosing diabetic foot infections, especially the currently available imaging techniques, and developed a proposed diagnostic flow chart, for evaluating patients with a diabetic foot wound.
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NewsBot · Jan 24, 2014

The microbiologic profile of diabetic foot infections in Turkey: a 20-year systematic review : Diabetic foot infections in Turkey.
Hatipoglu M, Mutluoglu M, Uzun G, Karabacak E, Turhan V, Lipsky BA.
Eur J Clin Microbiol Infect Dis. 2014 Jan 23.

The causative pathogens in diabetic foot infections differ in studies of European compared with Asian populations. The purpose of this study was to determine the causative microorganisms and their antibiotic sensitivity patterns in diabetic patients with a foot infection in Turkey, a country at the crossroads of these two continents. We performed a comprehensive literature search to identify all published studies pertaining to DFIs in patients cared for in Turkey. To assess changes in causative organisms and their antibiotic sensitivity patterns over time, we compared the results of just the most recent 5 years (2007-2011) with those of the past 20-years (1989-2011). We identified 31 studies meeting our inclusion criteria. Overall, these studies reported 2,097 patients, from whom 1,974 microorganisms were isolated. The total percentage of gram-negative and gram-positive aerobic bacteria were similar in each of the assessed periods. The rate of isolation of Staphylococcus aureus during the entire period, compared with just the past 5 years, was 23.8 % and 19.1 %, respectively, while the rate of methicillin-resistant S. aureus was 7.8 % and 5.7 %, respectively. The isolation rate of Pseudomonas aeruginosa was 13.7 % for the entire period and 14.9 % for the past 5 years. While linezolid, vancomycin and teicoplanin were the most active agents against gram-positive microorganisms, imipenem and cefoperazone-sulbactam were the most active against gram-negative microorganisms. This systematic review demonstrated few substantial changes in diabetic foot microbiology over the past 20 years. The data may help develop and update local clinical guidelines regarding antibiotic therapy for diabetic foot infections in Turkey. Further studies, especially with optimal culture methods, would be useful to validate these findings.
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NewsBot · Feb 4, 2014

Microbiological profile of diabetic foot ulcers and its antibiotic susceptibility pattern in a teaching hospital, Gujarat
Vaidehi J. Mehta, Kunjan M. Kikani, Sanjay J. Mehta.
Int J Basic Clin Pharmacol. 2014; 3(1): 92-95

Background: Diabetic foot lesions are a major medical, social and economic problem and are the leading cause of hospitalization for patients with diabetes worldwide. Infection sometimes leads to amputation of the infected foot if not treated promptly. The present study was conducted to isolate and identify the bacterial pathogens associated with diabetic foot ulcer and to find out its antibiotic susceptibility pattern to reduce the risk of complications.
Methods: Total 100 pus samples were collected from patients having diabetic foot ulcer, during July to October 2012. Samples were processed as per standard guidelines.
Results: Out of 100 pus samples, 73 (73%) yielded growth of organisms making total of 92 isolates. Out of 92 bacterial isolates, 72 were gram negative and 20 were gram positive. Pseudomonas aeruginosa 25 (27%) was most common isolate causing diabetic foot infections followed by 20 (22%) Klebsiella sp., 17 (19%) E. coli, 15 (17%) S. aureus, 6 (7%) Proteus sp. and 4(3%) Enterococci, 2 (2%) Acinetobacter sp. and 2(2%) CONS and 1(1%) Providencia. Out of 72 GNB, 50 (69.4%) were extended spectrum β lactamase (ESBL) producer. Most gram negative isolates were resistant to levofloxacin, gentamicin, ampicillin-sulbactam and gatifloxacin. All GNB were sensitive to imipenem. Out of 15 S. aureus, 9 (60%) were Methicillin Resistant Staphylococcus aureus (MRSA) and were sensitive to vancomycin and linezolid.
Conclusions: Pseudomonas sp. was the most common cause of infections. Most isolates were multi drug resistance.
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NewsBot · Feb 8, 2014

Is Clostridium difficile associated with the ‘4C’ antibiotics? A retrospective observational study in diabetic foot ulcer patients
A. Collier, J. McLaren, J. Godwin, A. Bal
International Journal of Clinical Practice; Early View

Aims
Clostridium difficile is an anaerobic cytotoxin-producing bacterium that can cause infectious diarrhoea, pseudomembranous colitis and toxic megacolon. The major risk factors for developing C. difficile infection include recent or current antimicrobial use, diabetes, age over 65, proton pump inhibitor use, immunosuppression and previous infection with C. difficile. Most diabetic foot ulcers are polymicrobial.

