scholarly journals 109. Evaluating Predictive Value of Surgical Resected Proximal Bone Margins in Diabetic Foot Osteomyelitis with Clinical Outcomes at One Year

2021 ◽  
Vol 8 (Supplement_1) ◽  
pp. S67-S67
Author(s):  
Bruce Weng ◽  
Yasmin Oskooilar ◽  
Bishoy Zakhary ◽  
Chiao An Chiu ◽  
Nikki Mulligan ◽  
...  
Keyword(s):  
Staphylococcus Aureus ◽  
Clinical Outcomes ◽  
Antimicrobial Therapy ◽  
Diabetic Foot ◽  
Hemoglobin A1c ◽  
Smoking History ◽  
Positive Margins ◽  
Antibiotic Duration ◽  
One Year ◽  
Diabetic Foot Osteomyelitis

Abstract Background Diabetic foot osteomyelitis (DFO) remains a significant comorbidity in diabetes and often requires both surgical and medical interventions. Surgical bone resection with proximal margins is performed for treatment at our institution to guide antimicrobial therapy. Optimal antibiotic duration often remains unclear, along with clinical outcomes with negative margins. We evaluate if negative bone margins predict outcomes of DFO at one year in our county hospital. Methods A retrospectively cohort study assessed adult patients undergoing DFO amputations between 9/2016 to 9/2019. Patient data collected included demographics, smoking history, hemoglobin A1c (HbA1c), basic labs, microbiology, antibiotic duration, bone margin pathology. Physician review of records determined if intervention was successful. Primary outcome was met if no further amputation at the same site was required in the following 12 months. Results Of 92 patients, 57 had negative margins and 35 had positive margins for pathology confirmed osteomyelitis. Smoking history was significant in positive margins (35.1% vs 57.1%; p=0.038). Patients with negative margins had a successful outcome at 12 months compared to positive margins (86% vs 66%; p=0.003), but no significant differences in outcome at 6 months. Antibiotic days was reduced in negative margin individuals (mean 18 vs 30 days; p=0.001). Negative margins also demonstrated significant lower rates of readmission at 12 months (p=0.015). Staphylococcus aureus was notable in positive vs negative margins (57.1% vs 29.8%; p=0.017). MSSA was significantly noted in positive margins (45.7% vs 14%; p=0.001). MRSA was similar regardless of margin results (15.8% vs 11.4%; p=0.399). Initial ESR, CRP and HbA1c were similar between groups. Conclusion Our study noted that negative proximal bone margins resulted in more successful outcomes at 12 months and less days of antimicrobial therapy. Patients with negative margins had lower rates of readmission at 12 months for surgical site complications. Negative proximal bone margins results can guide antibiotic therapy and improve outcomes of resections. Presence of S. aureus was significant in positive margins and likely warrant consideration for further aggressive intervention. Clinical Characteristics of Patients with Diabetic Foot Osteomyelitis Clinical demographics, antibiotic usage, microbiology and results of patients presenting for diabetic foot osteomyelitis needing surgical amputation intervention. Abbreviations: HbA1c - Hemoglobin A1c; MSSA - methicillin-susceptible Staphylococcus aureus; MRSA - methicillin-resistant Staphylococcus aureus; CRP -C-reactive protein; ESR - erythrocyte sedimentation rate Disclosures All Authors: No reported disclosures

scholarly journals 318. Deferring Amputation in Diabetic Foot Osteomyelitis: Doing more Harm than Good?

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S231-S232
Author(s):  
Shiwei Zhou ◽  
Brian M Schmidt ◽  
Oryan Henig ◽  
Keith S Kaye
Keyword(s):  
Diabetic Foot ◽  
Medical Management ◽  
Wound Care ◽  
Cohort Analysis ◽  
Severity Of Illness ◽  
Complete Healing ◽  
Knee Amputation ◽  
Management Group ◽  
One Year ◽  
Diabetic Foot Osteomyelitis

