Background: Diabetic foot osteomyelitis (DFO) is a major complication and can lead to significant morbidity and mortality. Systemic antibiotic therapy is often initiated first line to achieve quiescence of infection. To perform a multi-centre case review of systemic antibiotic intervention to treat adults with DFO in England and Wales and compare with national guidelines \'Diabetic foot problems: prevention and management\'. Methods: Eight centres from England and Wales retrospectively collated data from a minimum of five adults (aged ≥ 18 years) from electronic case records. All patients were treated with systemic antibiotics following a new diagnosis of DFO (1 June 2021-31 December 2021). Results: 40 patients (35 males and 5 females) were included; the mean age was 62.3 years (standard deviation (SD) 13.0). Patients commenced systemic oral 14 (35%) or intravenous 26 (65%) antibiotic therapy following a new diagnosis of DFO. Twenty-seven (67.5%) patients were medically or surgically managed in the 12-week period with clinical quiescence of infection. Twenty-one patients (52.5%) had no recurrence of DFO infection within 12 weeks; seventeen (42.5%) of these patients had clinical quiescence of infection with systemic antibiotics alone without surgical intervention and nine (22.5%) of these cases had no recurrence of DFO. There were no cases of major amputation or death. All centres showed significant in-centre variability in systemic antibiotic management; variability was reported in the clinical and quantity indicators specifically to antibiotic selection, single versus dual therapy, mode of delivery and duration of treatment. Conclusions: This case review identifies there is existing variation when treating adults with systemic antibiotics for DFO. Further national guidance is required to standardise service delivery and care to improve patient outcomes.

The connection between vasculitis and infection is complex. The present study described a typical situation for a patient with unbalanced type 2 diabetes and chronic complications, in which a lack of adherence to the protection and care measures ultimately led to the appearance of some of the worst consequences of the condition, namely, ulceration, gangrene and amputation. In the context of an unstable condition with significant metabolic imbalance there was an impaired response to infections in the present patient, and the amputation resulted in wound persistence and ulcer development, followed by superinfection with methicillin-resistant Staphylococcus aureus according to the antibiogram performed. In this case, an episode of vasculitis was triggered without evidence of bacteraemia. The present case report highlighted the importance of proper hygiene and good metabolic control in patients with diabetes that suffer from amputations and conditions that expose them to certain complications, including vasculitis.

BACKGROUND: Diabetic-related foot condition is one of the most debilitating complications with a higher rate of failure in limb correction, reconstruction, or salvage surgery. Amputation is the final option after other surgical treatments have failed. Major amputation increases energy consumption, resulting in high dependency, decreased mobility, and poor prognosis. Consequently, minor amputation is preferred to resolve these problems but elevated wound complications leading to inadequate prosthesis fit, became a detriment to minor amputation. Strict selection of patients is crucial to ensure success and good functional outcomes as demonstrated in this retrospective study of this case series. Methods: This case series included six patients who underwent Pirogoff amputation with the modification described by Nather and reported the procedure\'s outcome. The inclusion criteria for subjects were the presence of palpable posterior tibial artery (PTA) or at least biphasic Doppler signal and ankle-brachial systolic index (ABSI) more than 0.70. Other demographic data as well as hematological, inflammatory, and biochemical parameters that may affect wound healing such as Hb, HbA1c, ESR, CRP, WBC, and albumin were recorded as well. The rate and time for wound healing and bone union, presence of complications, and final ambulatory status of patients were determined as the outcome of this study.
RESULTS: All of the patients had diabetic foot infections involving only the forefoot region with the presence of either palpable PTA or biphasic Doppler signal. Although the majority of the cases had deranged blood parameters, soft tissue and bone healing were achieved at variable times. Four had good outcomes as they were able to ambulate. One case was complicated with chronic wound dehiscence and another one had Pirogoff stump infection and required transtibial amputation.
CONCLUSIONS: With strict selection criteria, Pirogoff amputation may provide a good functional outcome with a lesser degree of complications compared to major amputation.

