Opinions about the most appropriate surgical management of diabetes‐related foot infection: a cross‐sectional survey

Abstract

Background There is a lack of high quality evidence to guide the optimal management of diabetes-related foot infection, particularly in cases of severe diabetes-related foot infection and diabetes-related foot osteomyelitis. This study examined the opinions of surgeons about the preferred management of severe diabetes-related foot infection. Methods Vascular and orthopaedic surgeons in Australia and New Zealand were invited to complete an online survey via email. The survey included multi-choice and open-ended questions on clinical management of diabetes-related foot infection. Responses of vascular surgeons and orthopaedic surgeons were compared using non-parametric statistical tests. Open-text responses were examined using inductive content analysis. Results 29 vascular and 20 orthopaedic surgeons completed the survey. One-third (28.6%) used best-practice guidelines to assist in decisions about foot infection management. Areas for guideline improvement identified included more specific advice regarding the indications for available treatments, more recommendations about non-surgical patient management and advice on how management can be varied in regions with limited health service resource. The probe-to-bone test and magnetic resonance imaging were the preferred methods of diagnosing osteomyelitis. Approximately half (51.2%) of respondents indicated piperacillin combined with tazobactam as the preferred antibiotic choice for empirical treatment of severe diabetes-related foot infection. Negative pressure wound therapy was the most common way of managing a wound following debridement. All vascular surgeons (100%) made revascularisation decisions based on the severity of ischemia while most orthopaedic surgeons (66.7%) were likely to refer to vascular surgeons to make revascularisation decisions. Vascular surgeons preferred using wound swabs while orthopaedic surgeons favoured tissue or bone biopsies to determine the choice of antibiotic. Respondents perceived a moderate variation in management decisions between specialists and supported the need for randomised controlled trials to test different management pathways. Conclusions Most vascular and orthopaedic surgeons do not use best-practice guidelines to assist in decisions about management of diabetes-related foot infection. Vascular and orthopaedic surgeons appear to have different preferences for wound sampling to determine choice of antibiotic. There is a need for higher quality evidence to clarify best practice for managing diabetes-related foot infection.

Diabetes-related foot disease: new insights with an antipodean focus

“…A survey of Australian Infectious Diseases (ID) physicians reported that management of patients with DFI accounted for approximately 19% of ID physician caseload, and there was marked heterogeneity in antimicrobial treatment regimen recommendations (Commons et al 2018). A survey of Australian and New Zealand vascular and orthopaedic surgeons found they had relatively similar management practices, but few were guided by best practice clinical guidelines for DFI (Seng et al 2022). An Australian study reported microbiology results from patients with DFI managed in a tertiary inpatient setting and revealed antimicrobial stewardship opportunities with overuse of antipseudomonal agents despite adherence to national antibiotic prescribing guidelines (Hand et al 2019).…”