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      Outcome in Patients of Diabetic Foot Infection with Multidrug Resistant Organisms

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          ABSTRACT

          Aim and objectives

          To study the spectrum of microorganisms in patients of diabetic foot infection (DFI) and to evaluate the outcome in patients of DFI with multidrug resistant organisms (MDRO).

          Materials and methods

          A total of 116 patients, visiting diabetic foot clinic of our institute with DFI were observed in a prospective manner. Diagnosis of infection was based on clinical findings using International Working Group on Diabetic Foot and Infection Diseases Society of America (IWGDF-IDSA). The microbiological profile of wound assessed at the time of admission and patients were followed up for wound healing rate, need for amputation and surgical interventions, hospital stay, and mortality for 6 months.

          Observation and results

          The microbiological profile of our patients showed that Gram-negative microorganisms were commonly isolated (78.4%) from our patients. The culture trends revealed that most common isolates were E. coli (33.6%), Pseudomonas (19.8%), Proteus (18%), Klebsiella (16%), Acinetobacter and Citrobacter among the Gram-negative organisms. Among Gram-positive organisms, Staphylococcus aureus was the most common isolate which was present in 29 (25%) of the patients. MDRO were isolated from 13.8% of patients. Most common MDRO isolated were methicillin-resistant S. aureus (MRSA) and vancomycin-resistant Enterococci (VRE). The outcome was assessed in terms of mortality rate, the rate of major amputation, rate of minor amputation, the rate of multiple surgical interventions, duration of hospitalisation and requirement of intensive care unit (ICU) admission, re-admission rate, antibiotic requirement which were not significantly different in patients with MDRO than that with non-MDRO (p-value > 0.05). The mean healing rate in patients with MDRO was not significantly different than that from patients with non-MDRO (p-value > 0.05).

          Conclusion

          Although the number of patients with MDRO is small as compared to non-MDRO, the study found that MDRO has no significance on the outcome of the patients with DFI.

          How to cite this article

          Gupta S, Attri A, Khanna S, Chander J, Mayankjayant. Outcome in Patients of Diabetic Foot Infection with Multidrug Resistant Organisms. J Foot Ankle Surg (Asia Pacific) 2018;5(2):51-55.

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          Most cited references18

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          A clinico-microbiological study of diabetic foot ulcers in an Indian tertiary care hospital.

          To determine the microbiological profile and antibiotic susceptibility patterns of organisms isolated from diabetic foot ulcers. Also, to assess potential risk factors for infection of ulcers with multidrug-resistant organisms (MDROs) and the outcome of these infections. Pus samples for bacterial culture were collected from 80 patients admitted with diabetic foot infections. All patients had ulcers with Wagner's grade 3-5. Fifty patients (62.5%) had coexisting osteomyelitis. Gram-negative bacilli were tested for extended spectrum beta-lactamase (ESBL) production by double disc diffusion method. Staphylococcal isolates were tested for susceptibility to oxacillin by screen agar method, disc diffusion, and mec A-based PCR. Potential risk factors for MDRO-positive samples were explored. Gram-negative aerobes were most frequently isolated (51.4%), followed by gram-positive aerobes and anaerobes (33.3 and 15.3%, respectively). Seventy-two percent of patients were positive for MDROs. ESBL production and methicillin resistance was noted in 44.7 and 56.0% of bacterial isolates, respectively. MDRO-positive status was associated with presence of neuropathy (P = 0.03), osteomyelitis (P = 0.01), and ulcer size >4 cm(2) (P < 0.001) but not with patient characteristics, ulcer type and duration, or duration of hospital stay. MDRO-infected patients had poor glycemic control (P = 0.01) and had to be surgically treated more often (P < 0.01). Infection with MDROs is common in diabetic foot ulcers and is associated with inadequate glycemic control and increased requirement for surgical treatment. There is a need for continuous surveillance of resistant bacteria to provide the basis for empirical therapy and reduce the risk of complications.
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            Ventilator-associated pneumonia by Staphylococcus aureus. Comparison of methicillin-resistant and methicillin-sensitive episodes.