UNASSIGNED: Chronic calcaneal osteomyelitis is a challenging condition associated with high relapse rates, requiring a multidisciplinary approach and various therapeutic options for effective management. We report a very rare case of a pyogenic osteomyelitis of the os calcis presented as a bone abscess.
METHODS: A diabetic male patient presented with chronic osteomyelitis of the calcaneus in the form of bone abscess with a cavity of 6*5 cm. After pus evacuation and debridement of the cavity, gentamycin-impregnated polymethylmethacrylate cement was used to locally assist in controlling the infection and to assure mechanical support. Antibiogram-based oral antibiotic was administrated for 6 weeks. At final follow-up, the patient could walk without any assistance and was able to raise his body on the operated heel, with no signs of infection.
UNASSIGNED: This case illustrates successful conservative surgical treatment of calcaneal abscess using antibiotic-impregnated cement for mechanical support and local infection control.
CONCLUSIONS: Incorporating antibiotic-impregnated cement into conservative foot surgeries for deeply embedded calcaneal abscesses provides effective infection control, mechanical support, and functional preservation, leading to successful treatment outcomes.

Infected diabetic foot ulcers can be difficult to treat and, despite appropriate antibiotic therapy, some diabetic foot infections (DFIs) require amputation. Bacteriophages (phages) are viruses that infect and kill bacteria. Phage therapy has been repeatedly used to successfully treat DFIs and other chronic wounds.
This article reports the provision of topical adjunctive anti-staphylococcal phage therapy to 10 patients with DFI at high risk of amputation at two UK hospitals as part of clinical care; tolerability and efficacy were clinically assessed.
The opinion of the experienced clinical teams caring for these patients was that 9 of the 10 patients appeared to benefit from adjunctive phage therapy. No adverse effects were reported by clinicians or patients. In 6 of 10 patients the clinical impression was that phage therapy facilitated clinical resolution of infection and limb salvage. Resolution of soft tissue infection was observed in a 7th patient but unresolved osteomyelitis required amputation. An 8th patient demonstrated eradication of Staphylococcus aureus from a polymicrobial infection and a 9th showed signs of clinical improvement before early cessation of phage therapy due to an unrelated event. One patient, with a weakly susceptible S aureus isolate, had no significant response.
This report describes the largest application of phage therapy in the United Kingdom to date and the first application of phage therapy for DFI in the United Kingdom and offers subjective hints toward impressive tolerability and efficacy. Phage therapy has the potential to transform the prevention and treatment of DFIs.

UNASSIGNED: Lower limb amputations secondary to diabetic foot infection/osteomyelitis (OM) are the most common cause for non-traumatic amputations of the lower extremity. Hind/midfoot amputations are commonly done for metatarsal (MT) OM. They are, however, associated with higher complication and revision rates and often lead to below knee amputation. In comparison, distal/forefoot toe disarticulation/ray amputation (R amp) have lesser revision rates/complications and give better functional outcome. Here, we report a case of 2nd R amp with an uncommon complication.
UNASSIGNED: A 42-year-old male with uncontrolled diabetes and bilateral diabetic neuropathy presented with discharging sinus over plantar aspect of the left foot since 1 week. There was no evidence of underlying OM on MRI. Wound healed with soft-tissue debridement and empirical antibiotics (culture negative) for 2 weeks. Re-debridement was done for a wound gape 6 weeks later. Infection resolved with targeted antibiotics (oral ciprofloxacin and doxycycline) for Enterobacter cloacae given for 1 month. Six months later, he developed pain and swelling in the left foot following prolonged barefoot walking and possible injury with a stone. There was local redness, swelling, and a plantar sinus. MRI revealed septic arthritis of the left 2nd metatarsophalangeal (MTP) joint, OM of the 2nd MT head, and an encapsulated soft-tissue abscess. Aggressive debridement with 2nd R amp and careful separation of encapsulated abscess was done leaving behind base of 2nd MT to maintain stability of the Lisfranc joint. Wound healed primarily. Targeted antibiotics for Methicillin Susceptible Staphylococcus aureus were given for 6 weeks. Good diabetic control and avoiding bare foot walking were advised and he is infection free, fully functional, and asymptomatic at 36 months. However, he was noted to have developed valgus deformity of the midfoot secondary to Charcot osteoarthropathy of the Lisfranc joints at 36 months follow-up, involving 1st, 3rd, and 4th TMT joints. The other foot did not show any evidence of Charcot arthropathy.
UNASSIGNED: Recurrent wound infections with subsequent OM are a common feature of diabetic foot. R amps have better functional outcomes with preserved foot stability, shorter length of hospitalization, and associated costs as compared to hind/midfoot amputations. They may, however, develop Charcot osteoarthropathy due to the void between adjoining MTs resulting in altered forces across the Lisfranc joints. Surgeons must beware of this complication, especially following R amps and monitor these patients with serial clinical and radiographic examination.

