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1.  SIRS Is Valid in Discriminating Between Severe and Moderate Diabetic Foot Infections 
Diabetes Care  2013;36(11):3706-3711.
OBJECTIVE
This retrospective, single-center study was designed to distinguish severe diabetic foot infection (DFI) from moderate DFI based on the presence or absence of systemic inflammatory response syndrome (SIRS).
RESEARCH DESIGN AND METHODS
The database of a single academic foot and ankle program was reviewed and 119 patients were identified. Severe DFI was defined as local infection associated with manifestation of two or more objective findings of systemic toxicity using SIRS criteria.
RESULTS
Patients with severe DFI experienced a 2.55-fold higher risk of any amputation (95% CI 1.21–5.36) and a 7.12-fold higher risk of major amputation (1.83–41.05) than patients with moderate DFI. The risk of minor amputations was not significantly different between the two groups (odds ratio 1.02 [95% CI 0.51–2.28]). The odds of having a severe DFI was 7.82 times higher in patients who presented with gangrene (2.03–44.81) and five times higher in patients who reported symptoms of anorexia, chills, nausea, or vomiting (2.22–11.25). The mean hospital length of stay for patients with severe DFI was ∼4 days longer than for patients with moderate DFI, and this difference was statistically significant.
CONCLUSIONS
SIRS is valid in distinguishing severe from moderate DFI in hospitalized patients. Patients with severe DFI, as by manifesting two or more signs of systemic inflammation or toxicity, had higher rates of major amputation and longer hospital stays and required more surgery and more subsequent admissions than patients who did not manifest SIRS.
doi:10.2337/dc13-1083
PMCID: PMC3816881  PMID: 24062324
2.  Diabetic foot infections: current concept review 
Diabetic Foot & Ankle  2012;3:10.3402/dfa.v3i0.18409.
The purpose of this manuscript is to provide a current concept review on the diagnosis and management of diabetic foot infections which are among the most serious and frequent complications encountered in patients with diabetes mellitus. A literature review on diabetic foot infections with emphasis on pathophysiology, identifiable risk factors, evaluation including physical examination, laboratory values, treatment strategies and assessing the severity of infection has been performed in detail. Diabetic foot infections are associated with high morbidity and risk factors for failure of treatment and classification systems are also described. Most diabetic foot infections begin with a wound and once an infection occurs, the risk of hospitalization and amputation increases dramatically. Early identification of infection and prompt treatment may optimize the patient's outcome and provide limb salvage.
doi:10.3402/dfa.v3i0.18409
PMCID: PMC3349147  PMID: 22577496
diabetic foot infection; ulcer; guidelines; surgery
3.  Inpatient Management of Diabetic Foot Disorders: A Clinical Guide 
Diabetes Care  2013;36(9):2862-2871.
The implementation of an inpatient diabetic foot service should be the goal of all institutions that care for patients with diabetes. The objectives of this team are to prevent problems in patients while hospitalized, provide curative measures for patients admitted with diabetic foot disorders, and optimize the transition from inpatient to outpatient care. Essential skills that are required for an inpatient team include the ability to stage a foot wound, assess for peripheral vascular disease, neuropathy, wound infection, and the need for debridement; appropriately culture a wound and select antibiotic therapy; provide, directly or indirectly, for optimal metabolic control; and implement effective discharge planning to prevent a recurrence. Diabetic foot ulcers may be present in patients who are admitted for nonfoot problems, and these ulcers should be evaluated by the diabetic foot team during the hospitalization. Pathways should be in place for urgent or emergent treatment of diabetic foot infections and neuropathic fractures/dislocations. Surgeons involved with these patients should have knowledge and interest in limb preservation techniques. Prevention of iatrogenic foot complications, such as pressure sores of the heel, should be a priority in patients with diabetes who are admitted for any reason: all hospitalized diabetic patients require a clinical foot exam on admission to identify risk factors such as loss of sensation or ischemia. Appropriate posthospitalization monitoring to reduce the risk of reulceration and infection should be available, which should include optimal glycemic control and correction of any fluid and electrolyte disturbances.
doi:10.2337/dc12-2712
PMCID: PMC3747877  PMID: 23970716
4.  Severity of Diabetic Foot Infection and Rate of Limb Salvage 
Background
Foot infections are limb threatening complications in patients with diabetes mellitus (DM) and proper classification of diabetic foot infection (DFI) severity is important in establishing the proper antibiotic regimen, the need for hospitalization and surgery and the risk of amputation. Our hypothesis was that patients with severe DFI would have a longer hospitalization than those with moderate DFI. The purposed of this study was two fold. The first purpose was to define DFI using readily available clinical information and objective parameters outlined by consensus statements. The second purpose of this study was the assess the amputation and limb salvage rates for hospitalized patients with DFI.
Materials and methods
The database of a single academic foot and ankle program was reviewed for patients who were hospitalized for a DFI from 2006-2011. Inpatient and outpatient electronic medical records identified 100 patients. Severe DFI was defined as having two or more objective findings of systemic toxicity and/or metabolic instability at the time of initial assessment.
Results
The length of stay was significantly shorter for patients with a moderate infection than those with a severe infection (median 5 days versus 8 days, p=0.021). A non-significant trend indicating higher rates of limb salvage in patients with moderate infections compared to patients with severe infections was observed (94% versus 80%, p=0.081).
Summary and Conclusion
As hypothesized, patients with severe DFI had a median hospital stay that was 60% longer than patients with moderate DFI. In this sample, 55% of patients with a severe DFI required some type of amputation compared to 42 % of patients with a moderate DFI.
doi:10.1177/1071100712467980
PMCID: PMC4016951  PMID: 23520292
diabetic foot infection definition severe
5.  Surgical Site Infections After Foot and Ankle Surgery 
Diabetes Care  2011;34(10):2211-2213.
OBJECTIVE
This prospective study was designed to evaluate the rate of surgical site infection (SSI) after foot and ankle surgery in patients with and without diabetes.
RESEARCH DESIGN AND METHODS
The study prospectively evaluated 1,465 consecutive foot and ankle surgical cases performed by a single surgeon.
RESULTS
The overall SSI rate in this study was 3.5%, with significantly more infections occurring in individuals with diabetes than in those without (9.5 vs. 2.4%, P < 0.001). Peripheral neuropathy, Charcot neuroarthropathy, current or past smoking, and increasing length of surgery were significantly associated with SSI on multivariate analysis.
CONCLUSIONS
This study demonstrates significant associations between the development of SSI and chronic complications of diabetes. We confirm previous findings that it is peripheral neuropathy and not diabetes itself that most strongly determines the development of postoperative infections in these surgical patients.
doi:10.2337/dc11-0846
PMCID: PMC3177737  PMID: 21816974
6.  The Charcot Foot in Diabetes 
Diabetes Care  2011;34(9):2123-2129.
The diabetic Charcot foot syndrome is a serious and potentially limb-threatening lower-extremity complication of diabetes. First described in 1883, this enigmatic condition continues to challenge even the most experienced practitioners. Now considered an inflammatory syndrome, the diabetic Charcot foot is characterized by varying degrees of bone and joint disorganization secondary to underlying neuropathy, trauma, and perturbations of bone metabolism. An international task force of experts was convened by the American Diabetes Association and the American Podiatric Medical Association in January 2011 to summarize available evidence on the pathophysiology, natural history, presentations, and treatment recommendations for this entity.
doi:10.2337/dc11-0844
PMCID: PMC3161273  PMID: 21868781

Results 1-7 (7)