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Management of diabetic foot infections in an era of increasing microbial resistance

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Abstract

Diabetic foot infections cause substantial morbidity, incur significant costs, and may lead to amputation. Resistant organisms, particularly methicillin-resistant Staphylococcus aureus (MRSA) and multidrug-resistant gram-negative organisms, are becoming more prevalent. Optimal management of diabetic foot infections is multimodal, and includes not only antimicrobial therapy but also biomechanical support and offloading, local wound care, glycemic control, assessment and treatment of underlying vascular disease, and surgical therapy when warranted. Antimicrobial therapy should be targeted at the likely etiologic agents and should take into consideration the depth and severity of infection. With expansion of the reservoir of resistant organisms, obtaining reliable deep cultures can help focus antimicrobial therapy against the dominant pathogens. Newer agents against resistant gram-positive and gramnegative organisms show promise in the treatment of diabetic foot infections.

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References and Recommended Reading

  1. Singh N, Armstrong DG, Lipsky BA: Preventing foot ulcers in patients with diabetes. JAMA 2005, 293:217–228.

    Article  PubMed  CAS  Google Scholar 

  2. Prompers L, Huijberts M, Apelqvist J, et al.: High prevalence of ischaemia, infection, and serious comorbidity in patients with diabetic foot disease in Europe. Baseline results from the Eurodiale study. Diabetologia 2007, 50:18–25.

    Article  PubMed  CAS  Google Scholar 

  3. Lavery LA, Armstrong DG, Wunderlich RP, et al.: Risk factors for foot infections in individuals with diabetes. Diabetes Care 2006, 29:1288–1293.

    Article  PubMed  Google Scholar 

  4. National Institute of Diabetes and Digestive and Kidney Diseases: National Diabetes Statistics 2007. Available at http://diabetes.niddk.nih.gov/DM/PUBS/statistics/#complications. Accessed May 2009.

  5. Lipsky BA, Berendt AR, Deery HG, et al.: Diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2004, 39:885–910.

    Article  PubMed  Google Scholar 

  6. Citron DM, Goldstein EJC, Merriam CV, et al.: Bacteriology of moderate-to-severe diabetic foot infections and in vitro activity of antimicrobial agents. J Clin Microbiol 2007, 45:2819–2828.

    Article  PubMed  Google Scholar 

  7. Dowd SE, Wolcott RD, Sun Y, et al.: Polymicrobial nature of chronic diabetic foot ulcer biofilm infections determined using bacterial tag encoded FLX amplicon pyrosequencing (bTEFAP). PLoS One 2008, 3:e3326.

    Article  PubMed  Google Scholar 

  8. Hartemann-Heurtier A, Robert J, Jacqueminet S, et al.: Diabetic foot ulcer and multidrug-resistant organisms: risk factors and impact. Diabet Med 2004, 21:710–715.

    Article  PubMed  CAS  Google Scholar 

  9. Richard JL, Sotto A, Jourdan N, et al.: Risk factors and healing impact of multidrug-resistant bacteria in diabetic foot ulcers. Diabetes Metab 2008, 34:363–369.

    Article  PubMed  Google Scholar 

  10. Kandemir O, Akbay E, Sahin E, et al.: Risk factors for infection of the diabetic foot with multi-antibiotic resistant microorganisms. J Infect 2007, 54:439–445.

    Article  PubMed  Google Scholar 

  11. Tentolouris N, Jude EB, Smirnof I et al.: Methicillin-resistant Staphylococcus aureus: an increasing problem in a diabetic foot clinic. Diabet Med 1999, 16:767–771.

    Article  PubMed  CAS  Google Scholar 

  12. Wagner A, Reike H, Angelkort B: Highly resistant pathogens in patients with diabetic foot syndrome with special reference to methicillin-resistant Staphylococcus aureus infections. Dtsch Med Wochenschr 2001, 126:1353–1356.

    Article  PubMed  CAS  Google Scholar 

  13. Dang CN, Prasad YDM, Boulton AJM, Jude EB: Methicillin-resistant Staphylococcus aureus in the diabetic foot clinic: a worsening problem. Diabet Med 2003, 20:159–161.

    Article  PubMed  CAS  Google Scholar 

  14. Tentolouris N, Petrikkos G, Vallianou N, et al.: Prevalence of methicillin-resistant Staphylococcus aureus in infected and uninfected diabetic foot ulcers. Clin Microbiol Infect 2006, 12:178–196.

    Article  Google Scholar 

  15. Stanaway S, Johnson D, Moulik P, Gill G: Methicillin-resistant Staphylococcus aureus (MRSA) isolation from diabetic foot ulcers correlates with nasal MRSA carriage. Diabetes Res Clin Pract 2007, 75:47–50.

