Diabetic Foot Infections: The Diagnostic Challenges

Diabetic foot infections (DFIs) are severe complications of long-standing diabetes, and they represent a diagnostic challenge, since the differentiation between osteomyelitis (OM), soft tissue infection (STI), and Charcot’s osteoarthropathy is very difficult to achieve. Nevertheless, such differential diagnosis is mandatory in order to plan the most appropriate treatment for the patient. The isolation of the pathogen from bone or soft tissues is still the gold standard for diagnosis; however, it would be desirable to have a non-invasive test that is able to detect, localize, and evaluate the extent of the infection with high accuracy. A multidisciplinary approach is the key for the correct management of diabetic patients dealing with infective complications, but at the moment, no definite diagnostic flow charts still exist. This review aims at providing an overview on multimodality imaging for the diagnosis of DFI and to address evidence-based answers to the clinicians when they appeal to radiologists or nuclear medicine (NM) physicians for studying their patients.

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Joint Consultation Clinic by Infectious Diseases Specialists and Podiatry team (ID-POD) Compliments the Care of Diabetic Patients with Foot Infections by Reducing Cost and Decreasing Outpatient Clinic Visits

Open Forum Infectious Diseases ◽

10.1093/ofid/ofx163.776 ◽

2017 ◽

Vol 4 (suppl_1) ◽

pp. S328-S328

Author(s):

Pushpalatha Bangalore Lingegowda ◽

Say-Tat Ooi ◽

Jyoti Somani ◽

Chelsea Law ◽

Boon Kiak Yeo

Keyword(s):

Infectious Diseases ◽

Diabetic Foot ◽

Wound Care ◽

Cost Savings ◽

Outpatient Setting ◽

Multidisciplinary Teams ◽

Diabetic Patients ◽

Wound Debridement ◽

Diabetic Foot Infections ◽

Before And After

Abstract Background Management of diabetic foot infections (DFI) is challenging and involves multidisciplinary teams to improve outcomes (1). Appropriate wound care of patients with DFI plays an important role in successfully curing infections and promote wound healing. In Singapore, Infectious Diseases (ID) specialists help in the management of DFI by recommending appropriate antibiotics for infected wounds while wound debridement are managed by Podiatrists (POD). When patients are hospitalized multidisciplinary teams including Vascular Surgery review patients. In the outpatient setting patients have multiple appointments including ID and Endocrinology etc. The time spent and costs incurred by patients for traveling to multiple appointments is considerable. A joint ID-POD clinic was initiated to reduce the cost and inconvenience for patients. Methods A joint weekly clinic was initiated in October’16 and the data was analyzed upto May’17. Finance was involved in deriving costs. The service costs for consultations payable by patients before and after the initiation of the joint clinic were compared. Results First 6 months experience of initiating the joint ID-POD clinic is reported. 35 unique patients had a total of 88 visits. 1/third of the patients had more than 2 visits to the joint clinic. For each visit to the joint clinic the patient paid 25% less compared with having separate clinics. The hospital lowered the service cost for the new clinic by 11%. This was done by minimizing the time involvement of the ID physician. Conclusion Joint ID-POD clinic for managing diabetic patients with foot infections revealed several advantages. Hospital outpatient visits for each patient decreased by 50% for those requiring care of both ID and POD, without compromising care. With the consolidation of care each individual patient had a cost savings of 25% for the joint consultation. This joint clinic while making it convenient for patients has revealed significant cost savings to patients especially for those requiring multiple visits. We recommend hospitals with high prevalence of Diabetes and Diabetic foot infections to consider joint ID-POD clinics to reduce hassle and increase saving for patients. Disclosures All authors: No reported disclosures.

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DIABETIC FOOT INFECTIONS;

The Professional Medical Journal ◽

10.29309/tpmj/2008.15.01.2718 ◽

2008 ◽

Vol 15 (01) ◽

pp. 153-161

Author(s):

MUHAMMAD SAEED AKHTAR ◽

MAQSOOD AHMAD ◽

MUHAMMAD BADAR BASHIR ◽

Muhammad Irfan ◽

Zahid Yasin Hashmie

Keyword(s):

