Mesut Mutluoglu

The implications of the presence of osteomyelitis on outcomes of infected diabetic foot wounds.

Abstract Aim: To assess the effect of the presence of osteomyelitis in patients with a diabetic foot infection. Methods: We reviewed the records of diabetic patients hospitalized at our medical center for a foot infection over a 2-y period. Using clinical, imaging, and microbiology results, we classified each patient as having diabetic foot osteomyelitis (DFO) or not. We then compared several outcome criteria of interest between the 2 groups. Results: Among 73 eligible patients, 37 were in the DFO group (DFO group), while the other 36 were in the soft tissue infection group (STI group). In comparison to the STI group, the DFO group had a significantly longer length of stay (LOS) in the hospital (42 (28.5–51) days vs 19.5 (13.2–29.5) days, p < 0.001), longer duration of antibiotic therapy (46.6 ± 19.9 days vs 22.0 ± 14.6 days, p < 0.001), longer duration of intravenous antibiotic therapy (32.3 ± 16.3 days vs 13.6 ± 14.3 days, p < 0.001), longer duration of wound before admission (44 (31–64.5) days vs 33 (23–45.5) days, p = 0.034), and longer time to wound healing (239.8 ± 108.2 days vs 183.1 ± 73 days, p = 0.011). There were more surgical procedures in the DFO group than in the STI group (24/37 (64.8%) vs 11/36 (30.5%), p = 0.003), and during hospitalization, 22 patients in the DFO group and 5 patients in STI group underwent minor amputation (59.4% vs 13.8%, p < 0.001). Conclusion: The presence of osteomyelitis negatively affects both the treatment and outcome of diabetic foot infections.

How reliable are cultures of specimens from superficial swabs compared with those of deep tissue in patients with diabetic foot ulcers

PURPOSE To assess the reliability of cultures of superficial swabs (SS) by comparing them with cultures of concomitantly obtained deep tissue (DT) specimens in patients with diabetic foot ulcers. METHODS We reviewed clinical and microbiological data from patients with diabetes who presented during a two-year period to our hyperbaric medicine center with a foot ulcer. We identified patients who had at least one concomitantly collected SS and DT pair of specimens sent for culture. RESULTS A total of 89 culture pairs were available from 54 eligible patients, 33 (61.1%) of whom were hospitalized. Wounds were infected in 47 (87.0%) of the patients and 28 (51.9%) patients had received antibiotic therapy within the previous month. Overall, 65 (73%) of the SS and DT pairs had identical culture results, but in 11 (16.9%) cases the cultures were sterile; thus, only 54 (69.2%) of the 78 culture-positive pairs had identical results. Compared with DT, SS cultures yielded ≥1 extra organism in 10 (11.2%) cases, missed at least one organism in 8 (9.0%), and were completely different in 6 (6.7%). When compared to DT culture results, SS cultures had a positive predictive value of 84.4%, negative predictive value of 44.0%, and overall accuracy of 73.0%. CONCLUSIONS In patients with diabetic foot ulcers, results of specimens for culture taken by SS did not correlate well with those obtained by DT. This suggests that SS specimens may be less reliable for guiding antimicrobial therapy than DT specimens.

Increasing incidence of Gram-negative organisms in bacterial agents isolated from diabetic foot ulcers

INTRODUCTION In the present study, we sought to identify the bacterial organisms associated with diabetic foot infections (DFIs) and their antibiotic sensitivity profiles. METHODOLOGY We retrospectively reviewed the records of wound cultures collected from diabetic patients with foot infections between May 2005 and July 2010. RESULTS We identified a total of 298 culture specimens (165 [55%] wound swab, 108 [36%] tissue samples, and 25 [9%] bone samples) from 107 patients (74 [69%] males and 33 [31%] females, mean age 62 ± 13 yr) with a DFI. Among all cultures 83.5% (223/267) were monomicrobial and 16.4% (44/267) were polymicrobial. Gram-negative bacterial isolates (n = 191; 61.3%) significantly outnumbered Gram-positive isolates (n = 121; 38.7%). The most frequently isolated bacteria were Pseudomonas species (29.8%), Staphylococcus aureus (16.7%), Enterococcus species (11.5%), Escherichia coli (7.1%), and Enterobacter species (7.1%), respectively. While 13.2% of the Gram-negative isolates were inducible beta-lactamase positive, 44.2% of Staphylococcus aureus isolates were methicillin resistant. CONCLUSIONS Our results support the recent view that Gram-negative organisms, depending on the geographical location, may predominate in DFIs.

