Diabetic Foot Osteomyelitis Research Articles

Evaluation of Adjuvant Antibiotic Loaded Injectable Bio-Composite Material in Diabetic Foot Osteomyelitis and Charcot Foot Reconstruction.

The management of diabetic foot osteomyelitis (DFO) is extremely challenging with high amputation rates reported alongside a five-year mortality risk of more than fifty percent. We describe our experience in using adjuvant antibiotic-loaded bio-composite material (Cerament) in the surgical management of DFO and infected Charcot foot reconstruction. We undertook a retrospective evaluation of 53 consecutive patients (54 feet) who underwent Gentamicin or Vancomycin-loaded Cerament application during surgery. The feet were categorised into two groups: Group 1, with infected ulcer and DFO, managed with radical debridement only (n = 17), and Group 2, requiring reconstruction surgery for infected and deformed Charcot foot. Group 2 was further subdivided into 2a, with feet previously cleared of infection and undergoing a single-stage reconstruction (n = 19), and 2b, with feet having an active infection managed with a two-stage reconstruction (n = 18). The mean age was 56 years (27-83) and 59% (31/53) were males. The mean BMI was 30.2 kg/m2 (20.8-45.5). Foot ulcers were present in 69% (37/54) feet. At a mean follow-up of 30 months (12-98), there were two patients lost to follow up and the mortality rate was 11% (n = 5). The mean duration of post-operative systemic antibiotic administration was 20 days (4-42). Thirteen out of fifteen feet (87%) in group 1 achieved complete eradication of infection. There was a 100% primary ulcer resolution, 100% limb salvage and 76% bony union rate within Group 2. However, five patients, all in group 2, required reoperations due to problems with bone union. The use of antibiotic-loaded Cerament resulted in a high proportion of patients achieving infection clearance, functional limb salvage and decrease in the duration of postoperative antibiotic therapy. Larger, preferably randomised, studies are required to further validate these observations.

The utility of chemical shift imaging and related Dixon images in evaluation of bone marrow edema-like changes in diabetic foot

BackgroundMagnetic resonance imaging (MRI) is the best diagnostic tool for suspected diabetic foot osteomyelitis (DFO); adding T1-based Dixon to MR technique can identify the bone marrow edema-like signal observed in neuropathic joints and differentiate it from that observed in DFO. The aim of this study was to assess the diagnostic efficacy of chemical shift imaging (T1 in-phase and out-of-phase) and related Dixon sequence in differentiation between infectious edema-like signal found in osteomyelitis and bland edema signals observed in osteomyelitis mimickers (as neuropathic arthropathy). The study was conducted on 50 patients who were referred by surgical outpatient clinics between January 2020 and January 2022; they underwent MRI of the foot including T1-Dixon sequence.ResultsThere were variable bone and joint affection, and the most common location of bony affection in the study was the hind-foot. Forty-four out of fifty patients had bone marrow edema-like signals. Thirty-seven patients (74%) were diagnosed with osteomyelitis, whereas seven (14%) patients were diagnosed with non-infective/bland bone marrow edema signals which were related to Charcot arthropathy and/or nearby infection. Both visual and quantitative assessments of chemical shift imaging showed high sensitivity and specificity in diagnosis of DFO. The optimal cut-off point of signal intensity ratio for diagnosis of DFO was 1.005 with high sensitivity and specificity.ConclusionsChemical shift imaging and related Dixon sequence were reliable methods in diabetic foot evaluation; they could help differentiate infectious edema-like changes of osteomyelitis from and bland edema of osteomyelitis mimickers with high sensitivity and specificity especially on using quantitative analysis of their signal abnormality.

Level of 25-hydroxyvitamin D and vitamin D receptor in diabetic foot ulcer and factor associated with diabetic foot ulcers

