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This study investigated the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in infected and uninfected diabetic foot ulcers of 84 patients with the two types of diabetes. S. aureus was the most common pathogen among the Gram-positive bacteria isolated from ulcers, and almost 50% of S. aureus isolates were MRSA. The prevalence of MRSA was significantly higher in patients with infected foot ulcers. MRSA infection or colonisation was not associated with factors (previous hospitalisation, use of antibiotics, etc.) known to predispose to MRSA colonisation or infection. The high prevalence of MRSA in patients with foot ulcers may reflect the increased prevalence of MRSA in the community.
This study investigated the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) in infected and uninfected diabetic foot ulcers of 84 patients with the two types of diabetes. S. aureus was the most common pathogen among the Gram-positive bacteria isolated from ulcers, and almost 50% of S. aureus isolates were MRSA. The prevalence of MRSA was significantly higher in patients with infected foot ulcers. MRSA infection or colonisation was not associated with factors (previous hospitalisation, use of antibiotics, etc.) known to predispose to MRSA colonisation or infection. The high prevalence of MRSA in patients with foot ulcers may reflect the increased prevalence of MRSA in the community
Methicillin-resistant Staphyloccocus aureus (MRSA) isolation from diabetic foot ulcers correlates with nasal MRSA carriage. Diabetes Res Clin Pract. 2006 Sep 8;
Stanaway S, Johnson D, Moulik P, Gill G
Quote:
Methicillin-resistant Staphylococcus aureus is increasingly isolated from diabetic foot ulcers, and may be associated with an adverse prognosis. We have explored the relationship between MRSA isolation from foot ulcers and nasal MRSA carriage. Over a 12 month period, 65 consecutively attending patients with diabetic foot ulceration were recruited. Demographic information was collected, and the ulcer and nose swabbed bacteriologically using standard techniques. The patients were mean age 61year, diabetes duration 14 year, and HbA(1c) 8.5%. There were 61% male and 85% with type 2 diabetes. Ulcers were neuropathic in 55%, ischaemic in 14% and neuroischaemic in 31%. MRSA was isolated from 12 (19%) ulcers, and 11 (17%) had nasal carriage. Of the MRSA positive ulcer patients 7/12 (58%) had nasal MRSA carriage, compared with 4/53 (8%) with MRSA negative ulcers (p<0.0003). We conclude that nasal MRSA carriage in diabetic patients is a significant risk factor for foot ulcer MRSA infection.
What is scary is that this is now becomig community based.I had at least 1 patient who,of course is diabetic with multiple abcesses.I drained these and the culture was MRSA.He was outpatient,so that was something I found curious.
I would certainly concur with you there, John. The number of clients attending the outpatient unit, I work at with report MRSA has increased significantly recently .
I noticed the advice given by the Infection Control nurse to a client recently diagnosed with MRSA infection indicated clearly the nasal passages as a potential source of cross infection to the feet. The client was given instruction on the importance of swabbing the nose with a prescribed antimicrobal solution.
Cameron,it shocked me to see an outpatient with MRSA.I think it is because(and I may be guilty of this as well) doctors overprescribe antibiotics and the bugs are developing a resistance to these meds.
Risk factors for infection of the diabetic foot with multi-antibiotic resistant microorganisms. J Infect. 2006 Sep 30;
Kandemir O, Akbay E, Sahin E, Milcan A, Gen R
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AIM: To investigate the risk factors for infection of the diabetic foot with multidrug resistant microorganisms.
METHODS: Amongst 102 diabetic patients with evidence of soft tissue infection of the foot who presented to our health center over a three year period, we investigated risk factors that might be predictive of multi-antibiotic resistance of the infecting organism.
RESULTS: Of 102 patients with a diabetic foot wound, bacteria were cultured from 73, yielding a total of 104 isolates. The number of multidrug resistant isolates was 42 from 36 cases and the number of isolates other than multidrug resistant ones was 62 from 37 cases. Previous antibiotic therapy (p=0.002) and its duration (p=0.0001), frequency of hospitalization for the same wound (p=0.000), duration of hospital stay (p=0.000) and osteomyelitis (p=0.001) were significant risk factors for infections with multidrug resistant microorganisms.
