The impact of preoperative antibiotics on culture of diabetic foot infection samples has not been studied. We found that increasing exposure to preoperative antibiotics was associated with less frequent growth of streptococci and anaerobes and more culture-negative results. In contrast, the yield of Staphylococcus aureus and Gram-negative bacilli was unaffected.
Background: Below-the-knee amputation (BKA) can be a detrimental outcome of diabetic foot osteomyelitis (DFO). Ideal treatment of DFO is controversial, but studies suggest minor amputation reduces the risk of BKA. We evaluated risk factors for BKA after minor amputation for DFO. Methods: This is a retrospective cohort of patients discharged from Denver Health Medical Center from February 1, 2012, through December 31, 2014. Patients who underwent minor amputation for diagnosis of DFO were eligible for inclusion. The outcome evaluated was BKA in the 6 months after minor amputation. Results: Of 153 episodes with DFO that met the study criteria, 11 (7%) had BKA. Failure to heal surgical incision at 3 months (P < .001) and transmetatarsal amputation (P = .009) were associated with BKA in the 6 months after minor amputation. Peripheral vascular disease was associated with failure to heal but not with BKA (P = .009). Severe infection, bacteremia, hemoglobin A1c, and positive histopathologic margins of bone and soft tissue were not associated with BKA. The median antibiotic duration was 42 days for positive histopathologic bone resection margin (interquartile range, 32–47 days) and 16 days for negative margin (interquartile range, 8–29 days). Longer duration of antibiotics was not associated with lower risk of BKA. Conclusions: Patients who fail to heal amputation sites in 3 months or who have transmetatarsal amputation are at increased risk for BKA. Future studies should evaluate the impact of aggressive wound care or whether failure to heal is a marker of another variable.
Background Septic arthritis is an orthopedic emergency that requires debridement. Previous authors reported that patients with inflammatory arthropathy, diabetes, infection with S. aureus, involvement of a large joint, and synovial fluid WBC >85,000 are associated with >1 debridements. The purpose of this study was to determine factors associated with 1 vs >1 debridements. Methods This is a retrospective cohort of adult patients hospitalized at Denver Health Medical Center with large joint septic arthritis between 7/1/2012 and 4/13/20. Patients with implanted orthopedic material, osteomyelitis, and recurrent septic arthritis were excluded. Septic arthritis was defined as a patient presenting with acute arthritis and positive culture OR negative culture and no other etiology. Both electronic capture and manual chart review were performed. Descriptive statistics were used to characterize the population. Statistical analyses included bivariate and multivariate analyses. Results Forty-four cases were included (26 knee [59.1%], 4 hip [9.1%], 6 elbow [13.6%], and 8 shoulder [18.2%]. The median age was 55.7 years (41.3–64.1], and 79.5% were male. The most common organisms were S. aureus (n=20, 45.5%) and beta-hemolytic Streptococcus (n=10, 22.7%). Three patients had no surgical debridement, 21 had 1 debridement, and 20 had >1 debridements. As compared to those who had 1 debridement, those with >1 debridements were more likely to be male (95% vs 61.9%, p=0.02) and to have a higher synovial fluid leukocyte count (102,761 vs 49,154, p=0.001), CRP at admission (162.5 vs 97.7, p=0.039), and WBC the day prior to debridement (13.4 vs 9.8, p=0.007). Intra-operative purulence trended to association with >1 debridements. Pre- to post-operative changes in opiate use, temperature, and ability to work with physical therapy were not associated with 1 vs >1 debridements. Both higher synovial fluid leukocyte counts and CRP value at admission were independently associated with >1 debridements (OR 2.31, p=0.015; OR 1.01, p=0.036 respectively). Conclusion Patients with higher synovial fluid leukocytes and CRP at admission were more likely to have >1 debridements. Additional studies with functional outcome scores are necessary to determine if >1 debridements are associated with better clinical outcomes. Disclosures All Authors: No reported disclosures
Background Randomized trials found oral step-down therapy to be as effective as intravenous (IV) therapy for infective endocarditis and bone and joint infections. However, the comparative effectiveness of IV versus oral step-down therapy for deep seated Staphylococcus aureus infections outside of the clinical trial setting is unknown. The objectives of this study were to compare treatment adherence and clinical outcomes between these two approaches in clinical practice. Methods This was a retrospective comparative effectiveness study involving adults hospitalized at an academic, safety net hospital between January 2019 to June 2021 with bacteremia, endocarditis, osteomyelitis, or septic arthritis due to S. aureus. Based on initial treatment plans, patients were categorized and analyzed in two groups: all IV or IV followed by oral step-down therapy. The co-primary outcomes were antibiotic adherence (percent of planned course received) and the proportion who completed therapy. The key secondary outcome of clinical failure was a composite of all-cause mortality, recurrent or new metastatic site of S. aureus infection, or requirement of an unplanned source control procedure. Results Of 249 patients included, 101 were in the all IV and 148 were in the oral step-down groups. Indications for treatment were osteomyelitis (72%), complicated bacteremia (25%), endocarditis (22%), septic arthritis (11%), and uncomplicated bacteremia (8%). Active substance abuse was observed in 43% of the IV group and 55% in the oral group. Between the all IV and oral step-down groups, antibiotic adherence rates did not differ significantly (Table); antibiotic therapy was completed by 93% vs 87% of patients (p = 0.13), respectively. Clinical failure occurred in 25% of the all IV group and 26% of the oral step-down group (p = 0.87). The frequency of other secondary outcomes was similar between groups; however, hospital length of stay was significantly longer in the IV group (Table). Table 1 Note: data presented as n (%) unless otherwise specified *within 6 months of hospital admission date for index infection Conclusion In clinical practice, oral step-down therapy for serious S. aureus infections was associated with similar rates of treatment adherence and completion, clinical outcomes and less health care resource utilization compared with IV therapy. Our findings support use of oral step-down therapy as an effective alternative to IV therapy. Disclosures All Authors: No reported disclosures.
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