BackgroundAt present, there is no clinical study to elucidate the correlation between vitamin D deficiency and the incidence of diabetic foot osteomyelitis (DFO).This study aims to clarify levels of 25-hydroxyvitamin D [25(OH)VD] in peripheral blood and vitamin D receptor (VDR) expression in wound margin tissues (T-VDR) of patients with type 2 diabetes mellitus (T2DM) with diabetic foot ulcer (DFU) and DFO, and to determine its correlation with treatment outcomes of DFU and DFO, and and its value as a potential biomarker for the diagnosis of DFU and DFO.Methods156 T2DM patients with DFU (DFU group), 100 T2DM patients without DFU (T2DM group), and 100 healthy controls (NC group). The DFU group patients were subdivided into DFO (n = 80) and NDFO groups (n = 76). The level of serum 25(OH)VD was measured via chemiluminescence immunoassay, and T-VDR expression level was determined by quantitative real-time PCR.ResultsThe levels of serum 25(OH)VD in the DFU group were significantly lower than the T2DM group [(10.3 (5.8, 18.7) vs 15.7 (8.6, 24.6) ng/mL, P = 0.002)]. Similarly, the levels of serum 25(OH)VD and T-VDR expression in the DFO group were statistically lower than the NDFO group [9.2 (5.2, 20.5) vs 12.8 (6.9, 22.1) ng/mL, P = 0.006)], [1.96 (0.61, 3.97) vs 3.11 (1.36, 5.11), P = 0.004)], respectively. Furthermore, the levels of serum 25(OH)VD and T-VDR expression in DFU patients were positively correlated with the ulcer healing rate of foot ulcer after 8 weeks of treatment ( P = 0.031, P = 0.016, respectively). Multivariate logistic regression analysis showed that low level of serum 25(OH)VD was an independent risk factor for DFU and DFO (ORDFU = 2.42, ORDFO = 3.05, P = 0.008, 0.001, respectively), and decreased T-VDR expression level was an independent risk factor for DFO (OR = 2.83, P = 0.004). Meanwhile, the ROC curve analysis indicated that the AUC of serum 25(OH)VD level for the diagnosis of DFU and DFO was 0.821 (95% CI, 0.754–0.886, P < 0.001) and 0.786 (95%CI, 0.643–0.867, P < 0.001), respectively. When establishing a diagnosis of DFO, the AUC of T-VDR expression level was 0.703 (95%CI: 0.618–0.853, P < 0.001).ConclusionsThe levels of serum 25(OH)VD and T-VDR expression in DFU and DFO decreased. Serum 25(OH)VD and T-VDR are potentially valuable biomarkers for diagnosis and prognosis of DFU and DFO..

Bacterial Diversity and Antibiotic Resistance in Patients with Diabetic Foot Osteomyelitis.

This study analysed the bacterial diversity, antibiotic susceptibility, and resistance in patients with complications of diabetic foot osteomyelitis (DFO). A retrospective observational study was carried out between September 2019 and September 2022 and involved 215 outpatients with a diagnosis of DFO at a specialized diabetic foot unit. A total of 204 positive bone cultures were isolated, including 62.7% monomicrobial cultures, and 37.3% were formed with at least two microorganisms. We observed that Proteus spp., Coagulase-negative staphylococci (CoNS), Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli, and Corynebacterium were the most frequently isolated microorganisms and accounted for more than 10% of the DFO cases. With stratification by Gram-positive (GP) and Gram-negative (GN) bacteria, we observed that 91.6% of cultures presented at least one GP bacteria species, and 50.4% presented at least one GN bacteria species. The most common GP species were CoNS (29%), S. aureus (25.8%), and Corynebacterium spp. (14%). The most frequent GN species consisted of Proteus spp. (32%), P. aeruginosa (23.3%), and E. coli (17.5%). The main antibiotics with resistance to GP-dominated infections were penicillins without β-lactamase inhibitor, and those in GN-dominated infections were sulfonamides and penicillins without β-lactamase. Significant differences were not observed in mean healing time in DFU with acute osteomyelitis (12.76 weeks (4.50;18)) compared to chronic osteomyelitis (15.31 weeks (7;18.25); p = 0.101) and when comparing cases with soft tissue infection (15.95 (6;20)) and those without such an infection (16.59 (7.25;19.75), p = 0.618). This study shows that when treatment of DFO is based on early surgical treatment, the type of DFO and the presence of soft infection are not associated with different or worse prognoses.

Outpatient Parenteral Antibiotic Therapy for Diabetic Foot Osteomyelitis in an Uninsured and Underinsured Cohort.