CONCLUSION: In conclusion, an appropriate antibiotic should be initiated promptly, wound perfusion should be effective, duration of hospital stay should be as short as possible and optimum hygiene should be provided during wound care to prevent infections of diabetic foot wound with multidrug resistant microorganisms.
The increasing incidence of MRSA is certainly worrying. In our high risk diabetes clinic we would probably see around 15-20 patients who currently have MRSA colinising in there wounds. I guess the difficult situation is when a wound comes in and is clinically infected, a Dr is called and a swab taken. Should the swab results be obtained to detemine the sensitivity of the organism?
I know Dr's often have a fair idea of the infecting organism but are these some things that may need to be put it place to prevent the increase in MRSA.
Should the swab results be obtained to detemine the sensitivity of the organism? .
Justin, this question highlights the difference between *empirical* and *targeted/directed* antibiotic therapy.
Empirical therapy makes an assumption about the *most likely* causative organism, and directs treatment towards that pathogen. A bit like using a 4 degree post on every foot pain that walks through the door - some will get better, most probably won't. If anything, this increases the prevalence of MRSA in the community.
Targeted/directed therapy relies on identifiying, through culture and sensitivity, the most appropriate antibioitic regieme. This is the standard you should work towards.
In reality, the practice of empiral dosing whilst awaiting the outcomes of C&S is the norm.
LL
The Following User Says Thank You to LuckyLisfranc For This Useful Post:
This paper was presented at the American Diabetes Association 66th Annual Scientific Sessions - June 9-13, 2006, Washington, D.C.: MRSA Isolation from Diabetic Foot Ulcers -Does It Affect Healing and Is the Problem Getting Worse?
FRAN L. GAME, WILLIAM J. JEFFCOATE.
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The isolation of methicillin resistant Staphylococcus aureus (MRSA) has increased in the last 25 years, and many believe that it is more virulent than its methicillin sensitive counterpart. In order to determine both the changing prevalence of MRSA and any relationship to healing of diabetic foot ulcers, we surveyed cohorts of consecutive patients and compared outcomes in those who were and were not MRSA positive. The first cohort (98 patients with 150 ulcers) comprised all those attending in the calendar months, November 2001 and February 2002. Each person was sampled only once. The second cohort (85 patients with 110 ulcers) was from four weeks in July-August 2004. Vigorous surface sampling for MRSA was performed with a saline-moistened swab. Outcomes at 6 months were determined by a blinded clinician using the detailed database maintained in the clinic, supplemented when necessary by case notes review. MRSA was isolated from 15 ulcers (10.0%) in 10 patients (10.2%) in the 2001/2002 cohort, and from 19 ulcers (17.3%) in 17 patients (20.0%) in 2004. When those positive for MRSA were compared with those which were negative, there were no differences in the proportion of ulcers healed at 6 months in either the 2001/2 (Pearson Chi-Square 0.181, p= 0.774) or the 2004 survey (0.217, p=0.309). There were no differences in time to healing in either cohort (Mann-Whitney U 80.5 p=0.142, and U 76.5, p=0.233, respectively). Similarly, there were no differences in the numbers of major amputations (Chi-Square 0.14, p=0.579, and 4.996, p=0.025) or deaths (Chi-Square 3.6, p=0.191, and 0.536, p=0.464). When the 2 cohorts were combined, no differences were observed between those from whom MRSA was and was not isolated, with respect to healing (Chi-Square 0.845, p=0.428), time to healing (U 474 p=0.615), amputation (Chi-Square 3.34, p=0.087) or death (Chi-Square 0.314, p=0.483). It is concluded that although colonisation of diabetic foot ulcers with MRSA is increasing, it is not associated with worse outcome
When i find a wound with mrsa or any organism I always wonder why i took the culture to begin with and then if i should treat with local meds or go the vanco zyvox route. I have had good results on wounds that appear clean with local treatment and get negative cultures within a week .
