Journal List > J Korean Foot Ankle Soc > v.19(3) > 1043344

Kim, Lee, Cho, Kwon, Kang, and Chun: Clinical Analysis of the Conservative Treatment for Diabetic Foot Osteomyelitis

Abstract

Purpose

The question of surgical versus non-surgical treatment for diabetic foot osteomyelitis remains subject to debate. The aims of this study were to analyse the outcome of conservative treatment (antibiotic treatment and conservative surgery) for diabetic foot osteomyelitis and identify the predictive factors of remission in conservative treatment of diabetic foot osteomyelitis.

Materials and Methods

Seventy-seven patients with diabetic foot osteomyelitis who initially received conservative treatment from January 2004 to July 2013 were identified, and their medical records were reviewed. Diabetic foot osteomyelitis was defined by imaging studies or histological evidence. Remission was defined as the absence of any sign of infection at the initial or contiguous site assessed at least 12 months after the end of treatment. The demographic, clinical, and therapeutic factors were analysed.

Results

The mean age of the patients was 62.7±12.2 years, and 47 patients (61.0%) were male. The median diabetes duration was 15.7±11.2 years and mean HbA1c was 8.7%±2.4%. Forty-eight patients (62.3%) healed with conservative treatment (antibiotic treatment and conservative surgery). Twenty-five patients (32.5%) underwent amputation. In the multivariate analysis, concomitant peripheral artery disease and inadequate antibiotic therapy were associated with failure of conservative treatment.

Conclusion

Antibiotics alone, or with conservative surgery, were successful in treatment of diabetic foot osteomyelitis in 62.3% of the patients. Concomitant peripheral artery disease and inadequate antimicrobial therapy were risk factors for remission in conservatively treated diabetic foot osteomyelitis.