Methods
As a result guidelines advise treatment with broad spectrum antibiotics which include the ‘4C's’ (clindamycin, cephalosporins, co-amoxiclav and ciprofloxacin) which are associated with a higher risk of C. difficile infection. Retrospective observational data (June 2008 to January 2012) for the diabetes foot ulcers were gathered from the Diabetes/Podiatry Clinic database in NHS Ayrshire and Arran and cross-matched with the NHS Ayrshire and Arran Microbiology database. There were 111 patients with mean age 59 years (range 24–94 years), 33 type 1 patients, 78 type 2 patients, mean duration of diabetes 16 years (6 months–37 years) and mean HbA1c 67 mmol/mol (54–108 mmol/mol) [8.3% (7.1–12%)].

Results
The total number of days antimicrobials prescribed for all patients was 7938 (mean number of antimicrobial days per patient = 71.5 days). There was one case of C. difficile infection of 111 patients giving an incidence of 1.25 cases per 10,000 patient-days of antibiotics/1 case per 209 foot ulcers.

Conclusions
Large doses, numbers and greater duration of antibiotic therapy all result in a greater degree of normal gut flora depletion. It is possible that the alterations in gut flora in diabetic foot ulcer patients protect them from antibiotic-induced C. difficile overgrowth.
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NewsBot · Mar 1, 2014

Multivariate Prediction Model for Early Detection and Classification of Bacterial Species in Diabetic Foot Ulcers
Azian Azamimi Abdullah, Nurlisa Yusuf, Mohammad Iqbal Omar, Ammar Zakaria, Latifah Munirah Kamarudin, Ali Yeon Md Shakaff, Abdul Hamid Adom, Maz Jamilah Masnan, Yeap Ewe Juan, Amizah Othman and Mohd Sadek Yassin
Advances in Intelligent Systems Research Feb 2014

Many diabetic patients eventually develop foot ulcers are at risk for further infection and subsequent amputation if they are not treated promptly. Hence, this study is focused on identifying wild type strain bacteria and standard ATCC bacte-ria using e-nose which are PEN3 and Cyranose320. Data collected from both e-nose are processed using multivariate classifier such as LDA, KNN, PNN, SVM and RBF. The results indicate that rapid detection of bacteria using e-nose has increased the effectiveness, effi-ciency, reliability and reduced diagnosis time in identifying bacterial species on foot ulcer infection.
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NewsBot · Mar 11, 2014

Etiological factors of infections in diabetic foot syndrome - attempt to define optimal empirical therapy.
Małecki R, Rosiński K, Adamiec R.
Adv Clin Exp Med. 2014 Jan-Feb;23(1):39-48.

BACKGROUND:
Diabetic foot syndrome (DFS) represents one of the most frequent reasons for lower limb amputation in developed countries. In most cases, it is associated with bacterial infection, requiring optimal antibiotic therapy.
OBJECTIVES:
The aim of this study was to identify the most frequent pathogens responsible for infections associated with DFS, establish the optimal protocol of empirical therapy, and ascertain the clinical variables that may determine the choice of the appropriate antibacterial agent.
MATERIAL AND METHODS:
The analysis included hospital records of patients treated at the Department between 2008 and 2010. A total of 102 individuals were identified; their material was cultured and tested for antibiotic susceptibility.
RESULTS:
A total of 199 bacterial strains were isolated. There was a predominance of Gram-positive bacteria, particularly Staphylococcus aureus, Staphylococcus coagulase-negative strains, and Enterococcus faecalis. Of note was the high percentage of E. faecalis infection (16.08%). One can speculate on the potential etiological factors in the case of some bacteria, e.g. patients infected with S. aureus were characterized by higher monocytosis and lymphocytosis as compared to other patients. Analysis of drug susceptibility revealed that ciprofloxacin has the highest (but still only 44%) efficacy of all agents tested as monotherapy, and a combination of piperacillin and tazobactam or amoxicillin and clavulanate with aminoglycosides is particularly beneficial.
CONCLUSIONS:
Staphylococcus spp. predominates amongst the etiological factors of DFS infection; however, the rate of E. faecalis infection is alarmingly high. Monotherapy enables effective treatment in a minority of cases; therefore, at least two-drug protocols should be implemented from the very beginning of the therapy.
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NewsBot · Apr 23, 2014

Polymerase chain reaction-denaturing gradient gel electrophoresis (PCR-DGGE): A promising tool to diagnose bacterial infections in diabetic foot ulcers.
Dunyach-Remy C, Cadière A, Richard JL, Schuldiner S, Bayle S, Roig B, Sotto A, Lavigne JP.
Diabetes Metab. 2014 Apr 18