I agree with Henry's post.Simple I and D does eradicate the infection in most if not all cases and hence the healing is quick and you may not even need antibiotics.I put the patients on them-a broad spectrum such as keflex works well here-and within a week or so,they are usually good to go.
Emergence of monomicrobial methicillin-resistant Staphylococcus aureus infections in diabetic foot osteomyelitis (retrospective study of 48 cases) Presse Med. 2007 Feb 26;
Couret G, Desbiez F, Thieblot P, Tauveron I, Bonnet R, Beytout J, Laurichesse H, Lesens O
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OBJECTIVE: Describe the clinical appearance, microorganisms involved, and prognosis of diabetic foot osteomyelitis.
METHOD: Retrospective study of 48 patients seen in 2004 for presumed osteomyelitis (exposed bone or suggestive radiographic or clinical picture). Specimens for culture came from swabs of wound discharge, needle aspiration and bone biopsy.
RESULTS: Forty-eight patients with diabetes and contiguous osteomyelitis of the foot were followed for a year. The principal microorganisms isolated were Staphylococcus aureus (58%) and Gram-negative bacilli (29%); 58% of the infections were monomicrobial, 31% of the microorganisms multidrug-resistant, and 85% of the patients were hospitalized, for a median duration of 30 days. Healing occurred in 40 patients, although 15 required amputation first, and 18 had a new infection at a different site (11 involving osteomyelitis) in the year after antibiotic treatment ended.
PERSPECTIVES: Diabetic foot osteomyelitis is a serious disease in view of its site and the microorganisms involved, which are often multidrug-resistant. There is a clear predominance of S. aureus. Medical treatment has an increasingly important role in its management and requires that samples be properly collected for bacteriological testing. The prognosis for these infections, which remains grim in view of the amputation rate and the high risk of new infection, could be improved by reinforcing prevention measures.
Epidemiology and prevalence of methicillin-resistant Staphylococcus aureus and Staphylococcus epidermidis in patients with diabetic foot ulcers: Focus on the differences between species isolated from individuals with ischemic vs. neuropathic foot ulcers.
Galkowska H, Podbielska A, Olszewski WL, Stelmach E, Luczak M, Rosinski G, Karnafel W. Diabetes Res Clin Pract. 2009 Mar 5. [Epub ahead of print]
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We examined whether foot ischemia or neuropathy with diabetic foot ulcer (DFU) promote selection of staphylococci species, evaluated frequency of MRSA and MRSE among strains yielded from patients with DFU and assessed multidrug resistance of isolates. Patients with DFU and foot osteomyelitis were divided into ischemic foot ulcer (IFU, n=21) and neuropathic foot ulcer (NFU, n=29) groups. Frequency of Staphylococcus epidermidis yielded from curettage of IFU was higher compared with NFU (P<0.05). S. epidermidis was also more frequently isolated from the toe web surface of patients with IFU compared with NFU (55% vs. 17.9%, respectively) and healthy volunteers (HV, n=20) (17.6%, P<0.05). These mostly MRSE strains (83.3-100%) originating from DFU patients were multidrug resistant (88.8%). Also, most of MRSA isolates were multidrug resistant (70.3%). Higher rates of MSSA from DFU patients than HV showed resistance to antimicrobials. This is the first report indicating that diabetic patients with IFU differ with NFU patients in higher frequency of S. epidermidis skin colonization and ulcer infection. We suggest that IFU should be defined as separate disease state of DFU and S. epidermidis should be appreciated as a nosocomial pathogen.
Are diabetic foot ulcers complicated by MRSA osteomyelitis associated with worse prognosis? Outcomes of a surgical series.
Aragón-Sánchez J, Lázaro-Martínez JL, Quintana-Marrero Y, Hernández-Herrero MJ, García-Morales E, Cabrera-Galván JJ, Beneit-Montesinos JV. Diabet Med. 2009 May;26(5):552-5.
