diabetes research and clinical practice 102 (2013) e45–e46
Contents available at ScienceDirect
Diabetes Research and Clinical Practice journ al h ome pa ge : www .elsevier.co m/lo cate/diabres
Letter to the Editor Comments on ‘Conservative management of diabetic foot osteomyelitis’ As implied by Acharya et al. [1] the issue of medical versus surgical management of diabetic foot osteomyelitis (DFO) remains controversial. While we welcome their contribution of addition data on this topic, we have several major concerns about their report. They introduce confusion by using the term ‘‘conservative’’ management to describe exclusively antibiotic (without surgical) treatment, while others use it to describe surgical treatment that avoids amputation [2]. Of greatest concern is their definition of osteomyelitis, which not only did not include a culture (or histopathology) of bone, it did not define which among the less accurate clinical findings they used were present in each case. While accepting that bone biopsy is not necessary for every patient with suspicion of DFO, we find it hard to put credence in a paper on the management of DFO in which almost half of the patients had a negative X-ray. In our experience only 15.8% of patients with a positive probe-tobone test had a negative X-ray [3]. Furthermore, we have found in series of patients that included moderate and severe infections, that bone changes on X-rays in cases of DFO treated surgically have no prognostic value, while early osteomyelitis – with no or minimal radiological changes – was associated with necrosis and ischemia, meaning more advanced disease [4,5]. The authors excluded patients with ‘‘limb threatening infections’’ without either defining this term or detailing the outcome of those patients. They speak about ‘‘courses’’ of antibiotic therapy, but never define the duration. In this era of increasing antibiotic-resistance, avoiding unnecessarily long treatment is key. Their primary endpoint was the percentage of patients who ‘‘healed.’’ Although not defined, we assume this means the closure of any overlying soft tissue wounds, but they provide no information about resolution of bone infection, such as imaging changes (when present) or elevated serum inflammatory markers. DFO frequently relapses (as it did in 17% of their patients), yet they do not detail the duration of patient follow-up (e.g., mean, median, range) post-treatment. The follow-up information provided does not allow the reader to calculate the true long-term effectiveness of this ‘‘conservative’’ management.
We applaud the authors for treating 92% of their cases as outpatients and for using oral (rather than parenteral therapy). These are points worth emphasizing. Unfortunately, we do not think the data they presented allows them to declare that ‘‘medical therapy was successful in treating osteomyelitis in 66.9%’’ of their patients.
Conflict of interest The authors declare that they have no conflict of interest.
references
[1] Acharya S, Soliman M, Egun A, Rajbhandari SM. Conservative management of diabetic foot osteomyelitis. Diabetes Res Clin Pract 2013. http://dx.doi.org/10.1016/ j.diabres.2013.06.010. pii:S0168-8227(13)00236-2. [2] Aragon-Sanchez J. Treatment of diabetic foot osteomyelitis: a surgical critique. Int J Low Extrem Wounds 2010;9:37–59. [3] Aragon-Sanchez J, Lipsky BA, Lazaro-Martinez JL. Diagnosing diabetic foot osteomyelitis: is the combination of probe-to-bone test and plain radiography sufficient for highrisk inpatients. Diabet Med 2011;28:191–4. [4] Arago´n-Sa´nchez J, La´zaro-Martı´nez JL, Campillo-Vilorio N, Quintana-Marrero Y, Herna´ndez-Herrero MJ. Controversies regarding radiological changes and variables predicting amputation in a surgical series of diabetic foot osteomyelitis. Foot Ankle Surg 2012;18:233–6. [5] Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2012;54:e132–73.