AIM:
The diagnosis of diabetic foot infections is difficult due to limitations of conventional culture-based techniques. The objective of this study was to evaluate the contribution of denaturing gradient gel electrophoresis (DGGE) in the microbiological diagnosis of diabetic foot ulcers in comparison to conventional techniques, and also to evaluate the need to perform a biopsy sample for this diagnosis.
METHODS:
Twenty diabetic patients (types 1 and 2) with foot ulcers (grades 1-4) were included. After debridement of their wounds, samples were taken in duplicate by surface swabbing and deep-tissue biopsy. The samples were analyzed by conventional culture and by a new molecular biology tool, DGGE technology.
RESULTS:
Polymerase chain reaction (PCR)-DGGE led to the identification of more bacteria than did conventional cultures (mean: 2.35 vs 0.80, respectively). In 11 cases, the technology detected pathogenic species not isolated by classical cultures. PCR-DGGE also identified significantly more pathogenic species at deep levels compared with species detected at superficial levels (87% vs 58%, respectively; P=0.03). In 9/20 cases, pathogenic bacteria were detected only in deep samples, revealing the need to perform tissue biopsy sampling.
CONCLUSION:
DGGE, achievable in 48h, could be a useful technique for the bacteriological diagnosis of diabetic foot infections. It may help to identify pathogenic bacteria in deeply infected ulcers, thereby contributing to a more appropriate use of antibiotics.
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NewsBot · Apr 23, 2014

Contribution of infection and peripheral artery disease to severity of diabetic foot ulcers in Chinese patients.
Hao D, Hu C, Zhang T, Feng G, Chai J, Li T.
Int J Clin Pract. 2014 Apr 22.

AIM:
The objective of the current ongoing study was to evaluate the characteristics of diabetic patients with newly diagnosed foot ulcer in Burn & Plastic Hospital of PLA General Hospital.
METHODS:
A total of 1002 consecutive patients presenting with a new foot ulcer between March 2007 and September 2013 were enrolled. All enrolled patients were classified based on presence or absence of collateral infection, disabling comorbidities and peripheral arterial disease (PAD).
RESULTS:
Of patients, 70.05% had PAD, which occurred significantly more in elderly adults. Patients with PAD had higher incidence of infection (58.9% vs. 41.5% in non-PAD group) and disabling comorbidities (79% in PAD and 61% in non-PAD; p < 0.038). There was no significant difference observed in depth, size and duration of foot ulcers between the PAD and non-PAD group of enrolled diabetic patients.
CONCLUSIONS:
Diabetic foot ulcer is more prominent in patients with PAD that is further reflected by significantly more underlying cases of infection and disabling comorbidity.
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NewsBot · May 3, 2014

A study of aerobic and anaerobic bacteria in diabetic foot ulcer and in vitro sensitivity of antimicrobial agent
Aasha Halpati, Kairavi J Desai, Ravindra Jadeja, Mayur Parmar.
Int J Med Sci Public Health. 2014; 3(5): -

Background: Diabetes mellitus is a chronic disorder affecting large population and a major public health problem .India ranking first in the world for diabetes. Diabetic patients are vulnerable to foot ulcer with polymicrobial infection.

Aims & Objective: Study was aimed to know etiology as well as antibiotic sensitivity that helps clinicians to select appropriate antimicrobial therapy.

Materials and Methods: The study was done from July 2010 to August 2011, in department of Microbiology, Sir T hospital and government medical college, Bhavnagar. 120 patients included from surgery dept. and samples were collected for aerobic and anaerobic culture, further identification was done by microscopy, culture and biochemical reaction. The antibiotic sensitivity testing was performed by Kirby Bauer method of disk diffusion using NCCLS guidelines.

Results: Out of 120 cases, total 150 bacterial species isolated with maximum aerobes (84%) and Staphylococcus aureus and Pseudomonas aeruginosa were commonest aerobic bacteria responsible for infection. Out of 24 Anaerobic isolates, 62.5% was Bacteroides species. Gram positive bacteria were sensitive to Vancomycin (100%) and gram negative bacteria were sensitive to Imipenam, Meropenam and Levofloxacin.

Conclusion: The study concludes that diabetic foot ulcer infection is always polymicrobial in nature. There was resistant pattern of aerobic bacteria to cephalosporin group may be due to indiscriminate usage of antibiotics. So, it is mandatory to screen all elder patients for diabetes as well as risk factors. Periodic surveillance is necessary to know multidrug resistant strains of hospital and to apply proper antibiotic policy.
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NewsBot · May 17, 2014

Correlation of adherence to the 2012 Infectious Diseases Society of America practice guidelines with patient outcomes in the treatment of diabetic foot infections in an outpatient parenteral antimicrobial programme.
Pence LM, Mock CM, Kays MB, Damer KM, Muloma EW, Erdman SM.
Diabet Med. 2014 May 13.

