SLR - September 2019 - Brennan A. Menninger
Reference: Shah S, Negrete A, Self T, Bergeron J, Twilla J. Comparison of Three Antimicrobial Strategies in Diabetic Foot Infections Post-Amputation. Therapeutic Advances in Infectious Disease. 2019; pp1-9.Scientific Literature Review
Reviewed By: Brennan A. Menninger, DPM
Residency Program: North Colorado Medical Center, Greeley, CO
Podiatric Relevance: The management of diabetic foot infection (DFI) is an integral part of many podiatrist’s daily practice. Often in conjunction with an infectious disease specialist, patients with DFIs require antibiotic therapy in addition to local wound care and in some cases surgery. In patients who are status post amputation, the route of antibiotic therapy (intravenous versus oral) is patient-dependent and based on factors such as amount of residual or dead infected bone as well as the state of the soft tissues. This article reviewed outcomes based on route of antibiotic therapy in patients who presented with DFIs and underwent amputation.
Methods: A retrospective review was conducted in a single healthcare system. Reviewed were adult hospital admissions for DFIs who underwent amputation. Specifically grouped were those who received IV, oral administration, or No Antibiotic (NA) therapy post amputation. Outcomes examined included overall length of stay, post-op length of stay, readmission rates, treatment failure rates, overall antimicrobial days and rates of clostridium difficile (C. diff).
Results: The overall length of stay did not differ between IV, PO and patients receiving no antibiotic therapy. The postoperative length of stay was greater in the IV group versus oral and no antibiotic groups. Treatment failure was greater in the IV group. The PO group had an overall higher number of days of therapy postoperatively than did the IV infusion group. There was no difference in C. diff rates between the groups.
Conclusions: Specific to this study, postoperative length of stay was shorter when patients were transitioned to PO antibiotics while there was no increase in readmission rates. In some instances, this can be related to severity of infection, as there may be a bias towards continuing IV antibiotics post surgery in patients with more severe infections. The authors did acknowledge this potential bias, as the admission white blood cell count was significantly higher in patients who received IV antibiotics after surgery. However, the admission qSOFA score did not significantly differ among the three groups. Moreover, this study did not show any differences in 30-day readmission or treatment failure rates between the three groups. These outcomes help demonstrate some justification for earlier transition to PO therapy post amputation/debridement, which can help expedite discharge and prevent unnecessary utilization of broad spectrum IV antibiotics and promote antibiotic stewardship.