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Aims The aim of this study was to compare the outcomes of surgical treatment of osteomyelitis caused by methicillin-resistant Staphylococcus aureus (MRSA) with cases caused by methicillin-sensitive Staphylococcus aureus (MSSA).
Methods We abstracted data of a series of 185 consecutive patients with diabetes and foot osteomyelitis undergoing surgery within the first 12 h after admission at a single hospital. Bone infection was confirmed by histopathological studies. Only cases where Staphylococcus aureus was isolated from bone specimens were included in this analysis. We analysed several variables between the two groups: MRSA vs. MSSA.
Results MRSA bone infection was associated with higher body temperature (P = 0.02) and white blood cell count (P = 0.02) than MSSA. Patients with MRSA infections underwent a greater number of surgical procedures (P = 0.03). Limb salvage was achieved in 93.6% of the patients, with no statistically significant difference in limb salvage rates between MRSA and MSSA-related osteomyelitis.
Conclusions From our experience, where treatment is based on early and aggressive surgical treatment, MRSA bone infections are not associated with worse prognosis
Although infection is a well-recognized barrier to healing, evidence has emerged that wound colonization with methicillin-resistant Staphylococcus aureus (MRSA) has the same effect, which has been quantified as increasing the time to healing twofold. MRSA is a concern for those with diabetic foot ulcers based on evidence of impaired healing when it is present in the wound. However, many studies have found the bacterial content of diabetic foot ulcers to be polymicrobial, which necessitates MRSA being placed in this environmental context. Multiple variables contribute to the development of infection, including the host response, tissue perfusion, ulcer depth, ulcer location, and an adequate source of nutrition. In view of these factors, it is difficult to attribute infection to one bacterial species.
Methicillin-resistant Staphylococcus aureus in Diabetic Foot Ulcers in a Chinese Care Hospital: Risk Factors for Infection and Prevalence.
Wang SH, Sun ZL, Guo YJ, Yang BQ, Yuan Y, Wei Q. J Med Microbiol. 2010 Jul 1. [Epub ahead of print]
Quote:
Retrospective case-control study of 118 (M: F, 68:50) Chinese type 2 diabetic patients with foot ulcers (Wagner's grade 3-5) were studied to determine the prevalence and risk factors for methicillin-resistant Staphylococcus aureus (MRSA) infection, in relation to community or hospital original parameters.. Ulcer specimens were processed for smear for Gram's staining, aerobic culture, and susceptibility identifications. Staphylococcus species were tested for methicillin resistance by using oxacillin. S.aureus was the most frequent pathogen (25.6%) in this population, a high proportion of S.aureus isolates were MRSA (63.4%). 65.4% met the definition of hospital associated MRSA (HA-MRSA) infections. Size of ulcer (adjusted OR 1.61; 95% CI 1.22-2.12) and osteomyelitis (adjusted OR 18.51, 95% CI 2.50-137.21) were independent predictors of MRSA infection. The HA-MRSA group had significantly different distributions from the community associated MRSA (CA-MRSA) group with respect to age, long history of diabetes, and length of hospital stay (all P<.001). Neuropathy, vascular disease (all P= .049), and osteomyelitis (P= .026) were the most common underlying conditions observed in the HA-MRSA group. This study makes contribution to precaution against the emergence of MRSA including different acquired MRSA among the Chinese population with diabetic foot ulcers based on their original or clinical parameter.
Diabetic foot ulcers are often complicated by infection. Among pathogens, Staphylococcus aureus predominates. The prevalence of methicillin-resistant S. aureus (MRSA) in infected foot ulcers is 15-30% and there is an alarming trend for increase in many countries. There are also data that recognize new strains of MRSA that are resistant to vancomycin. The risk for MRSA isolation increases in the presence of osteomyelitis, nasal carriage of MRSA, prior use of antibacterials or hospitalization, larger ulcer size and longer duration of the ulcer. The need for amputation and surgical debridement increases in patients infected with MRSA. Infections of mild or moderate severity caused by community-acquired MRSA can be treated with cotrimoxazole (trimethoprim/sulfamethoxazole), doxycycline or clindamycin when susceptibility results are available, while severe community-acquired or hospital-acquired MRSA infections should be managed with glycopeptides, linezolide or daptomycin. Dalbavancin, tigecycline and ceftobiprole are newer promising antimicrobial agents active against MRSA that may also have a role in the treatment of foot infections if more data on their efficacy and safety become available.
