scholarly journals Utility of Diagnostic Bone Biopsies in the Management of Osteomyelitis Through Retrospective Analysis: How Golden Is This Gold Standard?

2017 ◽  
Vol 4 (suppl_1) ◽  
pp. S91-S91
Author(s):  
Cole Hirschfeld ◽  
Shashi Kapadia ◽  
Joanna Bryan ◽  
Deanna Jannat-Khah ◽  
Benjamin May ◽  
...  
Keyword(s):  
Antimicrobial Therapy ◽  
Gold Standard ◽  
Bone Biopsy ◽  
Antibiotic Use ◽  
Empiric Therapy ◽  
Bone Culture ◽  
Needle Size ◽  
Empiric Antibiotics ◽  
Bone Biopsies ◽  
Bone Cultures

Abstract Background Bone biopsy is considered the gold standard for diagnosis and treatment of osteomyelitis (OM), but few studies have investigated the extent to which it influences antimicrobial therapy in non-vertebral bones. The purpose of this study was to evaluate clinician-initiated changes to empiric antimicrobial therapy after obtaining bone biopsy results. A secondary aim was to identify predictors of a positive bone culture. Methods We retrospectively reviewed all cases of non-vertebral OM in patients who underwent image-guided bone biopsies between 2009 and 2016. Data on pathologic and microbiologic yield were collected and logistic regression was used to determine potential factors affecting the microbiologic yield. Post-biopsy empiric antibiotics and final antibiotics were compared with determine if there was a change in antibiotic treatment after biopsy results were reported. Results We evaluated 203 bone biopsies in 185 patients. Samples from 115 (57%) cases were sent to pathology, of which 33 (29%) confirmed OM. All samples were sent to microbiology and 57 (28%) yielded a positive result. Diabetes (OR=2.39, P = 0.021) and white blood cell count (OR=1.13, P = 0.006) were significantly associated with positive bone cultures in multivariate analyses. There was no association between positive cultures and number of samples cultured, needle size, prior antibiotic use, or antibiotic-free days. Post-biopsy empiric antibiotics were given in 138 (68%) cases. Therapy was narrowed to target specific organisms in seven cases and changed due to inadequate empiric treatment in three cases. Targeted therapy was initiated in 4/65 cases, in which empiric antibiotics had been initially withheld. While final antibiotics were withheld in 38/146 with negative bone cultures, empiric antibiotics were discontinued in only eight cases. Conclusion In patients with non-vertebral OM, bone biopsy cultures rarely yielded results that necessitated changes in antibiotic management. Identified bone organisms were treated by empiric therapy in most patients. While bone biopsy remains the gold standard diagnostic test for OM, further work is needed to identify patients whose management may be impacted by this procedure. Disclosures All authors: No reported disclosures.

scholarly journals 1429. Diagnosis and Management of Osteomyelitis Associated with Stage IV Pressure Ulcers: Report of a Query to the Emerging Infections Network of the Infectious Diseases Society of America

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S521-S522
Author(s):  
Anjum S Kaka ◽  
Susan E Beekmann ◽  
Amy Gravely ◽  
Philip M Polgreen ◽  
James R Johnson
Keyword(s):  
Antimicrobial Therapy ◽  
Pressure Ulcers ◽  
Wound Care ◽  
Bone Biopsy ◽  
Stage Iv ◽  
Antibiotic Use ◽  
Future Research ◽  
Emerging Infections ◽  
Ulcer Base ◽  
Practice Variability

