The Use of Point-of-Care Bacterial Autofluorescence Imaging in the Management of Diabetic Foot Ulcers: A Pilot Randomized Controlled Trial

Rahma, Sara; Woods, Janet; Brown, Sarah; Nixon, Jane; Russell, David

doi:10.2337/dc21-2218

Cited by 24 publications

(30 citation statements)

References 33 publications

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“…However, a recent RCT by Rahma et al showed a 2-fold increase (22 vs. 45%) in 12-week healing rates on those DFUs whose therapeutic conduct had been influenced by FL-images. DFU healing rates more than doubled in the study arm while the antibiotic prescription rate was kept under 10% [ 17 ]. Price et al documented an increase in healing rates of outpatient DFUs by 23% while at the same time decreasing systemic antibiotic consumption by 33% after incorporating FL-imaging in their practice [ 16 ].…”

Section: Discussionmentioning

confidence: 99%

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Antibiotic Misuse in Wound Care: Can Bacterial Localization through Fluorescence Imaging Help?

Caputo¹,

Monterosa²,

Donald³

2022

Diagnostics

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(1) Background: Systemic antibiotic use in chronic wounds is alarmingly high worldwide. Between 53% to 71% of patients are prescribed at least one course per chronic wound. Systemic antibiotic use should follow antibiotic stewardship guidelines and ought to be reserved for situations where their use is deemed supported by clinical indications. Unfortunately, in the field of wound care, indiscriminate and often inadequate use of systemic antibiotics is leading to both patient complications and worsening antibiotic resistance rates. Implementing novel tools that help clinicians prevent misuse or objectively determine the true need for systemic antibiotics is essential to reduce prescribing rates. (2) Methods: We present a compendium of available systemic antibiotic prescription rates in chronic wounds. The impact of various strategies used to improve these rates, as well as preliminary data on the impact of implementing fluorescence imaging technology to finesse wound status diagnosis, are presented. (3) Results: Interventions including feedback from wound care surveillance and treatment data registries as well as better diagnostic strategies can ameliorate antibiotic misuse. (4) Conclusions: Interventions that mitigate unnecessary antibiotic use are needed. Effective strategies include those that raise awareness of antibiotic overprescribing and those that enhance diagnosis of infection, such as fluorescence imaging.

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Section: Discussionmentioning

confidence: 99%

“…High bacterial loads are often pathogenic [ 4 , 5 , 15 ] and indicate the need for clinical intervention. This device has been extensively validated for its ability to detect high bacterial loads [ 8 , 11 , 16 , 17 , 18 , 19 , 20 ] and has been used in other studies to inform wound care treatment plans [ 16 , 17 , 21 ].…”

Section: Methodsmentioning

confidence: 99%

Antibiotic Misuse in Wound Care: Can Bacterial Localization through Fluorescence Imaging Help?

Caputo¹,

Monterosa²,

Donald³

2022

Diagnostics

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“…As this was a single time point study, we did not assess the clinical impacts of improved CIBL detection, although there are other published works on this topic 47,49 . However, we did fortify the FL‐imaging diagnostic accuracy measures herein by conducting wound biopsy and quantitative culture analysis to confirm bacterial loads.…”

Section: Discussionmentioning

confidence: 99%

Point‐of‐care fluorescence imaging reveals extent of bacterial load in diabetic foot ulcers

