Remission in diabetic foot infections: Duration of antibiotic therapy and other possible associated factors

Gariani, Karim; Lebowitz, Dan; Dach, Elodie von; Kressmann, Benjamin; Lipsky, Benjamin A.

doi:10.1111/dom.13507

Cited by 53 publications

(93 citation statements)

References 28 publications

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“…We found no difference in clinical recurrence according to the various antibiotics we used, or when comparing the success in polymicrobial DFIs compared to monomicrobial episodes (46/109 vs 185/523; P = 0.18). Also, these would be other study questions, of which the results have been published previously …”

Section: Resultsmentioning

confidence: 99%

Stopping antibiotics after surgical amputation in diabetic foot and ankle infections—A daily practice cohort

Rossel

Lebowitz

Gariani

et al. 2019

Endocrino Diabet & Metabol

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Summary Objective The appropriate duration of antibiotic therapy for diabetic foot infections (DFI) after surgical amputations in toto is debated. There are discrepancies worldwide. Methods Using a clinical pathway for adult DFI patients (retrospective cohort analysis), we conducted a cluster‐controlled Cox regression analysis. Minimum follow‐up was 2 months. Results We followed 482 amputated DFI episodes for a median of 2.1 years after the index episode. The DFIs predominately affected the forefoot (n = 433; 90%). We diagnosed osteomyelitis in 239 cases (239/482; 50%). In total, 47 cases (10%) were complicated by bacteremia, 86 (18%) by abscesses and 139 (29%) presented with cellulitis. Surgical amputation involved the toes (n = 155), midfoot (280) and hindfoot (47). Overall, 178 cases (37%) required revascularization. After amputation, the median duration of antibiotic administration was 7 days (interquartile range, 1‐16 days). In 109 cases (25%), antibiotics were discontinued immediately after surgery. Overall, clinical failure occurred in 90 DFIs (17%), due to the same pathogens in only 38 cases. In multivariate analysis, neither duration of total postsurgical antibiotic administration (HR 1.0, 95% CI 0.99‐1.01) nor immediate postoperative discontinuation altered failure rate (HR 0.9, 0.5‐1.5). Conclusion According to our clinical pathway, we found no benefit in continuing postsurgical antibiotic administration in routine amputation for DFI. In the absence of residual infection (ie, resection at clear margins), antibiotics should be discontinued.

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Section: Resultsmentioning

confidence: 99%

Stopping antibiotics after surgical amputation in diabetic foot and ankle infections—A daily practice cohort

Rossel

Lebowitz

Gariani

et al. 2019

Endocrino Diabet & Metabol

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“…In one study of over 1000 episodes of moderate or severe DFI (including osteomyelitis), recurrent infection was noted in 25% of patients within 3 years. Risk of recurrence was higher in those with type 1 diabetes, immunosuppression, a sequestrum, who did not undergo amputation or revascularization, but was unrelated to the route or duration of antibiotic therapy …”

Section: Diagnosismentioning

confidence: 96%

“…And some of the newer advanced imaging studies, eg, WBC‐labelled SPECT/CT, FDG PET/CT, may be more sensitive in demonstrating resolution of infection. The current state of the art, however, is that DFO is at best in “remission” if diagnostic tests suggest improvement but should probably not be considered “cured” until there has been no evidence of recurrence for at least a year after the end of treatment . An additional outcome in patients treated for DFI is recurrence of the infection at the same location.…”

Section: Diagnosismentioning

confidence: 99%

“…Some studies of DFO (and other types of osteomyelitis) have shown that therapy for longer than 6 weeks offers no additional benefit, and based mostly on theoretical considerations, treatment for just 1 to 2 weeks (or less) should be sufficient for patients in whom all infected bone has been resected . One retrospective cohort study of 1018 DFI episodes (including some with DFO) found that neither the duration of antibiotic therapy nor the use of parenteral therapy affected the risk of recurrence of DFI . Unfortunately, there are no definitive signs or tests to inform the clinician when DFO is in remission, so long‐term (usually at least a year) follow‐up is recommended before declaring the infection cured.…”