Abstract Background Despite the high prevalence and morbidity of stage IV pressure ulcers, there are few clinical studies to guide diagnosis and treatment of osteomyelitis in such patients. Methods The Emerging Infections Network conducted an electronic survey of adult ID physicians in 2018 to determine their approach to managing patients with stage IV pressure ulcers (exposed bone, tendon, or muscle) and osteomyelitis. Results The overall response rate was 42% (558/1,332). Of the respondents, 94/558 (17%) had not seen such patients in the last year, so opted out. Of the remaining 464 respondents, 276 (60%) usually felt confident in diagnosing osteomyelitis by physical examination, and laboratory or imaging test results; the strongest indicator of osteomyelitis was thought to be palpable or visible bone at the ulcer base (Figure 1). Approaches to diagnosing osteomyelitis in patients with visible and palpable bone varied: 41% would assume osteomyelitis was present, 27% would try local wound care and pressure-offloading before doing tests, 22% would do diagnostic tests immediately, and 10% would follow another strategy. The preferred tests for osteomyelitis were bone biopsy (for culture or histopathology) and MRI (Figure 2). Regarding treatment, respondents differed widely regarding favored route(s) of antimicrobial therapy (all IV, partly IV and partly oral, or all oral), regardless of presumed pathogen (Figure 3). Respondents also differed widely regarding preferred duration of antimicrobial therapy, but generally would treat longer in the absence of full surgical debridement (P < 0.001 overall) (Figure 4). Overall, 62% of respondents believed that osteomyelitis under stage IV pressure ulcers usually or almost always is treated excessively. Most respondents (59%) had multiple suggestions for future research, primarily regarding the duration and utility of antimicrobial therapy in this context. Conclusion ID physicians (i) report significant practice variability in their approach to diagnosing and treating osteomyelitis underlying stage IV pressure ulcers, (ii) are concerned about excessive antibiotic use in such patients, and (iii) perceive a critical need for additional research in this area. Disclosures All authors: No reported disclosures.

scholarly journals 304. Predictors of mortality in carbapenem-resistant Enterobacteriales bacteremia

2020 ◽  
Vol 7 (Supplement_1) ◽  
pp. S150-S150
Author(s):  
Michael R Hovan ◽  
Vanessa Cedarbaum ◽  
Thomas Kirn ◽  
Thomas Kirn
Keyword(s):  
Mortality Rate ◽  
Healthcare Facility ◽  
Antibiotic Use ◽  
The United States ◽  
Empiric Therapy ◽  
Carbapenem Resistant ◽  
Increased Risk ◽  
Threat Level ◽  
Infection Source ◽  
Microbiological Data

Abstract Background Carbapenem-Resistant Enterobacteriales (CRE) bacteremia is associated with significant morbidity and mortality. CRE were assigned a threat level of “urgent” in the 2019 CDC report on antibiotic resistance in the United States. We attempted to identify predictors of 30-day mortality in patients with CRE bacteremia. Methods We performed a chart review of 146 patients with CRE bacteremia from January 2010 - July 2019. CRE was defined using the current CDC definition. Electronic medical records were reviewed to obtain clinical characteristics and outcomes including prior antibiotic use, comorbidities, prior location, treatment, hospital course, microbiological data and outcomes including in-hospital mortality. Results Of 146 patients included for analysis, the overall 30-day mortality rate was 36.3%. Patients admitted from a healthcare facility including outside hospitals, rehab, nursing homes, and LTACs had a 49.1% (29/59) 30-day mortality rate compared to 27.5% (24/87) for those admitted from home (RR=1.78, 95% CI 1.16–2.73, p=.0082). Patients with a Pitt bacteremia score ≥ 4 had a greater 30-day mortality rate (42.6%, 26/61) compared to those with a Pitt bacteremia score &lt; 4 (17.6%, 15/85) (RR=2.92, 95% CI 1.40–4.16, p=.0015). Patients that received inactive empiric therapy had a 30-day mortality rate of 36% (36/100) compared to 36.9% (17/46) in those that received active empiric therapy (RR=.9741, 95% CI .6155-1.59, p=.9109). Patients with isolates determined to have a meropenem MIC ≥ 4 had a 30-day mortality rate of 40.2% (37/92) while those with an MIC &lt; 4 had a 30-day mortality rate of 30.2% (16/53) (RR=1.33, 95% CI .8250–2.1513, p=.2408). A pulmonary source of bacteremia was associated with an increased risk of 30-day mortality (64.3%, 9/14) compared to all other sources of bacteremia (34.8%, 31/89) (RR=1.85, 95% CI 1.39–2.99, p=.0129). No other infection source was associated with an increased 30-day mortality rate. Conclusion Admission from a healthcare facility, Pitt bacteremia score ≥ 4, and pulmonary source of bacteremia were associated with increased risk of 30-day mortality. Interestingly, administration of active empiric therapy was not associated with a decreased mortality risk. Meropenem MIC was not predictive of 30-day mortality. Disclosures All Authors: No reported disclosures

scholarly journals Differences in Radiation Exposure of CT-Guided Percutaneous Manual and Powered Drill Bone Biopsy