Diabetic Foot ◽

Foot Ulcer ◽

Diabetic Foot Ulcer ◽

Diabetic Patients ◽

Surgical Department ◽

Diabetic Foot Infections ◽

Group A ◽

Hospital Stays ◽

Male Patients ◽

Group B

Objective: (1) To evaluate the effects of G-CSF in eliminating infection in diabetic foot wound (2) Tocompare the effects with conventional diabetic foot management. Design: Prospective, open, randomized comparativestudy. Setting: Medical&Surgical Department of Allied, DHQ Hospital & Nawaz Medicare Faisalabad. Period: FromJan 2000 to Nov 2000 Patients & Methods: Fifty diabetic patients with foot infections were included in this study. Themean age was 52 years ranging from 27 to 60 years. They were divided into two equal groups(Group A and Group B).Results: The male patients were 41(82%) and female 9(18%). Forty six percent of patients were on oral hypoglycaemicdrugs, and 54% on insulin. The trauma preceding infection was 20%, Peripheral neuropathy 94% and peripheralvascular disease 34%. Thirty two percent of patients were smoker. Group A were subjected to G-CSF ( Neupogen )therapy (n=25) subcutanously daily for 5days in addition to conventional measures. Whereas patients in Group Breceived only conventional therapy. Both groups received similar antibiotic and insulin treatment. G-CSF therapy wasassociated with earlier eradication of pathogens from the infected ulcer (median 5 [range 2-11] vs11 [6-31] days in thegroup B; (p=<O.000I), quicker resolution of cellulitis (6 vs l4 days; p<O.0001), shorter hospital stay (8 vsl6 days;p<O.000l), and a shorter duration of intravenous antibiotic treatment (7 vs l4 days ;p—0.0001).No G-CSF treatedpatient needed surgery, whereas three patients in group B underwent toe amputation and six had extensivedebridement under anaesthesia (p=0.00 1). G-CSF therapy was generally well tolerated. Conclusion: Granulocytecolony stimulating factor (G-CSF) may be used as a good adjuvant therapy along with conventional measures for themanagement of diabetic foot infection, as it promotes the healing of diabetic foot ulcer/cellulitis and consequentlyprevents many hazardous complications like amputation of limbs, long hospital stays, extensive and prolonged antibioticuse and last but not the least the total misery of the patients.

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Comparison of acute kidney injury in patients prescribed vancomycin in combination with piperacillin–tazobactam or cefepime for diabetic foot infections

Journal of Investigative Medicine ◽

10.1136/jim-2020-001594 ◽

2021 ◽

pp. jim-2020-001594

Author(s):

Sarah R Piccuirro ◽

Anthony M Casapao ◽

Alyssa M Claudio ◽

Carmen Isache ◽

Christopher A Jankowski

Keyword(s):

Acute Kidney Injury ◽

Diabetic Foot ◽

Group Versus ◽

Kidney Injury ◽

Acute Kidney Injury Network ◽

Hospital Charges ◽

Diabetic Patients ◽

Concomitant Therapy ◽

Total Hospital ◽

Diabetic Foot Infections

Concomitant therapy with vancomycin (VAN) and piperacillin–tazobactam (PTZ) has been associated with acute kidney injury (AKI). Diabetic patients may be more susceptible to AKI due to various factors. In an observational, retrospective, cohort study of adults treated for diabetic foot infections (DFIs), rates of AKI were compared between groups receiving VAN+PTZ versus VAN+cefepime (CFP). Among 356 patients screened for inclusion, 210 were analyzed. Forty-nine of 140 patients (35%) in the VAN+PTZ group and 5 of 70 patients (7%) in the VAN+CFP group developed AKI according to the Acute Kidney Injury Network criteria (OR 7.00 (95% CI 2.64 to 18.53), p<0.001). After adjusting for baseline differences, VAN+PTZ was an independent predictor of AKI (OR 6.21 (95% CI 2.30 to 16.72), p<0.001). Time to AKI was 102.1 hours (IQR 47–152.7) in the VAN+PTZ group versus 78.3 hours (IQR 39.8–100.6) in the VAN+CFP group (p>0.999). Median length of stay was significantly higher in the VAN+PTZ group at 11.9 days (IQR 7.9–17.8) versus 7.8 days (IQR 4.9–12.1) in the VAN+CFP group (p<0.001). VAN+PTZ was also associated with higher total hospital charges at US$99,742.83 (IQR US$69,342.50–US$165,549.59) compared with US$74,260.25 (IQR US$48,446.88–US$107,396.99) in the VAN+CFP arm (p<0.001). In conclusion, VAN+CFP should be the preferred empiric regimen in patients with severe DFI.

