Enterococci in Diabetic Foot Infections: Prevalence, Clinical Characteristics, and Outcomes.

Background: Diabetic foot infections (DFIs) are frequently polymicrobial, yet the relevance of each isolated pathogen, remains ill-defined. Specifically, the prevalence and pathogenicity of enterococcal DFIs and the impact of targeted antienterococcal treatment remain elusive. Methods: We collected demographic, clinical, and outcome-related data on patients admitted with DFIs to the Hadassah Medical Center diabetic foot unit between 2014 and 2019. The primary outcome was a composite of in-hospital death or major amputation. Secondary outcomes included any amputation, major amputation, length of stay (LOS), and 1-year major amputation or mortality rate. Results: Enterococci were isolated in 35% of 537 eligible DFI case patients, who were notable for a higher prevalence of peripheral vascular disease, increased levels of C-reactive protein, and higher Wagner scores. Infection in enterococci-positive individuals was mostly polymicrobial (96.8% vs 61.0% in non-enterococci-infected patients; P < .001). Enterococci-infected patients were more likely to undergo amputation (72.3% vs 50.1%; P < .001) and had longer hospital stays (median LOS, 22.5 vs 17 days; P < .001), but the primary end point of major amputation or in-hospital death did not differ between groups (25.5% vs 21.0%; P = .26). Appropriate antienterococcal antibiotics were used in 78.1% of enterococci-infected patients and, compared with results in untreated patients, were associated with a trend toward a lower rate of major amputations (20.4% vs 34.1%; P = .06) but longer hospitalization (median LOS, 24 vs 18 days; P = .07). Conclusions: Enterococci are common in DFIs and associated with higher rates of amputation and longer hospitalization. A reduction in major amputation rates with appropriate enterococci treatment is suggested retrospectively, meriting validation by future prospective studies.

Predictors and outcomes of diabetic foot ulcer infection with ESBL-producing bacteria in a large tertiary center.

OBJECTIVES: The aim of this study was to describe the predictors and outcomes of infection with extended-spectrum beta-lactamase (ESBL)-producing bacteria in patients with an acute diabetic foot infection (DFI). METHODS: The records of patients admitted with acute DFI to a large tertiary hospital during the years 2014-2018 were reviewed. Demographic, clinical, and laboratory data were collected, as well as outcomes regarding amputations and mortality. Only cultures obtained during the first 2 weeks following admission were considered. RESULTS: Cultures were available for 493 patients; 121 (24.5%) included bacteria suspected of being ESBL producers. Patients infected with ESBL-producing bacteria were older, more likely to have peripheral vascular disease (PVD), and had higher SINBAD and Wagner scores upon admission. They were also more likely to have been hospitalized in the recent 6 months. Major amputations were more prevalent in patients with versus without an ESBL-producing bacterial infection (30.6% vs 19.4%; P = 0.010), yet overall amputations and mortality rates were similar. CONCLUSIONS: ESBL-producing bacteria are common pathogens in DFI, more prevalent in older patients with PVD, advanced ulcers, and recent hospitalization. They are associated with higher rates of major amputation. These considerations may support the choice of empirical antibiotic therapy in patients admitted with an acute DFI.

[HOSPITALIZATIONS DUE TO ACUTE DIABETIC FOOT: ANNUAL TRENDS AND PREDICTORS OF MORBIDITY AND MORTALITY - 5-YEARS EXPERIENCE OF A MULTIDISCIPLINARY UNIT].