Abstract Background Diabetic foot osteomyelitis (DFO) is a leading cause of below knee amputation (BKA). Even when medical treatment is deemed unlikely to succeed, patients with DFO are often resistant to amputation. Methods An observational cohort analysis was done on patients with DFO at Michigan Medicine who were evaluated by podiatry and recommended BKA from Oct 2015 - Jun 2019. Primary outcome was mortality after BKA recommendation. Secondary outcomes were healing of affected limb, rate of BKA or above knee amputation (AKA) and total antibiotic days in the 6 months following. All intravenous antibiotics and oral courses of linezolid and fluoroquinolones were captured. Results Of 44 patients with DFO, 18 chose BKA, 26 chose medical management with wound care. Mean age of the cohort was 61, 68% male, 80% white with a median Charlson Comorbidity Index of 6 (IQR 4,7). The two groups were similar with regards to demographics and comorbid conditions. Those who chose medical management did so because their infection was non-life-threatening and they desired to avoid amputation. One-year mortality was greater in patients who were medically managed compared to those who had BKA (23.1% vs 0%, OR 11.7, 95% CI 0.6–222.9). Considering only the 33 patients who were followed for at least 2 years, 2-year mortality was also greater in the medically managed group compared to the BKA group (38.5% vs 5.6%, OR 10.6, 95% CI 1.2–92.7, Figure 1). Fewer patients in the medical management group had complete healing of their wound/stump compared to the BKA group (46.2% vs 88.9%, OR 9.3, 95% CI 1.8–49.1). In the medically managed group, 18 (69%) patients went on to require BKA or AKA at a median of 76.5 days compared to 2 (11%) in the BKA group who required AKA at 1 and 11 days following recommendation. Median antibiotic days were significantly greater in the medically managed group compared to the BKA group (55 IQR 42,78 vs 17 IQR 10,37, p=0.0017). Conclusion In this cohort of DFO patients where BKA was recommended, medical management was associated with increased mortality, poor healing of the affected limb, and excess antibiotic exposure compared to BKA. These findings are particularly notable as case mix and severity of illness were similar between the two groups. This study can be used to inform providers and patients in cases where BKA is recommended. Disclosures All Authors: No reported disclosures

scholarly journals A multicenter randomized placebo controlled trial of rifampin to reduce pedal amputations for osteomyelitis in veterans with diabetes (VA INTREPID)

2020 ◽  
Vol 20 (1) ◽  
Author(s):  
Mary T. Bessesen ◽  
Gheorghe Doros ◽  
Adam M. Henrie ◽  
Kelly M. Harrington ◽  
John A. Hermos ◽  
...  
Keyword(s):  
Diabetes Mellitus ◽  
United States ◽  
Antimicrobial Therapy ◽  
Diabetic Foot ◽  
Adjunctive Therapy ◽  
The United States ◽  
Quality Data ◽  
Free Survival ◽  
Primary Hypothesis ◽  
Diabetic Foot Osteomyelitis

Abstract Background The prevalence of diabetes mellitus continues to inexorably rise in the United States and throughout the world. Lower limb amputations are a devastating comorbid complication of diabetes mellitus. Osteomyelitis increases the risk of amputation fourfold and commonly presages death. Antimicrobial therapy for diabetic foot osteomyelitis (DFO) varies greatly, indicating that high quality data are needed to inform clinical decision making. Several small trials have indicated that the addition of rifampin to backbone antimicrobial regimens for osteomyelitis outside the setting of the diabetic foot results in 28 to 42% higher cure rates. Methods/design This is a prospective, randomized, double-blind investigation of the addition of 6 weeks of rifampin, 600 mg daily, vs. matched placebo (riboflavin) to standard-of-care, backbone antimicrobial therapy for DFO. The study population are patients enrolled in Veteran Health Administration (VHA), ages ≥18 and ≤ 89 years with diabetes mellitus and definite or probable osteomyelitis of the foot for whom an extended course of oral or intravenous antibiotics is planned. The primary endpoint is amputation-free survival. The primary hypothesis is that using rifampin as adjunctive therapy will lower the hazard rate compared with the group that does not use rifampin as adjunctive therapy. The primary hypothesis will be tested by means of a two-sided log-rank test with a 5% significance level. The test has 90% power to detect a hazard ratio of 0.67 or lower with a total of 880 study participants followed on average for 1.8 years. Discussion VA INTREPID will test if a rifampin-adjunctive antibiotic regimen increases amputation-free survival in patients seeking care in the VHA with DFO. A positive finding and its adoption by clinicians would reduce lower extremity amputations and their associated physical and emotional impact and reduce mortality for Veterans and for the general population with diabetic foot osteomyelitis. Given that rifampin-adjunctive regimens are currently employed for therapy for the majority of DFO cases in Europe, and only in a small minority of cases in the United States, the trial results will impact therapeutic decisions, even if the null hypothesis is not rejected. Trial registration Registered January 6, 2017 at ClinicalTrials.gov, NCT03012529.

