Concordance Between Bone Pathology and Bone Culture for the Diagnosis of Osteomyelitis in the Presence of Charcot Neuro-Osteoarthropathy

518

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.

Section: Diagnosismentioning

confidence: 99%

Section: Rationalementioning

confidence: 99%

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

Lipsky

Senneville

Abbas

et al. 2020

518

729

“…The low inter-rater agreement among pathologists on the diagnosis of osteomyelitis by histopathology 130 and the weak concordance between histopathology and culture of foot bone specimens 127 are subjects of debate. 131 This question was addressed in two more recent studies, but these also provide conflicting results. 132,133 Since there are no available data demonstrating a clear benefit of using BeBoP results on the outcome of patients treated for a DFO, and facilities for obtaining BeBoP are not always available, our recommendation for undertaking a BeBoP in patients with a suspicion of DFO was graded "conditional".…”

Section: Rationalementioning

confidence: 99%

IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes‐related foot infections (IWGDF/IDSA 2023)

Senneville,

Albalawi,

van Asten

et al. 2023

The International Working Group on the Diabetic Foot (IWGDF) has published evidence‐based guidelines on the management and prevention of diabetes‐related foot diseases since 1999. The present guideline is an update of the 2019 IWGDF guideline on the diagnosis and management of foot infections in persons with diabetes mellitus.The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used for the development of this guideline. This was structured around identifying clinically relevant questions in the P(A)ICO format, determining patient‐important outcomes, systematically reviewing the evidence, assessing the certainty of the evidence, and finally moving from evidence to the recommendation. This guideline was developed for healthcare professionals involved in diabetes‐related foot care to inform clinical care around patient‐important outcomes. Two systematic reviews from 2019 were updated to inform this guideline, and a total of 149 studies (62 new) meeting inclusion criteria were identified from the updated search and incorporated in this guideline. Updated recommendations are derived from these systematic reviews, and best practice statements made where evidence was not available. Evidence was weighed in light of benefits and harms to arrive at a recommendation. The certainty of the evidence for some recommendations was modified in this update with a more refined application of the GRADE framework centred around patient important outcomes. This is highlighted in the rationale section of this update. A note is also made where the newly identified evidence did not alter the strength or certainty of evidence for previous recommendations.The recommendations presented here continue to cover various aspects of diagnosing soft tissue and bone infections, including the classification scheme for diagnosing infection and its severity. Guidance on how to collect microbiological samples, and how to process them to identify causative pathogens, is also outlined. Finally, we present the approach to treating foot infections in persons with diabetes, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and bone infections; when and how to approach surgical treatment; and which adjunctive treatments may or may not affect the infectious outcomes of diabetes‐related foot problems.We believe that following these recommendations will help healthcare professionals provide better care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes‐related foot disease.

“…In practice, bone culture is used routinely in only a minority of centres and there have been very few reports of using bone histology at all. One recent study undertaken in people with active Charcot foot disease concluded that histology was of limited value in substantiating the diagnosis of osteomyelitis in this population . A number of other diagnostic approaches are used in the investigation of possible osteomyelitis, including CT, MRI, labelled white cell scans and newer imaging techniques such as SPECT/CT.…”

Section: Tests To Support the Diagnosis Of Infectionmentioning

confidence: 99%

Which diagnostic tests in everyday clinical practice are (not) useful in the management of diabetic foot disease?

Jeffcoate

Dinneen

2019

This commentary reviews the use of a small number of tests used in the routine management of foot disease in diabetes. The aim is to consider some of the evidence underlying the use of these tests and the difficulties that can be encountered in interpretation. All tests have their limitations and it is important for these to be understood by the clinicians who request them. There are few test results which are categorically diagnostic in the field of the diabetic foot and the majority merely provide supporting evidence for a diagnosis that is either less or more strongly suspected on other grounds.