Diabetic foot osteomyelitis (DFO) is usually treated with prolonged outpatient parenteral antibiotic therapy (OPAT). Evaluation and treatment of non-antibiotic aspects of DFO (e.g., peripheral artery disease [PAD]) are also recommended. There is limited data regarding OPAT practice patterns and outcomes for DFO. Single-center observational study of patients receiving OPAT for DFO in a large United States public hospital between January 2017 and July 2019. We abstracted data regarding microbiology test, antibiotics, clinical outcomes, and non-antibiotic DFO management. Ninety-six patients were included and some had >1 DFO-OPAT course during the study period (106 DFO-OPAT courses included). No culture was obtained in 40 (38%) of courses. Methicillin-resistant S. aureus (MRSA) was cultured in 15 (14%) and P. aeruginosa in 1 (1%) of DFO-OPAT courses. An antibiotic with MRSA activity (vancomycin or daptomycin) was used in 79 (75%) of courses and a parenteral antibiotic with anti-pseudomonal activity was used in 7 (6%) of courses. Acute kidney injury occurred in 19 (18%) DFO-OPAT courses. An ankle-brachial index measurement was obtained during or 6 months prior to the first DFO-OPAT course for 44 (49%) of patients. Forty-two (44%) patients died or had an amputation within 12 months of their initial hospital discharge. We found high rates of empiric antibiotic therapy for DFO and low uptake of the non-antibiotic aspects of DFO care. Better implementation of microbiological tests for DFO in addition to stronger integration of infectious disease and non-infectious diseases care could improve DFO outcomes.

Local Antibiotics in the Treatment of Diabetic Foot Infections: A Narrative Review.

Along with the increasing global burden of diabetes, diabetic foot infections (DFI) and diabetic foot osteomyelitis (DFO) remain major challenges for patients and society. Despite progress in the development of prominent international guidelines, the optimal medical treatment for DFI and DFO remains unclear as to whether local antibiotics, that is, topical agents and local delivery systems, should be used alone or concomitant to conventional systemic antibiotics. To better inform clinicians in this evolving field, we performed a narrative review and summarized key relevant observational studies and clinical trials of non-prophylactic local antibiotics for the treatment of DFI and DFO, both alone and in combination with systemic antibiotics. We searched PubMed for studies published between January 2000 and October 2022, identified 388 potentially eligible records, and included 19 studies. Our findings highlight that evidence for adding local antibiotic delivery systems to standard DFO treatment remains limited. Furthermore, we found that so far, local antibiotic interventions have mainly targeted forefoot DFO, although there is marked variation in the design of the included studies. Suggestive evidence emerging from observational studies underscores that the addition of local agents to conventional systemic antibiotics might help to shorten the clinical healing time and overall recovery rates in infected diabetic foot ulcers, although the effectiveness of local antibiotics as a standalone approach remains overlooked. In conclusion, despite the heterogeneous body of evidence, the possibility that the addition of local antibiotics to conventional systemic treatment may improve outcomes in DFI and DFO cannot be ruled out. Antibiotic stewardship principles call for further research to elucidate the potential benefits of local antibiotics alone and in combination with conventional systemic antibiotics for the treatment of DFI and DFO.

Approach to the Treatment of Diabetic Foot OsteomyelitisInsertion of Bioactive BONALIVE Via Plantar Approach and Consequently External Fixation for Diabetic Foot Osteomyelitis: A Case Report

Diabetic foot osteomyelitis (DFO) is a clinical problem with a high risk of amputation, and it is always a complication of a preexisting infected foot wound. Prevalence can be as high as 60%. There is no consensus in the current literature regarding the management of these patients and this remains an unsolved challenge for the case manager. Surgical therapy, antibiotic therapy, or conservative treatment are among the current common treatments. Each one of them has its inherent advantage and disadvantages. In the past few years, Bioactive and soluble glasses have had the potential for use in wound healing and infection eradication. The use of new bone substitutes aims to support the load of the bone segments and to ensure the eradication of the infectious process. The approach to the infection is also a challenge. We present the management of a case of DFO that has been treated by systemic antibiotics and the insertion of bioglass, Bonalive, via plantar approach and additional external fixation. This novel way of treatment allows the closure of a diabetic ulcer that was already planned for below-knee amputation (BKA) in other institutions. A long follow-up shows the resolution of the infectious process, no ulcer recurrence, and persistent recovery of the ability to walk. Our results are in line with current literature that suggests bioglass may be considered a useful option to manage DFO and achieve healing with a very conservative approach.

Role of bone biopsy and deep tissue culture for antibiotic stewardship in diabetic foot osteomyelitis.