Controversial Issues Regarding Positive Bone Margins in Surgery for Diabetic Foot Osteomyelitis: A Pilot Study

2021 ◽  
pp. 153473462110412
Author(s):  
Javier Aragón-Sánchez ◽  
Gerardo Víquez-Molina ◽  
María Eugenia López-Valverde
Keyword(s):  
Pilot Study ◽  
Diabetic Foot ◽  
Soft Tissues ◽  
Conservative Surgery ◽  
Histopathological Analysis ◽  
Positive Margins ◽  
Short Period ◽  
Median Period ◽  
A Minor ◽  
Diabetic Foot Osteomyelitis

Obtaining clean margins in patients who undergo surgical treatment for diabetic foot osteomyelitis (DFO) is recommended. We hypothesize that the rate of recurrence of the infection is not associated with positive margins, even when using a short-term duration of postoperative antibiotic treatment. We conducted a retrospective pilot study of patients who underwent surgery for DFO confirmed by histopathological analysis of the resected bone from August 1, 2020, to December 1, 2020. Bone samples were taken from the proximal margins to be studied by microbiology and histopathology. Twenty-five (89.3%) patients underwent conservative surgery, and 3 (10.7%) patients underwent a minor amputation. After surgery, the antibiotics were stopped in 19 (67.9%) patients and continued in 9 (32.1%) patients for a median period of 4 days. The microbiology of the bone margins was positive in 20 (71.4%) cases, but the histopathology of the bone margins was positive in just 7 (25%) cases. Recurrence of the infection was detected in 3 (10.7%) patients. Seventeen (68%) patients with microbiological-positive margins did not have a recurrence of infection, while 3 (100%) patients had a recurrence of infection ( P = .53). Six (24%) patients among those with histopathological-positive margins did not have a recurrence of infection, and1 (33.3%) patient had a recurrence of infection ( P = 1). The recurrence of infection was low and always detected in soft tissues, including the cases with a histopathological-positive bone margin. Postoperative antibiotics were administered for a short period of time and not based on the analysis of bone margins.

Successful Limb-sparing Treatment Strategy for Diabetic Foot Osteomyelitis

2012 ◽  
Vol 102 (4) ◽  
pp. 273-277 ◽  
Author(s):  
Alison M. Beieler ◽  
Timothy C. Jenkins ◽  
Connie S. Price ◽  
Carla C. Saveli ◽  
Merribeth Bruntz ◽  
...  
Keyword(s):  
Limb Salvage ◽  
Antimicrobial Therapy ◽  
Diabetic Foot ◽  
Surgical Margin ◽  
Initial Therapy ◽  
Surgical Debridement ◽  
Knee Amputation ◽  
End Point ◽  
Below The Knee ◽  
Diabetic Foot Osteomyelitis

Background: Diabetic foot osteomyelitis is common and causes substantial morbidity, including major amputations, yet the optimal treatment approach is unclear. We evaluated an approach to limb salvage that combines early surgical debridement or limited amputation with antimicrobial therapy. Methods: We conducted a retrospective cohort study of patients treated between May 1, 2005, and May 31, 2007. The primary end point was cure, defined as not requiring further treatment for osteomyelitis of the affected limb. The secondary end point was limb salvage, defined as not requiring a below-the-knee amputation or a more proximal amputation. Results: Fifty patients with diabetic foot osteomyelitis met the study criteria. Initial surgical management included local amputation in 43 patients (86%) and debridement without amputation in seven (14%). Most infections (n = 30; 60%) were polymicrobial, and Staphylococcus aureus was the most common pathogen (n = 23; 46%). Parenteral antibiotics were used in 45 patients (90%). Patients who had pathologic evidence of osteomyelitis at the surgical margin received therapy for a median of 43 days (interquartile range [IQR], 36–56 days), whereas those without evidence of residual osteomyelitis received therapy for a median of 19 days (IQR, 13–40 days). Overall, 32 patients (64%) were considered cured after a median follow-up of 26 months (IQR, 12–38 months). Fifteen of 18 patients (83%) who failed initial therapy were treated again with limb-sparing surgery. Limb salvage was achieved in 47 patients (94%), with only three patients (6%) requiring below-the-knee amputation. Conclusions: In patients with diabetic foot osteomyelitis, surgical debridement or limited amputation plus antimicrobial therapy is effective at achieving clinical cure and limb salvage. (J Am Podiatr Med Assoc 102(4): 273–277, 2012)

Staphylococcus aureus Pericarditis Presenting as Cardiac Tamponade Caused by Diabetic Foot Osteomyelitis

2018 ◽  
Vol 27 ◽  
pp. S275
Author(s):  
N. Bart ◽  
M. Parkinson ◽  
S. Hungerford ◽  
X. Brennan ◽  
B. Gunalingam
Keyword(s):  
Staphylococcus Aureus ◽  
Cardiac Tamponade ◽  
Diabetic Foot ◽  
Diabetic Foot Osteomyelitis

scholarly journals Treating Diabetic Foot Osteomyelitis: A Practical State-of-the-Art Update