Section: Treatmentmentioning

confidence: 99%

“…159 One retrospective cohort study of 1018 DFI episodes (including some with DFO) found that neither the duration of antibiotic therapy nor the use of parenteral therapy affected the risk of recurrence of DFI. 91 Unfortunately, there are no definitive signs or tests to inform the clini-…”

Section: Rationalementioning

confidence: 99%

See 2 more Smart Citations

Guidelines on the diagnosis and treatment of foot infection in persons with diabetes (IWGDF 2019 update)

Lipsky

Senneville

Abbas

et al. 2020

Diabetes Metabolism Res

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546

729

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The International Working Group on the Diabetic Foot (IWGDF) has published evidence‐based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the diagnosis and treatment of foot infection in persons with diabetes and updates the 2015 IWGDF infection guideline. On the basis of patient, intervention, comparison, outcomes (PICOs) developed by the infection committee, in conjunction with internal and external reviewers and consultants, and on systematic reviews the committee conducted on the diagnosis of infection (new) and treatment of infection (updated from 2015), we offer 27 recommendations. These cover various aspects of diagnosing soft tissue and bone infection, including the classification scheme for diagnosing infection and its severity. Of note, we have updated this scheme for the first time since we developed it 15 years ago. We also review the microbiology of diabetic foot infections, including how to collect samples and to process them to identify causative pathogens. Finally, we discuss the approach to treating diabetic foot infections, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and for bone infections, when and how to approach surgical treatment, and which adjunctive treatments we think are or are not useful for the infectious aspects of diabetic foot problems. For this version of the guideline, we also updated four tables and one figure from the 2016 guideline. We think that following the principles of diagnosing and treating diabetic foot infections outlined in this guideline can help clinicians to provide better care for these patients.

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IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes‐related foot infections (IWGDF/IDSA 2023)

Senneville,

Albalawi,

van Asten

et al. 2023

Diabetes Metabolism Res

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The International Working Group on the Diabetic Foot (IWGDF) has published evidence‐based guidelines on the management and prevention of diabetes‐related foot diseases since 1999. The present guideline is an update of the 2019 IWGDF guideline on the diagnosis and management of foot infections in persons with diabetes mellitus.The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used for the development of this guideline. This was structured around identifying clinically relevant questions in the P(A)ICO format, determining patient‐important outcomes, systematically reviewing the evidence, assessing the certainty of the evidence, and finally moving from evidence to the recommendation. This guideline was developed for healthcare professionals involved in diabetes‐related foot care to inform clinical care around patient‐important outcomes. Two systematic reviews from 2019 were updated to inform this guideline, and a total of 149 studies (62 new) meeting inclusion criteria were identified from the updated search and incorporated in this guideline. Updated recommendations are derived from these systematic reviews, and best practice statements made where evidence was not available. Evidence was weighed in light of benefits and harms to arrive at a recommendation. The certainty of the evidence for some recommendations was modified in this update with a more refined application of the GRADE framework centred around patient important outcomes. This is highlighted in the rationale section of this update. A note is also made where the newly identified evidence did not alter the strength or certainty of evidence for previous recommendations.The recommendations presented here continue to cover various aspects of diagnosing soft tissue and bone infections, including the classification scheme for diagnosing infection and its severity. Guidance on how to collect microbiological samples, and how to process them to identify causative pathogens, is also outlined. Finally, we present the approach to treating foot infections in persons with diabetes, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and bone infections; when and how to approach surgical treatment; and which adjunctive treatments may or may not affect the infectious outcomes of diabetes‐related foot problems.We believe that following these recommendations will help healthcare professionals provide better care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes‐related foot disease.

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Remission in diabetic foot infections: Duration of antibiotic therapy and other possible associated factors

Abstract: Our analysis found no threshold for the optimal duration or route of administration of antibiotic therapy to prevent recurrences of DFI. These limited data might support possibly shorter treatment duration for patients with DFI.

Cited by 53 publications

References 28 publications

Stopping antibiotics after surgical amputation in diabetic foot and ankle infections—A daily practice cohort

Stopping antibiotics after surgical amputation in diabetic foot and ankle infections—A daily practice cohort

Guidelines on the diagnosis and treatment of foot infection in persons with diabetes (IWGDF 2019 update)

IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes‐related foot infections (IWGDF/IDSA 2023)

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