2021 ◽  
Author(s):  
Sebastian Zensen ◽  
Sumitha Selvaretnam ◽  
Marcel Opitz ◽  
Denise Bos ◽  
Johannes Haubold ◽  
...  
Keyword(s):  
Radiation Exposure ◽  
Diagnostic Yield ◽  
Bone Biopsy ◽  
Lumbar Vertebrae ◽  
Bone Lesions ◽  
Anatomical Location ◽  
Thoracic Vertebrae ◽  
Level Of Evidence ◽  
Ct Guided ◽  
Bone Biopsies

Abstract Purpose Apart from the commonly applied manual needle biopsy, CT-guided percutaneous biopsies of bone lesions can be performed with battery-powered drill biopsy systems. Due to assumably different radiation doses and procedural durations, the aim of this study is to examine radiation exposure and establish local diagnostic reference levels (DRLs) of CT-guided bone biopsies of different anatomical regions. Methods In this retrospective study, dose data of 187 patients who underwent CT-guided bone biopsy with a manual or powered drill biopsy system performed at one of three different multi-slice CT were analyzed. Between January 2012 and November 2019, a total of 27 femur (A), 74 ilium (B), 27 sacrum (C), 28 thoracic vertebrae (D) and 31 lumbar vertebrae (E) biopsies were included. Radiation exposure was reported for volume-weighted CT dose index (CTDIvol) and dose–length product (DLP). Results CTDIvol and DLP of manual versus powered drill biopsy were (median, IQR): A: 56.9(41.4–128.5)/66.7(37.6–76.2)mGy, 410(203–683)/303(128–403)mGy·cm, B: 83.5(62.1–128.5)/59.4(46.2–79.8)mGy, 489(322–472)/400(329–695)mGy·cm, C: 97.5(71.6–149.2)/63.1(49.1–83.7)mGy, 627(496–740)/404(316–515)mGy·cm, D: 67.0(40.3–86.6)/39.7(29.9–89.0)mGy, 392(267–596)/207(166–402)mGy·cm and E: 100.1(66.5–162.6)/62.5(48.0–90.0)mGy, 521(385–619)/315(240–452)mGy·cm. Radiation exposure with powered drill was significantly lower for ilium and sacrum, while procedural duration was not increased for any anatomical location. Local DRLs could be depicted as follows (CTDIvol/DLP): A: 91 mGy/522 mGy·cm, B: 90 mGy/530 mGy·cm, C: 116 mGy/740 mGy·cm, D: 87 mGy/578 mGy·cm and E: 115 mGy/546 mGy·cm. The diagnostic yield was 82.4% for manual and 89.4% for powered drill biopsies. Conclusion Use of powered drill bone biopsy systems for CT-guided percutaneous bone biopsies can significantly reduce the radiation burden compared to manual biopsy for specific anatomical locations such as ilium and sacrum and does not increase radiation dose or procedural duration for any of the investigated locations. Level of Evidence Level 3.

scholarly journals Development of an Electronic Algorithm to Identify Inappropriate Antibiotic Prescribing for Pediatric Pharyngitis

2020 ◽  
Vol 41 (S1) ◽  
pp. s188-s189
Author(s):  
Jeffrey Gerber ◽  
Robert Grundmeier ◽  
Keith Hamilton ◽  
Lauri Hicks ◽  
Melinda Neuhauser ◽  
...  
Keyword(s):  
Predictive Value ◽  
Gold Standard ◽  
Antibiotic Stewardship ◽  
Chart Review ◽  
Antibiotic Use ◽  
Audit And Feedback ◽  
Urgent Care ◽  
Antibiotic Prescribing ◽  
Tract Infections ◽  
The Impact

