SURVEY OF ANTIBIOTICS STEWARDSHIP PRACTICES IN THE MANAGEMENT OF DIABETIC FOOT INFECTIONS
Main Article Content
Keywords
Diabetic Foot Infection, Diabetic Foot Ulcer, Empirical antibiotic therapy, Antibiotic resistance
Abstract
Background: Infection is a common epiphenomenon of diabetic foot disease and the most common reason for diabetes-related hospitalizations and lower extremity amputations. Choosing appropriate empirical antibiotics is challenging due to an inadequate microbiological information. Moreover, suboptimal selection of antibiotics will lead to a poor clinical outcome.
Objective: To evaluate empirical antibiotic preferences, regimen changes based on disease severity, common pathogens and antibiotic resistance in diabetic foot ulcer (DFU) management.
Methodology: A descriptive cross-sectional survey was conducted over four months among healthcare professionals in major tertiary care hospitals in Islamabad.
Results: Among 147 participants, 45% preferred Penicillin in minor and 32.7% preferred Oxazolidinones as empirical antibiotic in major diabetic foot wounds. Penicillin (59.9%) was observed to be the most resistant drug in diabetic foot patients. 81% of the healthcare professionals had suggested combination empirical antibiotic therapy. Gram Positive Aerobes (S. Aureus etc.) 46.3% were the most common microbe encountered pathogens.
Conclusions: Based on our study, a stepwise approach is being followed in antibiotic stewardship practice in diabetic foot infections. Initial therapy is usually empirical but may be modified according to the culture and sensitivity results and the patient's clinical response. This study can be used as a framework for local guideline development.
References
2. The Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Reports of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1997; 20:1183-97.
3. Global burden of diabetes. International Diabetes federation. Diabetic atlas fifth edition 2011, Brussels. (Accessed 18th December 2011). 8. Krolewski AS, Warram JH, Rand LI, Kahn CR. Epidemiologic approach to the etiology of type I diabetes mellitus and its complications. New England Journal of Medicine. 1987 Nov 26; 317(22):1390-8.
4. Miley DD, Terezhalmy GT. The patient with diabetes mellitus: etiology, epidemiology, principles of medical management, oral disease burden, and principles of dental management. Quintessence international. 2005 Nov 1; 36(10).
5. Khanolkar MP, Bain SC, Stephens JW. The diabetic foot. QJM: An International Journal of Medicine. 2008 Sep 1; 101(9):685-95. 37. Khanolkar MP, Bain SC, Stephens JW. The diabetic foot. QJM: An International Journal of Medicine. 2008 Sep 1;101(9):685-95. 38. Katsilambros N, Dounis E, Makrilakis K, Tentolouris N, Tsongas P. Atlas of the diabetic foot. John Wiley & Sons; 2010 Jan 21.
6. Bader MS. Diabetic foot infection. American family physician. 2008 Jul 1; 78(1):71-9.
7. Oyibo SO, Jude EB, Tarawneh I, Nguyen HC, Harkless LB, Boulton AJ. A comparison of two diabetic foot ulcer classification systems: the Wagner and the University of Texas wound classification systems. Diabetes care. 2001 Jan 1; 24(1):84-8.
8. Van Netten JJ, Bus SA, Apelqvist J, Lipsky BA, Hinchliffe RJ, Game F, Rayman G, Lazzarini PA, Forsythe RO, Peters EJ, Senneville E. Definitions and criteria for diabetic foot disease. Diabetes/metabolism research and reviews. 2020 Mar; 36:e3268.
9. Game F. Classification of diabetic foot ulcers. Diabetes/metabolism research and reviews. 2016 Jan; 32:186-94.
10. Mehraj M, Shah I. A review of Wagner classification and current concepts in management of diabetic foot. Int J Orthop Sci. 2018 Jan 1; 4(1):933-5.
11. https://www.researchgate.net/publication/51670468_Surgical_management_of_Diabetic_foot_ulcers_A_Tanzanian_university_teaching_hospital_experience
12. Charles PG, Uçkay I, Kressmann B, Emonet S, Lipsky BA. The role of anaerobes in diabetic foot infections. Anaerobe. 2015 Aug 1; 34:8- 13.
13. Barwell ND, Devers MC, Kennon B, Hopkinson HE, McDougall C, Young MJ, Robertson HM, Stang D, Dancer SJ, Seaton A, Leese GP. Diabetic foot infection: Antibiotic therapy and good practice International journal of clinical practice. 2017 Oct; 71(10):e13006.
14. Legat, F.J.; Krause, R.; Zenahlik, P.; Hoffmann, C.; Scholz, S.; Salmhofer, W.; Tscherpel, J.; Tscherpel, T.; Kerl, H.; Dittrich, P. Penetration of Piperacillin and Tazobactam into Inflamed Soft Tissue of Patients with Diabetic Foot Infection. Antimicrob. Agents Chemother. 2005, 49, 4368–4371.
15. Uçkay, I.; Pires, D.; Agostinho, A.; Guanziroli, N.; Öztürk, M.; Bartolone, P.; Tscholl, P.; Betz, M.; Pittet, D. Enterococci in Orthopedic Infections: Who Is at Risk Getting Infected? J. Infect. 2017, 75, 309–314.
16. 16). Lipsky BA. Evidence-based antibiotic therapy of diabetic foot infections. FEMS immunology & medical microbiology. 1999 Dec 1; 26(3-4):267-76
17. Zenelaj, B.; Bouvet, C.; Lipsky, B.A.; Uçkay, I. Do Diabetic Foot Infections with Methicillin-Resistant Staphylococcus Aureus Differ from Those with Other Pathogens? Int. J. Low. Extrem. Wounds 2014, 13, 263–272.
