Cultures of diabetic foot ulcers without clinical signs of infection do not predict outcomes

Sue E. Gardner, Ambar Haleem, Ying Ling Jao, Stephen L. Hillis, John E. Femino, Phinit Phisitkul, Kristopher P. Heilmann, Shannon M. Lehman, Carrie L. Franciscus

Research output: Contribution to journalArticle

15 Citations (Scopus)

Abstract

OBJECTIVE We examined associations between ulcer bioburden and ulcer outcomes in neuropathic diabetic foot ulcers (DFUs) that lacked clinical signs of infection.

RESEARCH DESIGN AND METHODS Three dimensions of bioburden (i.e., microbial load, microbial diversity, and the presence of likely pathogens) were measured at baseline using swab cultures obtained by Levine's technique. Subjects were assessed every 2 weeks for 26 weeks to determine the rate of healing and development of infection-related complications. Foot ulcers were off-loaded using total-contact casts and routinely debrided. To establish associations between bioburden and rate of healing, Cox proportional hazards and least squares regression were used after adjusting for ulcer depth, surface area, and duration.

RESULTS A total of 77 subjects completed the study. Sixty-five (84.4%) had ulcers that healed during follow-up; weeks-to-closure ranged from 2 to 26 (median 4.0). Mean (6 SD) percent reduction in surface area/week was 25.0% (6 23.33). Five (6.5%) of the DFUs developed an infection-related complication. None of the bioburden dimensions (i.e., microbial load, microbial diversity, or presence of likely pathogens) was significantly associated with weeks-to-closure or percent reduction in surface area per week. Weeks-to-closure was best predicted by ulcer duration, depth, and surface area (c-statistic = 0.75).

CONCLUSIONS Culturing DFUs that showed no clinical signs of infection had no predictive value for outcomes of DFUsmanaged with total-contact casts and routine debridement. These findings support recommendations of the Infectious Disease Society of America that culturing and antibiotics should be avoided in treating DFUs that show no clinical signs of infection.

Original languageEnglish (US)
Pages (from-to)2693-2701
Number of pages9
JournalDiabetes care
Volume37
Issue number10
DOIs
StatePublished - Oct 1 2014

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Diabetic Foot
Ulcer
Infection
Foot Ulcer
Debridement
Least-Squares Analysis
Communicable Diseases
Anti-Bacterial Agents

All Science Journal Classification (ASJC) codes

  • Internal Medicine
  • Endocrinology, Diabetes and Metabolism
  • Advanced and Specialized Nursing

Cite this

Gardner, S. E., Haleem, A., Jao, Y. L., Hillis, S. L., Femino, J. E., Phisitkul, P., ... Franciscus, C. L. (2014). Cultures of diabetic foot ulcers without clinical signs of infection do not predict outcomes. Diabetes care, 37(10), 2693-2701. https://doi.org/10.2337/dc14-0051
Gardner, Sue E. ; Haleem, Ambar ; Jao, Ying Ling ; Hillis, Stephen L. ; Femino, John E. ; Phisitkul, Phinit ; Heilmann, Kristopher P. ; Lehman, Shannon M. ; Franciscus, Carrie L. / Cultures of diabetic foot ulcers without clinical signs of infection do not predict outcomes. In: Diabetes care. 2014 ; Vol. 37, No. 10. pp. 2693-2701.
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abstract = "OBJECTIVE We examined associations between ulcer bioburden and ulcer outcomes in neuropathic diabetic foot ulcers (DFUs) that lacked clinical signs of infection.RESEARCH DESIGN AND METHODS Three dimensions of bioburden (i.e., microbial load, microbial diversity, and the presence of likely pathogens) were measured at baseline using swab cultures obtained by Levine's technique. Subjects were assessed every 2 weeks for 26 weeks to determine the rate of healing and development of infection-related complications. Foot ulcers were off-loaded using total-contact casts and routinely debrided. To establish associations between bioburden and rate of healing, Cox proportional hazards and least squares regression were used after adjusting for ulcer depth, surface area, and duration.RESULTS A total of 77 subjects completed the study. Sixty-five (84.4{\%}) had ulcers that healed during follow-up; weeks-to-closure ranged from 2 to 26 (median 4.0). Mean (6 SD) percent reduction in surface area/week was 25.0{\%} (6 23.33). Five (6.5{\%}) of the DFUs developed an infection-related complication. None of the bioburden dimensions (i.e., microbial load, microbial diversity, or presence of likely pathogens) was significantly associated with weeks-to-closure or percent reduction in surface area per week. Weeks-to-closure was best predicted by ulcer duration, depth, and surface area (c-statistic = 0.75).CONCLUSIONS Culturing DFUs that showed no clinical signs of infection had no predictive value for outcomes of DFUsmanaged with total-contact casts and routine debridement. These findings support recommendations of the Infectious Disease Society of America that culturing and antibiotics should be avoided in treating DFUs that show no clinical signs of infection.",
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Gardner, SE, Haleem, A, Jao, YL, Hillis, SL, Femino, JE, Phisitkul, P, Heilmann, KP, Lehman, SM & Franciscus, CL 2014, 'Cultures of diabetic foot ulcers without clinical signs of infection do not predict outcomes', Diabetes care, vol. 37, no. 10, pp. 2693-2701. https://doi.org/10.2337/dc14-0051