To describe organisms most frequently identified on bone biopsy or deep tissue culture and determine how culture data impacted antibiotic management in patients with diabetic foot osteomyelitis (DFO). We retrospectively reviewed patients admitted with a diabetic foot ulcer (DFU) between 3 March 2018 and 31 December 2019 and selected for patients diagnosed with infectious osteomyelitis (OM) of the lower extremity. We stratified patients by whether a bone biopsy or deep tissue culture was obtained and compared rates of antibiotic utilization with chi-squared and Fisher's exact tests. Of 305 patients with a DFU, 152 (50%) were clinically diagnosed with DFO. Forty-seven patients received 41 deep tissue cultures and 29 bone biopsy cultures for a total of 70 cultures. Of 45 (64%) positive cultures, 36 (80%) had Gram-positive organisms and 19 (42%) had Gram-negative organisms. MDR organisms were isolated in 7 (15%) patients. Culture data resulted in antibiotic changes in 41 (87%) patients. Therapy was narrowed in 29 (62%) patients and broadened due to inadequate empirical coverage in 4 (9%) patients. Culture data from 18 (40%) patients showed susceptibility to an oral treatment regimen with high bioavailability. There was no significant difference in rates of antibiotic utilization at discharge between patients who underwent bone biopsy or deep tissue culture relative to those who did not (77% versus 75%, P = 0.86), although less MRSA coverage was used (34% versus 50%, P = 0.047). In patients with DFO, deep tissue and bone biopsy cultures were infrequently obtained but resulted in targeted therapy changes in most patients. Culture data usually allowed for narrowing of antibiotics but revealed inadequate empirical coverage in a subset of patients.

Evaluation of diabetic foot ulcer with reference to demography, clinical presentation, and imaging modalities for diagnosis: An observational study

Background: Demography and clinical presentation of diabetic foot ulcer varies across geographical location. Multiple imaging modalities such as plain radiography and magnetic resonance imaging (MRI) are used to evaluate osteomyelitis or neuroarthropathy in diabetic foot. Plain radiography is a low cost and easily available test while MRI is reported to be of higher sensitivity and specificity for delineating the extent of soft tissue and bone involvement. Aims and Objectives: The study was designed to determine the spectrum of demographic and clinical findings and to find the utility of different diagnostic modalities such as clinical, plain radiography, and MRI that were used to differentiate between osteomyelitis and neuroarthropathy. Materials and Methods: After obtaining permission of Institute’s Ethics Committee’s permission, this observational study was carried out among patients, males and females aged 13 years and above, who presented with diabetic foot ulcer for treatment. The study spanned from March 2020 to August 2021 to reach a sample of 50 patients following non-random purposive sampling. A pro forma (containing history, physical examination findings, and laboratory investigations) was used to explore patient data. Besides clinical diagnosis, plain radiography and MRI were used to evaluate the clinical findings. Results: In the study, most of the subjects were between 51 and 70 years of age having diabetes for a duration of 5–15 years. The basis of complications observed is infections, ischemia, and neuroarthropathy. Among the diagnostic modalities used to reach a diagnosis of osteomyelitis or neuroarthropathy, MRI was able to pick up the diagnosis in a greater number of patients for above two entities. Osteomyelitis was identified in 24 (48%) patients and neuroarthropathy was identified in 22 (44%) patients. Use of plain radiography helped in reaching diagnosis in 30% of patients for each category. Clinical diagnosis about osteomyelitis or neuroarthropathy was made in 22% and 26% of patients, respectively. However, on analysis, it was not significant. Conclusion: The present study showed a male preponderance. Moreover, MRI was able to categorically diagnose different pathological parameters of osteomyelitis and neuroarthropathy. Marrow edema was detected in a larger proportion of patients among the MRI-diagnosed cases of osteomyelitis and neuroarthropathy. MRI appears to be more useful than plain radiography for clinical diagnosis.

Meta-Analysis: Outcomes of Surgical and Medical Management of Diabetic Foot Osteomyelitis.

