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Oral session 2: Diabetic foot infection
O2.1
Predictors of lower-extremity amputation in patients with an infected diabetic foot
ulcer
Kristy Pickwell, University Hospital Maastricht, Maastricht, Netherlands
Volkert Siersma, The Research Unit for General Practice and Section of General Practice,
Copenhagen, Denmark
Marleen Kars, University Hospital Maastricht, Maastricht, Netherlands
Eurodiale Consortium, University Hospital Maastricht, Maastricht, Netherlands
Nicolaas Schaper, University Hospital Maastricht, Maastricht, Netherlands
Aim: Infection commonly complicates diabetic foot ulcers and is associated with a poor
outcome. In a cohort of individuals with an infected diabetic foot ulcer we aimed to determine
independent predictors of lower-extremity amputation, the predictive value for amputation of
the International Working Group on the Diabetic Foot (IWGDF) classification system and, to
develop a risk score for predicting amputation.
Methods: We prospectively studied 575 patients with an infected diabetic foot ulcer
presenting to one of 14 diabetic foot clinics in 10 European countries.
Results:, Among these patients 159 (28%) underwent an amputation. Independent risk
factors for amputation were: periwound edema, foul smell, (non)-purulent exudate, deep
ulcer, positive probing to bone test, pretibial edema, fever, and elevated CRP-levels.
Increasing IWGDF severity of infection also independently predicted amputation. We
developed a risk score for any amputation and for amputations excluding the lesser toes
(including the variables sex, pain on palpation, periwound edema, ulcer size, ulcer depth and
PAD) that predicted amputation better than the IWGDF system (area under the ROC-curves
0.80, 0.78 and 0.67, respectively).
Conclusions: In individuals with an infected diabetic foot ulcer we identified independent
predictors of amputation, validated the prognostic value of the IWGDF classification system
and developed a new risk score for amputation that can be readily used in daily clinical
practice. Our risk score may have better prognostic accuracy than the IWGDF system, the
only currently available system, but our findings need to be validated in other cohorts.
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O2.2
Percutaneous isolated limb perfusion versus intravenous antibiotics for management
of infected diabetic foot ulcers
Paul Wraight, The Royal Melbourne Hospital, Melbourne, Australia
Steve Christov, The Royal Melbourne Hospital, Melbourne, Australia
McCann Jane, The Royal Melbourne Hospital, Melbourne, Australia
Melissa Byrne, 2Baker IDI Heart and Diabetes Institute, Melbourne, Australia
Rick Dowling, The Royal Melbourne Hospital, Melbourne, Australia
Peter Mitchell, The Royal Melbourne Hospital, Melbourne, Australia
David Kaye, 2Baker IDI Heart and Diabetes Institute, Melbourne, Australia
Aim: A first in human study of five individuals suggested that antibiotics administered by
percutaneous isolated limb perfusion (PILP) was safe and demonstrated significant
reductions in quantitative bacterial levels within 6 hours. This study compares antibiotic
concentrations in subjects with diabetes and lower limb infection, randomised to receive
ticarcillin/clavulanic acid (Timentin) delivered by PILP procedure or via intravenous delivery
alone.
Methods: Twenty individuals with a significant diabetes-related foot infection are to be
recruited. Individuals will be randomised 1:1 to receive Timentin either as a single 30 minute
episode of PILP in addition to standard intravenous Timentin or intravenous Timentin alone.
Individuals undergoing PILP will have an antegrade femoral artery catheter, retrograde
Venous Recovery Catheter and Venous Support Device inserted under local anaesthetic.
The catheters will be connected with an oxygenator, heater and cardiac perfusion pump to
create a lower limb circuit, with a proximal external tourniquet to isolate the limb circulation.,
Biochemistry, antibiotic levels and microbiology samples will be collected.
Results: Fifteen (of the planned 20) individuals have been recruited; 6 PILP, 7 Control and 2
withdrawals., All were male with Type 2 diabetes and mean age 63 years. No alteration in
vital signs or biochemical parameters from the limb or systemic circulation were recorded
during the 28 day follow-up. Ticarcillin concentrations in the limb circulation were on average
2.3 fold greater in the PILP group vs. control group at 15mins into antibiotic delivery (142.21
vs 61.02mcg/ml). At 1 hour post antibiotic infusion, Ticarcillin concentrations were 8.1 fold
greater in the control group vs PILP group (86.37 vs 10.63mcg/ml) despite both groups
receiving the same total dose of Timentin.
Conclusions: The results of this randomised study suggest that the early high peak in
antibiotic concentration in the lower limb circulation with PILP is likely to be contributing to
higher tissue absorption, thus explaining the lower systemic concentrations 1 hour after
antibiotic infusion., The antibiotic results however need to be correlated with the clinical and
microbiological results in order to assess the full benefit of PILP.
