Comment on Tone et al. Six-Week Versus Twelve-Week Antibiotic Therapy for Nonsurgically Treated Diabetic Foot Osteomyelitis: A Multicenter Open-Label Controlled Randomized Study. Diabetes Care 2015;38:302–307

Chronic diabetic foot osteomyelitis (DFO) is a frequent complication in adult polyneuropathy patients with long-standing diabetes mellitus. Regarding the conservative therapy, there are several crucial steps in adequate diagnosing and approaches. The management should be performed in a multidisciplinary approach following the findings of recent research, general principles of antibiotic therapy for bone; and according to (inter-)national guidance. In this chapter we emphasize the overview on the state-of-the-art management regarding the diagnosis and antibiotic therapy in DFO. In contrast, in this general narrative review and clinical recommendation, we skip the surgical, vascular and psychological aspects.

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Comparison of the efficacy of six-week versus twelve-week antibiotic therapy for the treatment of nonsurgical diabetic foot osteomyelitis

International Medicine ◽

10.5455/im.53372 ◽

2019 ◽

Vol 1 (5) ◽

pp. 274

Author(s):

Manouchehr Iranparvar ◽

Mohsen Arzanlou ◽

Elnaz Afrouzeh

Keyword(s):

Antibiotic Therapy ◽

Diabetic Foot ◽

Diabetic Foot Osteomyelitis

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An Open-Label, Randomized Study Comparing Efficacy and Safety of Intravenous Piperacillin/Tazobactam and Ampicillin/Sulbactam for Infected Diabetic Foot Ulcers

Surgical Infections ◽

10.1089/sur.2005.6.27 ◽

2005 ◽

Vol 6 (1) ◽

pp. 27-40 ◽

Cited By ~ 41

Author(s):

Lawrence Harkless ◽

Jack Boghossian ◽

Richard Pollak ◽

Wayne Caputo ◽

Adrian Dana ◽

...

Keyword(s):

Diabetic Foot ◽

Randomized Study ◽

Foot Ulcers ◽

Diabetic Foot Ulcers ◽

Efficacy And Safety ◽

Open Label

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320. Does Guideline-Based Management of Diabetic Foot Osteomyelitis Reduce Risk of Further Proximal Amputations?

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.516 ◽

2020 ◽

Vol 7 (Supplement_1) ◽

pp. S232-S232

Author(s):

Eugene Lee ◽

Jakrapun Pupaibool ◽

Laura Certain

Keyword(s):

Antibiotic Therapy ◽

Diabetic Foot ◽

Primary Outcome ◽

Adherence To Guidelines ◽

Diabetic Foot Infections ◽

Significant Difference ◽

Antibiotic Management ◽

Reduce Risk ◽

Reduced Risk ◽

Diabetic Foot Osteomyelitis

Abstract Background The antibiotic management of diabetic foot osteomyelitis involving surgical limb-sparing amputation is controversial. While there are several guidelines that provide recommendations regarding antibiotic therapy for diabetic foot osteomyelitis after amputation, we do not know of any studies that show that adherence to guidelines improves clinical outcomes. We assessed whether adherence to antibiotic choice and duration in accordance with our institution’s guidelines, which are based on IDSA guidelines, reduced risk of future amputations. Methods We conducted a retrospective cohort study of 110 patients with diabetic foot osteomyelitis treated with limb-sparing amputations at a VA hospital. We collected relevant clinical data such as patient comorbidities, antibiotic allergies, labs, imaging, culture data, histopathologic reports, pre-op and post-op antibiotics. We used our institutional guidelines, which are based on the 2012 IDSA Guidelines for the Diagnosis and Treatment of Diabetic Foot Infections, to assess antibiotic choice and duration for diabetic foot osteomyelitis therapy after amputation. We stratified cases as either adherent or non-adherent based on whether antibiotic choice and duration were both in accordance with our institutional guideline. For each case, we recorded the primary outcome of further proximal amputation occurring within six months or death from all causes within three months. Results We found a significant difference in primary outcomes between the groups that were treated with antibiotics adherent with guidelines and antibiotics non-adherent with guidelines. For patients who were treated with antibiotics that were non-adherent to guidelines, 15 of 36 (42%) patients needed further amputation or died. Of the patients treated according to guidelines, 12 of 74 (16%) patients needed further amputation or died. There was a statistically significant difference between these two groups (p=0.004). Conclusion Our study showed that guideline-based antibiotic therapy for diabetic foot osteomyelitis treated with amputation significantly lowered rates of further amputation compared to antibiotic therapies that were not adherent to guidelines. Disclosures All Authors: No reported disclosures

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Admission Time Deep Swab Specimens Compared With Surgical Bone Sampling in Hospitalized Individuals With Diabetic Foot Osteomyelitis and Soft Tissue Infection

The International Journal of Lower Extremity Wounds ◽

10.1177/1534734620916386 ◽

2020 ◽

pp. 153473462091638 ◽

Cited By ~ 1

Author(s):

Ana Belen Manas ◽

Surabhi Taori ◽

Raju Ahluwalia ◽

Hani Slim ◽

C. Manu ◽

...