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Multidisciplinary Approach for the Management and Treatment of Diabetic Foot Infections with a Resorbable, Gentamicin-Loaded Bone Graft Substitute

Journal of Clinical Medicine ◽

10.3390/jcm9113586 ◽

2020 ◽

Vol 9 (11) ◽

pp. 3586

Author(s):

Christine Whisstock ◽

Antonio Volpe ◽

Sasa Ninkovic ◽

Mariagrazia Marin ◽

Marco Meloni ◽

...

Keyword(s):

Bone Graft ◽

Diabetic Foot ◽

Multidisciplinary Approach ◽

Calcium Sulphate ◽

Bone Graft Substitute ◽

Diabetic Patients ◽

Ulcer Formation ◽

Adequate Treatment ◽

Diabetic Foot Infections ◽

Increased Risk

Diabetic patients are at increased risk of developing foot ulcers which may cause bone infections associated with a high probability of both amputation and mortality. Therefore, prompt diagnosis and adequate treatment are of key importance. In our Diabetic Foot Unit, effective multidisciplinary treatment of osteomyelitis secondary to diabetes involves the application of a gentamicin-eluting calcium sulphate/hydroxyapatite bone graft substitute to fill residual bone voids after debridement. The data of all patients treated with the gentamicin-eluting calcium sulphate/hydroxyapatite bone graft substitute for diabetic foot infections with ulcer formation and osteomyelitis at metatarsals, calcaneus and hindfoot at our institute from July 2013 to September 2016 were retrospectively collected and evaluated. A total of 35 patients were included in this retrospective single-arm case series and were either continuously followed up for at least one year or until healing was confirmed. Nineteen lesions affected the distal row of tarsus/talus, ten the calcaneus and a further six were located at the metatarsals. While all of the metatarsal lesions had healed at 1-year follow-up, the healing rate in the hindfoot region was lower with 62.5% at the calcaneus and 72.2% at the distal tarsus and talus at 12 months, respectively. The overall cure rate for ulcerous bone infection was 81.3%. In two calcaneal lesions (25%) and two lesions of distal tarsus/talus (11.1%) amputation was considered clinically necessary. Promising results were achieved in the treatment of diabetic foot infections with soft tissue ulcers by a multidisciplinary approach involving extensive debridement followed by adequate dead space management with a resorbable gentamicin-eluting bone graft substitute.

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Assessing Diabetic Foot Infections With the ThermoScale: A Comparative Thermometry Device Designed as a Patient Self-Screening Tool

The International Journal of Lower Extremity Wounds ◽

10.1177/1534734620948304 ◽

2020 ◽

pp. 153473462094830

Author(s):

Laure Arts ◽

Johan De Neve ◽

Samira Baharlou ◽

Nathalie Denecker ◽

Laura Kerselaers ◽

...

Keyword(s):

Temperature Measurement ◽

Diabetic Foot ◽

Characteristic Curve ◽

Screening Method ◽

Area Under The Curve ◽

Control Group ◽

Measurement Technology ◽

Diabetic Patients ◽

Home Setting ◽

Diabetic Foot Infections

Diabetic foot infection (DFI) is an important risk factor for amputation, and late diagnosis or referral is often incriminated for poor outcome. To enable an earlier diagnosis of DFI, comparative foot thermometry has been suggested as a self-screening method for patients in a home setting. We validated the efficacy of the ThermoScale, a weighing scale outfitted with temperature sensors that allows accurate temperature measurement in both feet. Temperature differentials in DFI patients (n = 52) were compared with a control group of similar diabetic patients (n = 45) without any foot wounds. Based on these findings, we drafted a receiver operating characteristic curve to determine an area-under-the-curve of 0.8455. This value suggests that the ThermoScale, as a diagnostic test, is reasonably accurate. A cutoff value of 2.15 °C temperature difference corresponded with a sensitivity of 88.9% and a specificity of 61.5%. As wearables, portable health electronics, and telemedicine become increasingly popular, we think that comparative temperature measurement technology is valuable in improving early diagnosis of DFIs.