Cerebral white-matter lesions in asymptomatic military divers.

INTRODUCTION There is some concern that over a period of years, diving may produce cumulative neurological injury even in divers who have no history of decompression sickness. We evaluated asymptomatic divers and controls for cerebral white-matter lesions using magnetic resonance imaging (MRI). METHODS The study enrolled 113 male military divers (34.4 +/- 5.6 yr) and 65 non-diving men (33.1 +/- 9.0 yr) in good health. Exclusion criteria included any condition that might be expected to produce neurological effects. Patent foramen ovale was not assessed. A questionnaire was used to elicit diving history. A 1.5-T MRI device was used to acquire T1, T2-weighted, and fluid attenuated inversion recovery (FLAIR) images of the brain. A lesion was counted if it appeared hyperintense on both T2-weighted and FLAIR images. RESULTS MRI revealed brain lesions in 26 of 113 divers (23%) and in 7 of 65 (11%) controls, a difference that was statistically significant. There was no significant difference between the groups with respect to blood pressure, smoking history, or alcohol consumption, and no subject reported a history of head trauma or migraine. There was no relationship between MRI findings and age, diving history, or lipid profile in divers. DISCUSSION The higher incidence of lesions in the cerebral white matter of divers confirms the possibility that cumulative, subclinical injury to the neurological system may affect the long-term health of military and recreational divers.

Performance of the probe-to-bone test in a population suspected of having osteomyelitis of the foot in diabetes.

BACKGROUND We investigated the validity of probe-to-bone testing in the diagnosis of osteomyelitis in a selected subgroup of patients clinically suspected of having diabetic foot osteomyelitis. METHODS Between January 1, 2007, and December 31, 2008, inpatients and outpatients with a diabetic foot ulcer were prospectively evaluated, and those having a clinical diagnosis of foot infection and at least one of the osteomyelitis clinical suspicion criteria were consecutively included in this study. RESULTS Sixty-five patients met the inclusion criteria and were prospectively enrolled in the study. Forty-nine patients (75.4%) were hospitalized, and the remaining 16 (24.6%) were followed as outpatients. Osteomyelitis was diagnosed in 39 patients (60.0%). Probe-to-bone test results were positive in 30 patients (46.1%). The positive predictive value for the probe-to-bone test was fairly high (87%), but the negative predictive value was only 62%. The sensitivity and specificity of the test were 66% and 84%, respectively. White blood cell counts and mean C-reactive protein levels did not statistically significantly differ between groups. However, erythrocyte sedimentation rates greater than 70 mm/h reached statistical significance between groups. Wound area and depth were not found to be statistically significantly different between groups. CONCLUSIONS Positive probe-to-bone test results and erythrocyte sedimentation rates greater than 70 mm/h provide some support for the diagnosis of diabetic foot osteomyelitis, but it is not strong; magnetic resonance imaging or bone biopsy will probably be required in cases of doubt.

Can procalcitonin predict bone infection in people with diabetes with infected foot ulcers? A pilot study

AIMS The diagnosis of osteomyelitis is a key step of diabetic foot management. Previous studies showed that procalcitonin (PCT), a novel infection marker, is superior to conventional infection markers in the diagnosis of diabetic foot infection. This study aimed to investigate the serum levels of PCT and other conventional infection markers in diabetic persons with and without osteomyelitis. METHODS Twenty-four patients (18 male, mean age: 61.9±10.8 years) with infected foot ulcers were prospectively enrolled. Clinical characteristics of the wounds were noted. Blood samples were obtained for biochemical analysis. Magnetic resonance imaging of the foot was performed in all patients to diagnose osteomyelitis. RESULTS Osteomyelitis was found in 13 of 24 (54%) patients. PCT levels were 66.7±43.5 pg/ml in patients with osteomyelitis and 58.6±35.5 pg/ml in patients without osteomyelitis. The difference did not reach statistical significance (p=0.627). Erythrocyte sedimentation rate, but not C-reactive protein and white blood cell count, was found significantly higher in patients with osteomyelitis. CONCLUSION In this group of patients, PCT failed to discriminate patients with bone infection. Erythrocyte sedimentation rate can be used as a marker of osteomyelitis in diabetic persons.