Anemia of inflammation, as found in many chronic disease states, is common among persons with diabetic foot infections but is typically mild and self-limited. Herein we present four cases of patients with foot infections accompanied by severe anemia (nadir hemoglobin <8 gm/dL and resulting in transfusion of 4 + units of blood) as well as significant weight loss (30 + pounds), hyponatremia (<135 mmol/L), hypoalbuminemia (nadir <2 gm/dL), uremia and other metabolic derangements.

This retrospective case-control study was designed to explore the association between the duration of diabetes and gram-negative bacterial infection in diabetic foot infections (DFIs). All DFI patients hospitalized in the Department of Endocrinology in the Sixth Affiliated Hospital of Sun Yat-sen University between 2013 and 2019 with positive microbial culture results were included. Cases were defined as DFI patients whose microbial cultures grew gram-negative bacteria (including polymicrobial flora). Controls were defined as DFI patients whose positive microbial cultures did not grow gram-negative bacteria. Clinical data were extracted from the hospital information system. Stabilized inverse probability weighting was used to balance between-group differences at baseline. Confounders were selected using a directed acyclic graph. Missing data were imputed with the multiple imputation of chained equations method. Odds ratios (ORs) with 95% confidence intervals (CIs) and Ptrend for associations between the duration of diabetes and gram-negative bacterial infection were obtained using binomial logistic regression models. The weighted OR of gram-negative bacterial infection for DFI patients with a moderate duration of diabetes (8~19 years) compared with those with a short duration (0~7 years) was 3.87 (95% CI: 1.15 to 13.07), and the OR for those with a longer duration (20~30 + years) was 7.70 (95% CI: 1.45 to 41.00), and there was a dose-response trend with increasing duration of diabetes (weighted Ptrend = 0.007). The results demonstrated that a long duration of diabetes might be associated with an increased risk of gram-negative bacterial infection in type 2 diabetes patients with DFI.

We identified deep diabetic foot infections by culture and conducted a case-control study examining the risk factors for moderate to severe methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (PsA) diabetic foot infections. Our MRSA prevalence was lower than literature values; PsA was higher. Gangrene may be predictive of Pseudomonas infection.

This work presents a protocol to prevent the transmission of multidrug-resistant infections. We focus on the Diabetic Foot Unit Podiatry Clinic Area attached to the University of Seville in particular. The most common complication for patients with diabetes is leg ulcers. Together with neuropathy, vasculopathy, and immunological response disorder, these individuals have a high predisposition to developing infections. Staphylococcus aureus is a highly prevalent microorganism in humans which, at times, may act as a pathogen. Due mainly to indiscriminate abuse of antibiotics, the methicillin-resistant strain known by its initials as MRSA is the most extended nosocomial infection globally and is a severe community and hospital healthcare problem. This paper describes compliance with new general recommendations on cleaning, hygiene, and decontamination, in addition to implementation of this specific protocol, after detection of cross infection (healthcare-related infection) in the studied unit in two patients with MRSA-infected ulcers. After an in-depth bibliographical review, strict hand hygiene measures and use of non-sterile gloves were used when treating all patients with a diabetic foot. Finally, we reflect on the need to educate healthcare personnel to guarantee correct prescription of selected antibiotics. The role of the podiatrist in the multidisciplinary team is highlighted not only in terms of management and treatment of lesions in diabetic patients, but also as a healthcare agent for the detection and prevention of MRSA together with other multidrug-resistant infections.