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Antibiotic Resistance in Diabetic Foot Soft Tissue Infections: A Series From Greece

The International Journal of Lower Extremity Wounds ◽

10.1177/1534734617737640 ◽

2017 ◽

Vol 16 (4) ◽

pp. 255-259 ◽

Cited By ~ 7

Author(s):

Maria Demetriou ◽

Nikolaos Papanas ◽

Periklis Panagopoulos ◽

Maria Panopoulou ◽

Efstratios Maltezos

Keyword(s):

Antibiotic Resistance ◽

Soft Tissue ◽

Diabetic Foot ◽

Soft Tissues ◽

Foot Ulcers ◽

Diabetic Foot Ulcers ◽

Soft Tissue Infections ◽

Diabetic Foot Infections ◽

Initial Choice ◽

Gram Positive Cocci

Diabetic foot infections are a common and serious problem for all health systems worldwide. The aim of this study was to examine the resistance to antibiotics of microorganisms isolated from infected soft tissues of diabetic foot ulcers, using tissue cultures. We included 113 consecutive patients (70 men, 43 women) with a mean age of 66.4 ± 11.2 years and a mean diabetes duration of 14.4 ± 7.6 years presenting with diabetic foot soft tissue infections. Generally, no high antibiotic resistance was observed. Piperacillin-tazobactam exhibited the lowest resistance in Pseudomonas, as well as in the other Gram-negative pathogens. In methicillin-resistant Staphylococcus aureus isolates, there was no resistance to anti-Staphylococcus agents. Of note, clindamycin, erythromycin, and amoxycillin/clavulanic acid exhibited high resistance in Gram-positive cocci. These results suggest that antibiotic resistance in infected diabetic foot ulcers in our area is not high and they are anticipated to prove potentially useful in the initial choice of antibiotic regimen.

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Increasing incidence of Gram-negative organisms in bacterial agents isolated from diabetic foot ulcers

The Journal of Infection in Developing Countries ◽

10.3855/jidc.2967 ◽

2013 ◽

Vol 7 (10) ◽

pp. 707-712 ◽

Cited By ~ 27

Author(s):

Vedat Turhan ◽

Mesut Mutluoglu ◽

Ali Acar ◽

Mustafa Hatipoglu ◽

Yalcın Onem ◽

...

Keyword(s):

Staphylococcus Aureus ◽

Diabetic Foot ◽

Geographical Location ◽

Antibiotic Sensitivity ◽

Diabetic Patients ◽

Tissue Samples ◽

Gram Negative ◽

Diabetic Foot Infections ◽

Pseudomonas Species ◽

Gram Negative Organisms

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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Determination of Tissue Penetration and Pharmacokinetics of Linezolid in Patients with Diabetic Foot Infections UsingIn VivoMicrodialysis

Antimicrobial Agents and Chemotherapy ◽

10.1128/aac.00445-11 ◽

2011 ◽

Vol 55 (9) ◽

pp. 4170-4175 ◽

Cited By ~ 31

Author(s):

Dora E. Wiskirchen ◽

Ashley Shepard ◽

Joseph L. Kuti ◽

David P. Nicolau

Keyword(s):

Protein Binding ◽

Diabetic Foot ◽

Terminal Phase ◽

Diabetic Patients ◽

Infected Wound ◽

Tissue Penetration ◽

Unbound Fraction ◽

Content Type ◽

Diabetic Foot Infections ◽

Wound Tissue

ABSTRACTStaphylococcus aureusand other Gram-positive organisms, including methicillin-resistantS. aureus, continue to be the predominant pathogens associated with diabetic foot infections. Consequently, linezolid is often used to treat these infections. The purpose of the current study was to describe the pharmacokinetic profile and determine the level of penetration of linezolid into healthy thigh tissue and infected wound tissue of the same extremity in 9 diabetic patients with chronic lower limb infections by use ofin vivomicrodialysis. Hourly plasma and dialysate samples were obtained over a 12-h dosing interval following 3 to 4 doses of linezolid (600 mg intravenously every 12 h). Plasma protein binding was also assessed at 1, 6, and 12 h postdose. The means ± standard deviations (SD) for the maximum concentration in serum (Cmax), the volume of distribution at terminal phase (Vz), and the half-life (t1/2) for linezolid in plasma were 11.99 ± 3.67 μg/ml, 0.71 ± 0.25 liters/kg of body weight, and 4.71 ± 1.23 h, respectively. Mean protein binding was 14.78% (range, 3.85 to 32.03%). The mean areas under the concentration-time curves from 0 to 12 h for the free, unbound fraction of linezolid (fAUC0–12values) ± SD for plasma, wound tissue, and thigh tissue were 51.24 ± 12.72, 82.76 ± 59.01, and 92.52 ± 60.44 μg · h/ml, respectively. Tissue penetration ratios (tissuefAUC to plasmafAUC) were similar for thigh (1.42; range, 1.08 to 2.23) and wound (1.27; range, 0.86 to 2.26) tissues (P= 0.648). With the currently approved dosing regimen, linezolid penetrated well into both healthy thigh tissue and infected wound tissue in these diabetic patients.

