Rossel Anne, Lebowitz Dan, Gariani Karim, Abbas Mohamed, Kressmann Benjamin, Assal Mathieu, Tscholl Philippe, Stafylakis Dimitrios, Uçkay Ilker
Department of Internal Medicine Geneva University Hospitals Geneva Switzerland.
Service of Infectious Diseases Geneva University Hospitals Geneva Switzerland.
Endocrinol Diabetes Metab. 2019 Feb 6;2(2):e00059. doi: 10.1002/edm2.59. eCollection 2019 Apr.
The appropriate duration of antibiotic therapy for diabetic foot infections (DFI) after surgical amputations in toto is debated. There are discrepancies worldwide.
Using a clinical pathway for adult DFI patients (retrospective cohort analysis), we conducted a cluster-controlled Cox regression analysis. Minimum follow-up was 2 months.
We followed 482 amputated DFI episodes for a median of 2.1 years after the index episode. The DFIs predominately affected the forefoot (n = 433; 90%). We diagnosed osteomyelitis in 239 cases (239/482; 50%). In total, 47 cases (10%) were complicated by bacteremia, 86 (18%) by abscesses and 139 (29%) presented with cellulitis. Surgical amputation involved the toes (n = 155), midfoot (280) and hindfoot (47). Overall, 178 cases (37%) required revascularization. After amputation, the median duration of antibiotic administration was 7 days (interquartile range, 1-16 days). In 109 cases (25%), antibiotics were discontinued immediately after surgery. Overall, clinical failure occurred in 90 DFIs (17%), due to the same pathogens in only 38 cases. In multivariate analysis, neither duration of total postsurgical antibiotic administration (HR 1.0, 95% CI 0.99-1.01) nor immediate postoperative discontinuation altered failure rate (HR 0.9, 0.5-1.5).
According to our clinical pathway, we found no benefit in continuing postsurgical antibiotic administration in routine amputation for DFI. In the absence of residual infection (ie, resection at clear margins), antibiotics should be discontinued.
对于糖尿病足感染（DFI）患者行手术全切术后抗生素治疗的合适疗程存在争议，全球范围内存在差异。
采用针对成年DFI患者的临床路径（回顾性队列分析），进行聚类对照Cox回归分析。最短随访时间为2个月。
我们对482例DFI截肢病例进行了随访，自首次发作起的中位随访时间为2.1年。DFI主要累及前足（n = 433；90%）。我们诊断出239例骨髓炎（239/482；50%）。总共有47例（10%）并发菌血症，86例（18%）并发脓肿，139例（29%）出现蜂窝织炎。手术截肢涉及脚趾（n = 155）、中足（280）和后足（47）。总体而言，178例（37%）需要血管重建。截肢后，抗生素给药的中位持续时间为7天（四分位间距，1 - 16天）。在109例（25%）中，术后立即停用抗生素。总体而言，90例DFI出现临床失败（17%），仅38例是由相同病原体导致。在多变量分析中，术后抗生素总给药持续时间（风险比1.0，95%置信区间0.99 - 1.01）以及术后立即停药均未改变失败率（风险比0.9，0.5 - 1.5）。
根据我们的临床路径，我们发现在DFI常规截肢术后继续使用抗生素并无益处。在没有残余感染（即切除边缘清晰）的情况下，应停用抗生素。