Background: Antibiotic overuse contributes to antibiotic resistance and unnecessary adverse drug effects. Antibiotic stewardship interventions have primarily focused on acute-care settings. Most antibiotic use, however, occurs in outpatients with acute respiratory tract infections such as pharyngitis. The electronic health record (EHR) might provide an effective and efficient tool for outpatient antibiotic stewardship. We aimed to develop and validate an electronic algorithm to identify inappropriate antibiotic use for pediatric outpatients with pharyngitis. Methods: This study was conducted within the Children’s Hospital of Philadelphia (CHOP) Care Network, including 31 pediatric primary care practices and 3 urgent care centers with a shared EHR serving >250,000 children. We used International Classification of Diseases, Tenth Revision (ICD-10) codes to identify encounters for pharyngitis at any CHOP practice from March 15, 2017, to March 14, 2018, excluding those with concurrent infections (eg, otitis media, sinusitis), immunocompromising conditions, or other comorbidities that might influence the need for antibiotics. We randomly selected 450 features for detailed chart abstraction assessing patient demographics as well as practice and prescriber characteristics. Appropriateness of antibiotic use based on chart review served as the gold standard for evaluating the electronic algorithm. Criteria for appropriate use included streptococcal testing, use of penicillin or amoxicillin (absent β-lactam allergy), and a 10-day duration of therapy. Results: In 450 patients, the median age was 8.4 years (IQR, 5.5–9.0) and 54% were women. On chart review, 149 patients (33%) received an antibiotic, of whom 126 had a positive rapid strep result. Thus, based on chart review, 23 subjects (5%) diagnosed with pharyngitis received antibiotics inappropriately. Amoxicillin or penicillin was prescribed for 100 of the 126 children (79%) with a positive rapid strep test. Of the 126 children with a positive test, 114 (90%) received the correct antibiotic: amoxicillin, penicillin, or an appropriate alternative antibiotic due to b-lactam allergy. Duration of treatment was correct for all 126 children. Using the electronic algorithm, the proportion of inappropriate prescribing was 28 of 450 (6%). The test characteristics of the electronic algorithm (compared to gold standard chart review) for identification of inappropriate antibiotic prescribing were sensitivity (99%, 422 of 427); specificity (100%, 23 of 23); positive predictive value (82%, 23 of 28); and negative predictive value (100%, 422 of 422). Conclusions: For children with pharyngitis, an electronic algorithm for identification of inappropriate antibiotic prescribing is highly accurate. Future work should validate this approach in other settings and develop and evaluate the impact of an audit and feedback intervention based on this tool.Funding: NoneDisclosures: None

scholarly journals Validity of negative bone biopsy in suspicious bone lesions

2021 ◽  
Vol 10 (7) ◽  
pp. 205846012110306
Author(s):  
Mine B Lange ◽  
Lars J Petersen ◽  
Michael B Nielsen ◽  
Helle D Zacho
Keyword(s):  
Bone Biopsy ◽  
False Negative ◽  
Exclusion Criterion ◽  
Bone Lesions ◽  
False Negatives ◽  
Patient Morbidity ◽  
Bone Biopsies ◽  
Initial Biopsy ◽  
Valid Criterion

Background The presence of malignant cells in bone biopsies is considered gold standard to verify occurrence of cancer, whereas a negative bone biopsy can represent a false negative, with a risk of increasing patient morbidity and mortality and creating misleading conclusions in cancer research. However, a paucity of literature documents the validity of negative bone biopsy as an exclusion criterion for the presence of skeletal malignancies. Purpose To investigate the validity of a negative bone biopsy in bone lesions suspicious of malignancy. Material and Method A retrospective cohort of 215 consecutive targeted non-malignant skeletal biopsies from 207 patients (43% women, 57% men, median age 64, and range 94) representing suspicious focal bone lesions, collected from January 1, 2011, to July 31, 2013, was followed over a 2-year period to examine any additional biopsy, imaging, and clinical follow-up information to categorize the original biopsy as truly benign, malignant, or equivocal. Standard deviations and 95% confidence intervals were calculated. Results 210 of 215 biopsies (98%; 95% CI 0.94–0.99) showed to be truly benign 2 years after initial biopsy. Two biopsies were false negatives (1%; 95% CI 0.001–0.03), and three were equivocal (lack of imaging description). Conclusion Our study documents negative bone biopsy as a valid criterion for the absence of bone metastasis. Since only 28% had a confirmed diagnosis of prior cancer and not all patients received adequately sensitive imaging, our results might not be applicable to all cancer patients with suspicious bone lesions.

scholarly journals Development of an Electronic Algorithm to Target Outpatient Antimicrobial Stewardship Efforts for Acute Bronchitis