Armstrong

Edmonds

Serena

2023

International Wound Journal

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Elevated levels of bacteria, including biofilm, increase the risk of chronic wound infection and inhibit healing. Addressing asymptomatic high bacterial loads is challenged by a lack of clinical terminology and diagnostic tools. This post-hoc multicenter clinical trial analysis of 138 diabetic foot ulcers investigates fluorescence (FL)-imaging role in detecting biofilm-encased and planktonic bacteria in wounds at high loads. The sensitivity and specificity of clinical assessment and FL-imaging were compared across bacterial loads of concern (10 4 -10 9 CFU/g). Quantitative tissue culture confirmed the total loads. Bacterial presence was confirmed in 131/138 ulcers. Of these, 93.9% had loads >10 4 CFU/g. In those wounds, symptoms of infection were largely absent and did not correlate with, or increase proportionately with, bacterial loads at any threshold. FL-imaging increased sensitivity for the detection of bacteria across loads 10 4 -10 9 (P < .0001), peaking at 92.6% for >10 8 CFU/g. Imaging further showed that 84.2% of ulcers contained high loads in the periwound region.New terminology, chronic inhibitory bacterial load (CIBL), describes frequently asymptomatic, high bacterial loads in diabetic ulcers and periwound tissues, which require clinical intervention to prevent sequelae of infection. We anticipate this will spark a paradigm shift in assessment and management, enabling earlier intervention along the bacterial-infection continuum and supporting improved wound outcomes.

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“…A recent RCT reported a 2-fold increase in healing rates of DFUs intervened with a FL-imaging device throughout different stages of care. This included the initial assessment and subsequent evaluations ( Rahma et al., 2022 ). This RCT’s results were in line with a previous study by Price et al.…”

Section: Discussionmentioning

confidence: 99%

Use of fluorescence imaging to optimize location of tissue sampling in hard-to-heal wounds

Serena

Snyder

Bowler³

2023

Front. Cell. Infect. Microbiol.

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IntroductionWound microflora in hard-to-heal wounds is invariably complex and diverse. Determining the interfering organisms(s) is therefore challenging. Tissue sampling, particularly in large wounds, is subjective and, when performed, might involve swabbing or biopsy of several locations. Fluorescence (FL) imaging of bacterial loads is a rapid, non-invasive method to objectively locate microbial hotspots (loads >104 CFU/gr). When sampling is deemed clinically necessary, imaging may indicate an optimal site for tissue biopsy. This study aimed to investigate the microbiology of wound tissue incisional biopsies taken from sites identified by FL imaging compared with sites selected by clinical judgment.MethodsA post hoc analysis of the 350-patient FLAAG wound trial was conducted; 78 wounds were included in the present study. All 78 wounds were biopsied at two sites: one at the center of the wound per standard of care (SoC) and one site guided by FL-imaging findings, allowing for comparison of total bacterial load (TBL) and species present.ResultsThe comparison between the two biopsy sites revealed that clinical uncertainty was higher as wound surface area increased. The sensitivity of a FL-informed biopsy was 98.7% for accurately finding any bacterial loads >104 CFU/g, compared to 87.2% for SoC (p=0.0059; McNemar test). Regarding species detected, FL-informed biopsies detected an average of 3 bacterial species per biopsy versus 2.2 species with SoC (p < 0.001; t-test). Microbial hotspots with a higher number of pathogens also included the CDC’s pathogens of interest.Conclusions & perspectiveFL imaging provides a more accurate and relevant microbiological profile that guides optimal wound sampling compared to clinical judgment. This is particularly interesting in large, complex wounds, as evidenced in the wounds studied in this post hoc analysis. In addition, fluorescence imaging enables earlier bacterial detection and intervention, guiding early and appropriate wound hygiene and potentially reducing the need for antibiotic use. When indicated, this diagnostic partnership with antibiotic stewardship initiatives is key to ameliorating the continuing threat of antibiotic resistance.

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The Use of Point-of-Care Bacterial Autofluorescence Imaging in the Management of Diabetic Foot Ulcers: A Pilot Randomized Controlled Trial

Cited by 24 publications

References 33 publications

Antibiotic Misuse in Wound Care: Can Bacterial Localization through Fluorescence Imaging Help?

Antibiotic Misuse in Wound Care: Can Bacterial Localization through Fluorescence Imaging Help?

Point‐of‐care fluorescence imaging reveals extent of bacterial load in diabetic foot ulcers

Use of fluorescence imaging to optimize location of tissue sampling in hard-to-heal wounds

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