The aim of this study was to evaluate clinical outcomes in the published literature on medical and surgical management of diabetic foot osteomyelitis (DFO). A PubMed and Google Scholar search of articles relating to DFO was performed over the dates of January 1931 to January 2020. Articles that involved Charcot arthropathy, case reports, small case series, review articles, commentaries, nonhuman studies, and non-English articles were excluded. The Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool was used to rate the bias of each study. A meta-analysis was performed using random-effects and inverse variance methods. The search yielded 1192 articles. After review and the removal of articles that did not meet inclusion criteria, 28 articles remained. Eighteen articles were related to the medical management of DFO and 13 articles were related to surgical management. Three articles looked at a combination of medical and surgical management and were included in both groups. Heterogeneity was evaluated using Cochran Q, I 2, τ2, and τ. The average success rate was 68.2% (range, 17.0%-97.3%) for medical treatment and 85.7% (range, 65.0%-98.8%) for surgical and medical treatment. There were significant inconsistencies in accounting for peripheral arterial disease and peripheral neuropathy. There was significant heterogeneity in outcomes between studies. However, there was a high rate of successful treatment and a wide range between patients with medical treatment and combined surgical and medical treatment. Additional properly designed prospective studies with gold-standard references for diagnosing osteomyelitis are needed to help determine whether medical management of DFO can be successful without surgical intervention.

Risk factors for foot ulcer recurrence in patients with comorbid diabetic foot osteomyelitis and diabetic nephropathy: A 3-year follow-up study.

This study aimed to explore the risk factors for foot ulcer recurrence in patients with comorbid diabetic foot osteomyelitis (DFO) and diabetic nephropathy (DN). This is a prospective cohort study. Between May 2018 and May 2021, we selected 120 inpatients with comorbid severe diabetic foot infection (PEDIS Grade 3 or above) and DN for inclusion in our study. All cases were followed up for 36 months. The study outcomes were whether foot ulcer recurred and the time to recurrence. The risk factors of ulcer recurrence were analysed by comparing the data of the three groups. According to the recurrence of foot ulcer, the participants were divided into three groups: Group A (no foot ulcer recurrence, n=89), Group B (foot ulcer recurrence within 12-36 months, n=19) and Group C (foot ulcer recurrence within 6-12 months, n=12). The multivariate Cox regression analysis showed that urine albumin-creatinine ratio (UACR) (HR: 1.008, 95% CI: 1.005-1.011, P < .001) and vibration perception threshold (VPT) (HR: 1.064, 95% CI: 1.032-1.096, P < .001) were identified as independent risk factors. Kaplan-Meier curves showed a significant positive association between UACR or VPT and the risk of foot ulcer recurrence (log rank, all P < .05). Areas under the ROC curves for UACR, VPT and the combination of UACR and VPT were 0.802, 0.799 and 0.842, respectively. The best cut-off values of UACR and VPT were 281.51 mg/g and 25.12 V, respectively. In summary, elevated UACR and VPT were independent risk factors. The best clinical cut-off values of UACR and VPT for prediction of foot ulcer recurrence were 281.51 mg/g and 25.12 V, respectively. Besides, our results suggested that microcirculation disorders rather than macrovascular complications play a major role in the recurrence of foot ulcer in patients with comorbid DFO and DN.

123-OR: Shotgun LC/MS Proteomics Uncovers Potential Markers of Diabetic Foot Osteomyelitis

Osteomyelitis is the leading cause of non-traumatic lower limb amputation in patients living with diabetes. The pathophysiology of diabetic foot osteomyelitis (DFO) is complex and incompletely understood. Using FFPE bone biopsies obtained from patients with suspicious clinical presentation of DFO, we characterized the proteome of bone infection in the diabetic microenvironment. A discovery LC/MS approach was used to identify molecules of interest in subjects diagnosed with DFO versus no DFO based on histopathology findings. In total, 2,135 proteins were identified across 18 DFO and 12 non-DFO TMT labeled samples. After applying data filtering and imputing missing values, 668 proteins were retained for statistical analysis. Of 66 significant proteins (p&amp;lt;0.05) , 8 demonstrated twofold abundance decreases in DFO with respect to non-DFO samples, while 8 proteins were enriched by at least onefold. Ontological analysis suggested that proteins regulating chemokine signaling and integrin mediated cascades are reduced in DFO, potentially resulting in suppression of downstream MAPK pathways, and impairing inflammatory response and cellular adhesion. Our analysis demonstrates that archived FFPE samples are a rich source for elucidating molecular mechanisms associated with diabetic foot infection and may improve accuracy of diagnosis, contribute to novel therapeutic approaches, and uncover new disease biomarkers. Disclosure A.Sherwood: None. K.L.Rubitschung: None. P.Crisologo: None. H.Hwang: None. L.A.Lavery: Advisory Panel; Acera Surgical Inc., Uluru, Research Support; Integra, Smith+Nephew, Tissue tech. O.K.Oz: None. Funding American Diabetes Association (1-17-ICTS-056) ;

Foot Osteomyelitis Location and Rates of Primary or Secondary Major Amputations in Patients With Diabetes.