    Article  PubMed  CAS  Google Scholar 

  16. Lipsky BA: New developments in diagnosing and treating diabetic foot infections. Diabetes Metab Res Rev 2008, 24:S66–S71.

    Article  PubMed  Google Scholar 

  17. Chang S, Sievert DM, Hageman JC et al.: Infection with vancomycin-resistant Staphylococcus aureus containing the vanA resistance gene. New Engl J Med 2003, 348:1342–1347.

    Article  PubMed  Google Scholar 

  18. Shankar EM, Mohan V, Premalatha G, et al.: Bacterial etiology of diabetic foot infections in South India. Eur J Intern Med 2005, 16:567–570.

    Article  PubMed  CAS  Google Scholar 

  19. Varaiya AY, Dogra JD, Kulkarni MH, Bhalekar PN: Extended-spectrum beta-lactamase-producing Escherichia coli and Klebseilla pneumoniae in diabetic foot infections. Indian J Pathol Microbiol 2008, 51:370–372.

    Article  PubMed  Google Scholar 

  20. Game F, Jeffcoate W: MRSA and osteomyelitis of the foot in diabetes. Diabet Med 2004, 21:16–19.

    Article  PubMed  Google Scholar 

  21. Vardakas KZ, Horianopoulou M, Falagas ME: Factors associated with treatment failure in patients with diabetic foot infections: an analysis of data from randomized controlled trials. Diabetes Res Clin Pract 2008, 80:344–351.

    Article  PubMed  CAS  Google Scholar 

  22. Lipsky BA: Medical treatment of diabetic foot infections. Clin Infect Dis 2004, 39:S104–S114.

    Article  PubMed  Google Scholar 

  23. Lavery LA, Armstrong DG, Peters EJG, Lipsky BA: Probeto-bone test for diagnosing diabetic foot osteomyelitis: reliable or relic. Diabetes Care 2007, 30:270–274.

    Article  PubMed  Google Scholar 

  24. Butalia S, Palda VA, Sargeant RJ, et al.: Does this patient with diabetes have osteomyelitis of the lower extremity? JAMA 2008, 299:806–813.

    Article  PubMed  CAS  Google Scholar 

  25. Dinh MT, Abad CL, Safdar N: Diagnostic accuracy of the physical examination and imaging tests for osteomyelitis underlying diabetic foot ulcers: meta-analysis. Clin Infect Dis 2008, 47:519–527.

    Article  PubMed  Google Scholar 

  26. Slater RA, Lazarovitch T, Boldur I, et al.: Swab cultures accurately identify bacterial pathogens in diabetic foot wounds not involving bone. Diabet Med 2004, 21:705–709.

    Article  PubMed  CAS  Google Scholar 

  27. Pellizzer G, Strazzabosco M, Presi S, et al.: Deep tissue biopsy vs. superficial swab culture monitoring in the microbiological assessment of limb-threatening diabetic foot infection. Diabet Med 2001, 18:822–827.

    Article  PubMed  CAS  Google Scholar 

  28. Senneville E, Lombart A, Beltrand E, et al.: Outcome of diabetic foot osteomyelitis treated nonsurgically. Diabetes Care 2008, 31:637–642.

    Article  PubMed  Google Scholar 

  29. Senneville E, Morant H, Descamps D, et al.: Needle puncture and transcutaneous bone biopsy cultures are inconsistent in patients with diabetes and suspected osteomyelitis of the foot. Clin Infect Dis 2009, 48:888–893.

    Article  PubMed  Google Scholar 

  30. Senneville E, Melliez H, Beltrand E, et al.: Culture of percutaneous bone biopsy specimens for diagnosis of diabetic foot osteomyelitis: concordance with ulcer swab cultures. Clin Infect Dis 2006, 42:57–62.

    Article  PubMed  Google Scholar 

  31. Oberdorfer K, Swoboda S, Hamann A, et al.: Tissue and serum levofloxacin concentrations in diabetic foot infection patients. J Antimicrob Chemother 2004, 54:836–839.

    Article  PubMed  CAS  Google Scholar 

  32. Legat FJ, Krause R, Zenahlik P, et al.: Penetration of piperacillin and tazobactam into inflamed soft tissue of patients with diabetic foot infection. Antimicrob Agents Chemother 2005, 49:4368–4371.

    Article  PubMed  CAS  Google Scholar 

  33. Stein GE, Schooley S, Peloquin CA, et al.: Linezolid tissue penetration and serum activity against strains of methicillin-resistant Staphylococcus aureus with reduced vancomycin susceptibility in diabetic patients with foot infections. J Antimicrob Chemother 2007, 60:819–823.

