Multifaceted Strategy Improves Outcomes of Patients Hospitalized with a Diabetic Foot Infection

Abstract

Diabetic foot infections (DFIs) are associated with major morbidity, reduced quality of life and increased mortality. Osteomyelitis is a leading cause of lower-extremity amputation in diabetic patients. We aimed to examine whether a multifaceted strategy for treating hospitalized patients with a DFI effectively influenced microbiological culture results and outcomes. A retrospective cohort-study in a 1100-bed, tertiary-care university hospital was conducted. Adult patients with a DFI admitted to the orthopedics department between 2015 and 2019 were included. During the pre-intervention period (2015-2016), one general orthopedic department was in operation. In the post-intervention period (2017-2019), a second department was created with a designated “complicated wound unit". The multifaceted strategy included revising local guidelines for DFI culturing emphasizing bone cultures, correct sample handling, and adjusting antibiotic treatment to culture results. Additionally, a weekly multidisciplinary-team grand round was instigated and post-discharge outpatient follow-up was scheduled. 652 patients with DFIs were included; 101 during the pre-intervention period and 551 during the post-intervention period. Compared to the pre-intervention, during the post-intervention period mainly bone or deep-tissue cultures were performed (9.7% vs. 98.2%, P < 0.001). Bacteriology cultures in the pre-intervention versus post-intervention period revealed: among staphylococcus isolates, fewer methicillin-resistant Staphylococcus aureus detected (20.4% vs. 9.8%, P = 0.010); within Enterobacteriaceae isolates, fewer extended-spectrum β-lactamase producing bacteria detected (51.6% vs. 23.6%, P < 0.001); a decrease in Pseudomonas aeruginosa isolates (28% vs. 10.6%, P < 0.001) and an increase in anaerobic bacterial isolates (0 vs. 11.1%, P < 0.001). On multivariate regression, the post-intervention period (ie multifaceted strategy) was a protective measure against readmissions (P = 0.007 OR 0.50 95% CI 0.30-0.82). We conclude that our interventive multifaceted strategy led to accurate bacterial diagnosis, de-escalation of antibiotic treatment and readmission reduction.