• 1

    Centers for Disease Control and Prevention: National Diabetes Statistics Report: estimates of diabetes and its burden in the United States, 2014. Available at: https://www.silverbook.org/reference/national-diabetes-statistics-report-2014-estimates-of-diabetes-and-its-burden-in-the-united-states/. Accessed May 1, 2017.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, et al.: The global burden of diabetic foot disease. Lancet 366: 1719, 2005.

  • 3

    Young MJ, Boulton AJ, Macleod AF, et al.: A multicentre study of the prevalence of diabetic peripheral neuropathy in the United Kingdom hospital clinic population. Diabetologia 36: 150, 1993.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Flynn MD, Tooke JE: Aetiology of diabetic foot ulceration: a role for the microcirculation? Diabet Med 9: 320, 1992.

  • 5

    Logerfo FW, Coffman JD: Current concepts. Vascular and microvascular disease of the foot in diabetes. Implications for foot care. N Engl J Med 311: 1615, 1984.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Pecoraro RE, Reiber GE, Burgess EM: Pathways to diabetic limb amputation. Basis for prevention. Diabetes Care 13: 513, 1990.

  • 7

    Ramsey SD, Newton K, Blough D, et al.: Incidence, outcomes, and cost of foot ulcers in patients with diabetes. Diabetes Care 22: 382, 1999.

  • 8

    Kalish J, Hamdan A: Management of diabetic foot problems. J Vasc Surg 51: 476, 2010.

  • 9

    Cahn A, Elishuv O, Olshtain-Pops K: Establishing a multidisciplinary diabetic foot team in a large tertiary hospital: a workshop. Diabetes Metab Res Rev 30: 350, 2014.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Clerici G, Faglia E: Saving the limb in diabetic patients with ischemic foot lesions complicated by acute infection. Int J Low Extrem Wounds 13: 273, 2014.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Uçkay I, Gariani K, Pataky Z, et al.: Diabetic foot infections: state-of-the-art. Diabetes Obes Metab 16: 305, 2014.

  • 12

    Walsh JW, Hoffstad OJ, Sullivan MO, et al.: Association of diabetic foot ulcer and death in a population-based cohort from the United Kingdom. Diabet Med 33: 1493, 2016.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 13

    International Diabetes Federation: Diabetes Atlas, 7th Ed, International Diabetes Federation, Brussels, 2015.

  • 14

    Mills JL Sr, Conte MS, Armstrong DG, et al.: The Society for Vascular Surgery Lower Extremity Threatened Limb Classification System: risk stratification based on wound, ischemia, and foot infection (WIfI). J Vasc Surg 59: 220, 2014.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Ward R, Dunn J, Clavijo L, et al.: Outcomes of critical limb ischemia in an urban, safety net hospital with high WIfI amputation scores. Ann Vasc Surg 38: 84, 2017.

  • 16

    Armstrong DG, Boulton AJM, Bus SA: Diabetic foot ulcers and their recurrence. N Engl J Med 376: 2367, 2017.

  • 17

    Davis WA, Norman PE, Bruce DG, et al.: Predictors, consequences and costs of diabetes-related lower extremity amputations complicating type 2 diabetes: the Fremantle Diabetes Study. Diabetologia 49: 2634, 2006.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 18

    Mayfield JA, Reiber GE, Samders LJ, et al.: Preventive foot care in diabetes. Diabetes Care 27 (suppl 1): S63, 2004.

  • 19

    Apelqvist J, Larson J, Agardh CD: Long-term prognosis for diabetic patients with foot ulcers. J Intern Med 233: 485, 1993.

  • 20

    Faglia E, Favales F, Morabito A: New ulceration, new major amputation, and survival rates in diabetic subjects hospitalized for foot ulceration from 1990 to 1993: a 6.5-year follow up. Diabetes Care 24: 78, 2001.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 21

    Jonsson B: Revealing the cost of type II diabetes in Europe. Diabetologia 45 (suppl 1): S5, 2002.