Medicina ◽  
2021 ◽  
Vol 57 (4) ◽  
pp. 339
Author(s):  
Benjamin A. Lipsky ◽  
İlker Uçkay
Keyword(s):  
Clinical Outcomes ◽  
Antimicrobial Stewardship ◽  
Diabetic Foot ◽  
Health Care Professionals ◽  
State Of The Art ◽  
Surgical Techniques ◽  
Surgical Approaches ◽  
Oral Antibiotic ◽  
Ongoing Research ◽  
Diabetic Foot Osteomyelitis

Background and Objectives: Diabetic foot osteomyelitis (DFO) can be difficult to treat and securing optimal clinical outcomes requires a multidisciplinary approach involving a wide variety of medical, surgical and other health care professionals, as well as the patient. Results of studies conducted in the past few years have allowed experts to formulate guidelines that can improve clinical outcomes. Material and Methods: We conducted a narrative review of the literature on treat- ment of DFO, with an emphasis on studies published in the last two years, especially regarding antimicrobial therapies and surgical approached to treatment of DFO, supplemented by our own extensive clinical and research experience in this field. Results: Major amputations were once com- mon for DFO but, with improved diagnostic and surgical techniques, “conservative” surgery (foot- sparing, resecting only the infected and necrotic bone) is becoming commonplace, especially for forefoot infections. Traditional antibiotic therapy, which has been administered predominantly in- travenously and frequently for several months, can often be replaced by appropriately selected oral antibiotic regimens following only a brief (or even no) parenteral therapy, and given for no more than 6 weeks. Based on ongoing studies, the recommended duration of treatment may soon be even shorter, especially for cases in which a substantial portion of the infected bone has been resected. Using the results of cultures (preferably of bone specimens) and antimicrobial stewardship princi- ples allows clinicians to select evidence-based antibiotic regimens, often of a limited pathogen spec- trum. Intra-osseous antimicrobial and surgical approaches to treatment are also evolving in light of ongoing research. Conclusions: In this narrative, evidenced-based review, taking consideration of principles of antimicrobial stewardship and good surgical practice, we have highlighted the recent literature and offered practical, state-of-the-art advice on the antibiotic and surgical management of DFO.

scholarly journals 188. The Role of Bone Pathology in the Management of Residual Osteomyelitis After Amputation for Diabetic Foot Infections

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S222-S223
Author(s):  
Eugene Lee ◽  
Jakrapun Pupaibool ◽  
Laura Certain
Keyword(s):  
Cohort Study ◽  
Antibiotic Therapy ◽  
Retrospective Cohort Study ◽  
Diabetic Foot ◽  
Retrospective Cohort ◽  
Primary Outcome ◽  
Categorical Variables ◽  
Proximal Margin ◽  
Positive Margins ◽  
Diabetic Foot Osteomyelitis

Abstract Background Diabetic foot osteomyelitis is a common infection often treated by a combination of antibiotic therapy and limb-sparing amputation. During amputation, IDSA guidelines recommend histopathological analysis of the proximal resection margin, but there are few studies evaluating the prognostic value of such analysis. We did a retrospective cohort study to evaluate whether histopathologic findings predict the clinical outcomes of further proximal amputation or death. Methods We conducted a retrospective cohort study at a VA hospital reviewing 84 patients. We evaluated patients who had a diagnosis of diabetes mellitus with diabetic foot osteomyelitis who were treated with limb-sparing amputations. All cases that were included had adequate histopathological description of the proximal margin of the amputation site. We also collected relevant clinical data including comorbidities, labs, culture data and pre-op and post-op antibiotics. The primary outcome was defined as the need for further proximal resection at the amputation site within six months of the original amputation or death from all causes within three months of the original amputation. Categorical variables were compared using Fischer’s exact test or the Chi-Square test. Continuous variables were compared using the t-test. Results We found a statistically significant difference (p=0.0003) of the primary outcome with 10 of 19 (53%) patients with positive margins needing further surgical resection and 1 of 19 (5%) patients dying. Of the patients with negative margins, 9 of 55 (14%) patients needed further surgery and none died. Conclusion Our study showed that patients with residual osteomyelitis at the proximal margin were more likely to need further proximal amputation or die. We did not have adequate power to assess whether extended antibiotic therapy improved outcomes for patients with positive margins, but there was no suggestion that it did. Further research will be needed to elucidate what the ideal duration of antibiotic therapy is for residual osteomyelitis after amputation for diabetic foot osteomyelitis. Disclosures All Authors: No reported disclosures

Oral Antimicrobial Therapy for Diabetic Foot Osteomyelitis

2006 ◽  
Vol 27 (10) ◽  
pp. 771-779 ◽  
Author(s):  
John M. Embil ◽  
Greg Rose ◽  
Elly Trepman ◽  
Mary Cheang M. Math ◽  
Frank Duerksen ◽  
...  
Keyword(s):  
Antimicrobial Therapy ◽  
Diabetic Foot ◽  
Diabetic Foot Osteomyelitis
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