Antimicrobial stewardship opportunities among inpatients with diabetic foot infections: microbiology results from a tertiary hospital multidisciplinary unit

Hand, Robert; Manning, Laurens; Ritter, Jens Carsten; Norman, Paul; Lamb, Lydia S; Makepeace, Ashley; Sankhesara, D.; Hamilton, Emma; Ingram, Paul R.

doi:10.1111/imj.14251

Cited by 7 publications

(5 citation statements)

References 16 publications

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“…[57] In contrast, an Australian study determined that 83% of patients received empirical antibiotic treatment that complied with national guidelines. [58] A study carried out in Poland yielding outcomes similar to our findings found that although there was good adherence to local prescribing guidelines, the guidelines themselves did not cover the most common pathogens responsible for DFU infection. [59] Only two patients had samples collected for microbiological testing and culture identification.…”

Section: Researchsupporting

confidence: 72%

The antimicrobial susceptibility patterns of diabetic foot ulcers in the South African public healthcare sector

Turner,

Leigh-de Rapper,

Mokoena

et al. 2024

S Afr Med J

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Background. Diabetic foot syndrome is defined as the presence of a diabetic foot ulcer (DFU) associated with neuropathy, peripheral artery disease and infection. While the use of antimicrobials in the treatment of DFU infection remains a mainstay, the choice of antimicrobial remains problematic owing to the presence of multidrug-resistant polymicrobial infections. In the South African public healthcare sector, the treatment of DFUs is based on the Standard Treatment Guidelines (STGs) and the Essential Drug List. These guidelines are developed using evidence-based medicine and are based on global susceptibility patterns rather than local susceptibility data, and may not provide the most appropriate treatment options. Objectives. To determine the antimicrobial susceptibility patterns of DFUs isolated from patients visiting selected Gauteng provincial public hospitals in order to determine a clinically effective treatment protocol for the management of these infections. Methods. Sample swabs were taken from 51 DFUs using the Levine method. Each sample swab was spread onto blood agar plates, and thereafter individual pathogens were isolated. The antimicrobial susceptibility patterns of all isolated pathogens were determined using zone of inhibition measurements. Pathogens were grouped according to macromorphological characteristics as well as susceptibility patterns, and a representative isolate from each group was then identified. Results. A total of 51 DFU ulcer swabs from 45 patients were included in the study. From the sample swabs, a total of 445 pathogens were isolated. The most effective antimicrobial was found to be gentamicin, followed by ciprofloxacin. Amoxicillin/clavulanic acid, the first-line treatment according to the STGs, was found to be ineffective for many of the isolated pathogens. The most commonly isolated pathogens were Proteus mirabilis, Enterococcus faecalis and Pseudomonas aeruginosa. Conclusion. These findings demonstrate the urgent need to reassess the STGs and base treatment plans on local epidemiological data. This study provides valuable data on common causative pathogens in DFU infections, as well as the resistance patterns of these pathogens, forming a baseline on which to base future DFU treatment plans.

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Section: Researchsupporting

confidence: 72%

The antimicrobial susceptibility patterns of diabetic foot ulcers in the South African public healthcare sector

Turner,

Leigh-de Rapper,

Mokoena

et al. 2024

S Afr Med J

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“…Our findings are consistent with previous studies in the United States noting discrepancies between empiric anti-MRSA and antipseudomonal therapies and microbiologic results with these organisms. 6,11,12 In contrast, in Western Australia, Hand et al 13 found a significant difference between the frequency of empiric antipseudomonal therapy and the frequency of isolation of P. aeruginosa in microbiologic testing; however, there was no significant difference between the frequency of empiric anti-MRSA therapy and the frequency of isolation of MRSA in microbiologic testing, 12.6% versus 11.9%, respectively. Notably, Western Australia has a wellestablished screening program for patients at high risk of MRSA with positive results prompting an electronic flag in the patient's medical record.…”

Section: Discussionmentioning

confidence: 93%

“…Our study focused on the NPV of risk factors with the goal of identifying patients for whom empiric broad-spectrum therapies could be withheld. Hand et al 13 found that the positive and negative predictive values of prior infection or colonization with MRSA for the subsequent recovery of MRSA were 54% and 97%, respectively. Mergenhagen et al 5 evaluated the utility of MRSA nares screening for patients with DFI.…”

Section: Discussionmentioning

confidence: 99%

Fear of Missing Organisms (FOMO): the discordance among broad-spectrum empiric antibiotic therapy, microbiologic results, and definitive antibiotic therapy for diabetic foot infections and lower extremity osteomyelitis