  • 22

    Colagiuri S, Colagiuri R, Conway B, et al.: DiabCost Australia. Assessing the Burden of Type 2 Diabetes in Australia, Canberra, Diabetes Australia, 2003.

  • 23

    National Diabetes Data Group: Diabetes in America, 2nd Ed, National Institutes of Health, Bethesda, MD, 1995.

  • 24

    Bravo-Molina A, Linares-Palomino JP, Lozano-Alonso S, et al.: Influence of wound scores and microbiology on the outcome of the diabetic foot syndrome. J Diabetes Complications 30: 329, 2016.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    van Asten SA, La Fontaine J, Peters EJ, et al.: The microbiome of diabetic foot osteomyelitis. Eur J Clin Microbiol Infect Dis 35: 293, 2016.

  • 26

    Lipsky BA, Berendt AR, Cornia PB, et al.: 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis 54: e132, 2012.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 27

    Kanjilal S, Sater MRA, Thayer M, et al.: Trends in antibiotic susceptibility in Staphylococcus aureus in Boston, Massachusetts, from 2000 to 2014. J Clin Microbiol 56: e01160, 2017.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 28

    Lavery L, Ashry H, Van Houtum W, et al.: Variation in the incidence and proportion of diabetes-related amputations in minorities. Diabetes Care 19: 48, 1996.

Multidisciplinary Limb Salvage Service Reduces Major Amputations in Diabetic Foot Infections

Eric Pillado Harbor UCLA Medical Center, Torrance, CA.

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Christian de Virgilio Harbor UCLA Medical Center, Torrance, CA.

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Eli Ipp Harbor UCLA Medical Center, Torrance, CA.

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Richard Murphy Geisel School of Medicine at Dartmouth, Hanover, NH.

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Fred Bongard Harbor UCLA Medical Center, Torrance, CA.

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Kimberly Lauer Harbor UCLA Medical Center, Torrance, CA.

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Ashley J. Miller Harbor UCLA Medical Center, Torrance, CA.

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Background: Diabetic foot infections (DFIs) can lead to limb loss and mortality. To improve patient care at a safety-net teaching hospital, we created a multidisciplinary limb salvage service (LSS).

Methods: We recruited a cohort prospectively and compared it to a historical control group. Adults admitted to the newly established LSS for DFI during a 6-month period from 2016 to 2017 were included prospectively. Patients admitted to the LSS had routine endocrine and infectious diseases consultations according to a standardized protocol. A retrospective analysis of patients admitted to the acute care surgical service for DFI before creation of the LSS during an 8-month period from 2014 to 2015 was performed.

Results: A total of 250 patients were divided into two groups: the pre-LSS (n = 92) and the LSS (n = 158) groups. There were no significant differences in baseline characteristics. Although all patients were ultimately diagnosed with diabetes, more patients in the LSS group had hypertension (71% versus 56%; P = .01) and a prior diagnosis of diabetes mellitus (92% versus 63%; P < .001) compared to the pre-LSS group. Significantly, with the LSS, fewer patients underwent a below-the-knee amputation (3.6% versus 13%; P = .001). There was no difference in the length of hospital stay or 30-day readmission rate between the groups. Further broken down into Hispanic versus non-Hispanic, we noted that Hispanics had significantly lower rates of below-the-knee amputations (3.6% versus 13.0%; P = .02) in the LSS cohort.

Conclusions: The initiation of a multidisciplinary LSS decreased the below-the-knee amputation rate in patients with DFIs. Length of stay was not increased, nor was the 30-day readmission rate affected. These results suggest that a robust multidisciplinary LSS dedicated to the management of DFIs is both feasible and effective, even in safety-net hospitals.

Corresponding author: Ashley J. Miller, DPM, Harbor UCLA Medical Center, 1000 W Carson St, Torrance, CA 90509. (E-mail: amiller@dhs.lacounty.gov).
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