Selecting empirical therapy for a diabetic foot infection (DFI) requires knowing how likely infection with Pseudomonas aeruginosa is in a particular patient. We designed this study to define the risk factors associated with P aeruginosa in DFI.
We performed a preplanned microbiological subanalysis of data from a study assessing the effects of treatment with intralesional epidermal growth factor for diabetic foot wounds in patients in Turkey between January 1, 2012, and December 31, 2013. Patients were screened for risk factors, and the data of enrolled individuals were recorded in custom-designed patient data forms. Factors affecting P aeruginosa isolation were evaluated by univariate and multivariate logistic regression analyses, with statistical significance set at P < .05.
There were 174 patients enrolled in the main study. Statistical analysis was performed in 90 evaluable patients for whom we had microbiological assessments. Cultures were sterile in 19 patients, and 89 bacterial isolates were found in the other 71. The most frequently isolated bacteria were P aeruginosa (n = 23, 25.8%) and Staphylococcus aureus (n = 12, 13.5%). Previous lower-extremity amputation and a history of using active wound dressings were the only statistically significant independent risk factors for the isolation of P aeruginosa in these DFIs.
This retrospective study provides some information on risk factors for infection with this difficult pathogen in patients with DFI. We need prospective studies in various parts of the world to better define this issue.
Background: Exercise has not been studied extensively in persons with active neuropathic diabetic foot wounds, primarily because a device does not exist that allows patients to exercise while sufficiently off-loading pressure at the ulcer site. The purpose of this project was to demonstrate a device that reduces cycling plantar forefoot pressure.
Methods: Ten healthy participants rode a recumbent bicycle under three cycling conditions. While the left foot interaction remained constant with a standard gym shoe and pedal, the right foot was exposed to a control condition with standard gym shoe and pedal, gym shoe and specialized cleat, and gym shoe with an off-loading insole and specialized cleat. Pressure and contact area of the plantar aspect of the feet were recorded for a 10-sec interval once during each minute of each condition’s 7-min trial.
Results: The off-loading insole and specialized cleat condition yielded significantly lower (P < .01) peak pressure, contact area, and pressure–time integral values in the forefoot than the specialized cleat condition with gym shoe, which yielded significantly lower values (P < .01) than the standard gym shoe and pedal.
Conclusion: Modifications to footwear may alter plantar forefoot pressures, contact area, and pressure–time integrals while cycling. The CLEAR Cleat could play a significant role in the facilitation of fitness in patients with (or at high risk for) neuropathic wounds. (J Am Podiatr Med Assoc 98(4): 261–267, 2008)
We conducted a post-hoc retrospective analysis of patients enrolled in a randomized controlled trial to evaluate overall costs of negative pressure wound therapy (NPWT; V.A.C. Therapy; KCI USA, Inc, San Antonio, Texas) versus advanced moist wound therapy (AMWT) in treating grade 2 and 3 diabetic foot wounds during a 12-week therapy course.
Data from two study arms (NPWT [n = 169] or AMWT [n = 166]) originating from Protocol VAC2001-08 were collected from patient records and used as the basis of the calculations performed in our cost analysis.
A total of 324 patient records (NPWT = 162; AMWT = 162) were analyzed. There was a median wound area reduction of 85.0% from baseline in patients treated with NPWT compared to a 61.8% reduction in those treated with AMWT. The total cost for all patients, regardless of closure, was $1,941,472.07 in the NPWT group compared to $2,196,315.86 in the AMWT group. In patients who achieved complete wound closure, the mean cost per patient in the NPWT group was $10,172 compared to $9,505 in the AMWT group; the median cost per 1 cm2 of closure was $1,227 with NPWT and $1,695 with AMWT. In patients who did not achieve complete wound closure, the mean total wound care cost per patient in the NPWT group was $13,262, compared to $15,069 in the AMWT group. The median cost to close 1 cm2 in wounds that didn't heal using NPWT was $1,633, compared to $2,927 with AMWT.
Our results show greater cost effectiveness with NPWT versus AMWT in recalcitrant wounds that didn't close during a 12-week period, due to lower expenditures on procedures and use of health-care resources.
Hyperbaric oxygen therapy is an adjunctive wound-healing modality receiving increasing use for problem wounds, particularly diabetic foot wounds. Nevertheless, few clinicians understand the physiologic basis for this modality; how patients are selected, or the expected results. The author reviews the development of hyperbaric oxygen therapy, selection of patients, and clinical studies of this modality for diabetic patients with foot wounds.
Stenotrophomonas maltophilia is an uncommon gram-negative bacterium often found in individuals with long-standing broad-spectrum antibiotic use or catheter use; individuals undergoing hemodialysis; and individuals with prolonged respiratory disease, specifically, cystic fibrosis. To our knowledge, there are few reported cases of S maltophilia being the causative pathogen of infection in a diabetic foot wound.
Following multiple surgical procedures and deep tissue cultures, S maltophilia was determined to be a secondary opportunistic colonizer of the wound, necessitating a change in antibiotic therapy.
The cultured pathogen was sensitive to ceftazidime, levofloxacin, and trimethoprim-sulfamethoxazole. The treatment team chose to use ceftazidime, as it also provided antibiotic coverage for the initial wound and blood cultures. Change in antibiotic therapy was initiated following multiple surgical procedures and angioplasty of the lower limb. The patient was discharged with a peripheral intravenous central catheter for outpatient antibiotic therapy.
Prolonged exposure to broad-spectrum antibiotics in individuals with multiple comorbidities including diabetes mellitus provides an advantageous environment for growth of uncommon multidrug-resistant organisms. Stenotrophomonas maltophilia may complicate the treatment of diabetic foot infections as an opportunistic pathogen. Understanding the implication of long-term broad-spectrum antibiotic treatment in the diabetic patient is important in managing postoperative complications and determining the correct course of treatment. The emergence of atypical pathogens in diabetic wounds must be managed appropriately.