            All episodes of ventilator-associated pneumonia (VAP) caused by Staphylococcus aureus were prospectively analyzed for a 30-mo period. Methicillin-sensitive S. aureus (MSSA) was isolated in 38 episodes and methicillin-resistant S. aureus (MRSA) in 11 others. The two groups were similar regarding sex, severity of underlying diseases, prior surgery, and presence of renal failure, diabetes, cardiopathy, and coma. MRSA-infected persons were more likely to have received steroids before developing infection (relative risk [RR] = 3.45, 95% confidence interval [CI] = 1.38-8.59), to have been ventilated > 6 d (RR = 2.03, 95% CI = 1.36-3.03), to have been older than 25 yr (RR = 1.50, 95% CI = 1.09-2.06), and to have had preceding chronic obstructive pulmonary disease (RR = 2.76, 95% CI = 0.89-8.56) than MSSA-infected patients. MSSA-infected persons were more likely than MRSA-infected patients to have cranioencephalic trauma (RR = 1.94, 95% CI = 1.22-3.09). All patients with MRSA VAP had previously received antibiotics, compared with only 21.1% of those with MSSA infection (p < 0.000001). The incidence of empyema was similar in both groups; nevertheless, the presence of bacteremia and septic shock was more frequent in the MRSA group. Finally, mortality directly related to pneumonia was significantly higher among patients with MRSA episodes (RR = 20.72, 95% CI = 2.78-154.35). This analysis was repeated for monomicrobial episodes, and the difference remained statistically significant. We conclude that MRSA and MSSA strains infect patients with different demographic profiles; previous antibiotic therapy is the most important risk factor for developing MRSA infection.(ABSTRACT TRUNCATED AT 250 WORDS)
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              • Article: not found

              Methicillin-resistant Staphylococcus aureus in the diabetic foot clinic: a worsening problem.

              To determine if there has been a change in the prevalence of pathogenic organisms in foot ulcers in diabetic patients in 2001 compared with our previous study in 1998. A retrospective analysis of wound swabs taken from infected foot ulcers in diabetic patients attending the outpatient clinic in the Manchester Foot Hospital over a twelve-month period. A total of 63 patients with positive wound swabs were identified. Gram-positive aerobic bacteria still predominate (84.2%) and the commonest single isolate remains Staphylococcus aureus (79.0%) which is higher than we previously reported. MRSA was isolated in 30.2% of the patients which is almost double the proportion of MRSA-affected patients three years ago. This did not appear to be related to prior antibiotic usage. There was no increase in hospitalisation because of MRSA infection. The problem of MRSA continues to increase despite the precautions taken to prevent MRSA spread. There is a need for a multi-centre study looking into the prevalence of MRSA in diabetic foot ulcer and how this can be reduced in the diabetic foot clinic.
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                Author and article information

                Contributors
                Role: Associate Professor
                Role: Professor and Head
                Role: Senior Resident
                Role: Professor and Head
                Role: Associate Professor
                Journal
                JFASAP
                Journal of Foot and Ankle Surgery (Asia Pacific)
                JFASAP
                Jaypee Brothers Medical Publishers
                2348-280X
                2394-7705
                July-December 2018
                : 5
                : 2
                : 51-55
                Affiliations
                [1,2,3,5 ] Department of Surgery, Government Medical College and Hospital, Chandigarh, India
                [4 ] Department of Microbiology, Government Medical College and Hospital, Chandigarh, India
                Author notes
                Sanjay Gupta, Associate Professor, Department of Surgery, Government Medical College and Hospital, Chandigarh, India, e-mail: sandiv99@ 123456me.com
                Article
                10.5005/jp-journals-10040-1089
                f6ffca78-291f-446d-bfd0-6bc373ad6649
                Copyright © 2018; Jaypee Brothers Medical Publishers (P) Ltd.

                Creative Commons Attribution 4.0

                History
                Categories
                ORIGINAL ARTICLE
                Custom metadata
                jfasap-2018-5-51.pdf

                General medicine,Pathology,Surgery,Sports medicine,Anatomy & Physiology,Orthopedics
                Diabetic foot infection,Methicillin-resistant, S. aureus ,Multidrug-resistant organisms

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