AIM:
To evaluate adherence to the 2012 Infectious Diseases Society of America practice guidelines for the management of patients with diabetic foot infections and to determine an association between adherence and clinical outcome.
METHODS:
A retrospective chart review was performed to evaluate the management and clinical outcomes of patients with diabetic foot infections treated with outpatient parenteral antimicrobial therapy between 1 January 2011 and 30 June 2012 at Wishard Health Services/Eskenazi Health. Adherence to individual Infectious Diseases Society of America diabetic foot infection treatment guideline recommendations was measured, and then assessed in relation to clinical outcome.
RESULTS:
A total of 57 patients (61% male, mean age 54 years) with moderate to severe diabetic foot infection met the inclusion criteria. None of the treatment courses of these patients adhered to all the Infectious Diseases Society of America guideline recommendations. The recommendations most frequently adhered to were consultation of appropriate multidisciplinary teams (n=54, 94.7%) and performance of diagnostic imaging (n=52, 89.5%). The recommendations least frequently adhered to were diabetic foot wound classification scoring on admission (n=0, 0%), appropriate culture acquisition (n=12, 21.2%), surgical intervention when indicated (n=32, 46.2%) and appropriate empiric antibiotic selection (n=34, 59.7%). Of 56 patients, 52 (92.9%) experienced clinical cure at the end of outpatient parenteral antimicrobial therapy compared with 34 of 53 patients (64%) at 6 months after the completion of therapy. Adherence to individual guidelines was not associated with clinical outcome. Patients who experienced treatment failure were more likely to have severe diabetic foot infection or peripheral neuropathy.
CONCLUSIONS:
Adherence to the Infectious Diseases Society of America diabetic foot infection guideline recommendations was found to be suboptimal in the present study. The effect of adhering to individual Infectious Diseases Society of America diabetic foot infection recommendations on clinical outcome needs to be investigated
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NewsBot · May 25, 2014

Clinical distribution and antimicrobial resistance analysis of 754 pathogenic bacteria in diabetic foot infection
Shen Q, Lin D, Zhu H, Ge S, Wu W, Pan X, Gu X, Gu X, Shen F.
Zhonghua Yi Xue Za Zhi. 2014 Apr;94(12):889-94.

OBJECTIVE:
To explore the microbiological profiles and antibiotic susceptibility patterns of organisms isolated from diabetic foot ulcers so as to provide selection rationales of antibiotics.
METHODS:
A retrospective study was conducted on the microbiological profiles and antibiotic susceptibilities in 754 strains of pathogens isolated from 519 patients with diabetic foot ulcers at our hospital from January 2010 to August 2013. The inter-group data were compared by Chi-square test.
RESULTS:
There were 322 (62.0%) males and 197 (38.0%) females. Their mean age was (67.7 ± 12.3) (30-93) years, duration of diabetes 10 (0-40) years, duration of lower-limb lesion 1.0 (0.0-72.0) months and HbA1c (9.09% ± 2.28%). Among 444 (85.5%) cases, a total of 754 strains of pathogens were isolated. Gram-positive aerobes were the most frequently isolated (47.3%, 357 strains) and followed by gram-negative aerobes and fungus (40.3% vs 12.3%, 304 vs 93 strains respectively). With rising Wagner's grades, bacterial floras transformed from Gram-positive cocci to Gram-negative rods while fungus and composite infections increased. And 122 strains were of multi drug resistant organisms (MDRO). Among 357 strains of Gram-positive bacteria, Staphylococcus aureus, Staphylococcus epidermidis and Enterococcus faecalis were dominating floras. Staphylococcus was highly resistant to penicillin G, erythromycin, and oxacillin while vancomycin and linezolid were the most effective agents against gram-positive bacteria. Among 304 strains of gram-negative bacteria, enterobacteria were the most prevalent, including 48 strains of Escherichia coli, 34 strains of Proteus mirabilis and 31 strains of Proteus vulgaris. And there were 29 strains of Pseudomonas aeruginosa. Enterobacteria were highly resistant to ampicillin, followed by bactrim and furadantin while meropenem, imipenem, piperacillin/sulbactam, sulperazone and cefepime were the most effective agents. The predominant fungus was Blastomyces albicans.
CONCLUSIONS:
In patients with severe diabetic foot ulcers, Gram-negative rods predominate while the prevalence of fungus and composite infections increases. Vancomycin and imipenem maintain highly antibacterial activity. It is essential to pay attention to pathogen survey and use antibiotics more rationally.
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NewsBot · Jun 12, 2014