Cultures of diabetic foot ulcers without clinical signs of infection do not predict outcomes. / Gardner, Sue E.; Haleem, Ambar; Jao, Ying Ling; Hillis, Stephen L.; Femino, John E.; Phisitkul, Phinit; Heilmann, Kristopher P.; Lehman, Shannon M.; Franciscus, Carrie L.

In: Diabetes care, Vol. 37, No. 10, 01.10.2014, p. 2693-2701.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Cultures of diabetic foot ulcers without clinical signs of infection do not predict outcomes

AU - Gardner, Sue E.

AU - Haleem, Ambar

AU - Jao, Ying Ling

AU - Hillis, Stephen L.

AU - Femino, John E.

AU - Phisitkul, Phinit

AU - Heilmann, Kristopher P.

AU - Lehman, Shannon M.

AU - Franciscus, Carrie L.

PY - 2014/10/1

Y1 - 2014/10/1

N2 - OBJECTIVE We examined associations between ulcer bioburden and ulcer outcomes in neuropathic diabetic foot ulcers (DFUs) that lacked clinical signs of infection.RESEARCH DESIGN AND METHODS Three dimensions of bioburden (i.e., microbial load, microbial diversity, and the presence of likely pathogens) were measured at baseline using swab cultures obtained by Levine's technique. Subjects were assessed every 2 weeks for 26 weeks to determine the rate of healing and development of infection-related complications. Foot ulcers were off-loaded using total-contact casts and routinely debrided. To establish associations between bioburden and rate of healing, Cox proportional hazards and least squares regression were used after adjusting for ulcer depth, surface area, and duration.RESULTS A total of 77 subjects completed the study. Sixty-five (84.4%) had ulcers that healed during follow-up; weeks-to-closure ranged from 2 to 26 (median 4.0). Mean (6 SD) percent reduction in surface area/week was 25.0% (6 23.33). Five (6.5%) of the DFUs developed an infection-related complication. None of the bioburden dimensions (i.e., microbial load, microbial diversity, or presence of likely pathogens) was significantly associated with weeks-to-closure or percent reduction in surface area per week. Weeks-to-closure was best predicted by ulcer duration, depth, and surface area (c-statistic = 0.75).CONCLUSIONS Culturing DFUs that showed no clinical signs of infection had no predictive value for outcomes of DFUsmanaged with total-contact casts and routine debridement. These findings support recommendations of the Infectious Disease Society of America that culturing and antibiotics should be avoided in treating DFUs that show no clinical signs of infection.

AB - OBJECTIVE We examined associations between ulcer bioburden and ulcer outcomes in neuropathic diabetic foot ulcers (DFUs) that lacked clinical signs of infection.RESEARCH DESIGN AND METHODS Three dimensions of bioburden (i.e., microbial load, microbial diversity, and the presence of likely pathogens) were measured at baseline using swab cultures obtained by Levine's technique. Subjects were assessed every 2 weeks for 26 weeks to determine the rate of healing and development of infection-related complications. Foot ulcers were off-loaded using total-contact casts and routinely debrided. To establish associations between bioburden and rate of healing, Cox proportional hazards and least squares regression were used after adjusting for ulcer depth, surface area, and duration.RESULTS A total of 77 subjects completed the study. Sixty-five (84.4%) had ulcers that healed during follow-up; weeks-to-closure ranged from 2 to 26 (median 4.0). Mean (6 SD) percent reduction in surface area/week was 25.0% (6 23.33). Five (6.5%) of the DFUs developed an infection-related complication. None of the bioburden dimensions (i.e., microbial load, microbial diversity, or presence of likely pathogens) was significantly associated with weeks-to-closure or percent reduction in surface area per week. Weeks-to-closure was best predicted by ulcer duration, depth, and surface area (c-statistic = 0.75).CONCLUSIONS Culturing DFUs that showed no clinical signs of infection had no predictive value for outcomes of DFUsmanaged with total-contact casts and routine debridement. These findings support recommendations of the Infectious Disease Society of America that culturing and antibiotics should be avoided in treating DFUs that show no clinical signs of infection.

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DO - 10.2337/dc14-0051

M3 - Article

VL - 37

SP - 2693

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