Development of predictive nomograms for clinical use to quantify the risk of isolating resistance prone organisms in patients with infected foot ulcers.

A Farkas,C F Stavropoulos,A Yassin,J C Lantis,G L An,F Liu,K Bui,F Lin,A Pakholskiy

doi:10.1017/s0950268818003667

Abstract

Pseudomonas aeruginosa and methicillin-resistant Staphylococcus aureus (MRSA) have been considered prevalent pathogens in foot infections. However, whether empiric therapy directed against these organisms is necessary, and in whom to consider treatment, is rather unclear. The aim of this study was to develop predictive algorithms for forecasting the probability of isolating these organisms in the infected wounds of patients in a population where the prevalence of resistant pathogens is low. This was a retrospective study of regression model-based risk factor analysis that included 140 patients who presented with infected, culture positive foot ulcers to two urban hospitals. A total of 307 bacteria were identified, most frequently MRSA (11.1%). P. aeruginosa prevalence was 6.5%. In the multivariable analysis, amputation (odds ratio (OR) 5.75, 95% confidence interval (CI) 1.48-27.63), renal disease (OR 5.46, 95% CI 1.43-25.16) and gangrene (OR 2.78, 95% CI 0.82-9.59) were identified as risk factors associated with higher while diabetes (OR 0.07, 95% CI 0.01-0.34) and Infectious Diseases Society of America infection severity >3 (OR 0.18, 95% CI 0.03-0.65) were associated with lower odds of P. aeruginosa isolation (C statistic 0.81). Similar analysis for MRSA showed that amputation was associated with significantly lower (OR 0.29, 95% CI 0.09-0.79) risk, while history of MRSA infection (OR 5.63, 95% CI 1.56-20.63) and osteomyelitis (OR 2.523, 95% CI 1.00-6.79) was associated with higher odds of isolation (C statistic 0.69). We developed two predictive nomograms with reasonable to strong ability to discriminate between patients who were likely of being infected with P. aeruginosa or MRSA and those who were not. These analyses confirm the association of some, but also question the significance of other frequently described risk factors in predicting the isolation of these organisms.

Highlights

Foot ulcers can be a common and serious problem in patients with diabetes and peripheral vascular diseases (PVDs)
While the findings of our analysis from this population confirm the close association of some, it questions the significance of other frequently described risk factors used in the decision making of selecting empiric treatment for an multi-drug-resistant organisms (MDRO) associated foot infection [5,6,7,8,9,10, 12,13,14,15, 16, 24, 25]
We demonstrated that previous isolation of a methicillin-resistant Staphylococcus aureus (MRSA) is an additional risk factor for infection with this organism in foot ulcers, findings that are similar to what was established in a study done by Lavery et al, where history of a MRSA infection within the past 12 months in the univariable analysis was shown to be significantly associated with developing a future MRSA infection [16]

Summary

Introduction

Foot ulcers can be a common and serious problem in patients with diabetes and peripheral vascular diseases (PVDs). According to the International Diabetes Federation, the prevalence of diabetic foot ulcers was 13% in North America in 2017, with a global average of 6.4% [1]. These ulcers are frequently complicated by infection that can lead to hospitalisation, and sometimes, amputations [2]. Bacteriology of these ulcers, especially those associated with diabetes, are often polymicrobial, with methicillin-resistant Staphylococcus aureus (MRSA) and coagulase negative staphylococci being the most frequently isolated. While P. aeruginosa is reported in many patients, it is often a nonpathogenic coloniser when isolated from wounds

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