Current concepts in the surgical management of acute the diabetic foot infections
Javier La Fontaineemail, Kavita Bhavan, Talal K. Talal, Lawrence A. Lavery
The Foot; Articles in Press

Diabetic foot complications are common, costly, and difficult to treat. Peripheral neuropathy, repetitive trauma, and peripheral vascular disease are common reasons that lead to ulcers, infection, and hospitalization. Individuals with diabetes presenting with foot infection require optimal medical and surgical management to accomplish limb salvage and prevent amputation; aggressive short-term and meticulous long-term care plans are required. Multiple classification systems have been recommended to ease the understanding and the management of these infections. Multi-disciplinary approach is the mainstay for a successful management. Such teams typically include multiple medical, surgical, and nursing specialties across a variety of public and private health care systems. This article is an overview in how to medically and surgically approach the diabetic foot infection with emphasis in soft tissue infection
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NewsBot · Jun 17, 2014

Ertapenem for Diabetic Foot Infections in China: A Multicentre, Randomised, Double-Blinded, Active-Controlled Study
ZR XU, XW RAN, YANG XIAN, XD YAN, GY YUAN, SM MU, JF SHEN, BS ZHANG, WJ GAN, JUE WANG,
Presented at the 74th American Diabetes Association Mtg; San Francisco; June 14-17 2014

Diabetic foot infections (DFIs) are common and serious complications affecting worldwide diabetes population. Few randomised studies have assessed antibiotic regimens in Asian populations. Our objective was to assess the efficacy and safety of ertapenem versus piperacillin/tazobactam (TZP) for DFIs in Chinese population.

Diabetic adults (n=565) with moderate-to-severe DFIs requiring intravenous (IV) antibiotics were randomly assigned either ertapenem (1g daily) or TZP (4.5g every 8h) for a minimum of 5 days. Oral amoxicillin/clavulanate (625mg every 12h) could be given for 23 days at maximum after IV therapy. Vancomycin may be allowed for bacterial species known resistant (i.e. Enterococcus spp) to study therapy. The primary outcome was the proportion of patients with a favourable clinical response on the day that IV antibiotic was discontinued (DCIV). An evaluable-patient population was identified for primary analysis. Safety was assessed across the study.

At DCIV, 443 patients were assessed clinically evaluable and 533 MITT qualified. Baseline characteristics between groups were comparable. Findings on primary outcome were summarised in table.

Safety was similar by ertapenem versus TZP based on drug-related AE (13.5% vs. 16.0%) and AE leading to discontinuation (4.0% vs. 5.8%).

Ertapenem is non-inferior to piperacillin/tazobactam and may be an option for DFIs in China.
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NewsBot · Jun 22, 2014

Superantigens of Staphylococcus aureus from Patients with Diabetic Foot Ulcers.
Vu BG, Stach CS, Salgado-Pabón W, Diekema DJ, Gardner SE, Schlievert PM.
J Infect Dis. 2014 Jun 20. pii: jiu350.

BACKGROUND:
Diabetic foot ulcer (DFU) infections are challenging. Staphylococcus aureus is the most commonly isolated pathogen in DFUs. Superantigens (SAgs) are causative in many S. aureus infections. We hypothesized both that DFU S. aureus will produce large SAg numbers, consistent with skin infections, and that certain SAgs will be over-represented. We assessed the SAg and α-toxin profile of isolates from DFU patients compared to other sources.
MATERIALS:
S. aureus (25) from DFU patients were characterized. Polymerase chain reaction was used to detect genes for methicillin-resistance and SAgs. Some SAgs and the α-toxin were quantified. We compared the SAg profile of DFU isolates with profiles of SAgs from patients with atopic dermatitis (skin) and vaginal isolates (mucosa).
RESULTS:
Most DFU isolates were methicillin-susceptible (64%), with USA100 the most common clonal group. The SAg gene profile of DFU isolates most closely resembled atopic dermatitis, having the highest number of different SAg genes per isolate, and high prevalence of staphylococcal enterotoxin D and the enterotoxin gene cluster. DFU isolates also had a high prevalence of staphylococcal enterotoxin-like X.
CONCLUSIONS:
The SAg profile of DFU isolates was more like skin than mucosal isolates. SAgs offer selective advantages in facilitating DFU infections and suggest therapies.
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