INTRODUCTION: Since 2012, patients presenting to our hospital with an acute diabetic foot are hospitalized in a dedicated unit. This study describes patients' characteristics and trends in amputations, procedures and mortality during the years 2014-2018. METHODS: We retrospectively reviewed the electronic medical records of 694 patients admitted to the unit during the study period. We collected demographic, clinical and laboratory data, procedures and outcomes. Annual trends were studied as well as predictors to any or major amputation and to mortality within 1 year following discharge. RESULTS: The mean age was 63.8±12.7 years and 75.4% of the patients were male. There was a high prevalence of neuropathy, peripheral artery disease and ischemic heart disease (55.3%, 66.1% and 44.2% respectively). Previous hospitalization was noted for 62.0% of the patients and 38.3% had undergone a previous amputation. The majority of the patients had chronic kidney disease and 19.0% were dialysis patients. During hospitalization, 54.3% of the patients underwent any amputation, 25.2% had a major amputation and 6.2% died. The mortality rate within 1 year of discharge was 24.5%. There were no changes in patient demographics, characteristics or outcomes during the study years, although an increase in the proportion of patients who had undergone previous amputation, and of current smokers in recent years was noted. Moreover, in recent years more vascular procedures and surgical procedures in the operating room were performed. Older age, recent hospitalization, previous amputation, neuropathy, ischemic heart disease, peripheral vascular disease, chronic renal insufficiency, elevated inflammatory markers, a progressive ulcer, and a midfoot or hindfoot (vs. forefoot) ulcer were all associated with major amputations. CONCLUSIONS: During the study period, patients' characteristics remained generally stable as did amputation and mortality rates. The high 1-year mortality rate of this population is indicative of these patients' significant morbidity.

Association of Inpatient Glucose Measurements With Amputations in Patients Hospitalized With Acute Diabetic Foot.

CONTEXT: The association of inpatient glucose measurements with amputations in patients admitted with acute diabetic foot has not been described. OBJECTIVE: To evaluate the relationship of hyperglycemia, hypoglycemia, and glucose variability during hospitalization with amputations in patients hospitalized with acute diabetic foot. DESIGN: Retrospective cohort study. SETTING: Academic tertiary hospital. PATIENTS: We reviewed demographic, clinical, laboratory, and point-of-care glucose data in patients hospitalized with acute diabetic foot in the Diabetic Foot Unit during 2015 through 2017. MAIN OUTCOME MEASURES: The primary outcomes were any or major amputations during hospitalization. Secondary outcomes included length of hospitalization and in-hospital mortality. RESULTS: During the study period, 418 patients were hospitalized in the Diabetic Foot Unit and 45,496 glucose measurements were taken. Patients experiencing any hyperglycemia and any or severe hypoglycemia were more likely to undergo any or major amputations during hospitalization. High glycemic variability was associated with major amputations. Peripheral vascular disease (PVD), high Wagner score, and hypoglycemia were independent predictors of amputations. Older age, PVD, previous amputation, elevated white blood cell level, high Wagner score, and hypoglycemia were independent predictors of major amputations. CONCLUSIONS: In-patient hypoglycemia emerged as an independent risk factor for any and major amputations. Although it is unclear whether hypoglycemia directly contributes to adverse outcomes or is simply a biomarker of disease severity, efforts to minimize in-hospital hypoglycemic events are warranted.

Monitoring PDT-induced damage using spectrally resolved reflectance imaging of tissue oxygenation.

Photodynamic therapy (PDT) with chlorin e6 (Chl) was monitored in vivo using vital microscopy and Fourier transform spectral imaging (FT-SI). Mammary C26 colon carcinoma, implanted intradermally in a mouse, was irradiated at 650 nm with various radiant exposures, 3 h after administration of 5 mg/kg Chl. The photodynamic response (PDR) in the skin flap with tumor was expressed as microcirculation disturbances (thrombi formation, multiple embolizations, arteriolar occlusion and venous stasis) and, dependent on the radiant exposure, was transient or permanent. These biological manifestations were accompanied by a change in hemoglobin (Hb)/oxyhemoglobin (HbO2) absorption spectra obtained in vivo by FT-SI. False-color mapping of hemoglobin oxygen saturation (OS) visualized the alteration of tissue oxygenation. The results demonstrate, for the first time, that FT-SI can serve as a sensitive non-invasive tool for OS monitoring of PDT effects.