Severe burn injury associated with misuse of forced-air warming device

To the Editor:A 64-year-old male was admitted to our department witha third-degree burn on his left ankle. His medical historyrevealed type 2 diabetes of 12 years’ duration and coronarybypass surgery 3 weeks previously. The patient claimedthat he had noticed large blisters on his left ankle when heawoke from anesthesia after coronary bypass surgery. Afterdetailed questioning it became evident that because thepatient began complaining of cold after surgery, he washeated with a forced-air warming system. The nozzle of thedevice was not connected to the blanket, however, and hotair at 40–43 C was blown directly on to the patient’s legsfor nearly 2 h. On examination, a third-degree burn of12 9 5 cm in size and surrounding hyperemia was docu-mented (Fig. 1). His pedal pulses were absent bilaterally.The 10-g-Semmes–Weinstein monofilament test revealedreduced sensation suggestive of diabetic peripheral neu-ropathy. The patient required 3 months of wound care andhyperbaric oxygen therapy to heal the wound.Forced-air warming is one of the most frequently usedmethods of patient warming in the operating room [1]. Thisdevice comprises an electrical heater unit, a hose, and ablanket. Hot air generated by the electrical heater istransferred to the blanket via the hose. Burn injuriesassociated with forced-air warming systems are extremelyrare when the device is used according to the manufac-turer’s instruction [2]. However, improper use of thedevices exposes patients to a considerable risk of burninjury [3]. Moreover, even if the device had been usedadequately, the connection could have come off acciden-tally. General misuse of this system is detaching the hosefrom the blanket and blowing hot air directly on to thepatient’s skin. This practice is called ‘‘hosing’’. Hosingcauses concentration of hot air at a single spot for anextended time period. Although a few cases including asevere burn injury of lower extremities have been reported[4], the dangers of ‘‘hosing’’ are not known by everyone.The Food and Drug Administration has issued a warningand requested submission of hosing-associated hazards [5].In addition, one of the manufacturers has started a cam-paign by posting a website (http://stophosing.com)toinform clinicians about the dangers of the use of forced-airwarming units without blankets [4].Our patient had both diabetic angiopathy and sensoryneuropathy. We think that diabetes also increased the riskof burn injury in our patient. Diabetic angiopathy andneuropathy makes skin more vulnerable to injuries.Because of diabetic sensory neuropathy in his lowerextremities, the patient did not perceive the temperature ofthe hot air correctly and hence could not warn the techni-cian to stop hosing.

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

Background and Objective: The treatment of diabetic foot osteomyelitis (DFO) is a controversial issue, with disagreement regarding whether the best treatment is surgical or conservative. The purpose of this study was to compare the outcome of patients with DFO who were treated with antibiotherapy alone and those who underwent concurrent minor amputation. Methods: Hospital records of patients who were diagnosed as having DFO within a 2-year study period were retrospectively reviewed. Patients were divided into two groups: those who received antibiotherapy alone and those who underwent concurrent minor amputation. Groups were compared in terms of duration in hospitalization, antibiotherapy, and wound healing. Results: Thirty seven patients were included in the study. These comprised patients who received antibiotherapy alone (ABG, n=15) and patients who underwent concurrent minor amputation (AB-MAG, n=22). Hospitalization duration was 37.2 (± 16.2) days in ABG and 52.8 (± 40.2) days in AB-MAG (p = 0.166). Mean duration of antibiotherapy was 45.0 (± 21.7) days in ABG and 47.7 (± 19) days in AB-MAG (p = 0.689). Wound healing duration was 265.2 (± 132.7) days in ABG and 222.6 (± 85.9) days in AB-MAG (p = 0.243). None of the outcome measures were significantly different between ABG and AB-MAG. Conclusions: Our results have shown similar outcomes for both patient groups who received antibiotherapy alone and who underwent concurrent minor amputations. Considering the small sample sizes in this study, it is important to confirm these results on a larger scale.

Piperacillin/tazobactam-induced neutropenia, thrombocytopenia, and fever during treatment of a diabetic foot infection.

Abstract Piperacillin/tazobactam (PTZ) is frequently used in patients with diabetic foot infections. Herein, we report a patient who developed severe neutropenia, thrombocytopenia, and fever while receiving PTZ for a diabetic foot infection. We recommend vigilance when long-term PTZ use is planned in patients with diabetic foot infections.

