Predictive Effect of Inflammatory Response and Foot Ulcer Localization on Outcome in Younger and Older Individuals with Infected Diabetic Foot Syndrome.

The diabetic foot syndrome (DFS) is the most important cause for non-traumatic major amputation in adult individuals and actually one of the most frightening events in diabetics' life. Despite the often protracted treatment of infected DFS at the end patients are often confronted with amputation. We investigated 352 individuals with infected DFS in two age separated-groups. Older individuals presented with significant worse renal function and lower HbA1c on day of admittance. Most detected ulcers involved the plantar sides of the metatarsal heads (MTH) and the toes. We saw an age-dependent translocation of foot ulcers from plantar and hindfoot to the forefoot and toes. In average every third wound provoked amputation, in the majority (94%) minor amputations, only 1.9% major amputations occurred. Lesions of the 5th toe or its MTH and interdigital or interphalangeal joint ulcers led to amputation in more than 60%. Worse renal function and WBC above 11 tsd/µl were linked with higher amputation risk. But in particular current scoring systems like SINBAD or Wagner-Armstrong scale and thus finally clinician's assessment of the wound situation gave a substantial hint for subsequent amputation - regardless of age.

Bacterial diversity and inflammatory response at first-time visit in younger and older individuals with diabetic foot infection (DFI).

AIM: Infection of a diabetic foot ulcer (DFU) is common. More than the half of DFUs become infected and 15-20% of them necessitate amputation in course of treatment. Diabetic foot infection (DFI) is therefore the major cause for non-traumatic lower limb amputation in Germany. Prompt and effective treatment of DFI is mandatory to safe limbs and lives. We investigated if there are relevant differences in evoked inflammatory response between different species and age-separated groups. We further investigated if there is an impact of ulcer localization on bacterial diversity. METHODS: For a 12-month period, we investigated 353 individuals with infected DFU, their laboratory results and bacterial diversity at first-time visit in a Diabetic Foot Care Center in Southern Germany. RESULTS: The ulcer microbiota was dominated by gram-positive species, primary Staphylococcus aureus. The gram-negative sector was mainly formed by Pseudomonas aeruginosa and Enterobacteriaceae (Proteus spp., Enterobacter spp., Escherichia coli and Klebsiella spp.). With increase in age, P. aeruginosa and S. aureus became more frequent, while Streptococci decreased. Ischemic and/or deep wounds were more likely to bear gram-negative species. Inflammatory response did not differ between gram-positive and gram-negative species, while Streptococci and Proteus spp. induced the highest serum inflammation reaction in their category. Streptococci, Enterobacter spp. and E. coli were more frequent in summer, while Enterococci spp., coagulase-negative Staphylococci and P. aeruginosa were more prevalent in winter half-year. DFIs of the forefoot and plantar side are mostly caused by gram-positive species, while Enterobacteriaceae were most frequent in plantar ulcerations. CONCLUSION: Gram-positive species dominate bacterial spectrum in DFI. With increase in age, S. aureus, Streptococci and Pseudomonas aeruginosa became more frequent. The inflammatory response did not differ significantly between different species, but gram-negative species were slightly but not significant more frequent in ischemic wounds. Climatic distinction like summer or winter half-year as well as foot ulcer localization seems to influence bacterial diversity in DFUs.

Antimicrobial Photodynamic Therapy in Infected Diabetic Foot Ulcers: A Multicenter Preliminary Experience.

BACKGROUND: The increasing resistance of bacteria to antibiotics and the frequency of comorbid conditions of patients make the treatment of diabetic foot infections problematic. In this context, photodynamic therapy could be a useful tool to treat infected wounds. The aim of this study was to evaluate the effect of repeated applications of a phthalocyanine derivative (RLP068) on the bacterial load and on the healing process. METHODS: The present analysis was performed on patients with clinically infected ulcers who had been treated with RLP068. A sample for microbiological culture was collected at the first visit before and immediately after the application of RLP068 on the ulcer surface, and the area was illuminated for 8 minutes with a red light. The whole procedure was repeated three times per week at two centers (Florence and Arezzo, Italy) (sample A), and two times per week at the third center (Stuttgart, Germany) (sample B) for 2 weeks. RESULTS: Sample A and sample B were composed of 55 and nine patients, respectively. In sample A, bacterial load decreased significantly after a single treatment, and the benefit persisted for 2 weeks. Similar effects of the first treatment were observed in sample B. In both samples, the ulcer area showed a significant reduction during follow-up, even in patients with ulcers infected with gram-negative germs or with exposed bone. CONCLUSIONS: RLP068 seems to be a promising topical wound management procedure for the treatment of infected diabetic foot ulcers.