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O2.3
Negative pressure with instillation in the management of severely infected diabetic
foot ulceration
Chiara Goretti, University of Pisa, Pisa, Italy
Alberto Coppelli, University of Pisa, Pisa, Italy
Carlo Tascini, University of Pisa, Pisa, Italy
Elisabetta Iacopi, University of Pisa, Pisa, Italy
Alberto Piaggesi, University of Pisa, Pisa, Italy
Aim: To evaluate the safety and effectiveness of Negative Pressure Wound Therapy with
Instillation (i-NPWT), in the management of the severely infected ulceration of the diabetic
foot (DF)
Method: A group of consecutive type 2 diabetic inpatients with acutely infected ulceration
(Group A - N. 22; age 68.4±12.1 yrs, duration of diabetes 21.7±12.3 yrs, HbA1c 8.8±2.1%,
BMI 28.6±2.9 kg/m2), was treated with i-NPWT on top of standard treatment consisting in
surgical debridement, revascularization if needed, offloading and systemic antibiotic, while
admitted. Instillation of a polyhexanide solution was delivered for 15' every three hours on a
continuous NPWT application scheme. Patients, compared with a matched control group
with the same clinical characteristics treated with NPWT without instillation (Group B), were
followed up for 6 months to evaluate Healing Rate (HR), Healing Time (HT), Negativization
of Coltural Exams (NCE), Duration of Antibiotic Therapy (DAT) and adverse events.
Results: HR was of 91% in Group A and 85% in Group B (n.s.); HT in Group A was
68.5±18.4days vs 97.4±29.1 days in Group B (p<0.05)., NCE during he observation period
was reached in 95% of Group A patients vs 45% in Group B (p<0.01), DAT was 12.4±5.9
days in Group A vs 28.9±11.6 days in Group B, respevctively. No difference in adverse
events, was observed throughout the study period between the two groups.
Conclusion: On top of standard treatment ì-NPWT proved to be as safe and more effective
than NPWT, in the management of the infected lesions of the diabetic foot.
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O2.4
Biofilm in diabetic patients with foot infection
Barcin Ozturk, University of Adnan Menderes School of Medicine, Aydin, Turkey
Bulent Ertugrul, University of Adnan Menderes School of Medicine, Aydin, Turkey
Esra Corekli, University of Adnan Menderes School of Medicine, Aydin, Turkey
Background: Chronic wounds remain open for a long time, thus increase the possibility of
bacterial infection. Polymicrobial, infections, predominate among causes of severe diabetic
foot infections. The existence of biofilms in acute partial-thickness and chronic wounds has
been documented.
Methods: A total of one Turkish medical centre was included in this prospective study
conducted from 2013 to 2014. The data on enrolled subjects were recorded in patient followup forms. On admission, specimens for culture were obtained following cleansing and the
debridement of the wound by swabbing the ulcer base, curettage, needle aspiration or
biopsy, depending on the wound depth. Bioﬁlm, production, was assessed by the method of
O’Toole and Kolter. Biofilms formed in 96-well microtitre plates. For biofilm growth, the
Tryptic Soy Broth (TSB), medium with 0.25 % glucose was used. Slime formation at 48
hours was evaluated with crystal violet, using a spectrophotometer at a wavelength of 595
nm . Wells with optical density ≥ 1 000 were considered as slime positive.
Results: We included a total of 48 diabetic foot infections from 37 patients., A total of 59
causative bacteria were isolated from soft and/or bone tissue samples. Fourty seven (80%)
of 59 isolates produced biofilm. The most frequently isolated species was Meticillin resistant
CoN Staphylococcus, (n=13, 22%).,
Comments: An important obstacle during the healing of chronic wounds is that the formation
of biofilm by the growing, infective organisms. There are very few studies indicating the
presence of a biofilm in the diabetic foot ulcers. Our study showed that biofilm formation
rates in diabetic foot infections are very high. Managing the biofilm in chronic wounds
effectively is an important component of wound healing therapy., Treatment methods like
debritment and use of quorum sensing inhibitors (QSI) which provide biofilm elimination,
might be able to eliminate the infecting bacteria and recreate a normal healing process
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O2.5
KPC-producing Klebsiella pneumoniae rectal colonization is a risk factor for mortality
in patients with diabetic foot infections
Carlo Tascini, U.O.Malattie Infettive - Azienda Ospedaliera Universitaria Pisana, Pisa, Italy
Elisabetta Iacopi, University of Pisa, Pisa, Italy
Alberto Coppelli, University of Pisa, Pisa, Italy
Chiara Goretti, University of Pisa, Pisa, Italy
Alberto Piaggesi, University of Pisa, Pisa, Italy
Aim: The incidence of infection with strains of Klebsiella pneumoniae-producing
carbapenemases (KPC-Kp) has been increasing worldwide. To identify if KPC-Kp
colonization and infection in diabetic patients with foot infection (DFI) is associated with
increased mortality we conducted a retrospective, matched case-control study.
Methods: Cases consisted of adult inpatients with a DFI who had a documented isolation of
a KPC-Kp strain from a rectal swab. For each case we selected at least one matched control
with no KPC-Kp-positive cultures on a rectal swab.
Results: Between 1 December 2010 and 31 March 2014 we identified 21 patients with DFI
with rectal colonization by KPC-Kp. In 6/21 (28%) of these patients KPC-Kp was also
isolated from the diabetic foot wound. Comparing the 21 patients colonized with KPC-Kp
with the 25 controls, matched by time period, we found the groups were not significantly
different with regard to their mean age, gender, Charlson score, University of Texas score,
number of negative outcomes or number of previous admissions. Compared to patients in
the control group, who had an overall mortality of 4%, mortality was significantly higher in
patients with rectal colonization by KPC-Kp (40%, p= 0.013) and in KPC-Kp DFI patients
(67%; p= 0.002). Using multivariate logistic regression analysis we found that colonization
with KPC-Kp was the only independent risk factor significantly associated with mortality
(OR=22.41, 95%CI: 3.43 – 455.28, p= 0.006).
Conclusion: Colonization and foot infection with KPC-Kp is associated with a significant,
increased mortality in DF patients.
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