2020 ◽  
Vol 41 (S1) ◽  
pp. s32-s32
Author(s):  
Ebbing Lautenbach ◽  
Keith Hamilton ◽  
Robert Grundmeier ◽  
Melinda Neuhauser ◽  
Lauri Hicks ◽  
...  
Keyword(s):  
Antimicrobial Stewardship ◽  
Predictive Value ◽  
Gold Standard ◽  
Chart Review ◽  
Acute Bronchitis ◽  
Antibiotic Use ◽  
Antibiotic Prescribing ◽  
Diagnostic Codes ◽  
Icd 10 ◽  
The Impact

Background: Antibiotic resistance has increased at alarming rates, driven predominantly by antibiotic overuse. Although most antibiotic use occurs in outpatients, antimicrobial stewardship programs have primarily focused on inpatient settings. A major challenge for outpatient stewardship is the lack of accurate and accessible electronic data to target interventions. We sought to develop and validate an electronic algorithm to identify inappropriate antibiotic use for outpatients with acute bronchitis. Methods: This study was conducted within the University of Pennsylvania Health System (UPHS). We used ICD-10 diagnostic codes to identify encounters for acute bronchitis at any outpatient UPHS practice between March 15, 2017, and March 14, 2018. Exclusion criteria included underlying immunocompromising condition, other comorbidity influencing the need for antibiotics (eg, emphysema), or ICD-10 code at the same visit for a concurrent infection (eg, sinusitis). We randomly selected 300 (150 from academic practices and 150 from nonacademic practices) eligible subjects for detailed chart abstraction that assessed patient demographics and practice and prescriber characteristics. Appropriateness of antibiotic use based on chart review served as the gold standard for assessment of the electronic algorithm. Because antibiotic use is not indicated for this study population, appropriateness was assessed based upon whether an antibiotic was prescribed or not. Results: Of 300 subjects, median age was 61 years (interquartile range, 50–68), 62% were women, 74% were seen in internal medicine (vs family medicine) practices, and 75% were seen by a physician (vs an advanced practice provider). On chart review, 167 (56%) subjects received an antibiotic. Of these subjects, 1 had documented concern for pertussis and 4 had excluding conditions for which there were no ICD-10 codes. One received an antibiotic prescription for a planned dental procedure. Thus, based on chart review, 161 (54%) subjects received antibiotics inappropriately. Using the electronic algorithm based on diagnostic codes, underlying and concurrent conditions, and prescribing data, the number of subjects with inappropriate prescribing was 170 (56%) because 3 subjects had antibiotic prescribing not noted based on chart review. The test characteristics of the electronic algorithm (compared to gold standard chart review) for identification of inappropriate antibiotic prescribing were the following: sensitivity, 100% (161 of 161); specificity, 94% (130 of 139); positive predictive value, 95% (161 of 170); and negative predictive value, 100% (130 of 130). Conclusions: For outpatients with acute bronchitis, an electronic algorithm for identification of inappropriate antibiotic prescribing is highly accurate. This algorithm could be used to efficiently assess prescribing among practices and individual clinicians. The impact of interventions based on this algorithm should be tested in future studies.Funding: NoneDisclosures: None

Culture Concordance in Different Sections of the Metatarsal Head: Interpretations of Microbiological Results

2021 ◽  
pp. 153473462110037
Author(s):  
Raul Juan Molines-Barroso ◽  
Esther García-Morales ◽  
David Sevillano-Fernández ◽  
Yolanda García-Álvarez ◽  
Francisco J. Álvaro-Afonso ◽  
...  
Keyword(s):  
Diabetic Foot ◽  
Bone Biopsy ◽  
Bacterial Load ◽  
False Negative ◽  
Metatarsal Bone ◽  
High Rate ◽  
Microbiological Analysis ◽  
High Tendency ◽  
Metatarsal Bones ◽  
Bone Biopsies