Topical Ozone and Chronic Wounds: Improper Use of Therapeutic Tools May Delay Wound Healing

Dear Editor, We present a patient with multiple non-healing lower extremity ulcers, and further discuss the inappropriate use of topical ozone therapy and the need for a comprehensive approach to wound management. A 40-year-old male patient, with diabetes mellitus and coronary artery disease of two years’ duration, applied to our hyperbaric and wound care center for multiple non-healing necrotic ulcers over his legs [Figure 1]. Ulcers occurred around his ankles three months ago and spread proximally thereafter, despite topical antibiotic therapy and gauze dressings delivered at a local hospital. Sunk into despair, he was attracted from flyers advertising ozone therapy for chronic wounds. Thus, during the following four weeks, he received several topical ozone therapy sessions, which yielded no further significant signs of improvement. Eventually, he was suggested bilateral lower extremity amputation by a surgeon. On physical examination, he had multiple, necrotic, and infected deep ulcers in variable sizes reaching tendons in some areas [Figure 1]. The ulcers had sharp edges and erythema around. He had significant bilateral edema on his lower extremities due to heart failure. He showed high levels of inflammatory markers [WBC: 22.400/ μl, C-reactive protein (CRP): 49 mg/L, erythrocyte sedimentation rate (ESR): 92 mm/h] and wound culture grew Escherichia coli. Pathology of the lesions revealed leukocytoclastic vasculitis. We hospitalized the patient and undertook a holistic approach comprising aggressive anti-edema treatment, culture-driven intravenous antibiotic regimen, and comprehensive daily wound care, including debridement of necrotic tissues and management of exudates. The multidisciplinary approach resolved his lesions rapidly, and the wound size and depth showed significant reduction. We discharged the patient after one-month care and continued follow-up as an outpatient for an additional four weeks. All ulcers of both legs almost totally epithelized in 8 weeks [Figure 2]. The patient was lost to follow-up after this time. Figure 1 He had multiple, necrotic, and infected deep ulcers on both legs Figure 2 Almost all ulcers of both legs epithelized in 8 weeks Ozone therapy is administered for a wide spectrum of disorders ranging from diabetes to rheumatoid arthritis and from Alzheimers disease to HIV. Although recent studies highlight the mechanism of action of ozone, improper use and toxicity of ozone therapy is still a concern. Ozone is a reactive gas and may be toxic if not used in therapeutic doses. Medical ozone therapy uses a gas mixture of ozone and oxygen, which never contains less than 95% oxygen.[1] There are several routes of ozone application. These include autohemotherapy, intramuscular, intra-articular, and paravertebral injections, rectal or vaginal insufflations, and topical ozone application. A number of studies suggest that ozone therapy may have a role in the treatment of chronic wounds. Martinez-Sanchez et al. used three different routes of ozone application concurrently in diabetic patients with chronic wounds and compared the results with matched controls.[2] Patients in the ozone therapy group were treated by rectal ozone insufflations, topical ozone, and wound dressings with ozonized sunflower oil. Although the number of patients with complete healing was similar in both groups, ozone therapy increased the healing rate of wounds and reduced the hospitalization time.[2] Wainstein et al. used topical ozone therapy in addition to standard therapy in diabetic wounds.[3] Although the intention-to-treat analysis failed to show any benefit, the per-protocol analysis revealed that topical ozone therapy might confer clinical benefit when added to conventional treatment in diabetic wounds smaller than 5 cm2.[3] Yet, the treatment of problem wounds accompanying multiple comorbidities, such as the one described here, presents a considerable therapeutic challenge and requires a multidisciplinary approach. The standard of care for treating chronic ulcers has been well established, and early and appropriate treatment is the cornerstone of treatment because even superficial wounds may, in time, progress to the subcutaneous tissues, muscles, tendons, or bones. Focusing on the so-called “advanced wound healing modalities” may sometimes result in an unintentional neglect of principles of wound care, and hence may lead to incurable wounds, which may ultimately require foot amputation. Our case is a representative of improper wound management and improper implementation of ozone therapy, which although caused no direct harm to the patient, failed to heal the wounds. Once comprehensive wound care management policies targeting underlying factors were applied in our department, all ulcers responded well and showed a significant step towards healing. This case report highlights two major issues. First, the role of ozone therapy is still poorly defined in the management of foot ulcers and should be used with caution. Randomized controlled studies are necessary to validate its beneficial effects (if any) and to define those patients who can be expected to derive the maximum benefit from ozone therapy. Second, adjunctive therapies should only be applied when conventional treatments fail to heal the wound.