References

1. Jeffcoate WJ, Lipsky BA. Controversies in diagnosing and managing osteomyelitis of the foot in diabetes. Clin Infect Dis. 2004; 39(Suppl 2):S115–22.
crossref
2. Balsells M, Viadé J, Millán M, García JR, García-Pascual L, del Pozo C, et al. Prevalence of osteomyelitis in non-healing diabetic foot ulcers: usefulness of radiologic and scintigraphic findings. Diabetes Res Clin Pract. 1997; 38:123–7.
crossref
3. Newman LG, Waller J, Palestro CJ, Schwartz M, Klein MJ, Hermann G, et al. Unsuspected osteomyelitis in diabetic foot ulcers. Diagnosis and monitoring by leukocyte scanning with indium in 111 oxyquinoline. JAMA. 1991; 266:1246–51.
crossref
4. Lipsky BA. Osteomyelitis of the foot in diabetic patients. Clin Infect Dis. 1997; 25:1318–26.
crossref
5. Shanmugam P, Jeya M, Linda Susan S. The bacteriology of diabetic foot ulcers, with a special reference to multidrug resistant strains. J Clin Diagn Res. 2013; 7:441–5.
crossref
6. Resnick HE, Carter EA, Lindsay R, Henly SJ, Ness FK, Welty TK, et al. Relation of lower-extremity amputation to all-cause and cardiovascular disease mortality in American Indians: the Strong Heart Study. Diabetes Care. 2004; 27:1286–93.
7. Tentolouris N, Al-Sabbagh S, Walker MG, Boulton AJ, Jude EB. Mortality in diabetic and nondiabetic patients after amputations performed from 1990 to 1995: a 5-year follow-up study. Diabetes Care. 2004; 27:1598–604.
8. Aragón-Sánchez FJ, Cabrera-Galván JJ, Quintana-Marrero Y, HernándezHerrero MJ, Lázaro-Martínez JL, García-Morales E, et al. Outcomes of surgical treatment of diabetic foot osteomyelitis: a series of 185 patients with histopathological confirmation of bone involvement. Diabetologia. 2008; 51:1962–70.
crossref
9. Lázaro-Martínez JL, Aragón-Sánchez J, García-Morales E. Antibiotics versus conservative surgery for treating diabetic foot osteomyelitis: a randomized comparative trial. Diabetes Care. 2014; 37:789–95.
crossref
10. Acharya S, Soliman M, Egun A, Rajbhandari SM. Conservative management of diabetic foot osteomyelitis. Diabetes Res Clin Pract. 2013; 101:e18–20.
crossref
11. Senneville E, Lombart A, Beltrand E, Valette M, Legout L, Ca-zaubiel M, et al. Outcome of diabetic foot osteomyelitis treated nonsurgically: a retrospective cohort study. Diabetes Care. 2008; 31:637–42.
12. Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections Clin Infect Dis. 2012; 54:e132–73.
13. Met R, Bipat S, Legemate DA, Reekers JA, Koelemay MJ. Diagnostic performance of computed tomography angiography in peripheral arterial disease: a systematic review and metaanalysis. JAMA. 2009; 301:415–24.
14. Vouillarmet J, Morelec I, Thivolet C. Assessing diabetic foot osteomyelitis remission with white blood cell SPECT/CT imaging. Diabet Med. 2014; 31:1093–9.
crossref
15. Eneroth M, Larsson J, Apelqvist J. Deep foot infections in patients with diabetes and foot ulcer: an entity with different characteristics, treatments, and prognosis1 J Diabetes Complications. 1999; 13:254–63.
16. Gibbons GW. Lower extremity bypass in patients with diabetic foot ulcers. Surg Clin North Am. 2003; 83:659–69.
crossref
17. Taylor LM Jr, Porter JM. The clinical course of diabetics who require emergent foot surgery because of infection or ischemia. J Vasc Surg. 1987; 6:454–9.
crossref
18. Giurini JM, Rosenblum BI. The role of foot surgery in patients with diabetes. Clin Podiatr Med Surg. 1995; 12:119–27.
19. Bamberger DM, Daus GP, Gerding DN. Osteomyelitis in the feet of diabetic patients. Long-term results, prognostic factors, and the role of antimicrobial and surgical therapy. Am J Med. 1987; 83:653–60.
20. Armstrong DG, Harkless LB. Outcomes of preventative care in a diabetic foot specialty clinic. J Foot Ankle Surg. 1998; 37:460–6.
crossref
21. Boyko EJ, Ahroni JH, Davignon D, Stensel V, Prigeon RL, Smith DG. Diagnostic utility of the history and physical examination for peripheral vascular disease among patients with diabetes mellitus. J Clin Epidemiol1. 1997; 50:659–68.
crossref
22. Apelqvist J, Larsson J, Agardh CD. The importance of peripheral pulses, peripheral oedema and local pain for the outcome of diabetic foot ulcers. Diabet Med. 1990; 7:590–4.
crossref
23. Armstrong DG, Liswood PJ, Todd WF. 1995 William J. Stickel Bronze Award. Prevalence of mixed infections in the diabetic pedal wound. A retrospective review of 112 infections. J Am Podiatr Med Assoc. 1995; 85:533–7.
crossref
24. Boulton AJ. The pathogenesis of diabetic foot problems: an overview. Diabet Med. 1996; 13(Suppl 1):S12–6.
crossref
25. Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care. 1998; 21:855–9.
crossref

Table 1.
Baseline Characteristics of Study Subjects
Variable Total (n=77)
Age (yr) 62.7±12.2
Sex (male/female) 47/30 (61.0/39.0)
HbA1c (%) 8.7±2.4
Erythrocyte sedimentation rate (mm/hr) 84.01±35.44
C-reactive protein (mg/dL) 9.06±8.53
Diabetic duration (yr) 15.7±11.2
Diabetes with end organ damage 48 (62.3)
Insulin user 45 (58.4)

Values are presented as mean±standard deviation or number (%).

