I had intended to call this editorial Infected after the album and single by “The The”. However, this is not the focus of the articles highlighted this quarter. My initial experiences of managing diabetes foot ulceration, a very long time ago, probably taught me some bad habits in terms of antibiotic use. My use of antibiotic treatments occasionally conflicts with our infection control and antibiotic stewardship policies – I am still a big fan of co-amoxiclav, but recently use a lot more doxycycline, and I continue to have doubts about flucloxacillin alone in the very chronic and typically previously treated and re-infected ulcers, which get through to us in a tertiary referral clinic. However, I have never used antibiotics for uninfected ulcers or to heal ulceration. The article by Abbas et al (summarised alongside) clearly sets out the rationale that supports this. The clinical diagnosis of infection promoted by the Infectious Diseases Society of America (IDSA) has done a lot to make antibiotic use more targeted and has even reduced the duration of medication for most patients. However, difficulties remain.
Not least of the difficulties is diagnosing osteomyelitis. The article by Khodaee et al (summarised on the next page) reviews the literature and concludes that a magnetic resonance imaging (MRI) scan should be performed on everyone who is suspected of having osteomyelitis. Certainly, my infectious diseases and orthopaedic colleagues are big fans. However, I still take the view that, if there are bits of bone crumbling in a wound, then an MRI scan, which is typically over sensitive, is probably superfluous. If there are no bone fragments, then a plain radiograph, which typically has <2% of the radiological exposure of a chest X-ray, can be used repeatedly at a lower cost and with easier access in most outpatient clinics than an MRI scan.
With growing antibiotic resistance and the need for extended treatments in people with diabetes and osteomyelitis, I am grateful to my outpatient parenteral antimicrobial therapy (OPAT) colleagues for providing the treatment these patients need. Malone et al (summarised on the next page) demonstrate that OPAT can significantly reduce hospitalisation and make significant savings in treatment costs. However, it is important, particularly if the OPAT facility is not in the same place as their foot clinic, that these patients remain under multidisciplinary team foot clinic care for ongoing review of their offloading and debridement and to determine when treatment can end on clinical grounds.
To read the article summaries, please download the PDF from the article options link at right.
