Antibiotherapy with and without bone debridement in diabetic foot osteomyelitis: a retrospective cohort study

Senneville

et al. 2020

The optimal approaches to managing diabetic foot infections remain a challenge for clinicians. Despite an exponential rise in publications investigating different treatment strategies, the various agents studied generally produce comparable results, and high‐quality data are scarce. In this systematic review, we searched the medical literature using the PubMed and Embase databases for published studies on the treatment of diabetic foot infections as of June 2018. This systematic review is an update of previous reviews, the first of which was undertaken in 2010 and the most recent in 2014, by the infection committee of the International Working Group of the Diabetic Foot. We defined the context of literature by formulating clinical questions of interest, then developing structured clinical questions (PICOs) to address these. We only included data from controlled studies of an intervention to prevent or cure a diabetic foot infection. Two independent reviewers selected articles for inclusion and then assessed their relevant outcomes and the methodological quality. Our literature search identified a total of 15 327 articles, of which we selected 48 for full‐text review; we added five more studies discovered by means other than the systematic literature search. Among these selected articles were 11 high‐quality studies published in the last 4 years and two Cochrane systematic reviews. Overall, the outcomes in patients treated with the different antibiotic regimens for both skin and soft tissue infection and osteomyelitis of the diabetic foot were broadly equivalent across studies, except that treatment with tigecycline was inferior to ertapenem (±vancomycin). Similar outcomes were also reported in studies comparing primarily surgical and predominantly antibiotic treatment strategies in selected patients with diabetic foot osteomyelitis. There is insufficient high‐quality evidence to assess the effect of various adjunctive therapies, such as negative pressure wound therapy, topical ointments or hyperbaric oxygen, on infection related outcomes of the diabetic foot. In general, the quality of more recent trial designs are better in past years, but there is still a great need for further well‐designed trials to produce higher quality evidence to underpin our recommendations.

Section: Resultsmentioning

confidence: 99%

“…Saltoglu et al; Lipsky et al; Lauf et al; Grayson et al; Erstad et al; Lipsky et al; Lipsky et al; Lipsky et al; Lázaro‐Martínez et al; Ulcay et al; Tone et al, Li et al…”

Section: Resultsunclassified

Section: Resultsmentioning

confidence: 99%

See 1 more Smart Citation

Interventions in the management of infection in the foot in diabetes: a systematic review

Peters

Senneville

et al. 2020

“…Surgical resection of infected bone has long been the standard treatment of osteomyelitis, but over the past two decades, evidence from several retrospective case series, one retrospective cohort study, and one prospective controlled study has demonstrated that in properly selected patients, antibiotic therapy alone is effective. While treatment of DFO with antibiotics without surgical resection of bone may be considered for any patient with DFO, based on published data, the strongest cases for considering nonsurgical treatment include patients with limited DFO of the forefoot, who are medically stable, for whom there is no other mechanical need for surgical treatment of the foot, and for whom there is an appropriate antibiotic regimen .…”

Section: Treatmentmentioning

confidence: 99%

Guidelines on the diagnosis and treatment of foot infection in persons with diabetes (IWGDF 2019 update)

Senneville

Abbas

et al. 2020

521

729

The International Working Group on the Diabetic Foot (IWGDF) has published evidence‐based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the diagnosis and treatment of foot infection in persons with diabetes and updates the 2015 IWGDF infection guideline. On the basis of patient, intervention, comparison, outcomes (PICOs) developed by the infection committee, in conjunction with internal and external reviewers and consultants, and on systematic reviews the committee conducted on the diagnosis of infection (new) and treatment of infection (updated from 2015), we offer 27 recommendations. These cover various aspects of diagnosing soft tissue and bone infection, including the classification scheme for diagnosing infection and its severity. Of note, we have updated this scheme for the first time since we developed it 15 years ago. We also review the microbiology of diabetic foot infections, including how to collect samples and to process them to identify causative pathogens. Finally, we discuss the approach to treating diabetic foot infections, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and for bone infections, when and how to approach surgical treatment, and which adjunctive treatments we think are or are not useful for the infectious aspects of diabetic foot problems. For this version of the guideline, we also updated four tables and one figure from the 2016 guideline. We think that following the principles of diagnosing and treating diabetic foot infections outlined in this guideline can help clinicians to provide better care for these patients.

“…Mean duration of antibiotic treatment was surprisingly short, ranging from 6 to 42 days . The investigators of the two studies of predominantly surgery versus antibiotic therapy prescribed antibiotics for up to 90 days in the antibiotics group and 10 days for the surgery group in the RCT and 45 days and 48 days in the cohort study , respectively. The quality of most, but not all (Table S1), of these studies was generally good, and each reported no significant difference in outcome between the treatment arms or between oral and parenteral route of administration.…”

Section: Resultsmentioning

confidence: 99%

Interventions in the management of infection in the foot in diabetes: a systematic review

Peters

Aragón‐Sánchez

et al. 2016

The expert panel on diabetic foot infection (DFI) of the International Working Group on the Diabetic Foot conducted a systematic review seeking all published reports relating to any type of treatment for infection of the foot in persons with diabetes published as of 30 June 2014. This review, conducted with both PubMed and EMBASE, was used to update an earlier one undertaken on 30 June 2010 using the same search string. Eligible publications included those that had outcome measures reported for both a treated and a control population that were managed either at the same time, or as part of a before-and-after case design. We did not include studies that contained only information related to definition or diagnosis, but not treatment, of DFI. The current search identified just seven new articles meeting our criteria that were published since the 33 identified with the previous search, making a total of 40 articles from the world literature. The identified articles included 37 randomised controlled trials (RCTs) and three cohort studies with concurrent controls, and included studies on the use of surgical procedures, topical antiseptics, negative pressure wound therapy and hyperbaric oxygen. Among the studies were 15 RCTs that compared outcomes of treatment with new antibiotic preparations compared with a conventional therapy in the management of skin and soft tissue infection. In addition, 10 RCTs and 1 cohort study compared different treatments for osteomyelitis in the diabetic foot. Results of comparisons of different antibiotic regimens generally demonstrated that newly introduced antibiotic regimens appeared to be as effective as conventional therapy (and also more cost-effective in one study), but one study failed to demonstrate non-inferiority of a new antibiotic compared with that of a standard agent. Overall, the available literature was both limited in both the number of studies and the quality of their design. Thus, our systematic review revealed little evidence upon which to make recommendations for treatment of DFIs. There is a great need for further well-designed trials that will provide robust data upon which to make decisions about the most appropriate treatment of both skin and soft tissue infection and osteomyelitis in diabetic patients.