Javier Arago´n-Sa´nchez* Diabetic Foot Unit, La Paloma Hospital, Las Palmas de Gran Canaria, Spain Benjamin A. Lipskya,b,c,d Emeritus Professor of Medicine, University of Washington, United States b Infectious Diseases, University of Geneva, Switzerland c Green Templeton College, University of Oxford, United Kingdom d Graduate Entry Course, University of Oxford Medical School, United Kingdom
DOI of original article: http://dx.doi.org/10.1016/j.diabres.2013.06.010
a
e46
diabetes research and clinical practice 102 (2013) e45–e46
*Corresponding author at: C/Eduardo 1,48D, 35002 Las Palmas de Gran Canaria, Canary Islands, Spain. Tel.: +34 928383161; fax: +34 609569937 E-mail addresses: [email protected] [email protected] (J. Arago´n-Sa´nchez)
31 July 2013 0168-8227/$ – see front matter # 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.diabres.2013.10.007
Contents available at ScienceDirect
Diabetes Research and Clinical Practice journ al h ome pa ge : www .elsevier.co m/lo cate/diabres
Letter to the Editor Comments on ‘Conservative management of diabetic foot osteomyelitis’ As implied by Acharya et al. [1] the issue of medical versus surgical management of diabetic foot osteomyelitis (DFO) remains controversial. While we welcome their contribution of addition data on this topic, we have several major concerns about their report. They introduce confusion by using the term ‘‘conservative’’ management to describe exclusively antibiotic (without surgical) treatment, while others use it to describe surgical treatment that avoids amputation [2]. Of greatest concern is their definition of osteomyelitis, which not only did not include a culture (or histopathology) of bone, it did not define which among the less accurate clinical findings they used were present in each case. While accepting that bone biopsy is not necessary for every patient with suspicion of DFO, we find it hard to put credence in a paper on the management of DFO in which almost half of the patients had a negative X-ray. In our experience only 15.8% of patients with a positive probe-tobone test had a negative X-ray [3]. Furthermore, we have found in series of patients that included moderate and severe infections, that bone changes on X-rays in cases of DFO treated surgically have no prognostic value, while early osteomyelitis – with no or minimal radiological changes – was associated with necrosis and ischemia, meaning more advanced disease [4,5]. The authors excluded patients with ‘‘limb threatening infections’’ without either defining this term or detailing the outcome of those patients. They speak about ‘‘courses’’ of antibiotic therapy, but never define the duration. In this era of increasing antibiotic-resistance, avoiding unnecessarily long treatment is key. Their primary endpoint was the percentage of patients who ‘‘healed.’’ Although not defined, we assume this means the closure of any overlying soft tissue wounds, but they provide no information about resolution of bone infection, such as imaging changes (when present) or elevated serum inflammatory markers. DFO frequently relapses (as it did in 17% of their patients), yet they do not detail the duration of patient follow-up (e.g., mean, median, range) post-treatment. The follow-up information provided does not allow the reader to calculate the true long-term effectiveness of this ‘‘conservative’’ management.
We applaud the authors for treating 92% of their cases as outpatients and for using oral (rather than parenteral therapy). These are points worth emphasizing. Unfortunately, we do not think the data they presented allows them to declare that ‘‘medical therapy was successful in treating osteomyelitis in 66.9%’’ of their patients.
Conflict of interest The authors declare that they have no conflict of interest.
references
[1] Acharya S, Soliman M, Egun A, Rajbhandari SM. Conservative management of diabetic foot osteomyelitis. Diabetes Res Clin Pract 2013. http://dx.doi.org/10.1016/ j.diabres.2013.06.010. pii:S0168-8227(13)00236-2. [2] Aragon-Sanchez J. Treatment of diabetic foot osteomyelitis: a surgical critique. Int J Low Extrem Wounds 2010;9:37–59. [3] Aragon-Sanchez J, Lipsky BA, Lazaro-Martinez JL. Diagnosing diabetic foot osteomyelitis: is the combination of probe-to-bone test and plain radiography sufficient for highrisk inpatients. Diabet Med 2011;28:191–4. [4] Arago´n-Sa´nchez J, La´zaro-Martı´nez JL, Campillo-Vilorio N, Quintana-Marrero Y, Herna´ndez-Herrero MJ. Controversies regarding radiological changes and variables predicting amputation in a surgical series of diabetic foot osteomyelitis. Foot Ankle Surg 2012;18:233–6. [5] Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2012;54:e132–73.
Javier Arago´n-Sa´nchez* Diabetic Foot Unit, La Paloma Hospital, Las Palmas de Gran Canaria, Spain Benjamin A. Lipskya,b,c,d Emeritus Professor of Medicine, University of Washington, United States b Infectious Diseases, University of Geneva, Switzerland c Green Templeton College, University of Oxford, United Kingdom d Graduate Entry Course, University of Oxford Medical School, United Kingdom
DOI of original article: http://dx.doi.org/10.1016/j.diabres.2013.06.010
a
e46
diabetes research and clinical practice 102 (2013) e45–e46
*Corresponding author at: C/Eduardo 1,48D, 35002 Las Palmas de Gran Canaria, Canary Islands, Spain. Tel.: +34 928383161; fax: +34 609569937 E-mail addresses: [email protected] [email protected] (J. Arago´n-Sa´nchez)
31 July 2013 0168-8227/$ – see front matter # 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.diabres.2013.10.007