Keyword(s):

Soft Tissue ◽

Antibiotic Therapy ◽

Soft Tissue Infection ◽

Diabetic Foot ◽

Tissue Infection ◽

Surgical Debridement ◽

Deep Wound ◽

Negative Growth ◽

Diabetic Foot Osteomyelitis ◽

Prior Antibiotic Therapy

Whether deep swab cultures taken at admission reliably identify pathogens compared to surgical bone specimens in hospitalized individuals with diabetic foot osteomyelitis and soft tissue infection is unclear. Comparison of microbiological isolates between a deep wound swab (DWS) taken at the time of admission through the actively infected, discharging ulcer probing to the bone and the subsequent surgical bone sample (SBS) taken during surgical debridement was made. A total of 63 subjects (age 60.8 ± 13.5 years, 75% male, 80% Type 2 diabetes, HbA1C 8.9%±2.2%) were included. The proportion of Gram-positive (DWS 49% v SBS 52%) and Gram-negative (DWS 60% v SBS 60%) isolates was similar between the techniques. However, the overall concordance of isolates between the two techniques was only fair (κ=0.302). The best concordance was observed for Staphylococcus aureus (κ=0.571) and MRSA (κ=0.644). There was a correlation between number of isolates in SBS with prior antibiotic therapy of any duration (r= -0.358, p=0.005) and with the duration of ulceration (r=0.296, p=0.045); no clinical correlations were found for DWS. Prior antibiotic therapy (p=0.03) and duration of ulceration <8 weeks (p=0.025) were predictive of negative growth on SBS. In conclusion, we found only a fair concordance between deep wound swabs acquired at admission and surgical bone specimens in those presenting with a severe diabetic foot infection and features of osteomyelitis. Ensuring early surgical debridement of all infected tissue and obtaining bone specimens should be considered a clinical priority, which may also reduce the likelihood of negative growth on SBS.

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Three versus six weeks of antibiotic therapy for diabetic foot osteomyelitis: A prospective, randomized, non-inferiority pilot trial

Clinical Infectious Diseases ◽

10.1093/cid/ciaa1758 ◽

2020 ◽

Author(s):

Karim Gariani ◽

Truong-Thanh Pham ◽

Benjamin Kressmann ◽

François R Jornayvaz ◽

Giacomo Gastaldi ◽

...

Keyword(s):

Antibiotic Therapy ◽

Diabetic Foot ◽

Cox Regression ◽

Pilot Trial ◽

Median Number ◽

Hazard Ratio ◽

Surgical Debridement ◽

Systemic Antibiotic ◽

Systemic Antibiotic Therapy ◽

Diabetic Foot Osteomyelitis

Abstract Background In patients with diabetic foot osteomyelitis (DFO) who underwent surgical debridement, we investigated whether a short (3 weeks), compared with a long (6 weeks) duration of systemic antibiotic treatment is associated with non-inferior results for clinical remission and adverse events (AE). Methods In this prospective, randomized, non-inferiority, pilot trial, we randomized (allocation 1:1), patients with DFO after surgical debridement to either a 3-week or a 6-week course of antibiotic therapy. The minimal duration of follow-up after end of therapy was two months. We compared outcomes using Cox regression and non-inferiority analyses (25% margin, power 80%). Results Among 93 enrolled patients (18% females; median age 65 years), 44 were randomized to the 3-week arm and 49 to the 6-week arm. The median number of surgical debridement was 1 (range, 0-2 interventions). In the intention-to-treat (ITT) population, remission occurred in 37 (84%) of the patients in the 3-week arm compared to 36 (73%) in the 6-week arm (p=0.21). The number of AE was similar in the two study arms (17/44 vs. 16/49; p=0.51), as were the remission incidences in the per-protocol (PP) population (33/39 vs. 32/43; p=0.26). In multivariate analysis, treatment with the shorter antibiotic course was not significantly associated with remission (for the ITT population, hazard ratio 1.1, 95%CI 0.6-1.7; for the PP population hazard ratio 0.8, 95%CI 0.5-1.4). Conclusions In this randomized, controlled pilot trial, a post-debridement systemic antibiotic therapy course for DFO of 3-weeks gave similar (and statistically non-inferior) incidences of remission and AE to a course of 6 weeks.

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

Open Forum Infectious Diseases ◽

10.1093/ofid/ofaa439.498 ◽

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

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