Centers for Disease Control and Prevention: National diabetes statistics report. Atlanta, GA: Centers for Disease Control and Prevention, US Department of Health and Human Services; 2020. Available at: https://www.cdc.gov/diabetes/data/statistics-report/index.html. Accessed June 9, 2020.
Armstrong DG, Boulton AJM, Bus SA: Diabetic foot ulcers and their recurrence. N Engl J Med 376: 2367, 2017.
Stockl K, Vanderplas A, Tafesse E, et al.: Costs of lower-extremity ulcers among patients with diabetes. Diabetes Care 27: 2129, 2004.
Geraghty T, LaPorta G: Current health and economic burden of chronic diabetic osteomyelitis. Expert Rev Pharmacoecon Outcomes Res 19: 279, 2019.
Lavery LA, Crisologo PA, La Fontaine J, et al.: Are we misdiagnosing diabetic foot osteomyelitis? Is the gold standard gold? J Foot Ankle Surg 58: 713, 2019.
Selva Olid A, Solà I, Barajas-Nava LA, et al.: Systemic antibiotics for treating diabetic foot infections. Cochrane Database Syst Rev 9: CD009061, 2015.
Gariani K, Lebowitz D, Kressmann B, et al.: Oral amoxicillin-clavulanate for treating diabetic foot infections. Diabetes Obes Metab 21: 1483, 2019.
Embil JM, Rose G, Trepman E, et al.: Oral antimicrobial therapy for diabetic foot osteomyelitis. Foot Ankle Int 27: 771, 2006.
Euba G, Murillo O, Fernández-Sabé N, et al.: Long-term follow-up trial of oral rifampin-cotrimoxazole combination versus intravenous cloxacillin in treatment of chronic staphylococcal osteomyelitis. Antimicrob Agents Chemother 53: 2672, 2009.
Lipsky BA, Berendt AR, Cornia PB, et al.: 2012 IDSA clinical practice guideline for diagnosis and treatment of diabetic foot infections. Clin Infect Dis 54: e132, 2012.
Fincke BG, Miller DR, Christiansen CL, et al.: Variation in antibiotic treatment for diabetic patients with serious foot infections: a retrospective observational study. BMC Health Serv Res 10: 193, 2010.
Barwell ND, Devers MC, Kennon B, et al.; on behalf of the Scottish Diabetes Foot Action Group: Diabetic foot infection: antibiotic therapy and good practice recommendations. Int J Clin Pract 71: e13006, 2017.
Vas PRJ, Demetriou M, Papanas N: Oral antibiotic therapy in diabetic foot osteomyelitis: one small step or a giant leap of faith? Ann Transl Med 7(suppl 8): S266, 2019.
Lipsky BA, Senneville É, Abbas ZG, et al.: Guidelines on the diagnosis and treatment of foot infection in persons with diabetes (IWGDF 2019 update). Diabetes Metab Res Rev 36(suppl 1): e3280, 2020.
Shanafelt TD, Noseworthy JH: Executive leadership and physician well-being: nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc 92: 129, 2017.
Schmitt M, Blue A, Aschenbrener CA, et al.: Core competencies for interprofessional collaborative practice: reforming health care by transforming health professionals’ education. Acad Med 86: 1351, 2011.
Kowalski TJ, Matsuda M, Sorenson MD, et al.: The effect of residual osteomyelitis at the resection margin in patients with surgically treated diabetic foot infection. J Foot Ankle Surg 50: 171, 2011.
Schmidt BM, McHugh JB, Patel RM, et al.: Prospective analysis of surgical bone margins after partial foot amputation in diabetic patients admitted with moderate to severe foot infections. Foot Ankle Spec 12: 131, 2018.
Norris AH, Shrestha NK, Allison GM, et al.: 2018 Infectious Diseases Society of America clinical practice guideline for the management of outpatient parenteral antimicrobial therapy. Clin Infect Dis 68: 1, 2019.
Boulton A, Armstrong D, Hardman M, et al.: Diagnosis and management of diabetic foot infections. American Diabetes Association, Arlington, VA, 2020.
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 24(suppl 1): S145, 2008.
Background: Diabetic foot osteomyelitis is a common infection where treatment involves multiple services, including infectious diseases, podiatry, and pathology. Despite its ubiquity in the hospital, consensus on much of its management is lacking.
Methods: Representatives from infectious diseases, podiatry, and pathology interested in quality improvement developed multidisciplinary institutional recommendations culminating in an educational intervention describing optimal diagnostic and therapeutic approaches to diabetic foot osteomyelitis (DFO). Knowledge acquisition was assessed by preintervention and postintervention surveys. Inpatients with forefoot DFO were retrospectively reviewed before and after intervention to assess frequency of recommended diagnostic and therapeutic maneuvers, including appropriate definition of surgical bone margins, definitive histopathology reports, and unnecessary intravenous antibiotics or prolonged antibiotic courses.
Results: A postintervention survey revealed significant improvements in knowledge of antibiotic treatment duration and the role of oral antibiotics in managing DFO. There were 104 consecutive patients in the preintervention cohort (April 1, 2018, to April 1, 2019) and 32 patients in the postintervention cohort (November 5, 2019, to March 1, 2020), the latter truncated by changes in hospital practice during the coronavirus disease 2019 pandemic. Noncategorizable or equivocal disease reports decreased from before intervention to after intervention (27.0% versus 3.3%, respectively; P = .006). We observed nonsignificant improvement in correct bone margin definition (74.0% versus 87.5%; P = .11), unnecessary peripherally inserted central catheter line placement (18.3% versus 9.4%; P = .23), and unnecessary prolonged antibiotics (21.9% versus 5.0%; P = .10). In addition, by working as an interdisciplinary group, many solvable misunderstandings were identified, and processes were adjusted to improve the quality of care provided to these patients.
Conclusions: This quality improvement initiative regarding management of DFO led to improved provider knowledge and collaborative competency between these three departments, improvements in definitive pathology reports, and nonsignificant improvement in several other clinical endpoints. Creating collaborative competency may be an effective local strategy to improve knowledge of diabetic foot infection and may generalize to other common multidisciplinary conditions.