Morelli,

Son,

Bitar

et al. 2023

ASHE

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Objective: Empiric broad-spectrum antibiotic therapy is commonly prescribed for patients hospitalized with diabetic foot infections (DFI) and lower extremity osteomyelitis (OM). The primary objective was to evaluate the concordance between empiric antibiotic therapy, microbiologic results, and definitive antibiotic therapy with a focus on methicillin-resistant Staphylococcus aureus (MRSA) and resistant gram-negative organisms. The secondary objective was to evaluate the negative predictive values (NPV) of select risk factors for MRSA and resistant gram-negative organisms for microbiologic results with these organisms. Design: Retrospective cohort study. Setting: Safety-net health system in Ohio. Patients: Adults hospitalized and receiving antibiotic therapy for DFI or lower extremity OM in 2021. Results: For 259 unique patients, empiric therapies with activity against MRSA and resistant gram-negative organisms were administered to 224 (86.5%) and 217 (83.8%) patients, respectively. Definitive therapies with activity against MRSA and resistant gram-negative organisms were administered to 91 (35%) and 74 (28.6%) patients, respectively. Of 234 patients with microbiologic testing, 29 (12.4%) had positive cultures with MRSA and 41 (17.5%) with resistant gram-negative organisms. The NPVs of risk factors for MRSA and resistant gram-negative organisms for the absence of these organisms in culture were 91% and 85%, respectively. Conclusions: For patients hospitalized with DFI and lower extremity OM, our data suggest opportunities for substantial reductions in empiric therapies with activity against MRSA and resistant gram-negative organisms. The absence of risk factors for these organisms was reasonably good at predicting negative cultures with these organisms.

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“…A survey of Australian and New Zealand vascular and orthopaedic surgeons found they had relatively similar management practices, but few were guided by best practice clinical guidelines for DFI (Seng et al 2022). An Australian study reported microbiology results from patients with DFI managed in a tertiary inpatient setting and revealed antimicrobial stewardship opportunities with overuse of antipseudomonal agents despite adherence to national antibiotic prescribing guidelines (Hand et al 2019). The utility of wound swab vs tissue sampling in patients with DFI has been investigated by the CODIFI study, which found that the most commonly reported pathogens were Staphylococcus aureus (43.8%), Streptococcus (16.7%) and other aerobic Gram-positive cocci (70.6%) and 86.1% of tissue samples reported at least one potential pathogen compared with 70.1% of wound swabs collected (Nelson et al 2018).…”

Section: Diabetes-related Foot Infections: Microbiology and Microbiomementioning

confidence: 99%

Diabetes-related foot disease: new insights with an antipodean focus

Hamilton

Twigg

2023

Journal of Endocrinology

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Diabetes-related foot disease (DFD), defined as ulceration, infection, or destruction of tissues of the foot in a person with current or previously diagnosed diabetes mellitus, is associated with a heavy burden for both patients and the healthcare system with high morbidity, mortality and costs. Improved outcomes for people with DFD are achieved with an interdisciplinary approach and adherence to best practice clinical guidelines, however in the Australian context, the vastness of the country presents unique challenges in achieving optimal outcomes for all people with DFD, with variation in service delivery, availability and accessibility between metropolitan, rural and remote areas. Aboriginal and Torres Strait Islander Australians and people with diabetes living in rural and remote areas experience higher rates of lower extremity amputation and further efforts and resources are required to improve outcomes for these high risk groups. In recent years, there have been advances in knowledge, including the understanding of the pathogenesis of diabetes-related peripheral neuropathy, genetic polymorphisms and mechanisms of disease associated with acute Charcot neuroarthropathy, biomarkers and potential mediators of diabetes-related foot ulcer (DFU) healing, the microbiology and microbiome profile of DFUs, pressure assessment and management as well as an expanded understanding of DFU sequelae and comorbidities. In this review, we describe new insights into pathophysiology, sequelae and comorbidities of DFD with a focus on basic and translational aspects and contributions to the field from Australian and New Zealand DFD researchers.

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Antimicrobial stewardship opportunities among inpatients with diabetic foot infections: microbiology results from a tertiary hospital multidisciplinary unit

Cited by 7 publications

References 16 publications

The antimicrobial susceptibility patterns of diabetic foot ulcers in the South African public healthcare sector

The antimicrobial susceptibility patterns of diabetic foot ulcers in the South African public healthcare sector

Fear of Missing Organisms (FOMO): the discordance among broad-spectrum empiric antibiotic therapy, microbiologic results, and definitive antibiotic therapy for diabetic foot infections and lower extremity osteomyelitis

Diabetes-related foot disease: new insights with an antipodean focus

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