Cost avoidance using linezolid for methicillin-resistant Staphylococcus aureus infections in a specialist diabetes foot clinic.
Young MJ, Hodges G, McCardle JE. J Antimicrob Chemother. 2012 Aug 17.
Quote:
OBJECTIVES:
An audit was performed to determine whether linezolid (Zyvox, Pharmacia Limited, Sandwich, UK) was being used in accordance with local guidelines and if this had an effect on admissions for diabetes foot ulceration.
METHODS:
Seven hundred and four patient records from 2005 to 2010 in the Diabetes Foot Clinic, Royal Infirmary of Edinburgh were audited for methicillin-resistant Staphylococcus aureus (MRSA) infections, admissions and antibiotic use.
RESULTS:
Seventeen percent (n = 119) of patients had proven MRSA infections. Of these, 28% (n = 33) were prescribed linezolid, 94% (n = 31) for up to 14 days and none for >28 days. Eight (24%) had repeated courses. Ninety-one percent (n = 30) either avoided admission or were discharged early with resolution of infection. Four out of 33 patients had reversible blood abnormalities. The total cost for linezolid over this period was £58 000. However, 420 bed days, costing £500/day, were avoided, producing a total saving of £210 000 on inpatient costs.
CONCLUSIONS:
Linezolid guidelines reduced lengths of stay, inpatient costs and overuse of this expensive but effective treatment.
Relationship and susceptibility profile of Staphylococcus aureus infection diabetic foot ulcers with Staphylococcus aureus nasal carriage.
Taha AB. Foot (Edinb). 2012 Dec 19
Quote:
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
Co-Therapy Using Lytic Bacteriophage and Linezolid: Effective Treatment in Eliminating Methicillin Resistant Staphylococcus aureus (MRSA) from Diabetic Foot Infections.
Chhibber S, Kaur T, Sandeep Kaur. PLoS One. 2013;8(2):e56022.
Quote:
BACKGROUND:
Staphylococcus aureus remains the predominant pathogen in diabetic foot infections and prevalence of methicillin resistant S.aureus (MRSA) strains further complicates the situation. The incidence of MRSA in infected foot ulcers is 15-30% and there is an alarming trend for its increase in many countries. Diabetes acts as an immunosuppressive state decreasing the overall immune functioning of body and to worsen the situation, wounds inflicted with drug resistant strains represent a morbid combination in diabetic patients. Foot infections caused by MRSA are associated with an increased risk of amputations, increased hospital stay, increased expenses and higher infection-related mortality. Hence, newer, safer and effective treatment strategies are required for treating MRSA mediated diabetic foot infections. The present study focuses on the use of lytic bacteriophage in combination with linezolid as an effective treatment strategy against foot infection in diabetic population.
METHODOLOGY:
Acute hindpaw infection with S.aureus ATCC 43300 was established in alloxan induced diabetic BALB/c mice. Therapeutic efficacy of a well characterized broad host range lytic bacteriophage, MR-10 was evaluated alone as well as in combination with linezolid in resolving the course of hindpaw foot infection in diabetic mice. The process of wound healing was also investigated.
RESULTS AND CONCLUSIONS:
A single administration of phage exhibited efficacy similar to linezolid in resolving the course of hindpaw infection in diabetic animals. However, combination therapy using both the agents was much more effective in arresting the entire infection process (bacterial load, lesion score, foot myeloperoxidase activity and histopathological analysis). The entire process of tissue healing was also hastened. Use of combined agents has been known to decrease the frequency of emergence of resistant mutants, hence this approach can serve as an effective strategy in treating MRSA mediated foot infections in diabetic individuals who do not respond to conventional antibiotic therapy.
MRSA in diabetic foot ulcers
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