Antimicrobial Stewardship, Resistance and Emerging Pathogens
Background : Diabetic foot infections (DFIs) are associated with major morbidity and mortality. Many different organisms can cause DFIs. Accurate identification of bacteria involved in DFIs is crucial for accurate treatment. Opening a second orthopedic department provided the opportunity to implement new practices.
Methods : An intervention study employing a retrospective (pre-intervention) and prospective (intervention) cohort data. Pre-intervention period (2015-2016) included one orthopedic department, DFI patients located in separate rooms within the orthopedic department. Intervention period (2017) included a multifaceted strategy, including: a separate "complicated wound" unit within the new orthopedic department for DFI patients; local infection control guidelines updated; a dedicated infection control nurse assigned; writing guidelines for diabetic foot sample culturing; implementing antibiotic stewardship; conducting a weekly multidisciplinary-team grand round; and post-discharge outpatient follow-up. Data of DFI patients' medical records were collected including type of culture, culture results, length of in-hospital stay, and mortality.
Results : 314 patients with DFI were hospitalized; 101 (61±14y/o, 77% male) during the pre-intervention and 213 (62±12y/o, 74% male) during the intervention period. Demographic characteristics, blood-tests on admission, and osteomyelitis rates were similar in both periods. During the intervention vs. pre-intervention period: fewer underwent surgery (71.8% vs. 94.1%, P < 0.0001); fewer received antibiotics pre-surgery (84.5% vs. 98%, P < 0.0001); mainly bone and deep-tissue cultures performed (88.5% vs. 5.4%, P < 0.0001); Gram-positive isolates were more prevalent (50.4% vs. 31.2%, P=0.004); among Staphylococcus aureus isolates, fewer methicillin-resistant Staphylococcus aureus detected (38% vs. 76%, P=0.003); within Enterobacteriaceae isolates, fewer multidrug-resistant and expended-spectrum β-lactamase bacteria detected (51.7% vs. 71.8%, P=0.011); no difference found in Pseudomonas aeruginosa prevalence. In both periods, in-hospital stay and mortality were similar.
Conclusions : A multidisciplinary approach to DFI patients in an orthopedic department decreased surgical procedures, increased antibiotic stewardship, and increased the prevalence of sensitive bacterial isolates.