    Article  PubMed  CAS  Google Scholar 

  34. Lipsky BA, Stoutenburgh U: Daptomycin for treating infected diabetic foot ulcers: evidence from a randomized, controlled trial comparing daptomycin with vancomycin or semi-synthetic penicillins for complicated skin and skin structure infections. J Antimicrob Chemother 2005, 55:240–245.

    Article  PubMed  CAS  Google Scholar 

  35. Lipsky BA: Empirical therapy for diabetic foot infections: are there clinical clues to guide antibiotic selection. Clin Microbiol Infect 2007, 13:351–353.

    Article  PubMed  CAS  Google Scholar 

  36. Berendt AR, Peters EJG, Bakker K, et al.: Diabetic foot osteomyelitis: a progress report on diagnosis and a systematic review of treatment. Diabetes Metab Res Rev 2008, 24:S145–S161.

    Article  PubMed  Google Scholar 

  37. Lipsky BA, Itani K, Norden C; Linezolid Diabetic Foot Infections Study Group: Treating foot infections in diabetic patients: a randomized, multicenter, open-label trial of linezolid versus ampicillin-sulbactam/amoxicillin-clavulanate. Clin Infect Dis 2004, 38:17–24.

    Article  PubMed  CAS  Google Scholar 

  38. Arbeit RD, Maki D, Tally FP, et al.: The safety and efficacy of daptomycin for the treatment of complicated skin and skin-structure infections. Clin Infect Dis 2004, 38:1673–1681.

    Article  PubMed  CAS  Google Scholar 

  39. Lipsky BA, Armstrong DG, Citron DM, et al.: Ertapenem versus piperacillin/tazobactam for diabetic foot infections (SIDESTEP): prospective, randomised, controlled, doubleblinded, multicentre trial. Lancet 2005, 366:1695–1703.

    Article  PubMed  CAS  Google Scholar 

  40. Stengel D, Gorzer E, Schintler M, et al.: Second-line treatment of limb-threatening diabetic foot infections with intravenous fosfomycin. J Chemother 2005, 17:527–535.

    PubMed  CAS  Google Scholar 

  41. Tascini C, Menichetti F, Gemignani G, et al.: Clinical and microbiological efficacy of colistin therapy in combination with rifampin and imipenem in multidrug-resistant Pseudomonas aeruginosa diabetic foot infection with osteomyelitis. Int J Low Extrem Wounds 2006, 5:213–216.

    Article  PubMed  Google Scholar 

  42. Tascini C, Gemignani G, Palumbo F, et al.: Clinical and microbiological efficacy of colistin therapy alone or in combination as treatment for multidrug resistant Pseudomonas aeruginosa diabetic foot infections with or without osteomyelitis. J Chemother 2006, 18:648–651.

    PubMed  CAS  Google Scholar 

  43. Goldstein EJC, Citron DM, Warren YA, et al.: In vitro activities of dalbavancin and 12 other agents against 329 aerobic and anaerobic gram-positive isolates recovered from diabetic foot infections. Antimicrob Agents Chemother 2006, 50:2875–2879.

    Article  PubMed  CAS  Google Scholar 

  44. Goldstein EJC, Citron DM, Merriam CV, et al.: In vitro activity of ceftobiprole against aerobic and anaerobic strains isolated from diabetic foot infections. Antimicrob Agents Chemother 2006, 50:3959–3962.

    Article  PubMed  CAS  Google Scholar 

  45. Jeffcoate WJ, Lipsky BA: Controversies in diagnosing and managing osteomyelitis of the foot in diabetes. Clin Infect Dis 2004, 39:S115–22.

    Article  PubMed  Google Scholar 

  46. Lipsky BA, Holroyd KJ, Zasloff M: Topical versus systemic antimicrobial therapy for treating mildly infected diabetic foot ulcers: a randomized, controlled, double-blinded, multicenter trial of pexiganan cream. Clin Infect Dis 2008, 47:1537–1545.

    Article  PubMed  Google Scholar 

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  1. Division of Infectious Diseases, Massachusetts General Hospital, 55 Fruit Street, GRJ-504, Boston, MA, 02114, USA

    Sandra Bliss Nelson

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  1. Sandra Bliss Nelson
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Correspondence to Sandra Bliss Nelson.

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Nelson, S.B. Management of diabetic foot infections in an era of increasing microbial resistance. Curr Infect Dis Rep 11, 375–382 (2009). https://doi.org/10.1007/s11908-009-0053-z

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  • DOI: https://doi.org/10.1007/s11908-009-0053-z

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