Pittet D, Wyssa B, Herter-Clavel C, Kursteiner K, Vaucher J, Lew P D
Division of Infectious Diseases and Clinic of Orthopedic Surgery, University Hospital of Geneva, Switzerland.
Arch Intern Med. 1999 Apr 26;159(8):851-6. doi: 10.1001/archinte.159.8.851.
Diabetic foot lesion is associated with increased morbidity and high resource use. Although early amputation has been advocated in case of osteomyelitis, conservative treatment is a more attractive alternative.
To identify criteria predictive of failure of conservative treatment of diabetic foot ulcer at time of admission to the hospital.
We conducted a 5-year retrospective cohort study with prospective long-term follow-up of all diabetic patients admitted for a foot lesion at a large (1600-bed) teaching institution. Predetermined criteria were used for the diagnosis and classification of diabetic foot lesions (Wagner classification). Study variables included patient demographics and clinical parameters related to infection and diabetes. The average follow-up after hospital discharge was 2 years. Failure of conservative treatment was the main outcome measure. Independent predictor variables were selected by logistic regression analysis.
A total of 120 diabetic patients were admitted for foot lesions; complications of contiguous osteomyelitis, deep tissue involvement, and/or gangrenous lesions occurred in 78 (74%) of the 105 patients for whom charts were available. Fourteen patients (13%) underwent immediate amputation. Conservative treatment was successful for 57 (63%) of the 91 remaining patients. Success was achieved in 21 (81%) of 26 patients presenting with skin ulcer, 35 (70%) of 50 patients with deep tissue infection or suspected osteomyelitis, and 1 (7%) of 15 patients with gangrene (P<.001, chi2 for trend). Independent factors predictive of failure were the presence of fever (odds ratio [OR]=1.1 per degrees Celcius; 95% confidence interval [CI], 1.0-1.2) and increased serum creatinine level (OR=1.002 per micromoles per liter; 95% CI, 1.0020-1.0021) on admission, prior hospitalization for diabetic foot lesion (OR=1.4; 95% CI, 1.2-1.6), and gangrenous lesion (OR=1.8; 95% CI, 1.5-2.2). Other patient characteristics, demographics, duration of diabetes mellitus, neutrophil count, or the anatomical site of the lesion failed to predict outcome.
Conservative treatment, including prolonged, culture-guided parenteral and oral antibiotics, is successful without amputation in a large proportion of diabetic patients admitted for a foot skin ulcer or suspected osteomyelitis. Future studies comparing early amputation with novel therapeutic strategies for severe diabetic foot infection should take into account currently identified factors that predicted failure of conservative treatment on admission to the hospital.
糖尿病足病变与发病率增加及资源高消耗相关。尽管对于骨髓炎患者提倡早期截肢，但保守治疗是更具吸引力的选择。
确定在医院入院时预测糖尿病足溃疡保守治疗失败的标准。
我们进行了一项为期5年的回顾性队列研究，并对一家大型（拥有1600张床位）教学机构中因足部病变入院的所有糖尿病患者进行了前瞻性长期随访。使用预定标准对糖尿病足病变进行诊断和分类（瓦格纳分类法）。研究变量包括患者人口统计学特征以及与感染和糖尿病相关的临床参数。出院后的平均随访时间为2年。保守治疗失败是主要结局指标。通过逻辑回归分析选择独立预测变量。
共有120例糖尿病患者因足部病变入院；在有病历的105例患者中，78例（74%）出现了连续性骨髓炎、深部组织受累和/或坏疽性病变等并发症。14例患者（13%）接受了立即截肢。其余91例患者中，57例（63%）保守治疗成功。26例皮肤溃疡患者中有21例（81%）成功，50例深部组织感染或疑似骨髓炎患者中有35例（70%）成功，15例坏疽患者中有1例（7%）成功（趋势χ²检验，P<0.001）。预测失败的独立因素包括入院时发热（每摄氏度优势比[OR]=1.1；95%置信区间[CI]，1.0 - 1.2）、血清肌酐水平升高（每微摩尔每升OR=1.002；95% CI，1.0020 - 1.0021）、既往因糖尿病足病变住院（OR=1.4；95% CI，1.2 - 1.6）以及坏疽性病变（OR=1.8；95% CI，1.5 - 2.2）。其他患者特征、人口统计学特征、糖尿病病程、中性粒细胞计数或病变的解剖部位均无法预测结局。
对于因足部皮肤溃疡或疑似骨髓炎入院的大多数糖尿病患者，包括延长疗程、根据培养结果指导使用的胃肠外和口服抗生素在内的保守治疗无需截肢即可成功。未来比较早期截肢与严重糖尿病足感染新治疗策略的研究应考虑目前已确定的入院时预测保守治疗失败的因素。