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Diabetes a risk for antimicrobial resistance?

International Journal of Basic & Clinical Pharmacology ◽

10.18203/2319-2003.ijbcp20175103 ◽

2017 ◽

Vol 6 (12) ◽

pp. 2811 ◽

Cited By ~ 1

Author(s):

Vasavi Gedela ◽

Sree Lakshmi Gosala

Keyword(s):

Antimicrobial Resistance ◽

Diabetic Foot ◽

Foot Ulcer ◽

Diabetic Foot Ulcer ◽

Resistance Pattern ◽

Causative Organism ◽

Diabetic Patients ◽

Diabetic Foot Infections ◽

Significant Difference ◽

Resistance Rates

Background: Diabetic foot infections can cause substantial morbidity. The role of Diabetes mellitus in the antimicrobial resistance of pathogens in patients with foot infections is not well clarified. So, we compared the profile of antibiotic resistance in diabetic and non-diabetic foot ulcer infections. Objectives were to compare the antimicrobial resistance pattern in diabetic and non-diabetic lower limb infections.Methods: T Pus was isolated in 50 Diabetic and 50 non-diabetic foot ulcer infections. The organisms were isolated on specific media and antibiotic susceptibility was done by using Kirby-Bauer disc diffusion method.Results: The most frequent causative organism in diabetic and non-diabetics is Pseudomonas 27.5% vs 27.1%, Staphylococcus 24.1% vs 27.1%, Klebsiella 24.1% vs 22.03%, E. coli 10.3% vs 10.16%, Proteus 5.17% vs 5.08%. No significant differences in resistance rates to Amikacin, Penicillin, Ofloxacin, Vancomycin, Piperacillin + Tazobactum were observed between diabetic and non-diabetic patients. There is significant difference in resistance to Ampicillin (p=0.017).Conclusions: Diabetes per se does not seem to influence the susceptibility pattern to antimicrobials in our group of patients with foot ulcer infections.

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A clinical study of peripheral vascular disease due to atherosclerosis in diabetic foot infections

International Surgery Journal ◽

10.18203/2349-2902.isj20180806 ◽

2018 ◽

Vol 5 (3) ◽

pp. 931

Author(s):

A. Tyagi ◽

S. Lavanya ◽

G. Hari Prasad ◽

G. Hari Prasad

Keyword(s):

Clinical Study ◽

Vascular Disease ◽

Peripheral Vascular Disease ◽

Diabetic Foot ◽

Tertiary Care ◽

Diabetic Patients ◽

Peripheral Vascular ◽

Foot Care ◽

Below The Knee ◽

Diabetic Foot Infections

Background: Foot infection is a common problem affecting diabetics. Ischemia is a major factor contributing to progress and morbidity of the disease. The prevalence of peripheral vascular disease is higher in diabetics, with faster progression. The prevalence differs among populations. This study aimed to clinical prevalence of peripheral vascular disease due to atherosclerosis in patients with diabetic foot infections presenting to this tertiary care centre.Methods: This clinical study was conducted in ASRAM hospital, Eluru, Andhra Pradesh, India. All patients admitted with a diagnosis of diabetic foot infection to the department of general surgery during a period between October 2015 to October 2017, who fulfilled the inclusion and exclusion criteria, were enrolled for the study. After recording the pertinent information (as per performa), patients were subjected to a lower limb arterial Doppler and ABPI findings were tabulated.Results: Peripheral vascular disease was found in 35% of patients studied. Majority had distal below the knee vessels stenosis or occlusion. There was significant correlation with age, history of tobacco use and various risk factors. The clinical presentations and outcomes were worse in individuals found to have peripheral vascular compromise on arterial Doppler study.Conclusions: The care of diabetic patients should start with preventive measures which include proper foot care, glycaemic control and education about diabetic foot are key factors for better out come and quality of life.

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