Background:Diabetic foot osteomyelitis (DFO) often leads to amputations in the lower extremity. Data on the influence of the initial anatomical DFO localization on ultimate major amputation are limited.Methods:In this retrospective analysis, 583 amputation episodes in 344 patients (78 females, 266 males) were analyzed. All received a form of amputation in combination with antibiotic therapy. A multivariate logistic regression analysis with the primary outcome “major amputation” defined as an amputation above the ankle joint was performed. The association of risk factors including location of DFO, coronary artery disease, peripheral artery disease, neuropathy, nephropathy, and Charcot neuro-osteoarthropathy was analyzed.Results:Among 583 episodes, DFO was located in the forefoot in 512 (87.8%), in the midfoot in 43 (7.4%), and in the hindfoot in 28 episodes (4.8%). Overall, 53 of 63 (84.1%) major amputations were performed because of DFO in the setting of peripheral artery disease as primary indication. Overall, limb loss occurred in 6.1% (31/512) of forefoot, 20.9% (9/43) of midfoot, and 46.4% (13/28) of hindfoot DFO. Among these, 22 (41.5%) were performed as the primary treatment, whereas 31 (58.5%) followed previously failed minor amputations. Among this latter group of secondary major amputations, the DFO was localized to the forefoot in 23 of 583 (3.9%), the midfoot in 4 of 583 (0.7%) and the hindfoot in 4 of 583 (0.7%). In multivariate logistic regression analysis, initial hindfoot localization was a significant factor (P < .05), whereas peripheral artery disease, smoking, and a midfoot DFO were not found to be risk factors.Conclusion:In our retrospective series, the frequency of limb loss in DFO increased with more proximal initial foot DFO lesions, with almost half of patients losing their limbs with a hindfoot DFO.Level of Evidence:Level IV, retrospective cohort study.

Bioactive Glass in a Multi Drug Resistance Osteomyelitis in Diabetic Foot: Case Report.

Diabetic foot osteomyelitis (DFO) is a clinical problem with high risk of amputation. The treatment of DFO is still an unsolved challenge. Surgical therapy, antibiotic therapy or conservative treatment are still debated for the timing and the consequences. Long antibiotic therapies expose the selection of multidrug-resistant bacteria. Nowadays the use of new bone substitutes aims to support the load of the bone segments and to ensure the eradication of the infectious process after surgical treatment. A case report of digital osteomyelitis due to a multidrug resistant bacteria was treated with a conservative treatment and use of bioglass (Bonalive) that has the ability to inhibit bacterial growth. A long follow-up shows the resolution of infectious process, no ulcer recurrence and persistent recovery of its ability to walk. Our results agree with literature data and suggest that bioglass may be considered a useful option to manage DFO and achieve healing with a very conservative approach.

Conservative surgical treatment for metatarsal osteomyelitis in diabetic foot: experience of two French centres.

Conservative surgery (CS) for diabetic foot osteomyelitis (DFO) consists in removing all or part of the infected bone tissues without amputation, in complement with antibiotic therapy. Data on CS for DFO therapy are scarce. We performed a retrospective analysis of all DFO episodes treated with CS between 06/2007 and 12/2017. Remission was defined by the absence of soft-tissue infection, complete sustained (i.e.>1month) healing of the foot ulcer, favourable (i.e., stabilisation or improvement) radiological outcome, and no need for additional surgery during a 1-year follow-up. During the study period, 47 episodes (in 41 patients) were analysed. Excluding deaths (all unrelated to the DFO; n=3) or loss to follow-up before 1year (n=5), the remission rate was 64.2%. Most failures occurred during the first 6months (79%, 11/14). Patients who experienced failure had a higher rate of peripheral arterial disease with arterial stenosis than patients in remission (57% vs. 24%, P=0.03), a higher C-reactive protein rate at admission (116±112mg/L vs. 48±46mg/L, P=0.02), and a trend for a higher rate of abscesses (29% vs. 4%, P=0.06). At 1-year follow-up, foot ulcers related to transfer lesion were identified in 25.5% of the cases. At the last follow-up (mean 3±2years), the remission rate was 23/25 (92%). Our results suggest that CS is a therapeutic option in patients with localised but severe DFO. Clinicians should, however, consider the necessity of revascularisation, and higher risk of failure if surgery is performed in patients presenting with acute foot infections.