18. Lipsky BA, Berendt AR. Principles and practice of antibiotic therapy of diabetic foot infections. Diabetes/Metabolism Research and Reviews. 2000 Sep; 16(S1):S42-6.
19. Lipsky BA, Dryden M, Gottrup F, Nathwani D, Seaton RA, Stryja J. Antimicrobial stewardship in wound care: a Position Paper from the British Society for Antimicrobial Chemotherapy and European Wound Management Association. J Antimicrob Chemother. 2016 Nov; 71(11):3026-3035. doi: 10.1093/jac/dkw287. Epub 2016 Jul 25. PMID: 27494918.
20. Uçkay, I.; Berli, M.; Sendi, P.; Lipsky, B.A. Principles and Practice of Antibiotic Stewardship in the Management of Diabetic Foot Infections. Curr. Opin. Infect. Dis. 2019, 32, 95–101.
21. Lipsky BA. Empirical therapy for diabetic foot infections: are there clinical clues to guide antibiotic selection? Clinical microbiology and infection. 2007 Apr 1; 13(4):351-3.
22. Rahim K, Qasim M, Rahman H, Khan TA, Ahmad I, Khan N, Ullah A, Basit A, Saleha S. Antimicrobial resistance among aerobic biofilm producing bacteria isolated from chronic wounds in the tertiary care hospitals of Peshawar, Pakistan. Journal of Wound Care. 2016 Aug 2;25(8):480-6.
23. Lipsky BA, Senneville É, Abbas ZG, Aragón‐Sánchez J, Diggle M, Embil JM, Kono S, Lavery LA, Malone M, van Asten SA, Urbančič‐Rovan V. Guidelines on the diagnosis and treatment of foot infection in persons with diabetes (IWGDF 2019 update). Diabetes/metabolism research and reviews. 2020 Mar; 36:e3280.
24. Noor S, Ahmad J, Parwez I, Ozair M. Culture-based screening of aerobic microbiome in diabetic foot subjects and developing non-healing ulcers. Front Microbiol. 2016; 7: 1792.
25. Hatipoglu M, Mutluoglu M, Turhan V, et al. Causative pathogens and antibiotic resistance in diabetic foot infections: a prospective multi-center study. J Diabetes Complications. 2016; 30: 910-916.
26. Karmaker M, Sanyal SK, Sultana M, Hossain MA. Association of bacteria in diabetic and non-diabetic foot infection. An investigation in patients from Bangladesh. Journal of infection and public health. 2016 May 1; 9(3):267-77.
27. Murray, C. J. et al. Global burden of bacterial antimicrobial resistance in 2019: A systematic analysis. The Lancet 399, 629–655 (2022).
28. Shankar EM, Mohan V, Premalatha G, Srinivasan RS, Usha AR. Bacterial etiology of diabetic foot infections in South India. European journal of internal medicine. 2005 Dec 1; 16(8):567-70.
29. Charles PG, Uçkay I, Kressmann B, Emonet S, Lipsky BA. The role of anaerobes in diabetic foot infections. Anaerobe. 2015 Aug 1; 34:8- 13.
30. Kaimkhani GM, Siddiqui AA, Rasheed N, Rajput MI, Kumar J, Khan MH, Nisar S, Mustafa S, Yaqoob U, Rajput IM, Khan MH. Pattern of infecting microorganisms and their susceptibility to antimicrobial drugs in patients with diabetic foot infections in a tertiary care hospital in Karachi, Pakistan. Cureus. 2018 Jun 25; 10(6).
31. Ertugrul BM, Oncul O, Tulek N, Willke A, Sacar S, Tunccan OG, Yilmaz EM, Kaya O, Ozturk B, Turhan O, Yapar N. A prospective, multi-center study: factors related to the management of diabetic foot infections European journal of clinical microbiology & infectious diseases. 2012 Sep; 31:2345-52.
32. Muldoon EG, et al. Clin Infect Dis. 2013;doi:10.1093/cid/cit211.
33. Lipsky BA. Medical treatment of diabetic foot infections. Clinical Infectious Diseases. 2004 Aug 1; 39(Supplement_2):S104-14
34. Boyko EJ, Ahroni JH, Stensel VI, Forsberg RC, Davignon DR, Smith DG. A prospective study of risk factors for diabetic foot ulcer. The Seattle Diabetic Foot Study. Diabetes care. 1999 Jul 1; 22(7):1036-42.
Article Sidebar
Article Details
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
All articles published in JPTCP are licensed under Copyright Creative Commons Attribution-NonCommercial 4.0 International License.
Dr. Ehitzaz Afsar
House Officer- Federal Government Polyclinic Hospital Islamabad, Pakistan.
Dr. Maham Malik
House Officer- Khyber Teaching Hospital Peshawar, Pakistan.
Dr. Fazeelat Bibi
House Officer- Khyber Teaching Hospital Peshawar, Pakistan.
Dr. Aramish Iqbal
House Officer- Federal Government Polyclinic Hospital Islamabad, Pakistan.
Dr. Sidra Balqees
House Officer- Federal Government Polyclinic Hospital Islamabad, Pakistan
Dr. Aabid Ali
Associate Surgeon (General Surgery)- Federal Government Polyclinic Hospital Islamabad, Pakistan.