Microbiological cultures of per-wound bone biopsies have shown a lack of correlation and a high rate of false-negative results when compared with bone biopsy cultures in diabetic foot osteomyelitis. The selection of samples from the area of active osteomyelitis, which contains a complete census of the microorganisms responsible for the infection, is essential to properly guide antimicrobial treatment. We aimed to comparatively evaluate the quantitative and qualitative cultures taken from different areas, in metatarsal heads resected for osteomyelitis. For this purpose, we consecutively selected 13 metatarsal heads from 12 outpatients with plantar ulcers admitted to our diabetic foot unit. Metatarsal heads were divided transversally into 3 portions: plantar (A), central (B), and dorsal (C), and the 39 resulting samples were cultured. Qualitative and quantitative microbiological analysis was performed, and the isolated species and bacterial load, total and species specific, were compared between the 3 metatarsal bone segments. The primary outcome of the study was the bacterial diversity detected in the different bone sections. Cultures were positive in 12 of the 13 included metatarsal heads (92%). A total of 34 organisms were isolated from all specimens. Ten of the 12 cultures (83%) were polymicrobial. Ten of the 13 metatarsal heads (77%) had identical microbiological results in each of the 3 bone sections. The largest number of microorganisms was found in the central section. The overall concordance between sections was 91%. The predominant microorganisms were coagulase-negative staphylococci (41%). Statistical differences were not found in the bioburden between sections (range 3.25-3.41 log10 colony-forming unit/g for all sections; P = .511). The results of our study suggest that microorganisms exhibit a high tendency to spread along the metatarsal bone and that the degree of progression along the bone is species dependent. The central portions of metatarsal bones tend to accumulate a higher diversity of species. Thus, we recommend this area of bone for targeted biopsy in patients with suspected osteomyelitis.

scholarly journals Impact of Inactive Empiric Antimicrobial Therapy on Inpatient Mortality and Length of Stay

2006 ◽  
Vol 50 (10) ◽  
pp. 3355-3360 ◽  
Author(s):  
Kimberly K. Scarsi ◽  
Joe M. Feinglass ◽  
Marc H. Scheetz ◽  
Michael J. Postelnick ◽  
Maureen K. Bolon ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Antimicrobial Therapy ◽  
Medical Center ◽  
Academic Medical Center ◽  
Bloodstream Infections ◽  
Empiric Therapy ◽  
Inpatient Mortality ◽  
In Vitro Susceptibility ◽  
Empiric Antimicrobial Therapy

ABSTRACT The consequences of inactive empiric antimicrobial therapy are not well-described and may cause prolonged hospitalization or infection-related mortality. In vitro susceptibility results for 884 patients hospitalized at an academic medical center with gram-negative bloodstream infections (GNBI) from 2001 to 2003 were matched to antimicrobial orders within 24 h of culture. Clinical characteristics, organism, inpatient mortality, and length of stay after culture for patients with GNBI were compared between patients receiving active versus inactive empiric antimicrobial therapy. A total of 14.1% of patients with GNBI received inactive empiric therapy, defined as no antimicrobial therapy within 24 h of the culture active against the identified organism based on in vitro microbiology reports. Patients who received inactive therapy were more likely to be younger, to be infected with Pseudomonas aeruginosa, to have a nosocomial infection, and to receive antimicrobial monotherapy but less likely to be bacteremic with Escherichia coli or to have sepsis (P < 0.05). There were no significant differences in mortality between patients receiving active versus inactive empiric therapy (16.1% versus 13.6%, respectively) or in length of stay after positive culture (11.5 days versus 12.6 days, respectively). Only 45 patients had greater than 2 days of exposure to inactive therapy; however, 8/30 patients (26.7%) who never received active antimicrobial therapy died while in the hospital. Inactive empiric therapy was more common in healthier patients. Inactive antimicrobial therapy in the first 24 h did not significantly impact average outcomes for GNBI among hospitalized patients but may have caused harm to specific individuals.

scholarly journals Primary Results of Bone Biopsies in Outpatients with Neuropathic Ulcers

2017 ◽  
Vol 2 (3) ◽  
pp. 2473011417S0000 ◽  
Author(s):  
Alexandros Vris ◽  
Edward Massa ◽  
Raju Ahluwalia ◽  
Venu Kavarthapu
Keyword(s):  
Antibiotic Treatment ◽  
Bone Biopsy ◽  
Outpatient Setting ◽  
Limiting Factor ◽  
Anatomical Landmarks ◽  
Intact Skin ◽  
University Of Texas ◽  
Bone Biopsies ◽  
Foot Disease ◽  
Protective Sensation