Decreased accuracy of erythrocyte sedimentation rate in diagnosing osteomyelitis in diabetic foot infection patients with severe renal impairment: A retrospective cross-sectional study.

Rapid diagnosis and treatment of diabetic foot osteomyelitis (DFO) could reduce the risk of amputation and death in patients with diabetic foot infection (DFI). Erythrocyte sedimentation rate (ESR) is considered the most useful serum inflammatory marker for the diagnosis of DFO. However, whether severe renal impairment (SRI) affects its diagnostic accuracy has not been reported previously. To investigate the accuracy of ESR in diagnosing DFO in DFI patients with and without SRI. This was a retrospective cross-sectional study. From the inpatient electronic medical record system, the investigators extracted demographic information, diagnostic information, and laboratory test results of patients with DFI who had been hospitalized in Longhua Hospital from January 1, 2016 to September 30, 2021. Logistic regression was performed to analyze the interaction between ESR and SRI with adjustment for potential confounders. The area under the curve (AUC), cutoff point, sensitivity, specificity, prevalence, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR+), and negative likelihood ratio (LR-) were analyzed by receiver operating characteristic (ROC) curve analysis and VassarStats. A total of 364 DFI patients were included in the analysis. The logistic regression analysis results showed that elevated ESR increased the probability of diagnosing DFO (adjusted odds ratio [OR], 2.40; 95% confidence interval [CI], 1.75-3.28; adjusted P < 0.001); SRI was not associated with the diagnosis of DFO (adjusted OR, 3.20; 95% CI, 0.40-25.32; adjusted P = 0.271), but it had an obstructive effect on the diagnosis of DFO by ESR (adjusted OR, 0.48; 95% CI, 0.23-0.99; adjusted P = 0.048). ROC analysis in DFI patients without SRI revealed that the AUC of ESR to diagnose DFO was 0.76 (95% CI, 0.71-0.81), with the cutoff value of 45 mm/h (sensitivity, 67.8%; specificity, 78.0%; prevalence, 44.7%; PPV, 71.3%; NPV, 75.0%; LR+, 3.08; LR-, 0.41). In contrast, in patients with SRI, the AUC of ESR to diagnose DFO was 0.57 (95% CI, 0.40-0.75), with the cutoff value of 42 mm/h (sensitivity, 95.0%; specificity, 29.2%; prevalence, 45.5%; PPV, 52.8%; NPV, 87.5%; LR+, 1.34; LR-, 0.17). The accuracy of ESR in diagnosing DFO in DFI patients with SRI is reduced, and it may not have clinical diagnostic value in these patients.

The association between estimated glomerular filtration rate and prognosis in patients with diabetic foot osteomyelitis.

We aimed to explore the association between estimated glomerular filtration rate (eGFR) and prognosis in patients with diabetic foot osteomyelitis (DFO). Three hundred twenty-one DFO inpatients were enrolled and classified into four groups according to the eGFRs as follows: normal (≥90), mildly reduced (60-89), moderately reduced (30-59) and severely reduced (<30). These patients were followed-up for 6 months to observe the outcomes, including ulcer healing and amputation. The associations between eGFR and the outcomes were analysed by univariate and multivariate logistic regression models. Compared with patients with normal eGFR, patients with severely reduced eGFR group had higher risk of healing failure (OR=4.72, 95% CI: 1.44-15.48), total amputation (OR=4.50, 95% CI: 1.18-17.13) and minor amputation (OR=4.05, 95% CI: (1.04-15.87). Severely reduced eGFR in patients with DFO was an independent predictor for amputation and healing failure.

Association of continuous glucose monitoring-derived time in range with major amputation risk in diabetic foot osteomyelitis patients undergoing amputation.