Table 2.
Bacteria Isolated from Wound and Bone Cultures
Pathogen Total (n=77)
Non-identified pathogen 21 (27.3)
Gram-positive 25 (32.5)
Staphylococcus spp. 18 (23.4)
  MSSA 4 (5.2)
  MRSA 12 (15.6)
  MSCoNS 0 (0)
  MRCoNS 2 (2.6)
Streptococcus spp. 4 (5.2)
Enterococcus spp. 3 (3.9)
Gram-negative 13 (16.9)
 Enterobacteriaceae 8 (10.4)
  Escherichia coli 0 (0)
  Klebsiella spp. 2 (2.6)
  Proteus spp. 2 (2.6)
  Morganella morganii 3 (3.9)
  Serratia marcescens 1 (1.3)
Nonfermenting negative bacilli 5 (6.5)
Pseudomonas aeruginosa 4 (5.2)
Acinetobacter baumannii 1 (1.3)
Polymicrobial 18 (23.4)

Values are presented as number (%).

MSSA: methicillin-susceptible Staphylococcus aureus, MRSA: methicillin-resistant S. aureus, MSCoNS: methicillin-susceptible coagulase-negative Staphylococci, MRCoNS: methicillin-resistant coagulase-negative Staphylococci.

Table 3.
Clinical Characteristics Associated with Remission of Conservative Treatment in Patients with Diabetic Foot Osteomyelitis
Characteristic Failure (n=29) Remission (n=48) p-value*
Age (yr) 61.2±12.1 63.6±12.3 0.422
Sex (male/female) 14/15 33/15 0.094
HbA1c (%) 8.5±2.32 8.4±3.0 0.884
Diabetic duration (yr) 15.1±16.7 18.9±19.2 0.389
Diabetes with end organ damage 17 (58.6) 31 (64.6) 0.617
Insulin user 18 (62.0) 27 (56.2) 0.138
Underlying disease      
 Myocardial infarction 1 (3.4) 5 (10.4) 0.400
 Congestive heart failure 3 (10.3) 7 (14.6) 0.734
 Peripheral arterial disease 21 (72.4) 16 (33.3) 0.001
 Cerebrovascular disease 3 (10.3) 8 (16.7) 0.520
 Dementia 0 (0) 1 (2.1) <1.000
 Connective tissue disease 0 (0) 1 (2.1) <1.000
 Ulcer disease 0 (0) 1 (2.1) <1.000
 Mild liver disease 0 (0) 1 (2.1) <1.000
 Any tumor 1 (3.4) 4 (8.3) 0.645
 Moderate to severe renal disease 15 (52) 13 (28.8) 0.049
 Moderate to severe liver disease 1 (3.4) 1 (2.1) <1.000
 Metastatic solid tumor 0 (0) 1 (2.1) <1.000
Adjunctive therapy      
 Percutaneous transluminal angioplasty 6 (20.1) 2 (4.1) 0.047
 Irrigation and debridement 25 (86.1) 37 (76.2) 0.327
 Vacuum application 12 (41.3) 16 (33.3) 0.207
Identified pathogen 17 (68) 39 (75) 0.795
Staphylococcus aureus infection 7 (24.1) 9 (18.8) 0.560
Duration of antibiotics therapy (wk) 7.5±4.2 8.9±4.22 0.190
Inadequate antibiotic therapy 4 (13.8) 44 (91.3) <0.001
Infectious diseases department consultation 22 (75.9) 38 (79.2) 0.784

Values are presented as mean±standard deviation, number only, or number (%).

* By chi-square test for categorical variables and two-sample t-test for continuous variables.

Table 4.
Multivariate Analysis with Independent Predictors of Remission of Conservative Treatment in Patients with Diabetic Foot Osteomyelitis
Predictor Failure (n=29) Remission (n=48) Total (n=77) p-value* p-value Odds ratio
Underlying disease            
 Peripheral arterial disease 21 (72.4) 16 (33.3) 37 (48) 0.001 0.006 0.229
 Moderate to severe renal disease 15 (52) 13 (28.8) 28 (32.4) 0.049 0.260 0.229
Adjunctive therapy            
 Percutaneous transluminal angioplasty 6 (24) 2 (3.8) 8 (10.3) 0.047 0.889 1.18
 Inadequate antibiotic therapy 13 (52) 16 (30.7) 29 (37.6) <0.001 <0.001 71.42

Values are presented as number (%). By *chi-square test,

logistic regression.

TOOLS
Similar articles