Category: Diabetes Introduction/Purpose: Patients with Charcot foot disease often develop ulcers that probe to bone due to progressive deformity and loss of protective sensation. Infection of the ulcers and the underlying bone is common. In order to diagnose and treat osteomyelitis, especially in cases where reconstruction is planned, the pathogen must be isolated. The need for bone debridement and the duration of antibiotic treatment depends on the presence of bone infection. Percutaneous bone biopsies through intact skin is the gold standard for acquisition of samples for cultures. The presence of neuropathy negates the need for anaesthesia and renders biopsies possible in the outpatient setting. In our study we compare the results of bone biopsies with wound swabs and document the safety of the technique in clinic. Methods: Thirty five patients were included in the study. Inclusion criteria were the presence of neuropathy and foot ulcers with exposed bone (Grade 3 University of Texas wound classification). Samples were obtained by three different doctors with aseptic technique through intact skin and sent for cultures. The area of the bone where the sample was taken from was defined by the location of the ulcer, the available imaging and anatomical landmarks. Complications such as bleeding and entry point infection and delayed healing were documented. Superficial ulcer swabs were also obtained for comparison. Results: In 37 patients 2 procedures were abandoned due to pain; otherwise no complications during or after the biopsy were recorded and the procedure duration was 4 minutes at most. There was bacterial growth in 40% of bone biopsy samples, compared to 65.7% of superficial swabs. Cultures were polymicrobial in 35.7% of positive biopsies and 82.6% of positive ulcer swabs. Concordance between bone biopsy and swab results was seen in 16/35 (45.7%) of samples. In 7 patients both tests were negative and in 9 both positive. 7/9 of samples that were positive with both methods grew the same organism. Conclusion: Our study showed that there is poor concordance of the results of the two tests. Wound swabs have high rates of polymicrobial cultures; in comparision bone biopsies are more reliable in confirming a specific microbial organism and dictating the need for and type of antibiotic. Targeted antibiotics can thus be safely used, potentially reducing the complications and the cost of broad-spectrum antibiotic treatment. The technique of needle bone biopsy is easy, safe and reproducible, and pain is not a limiting factor for in outpatients with neuropathy.

scholarly journals Diabetic Foot Infection: Causative Pathogens and Empiric Antibiotherapy Considerations—The Experience of a Tertiary Center

2019 ◽  
Vol 18 (2) ◽  
pp. 122-128 ◽  
Author(s):  
José Miguel Neves ◽  
Bruno Duarte ◽  
Margarida Pinto ◽  
Ana Formiga ◽  
José Neves
Keyword(s):  
Diabetic Foot ◽  
Antibiotic Sensitivity ◽  
Antibiotic Use ◽  
Empiric Therapy ◽  
Tertiary Hospital ◽  
Gram Positive ◽  
Cross Sectional ◽  
Gram Positive Bacteria ◽  
Sensitivity Pattern ◽  
Tertiary Center

Most moderate-to-severe diabetic foot infections (DFIs) require hospitalization with urgent surgical approach and administration of empiric antibiotherapy. To ensure optimal antibiotic coverage, regular microbiological background updates are imperative. The purpose is to characterize the microbiological profile and the antibiotic sensitivity pattern of the DFI causative pathogens isolated within a specialized DFI unit of a tertiary hospital, in order to establish evidence-based policies regarding empirical antibiotic use. A cross-sectional study was conducted. Microbiological cultures and corresponding antibiotic sensitivity tests collected from moderate-to-severe DFIs as a first approach to the hospitalized patient were retrieved and analyzed during a 12-month period. Two groups were analyzed: inpatients that had been previously followed at the diabetic foot clinic of the hospital and inpatients without a previous contact with the hospital services. A total of 125 isolates obtained from 87 patients were deemed for analysis. Globally, a predominance of Gram-positive bacteria was observed (60%). Staphylococcus aureus was the most common pathogen. The global ratio of methicillin-sensitive S aureus to methicillin-resistant S aureus (MRSA) was 1.3:1, with similar findings in both groups. According to the antibiotic sensitivity test results, and within the recommended empiric antibiotic regimens for DFI, piperacillin/tazobactam seems to be the most suitable option. Gram-positive bacteria prevail as the main isolates in DFIs. Screening for MRSA-specific risk factors is mandatory. When going for a first empiric therapy, piperacillin/tazobactam is recommended in this institution, and an anti-MRSA agent should be added early, if necessary. We encourage continuous monitoring for the bacterial prevalence in Portuguese diabetic foot centers as it is paramount for the decision making regarding DFI protocols.

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