Objective:The metrics generated from continuous glucose monitoring (CGM), such as time in range (TIR), are strongly correlated with diabetes complications. This study explored the association of perioperative CGM-derived metrics with major amputation risk in patients with diabetic foot osteomyelitis (DFO).Methods:This study recruited 55 DFO patients with grade 3–4 wounds according to the Wagner Diabetic Foot Ulcer Classification System, all of whom underwent CGM for 5 days during the perioperative period. The CGM-derived metrics were defined in accordance with the most recent international consensus recommendations.Results:Patients with major amputation had significantly less TIR and higher time below range (TBR) (all p < 0.05). In binary logistic regression analyses, a lower TIR was associated with the risk of major amputation (odds ratio: 0.83 (95% confidence interval: 0.71–0.99), p = 0.039). This association remained statistically significant after adjustments for age, sex, body mass index, type of diabetes, smoking, drinking, durations of diabetes and DFU, ankle-brachial index, albumin, estimated-glomerular filtration rate, Society for Vascular Surgery wound, ischemia, and foot infection (WIfi) stage, multidrug-resistant organisms, and hemoglobin A1c. Further adjustment for the mean amplitude of glycemic excursion (MAGE) reduced this association. TBR was also independently associated with the risk of major amputation (odds ratio: 1.60 (95% confidence interval: 1.17–2.18), p = 0.003); this association persisted after adjustment for MAGE.Conclusion:Perioperative TIR (3.9–10.0 mmol/L) and TBR (<3.9 mmol/L) were significantly associated with major amputation in hospitalized patients with DFO.

The effectiveness of systemic antibiotics for osteomyelitis of the foot in adults with diabetes mellitus: a systematic review protocol

BackgroundOsteomyelitis of the foot is a major complication of diabetes that can be limb and life threatening. Systemic antibiotic pharmacotherapy is often used first line to eradicate infection and allow restoration of devitalised bone.The aim is to conduct a systematic review of the effectiveness of systemic antibiotics on osteomyelitis of the foot in adults with diabetes mellitus.MethodsA systematic review of all interventional studies treating osteomyelitis with systemic antibiotics in participants with diabetes mellitus and an ulcer of the foot below the malleoli will be conducted. Studies not available in English and in people below the age of 18 will be excluded. Study selection will follow the Patient Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA-P guidelines). The quality of the studies will be assessed using the Cochrane risk-of-bias tool (RoB 2) for all randomised controlled trials and the Newcastle–Ottawa Scale (NOS) will be used for non-randomised controlled trials. Electronic databases will be searched with no timeline restrictions.Data ExtractionAll identified references will be imported to the Rayyan Application. Studies for eligibility will be screened by two reviewers. One reviewer will perform the data extraction and quality appraisal will be conducted by two authors. If sufficient data is available, the quality will be analysed and a meta-analysis will be performed. Data synthesis will be conducted, and meta-analysis undertaken using RevMan 5.4.1 Meta-analysis software. Non-parametric data may be compared between selective intervention and outcomes.DiscussionThe results of this systematic review will identify the effectiveness of systemic antibiotic therapy on osteomyelitis of the foot in people with diabetes based on the set outcome measure criteria. The findings will establish if there are existing consistent standards or variation in practice when treating diabetic foot osteomyelitis (DFO). The study may establish if guidelines are required to standardise practice when treating DFO with systemic antibiotic therapy. This systematic review protocol will synthesise the existing evidence on the effectiveness of systemic antibiotic therapy for treating DFO.Trial registrationInternational Prospective Register for Systematic Reviews (PROSPERO) number CRD42021245424.

Treatment of Fusarium Osteomyelitis in a Diabetic Foot Ulcer Complicated by Antineoplastic Chemotherapy

Diabetic foot osteomyelitis (DFO) is a severe complication of diabetic foot ulcerations (DFUs). Fusarium osteomyelitis in patients who are severely immunocompromised is not well documented in current literature. Fusarium is an invasive fungal species that has been shown to respond poorly to antifungal therapy alone, and bone debridement is usually required. Treatment for DFO may consist of surgical amputation, antimicrobial therapy, and/or conservative surgery (CS) or bone debridement. The authors present a case of Fusarium osteomyelitis in a 77-year-old female with type 2 diabetes and acute myeloid leukemia, simultaneously undergoing chemotherapy. The patient had a DFU to the second digit with DFO suggested by magnetic resonance imaging. Bone cultures revealed coagulase-negative staphylococci and Fusarium species. Due to the patient's severely immunocompromised state, they were treated with CS and joint antifungal and antibiotic therapy. The DFU was healed in 6 weeks with no reoccurrence at 6 months. This case report, to the authors' knowledge, is the first to demonstrate successful remission of Fusarium osteomyelitis with a conservative procedure and adjunct antifungal therapy in an immunocompromised patient.