Empiric Antibiotics for Diabetic Foot Infection: What the Research Reveals

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I am David Armstrong. I'm professor of Surgery and I direct our Southwestern Academic Limb Salvage Alliance or SALSA, at the Keck School of Medicine, the University of Southern California in beautiful, sunny southern California, where when it's not sunny, it's still sunny.

Schmidt BM, Kaye KS, Armstrong DG, Pop-Busui R. Empirical Antibiotic Therapy in Diabetic Foot Ulcer Infection Increases Hospitalization. Open Forum Infect Dis. 2023 Oct 5;10(10):ofad495. doi: 10.1093/ofid/ofad495. PMID: 37849506; PMCID: PMC10578503.

This is a really fascinating study. So it, it comes on the tail of a lot of other work that our team and others have been doing, just in general, in management of the high risk diabetic foot. But this was a project that was led by one of my mentees, Dr. Brian Schmidt. And so one of the projects he's doing was just published, and his coworkers along with me, evaluated patients that were treated over a long period of time, university of Michigan. Now, of course, I'm at the University of Southern California, but I participated as well.

In the analysis of this study, what they found, and what we found collectively, was thatpatients who were, treated initially over a prolonged period of time empirically, actually had poorer outcomes in terms of healing and even poor outcomes like amputation over this prolonged period of time. What it was showing us was that the risk for adverse events, if we are giving someone a really broad spectrum agent and then just really not narrowing that appropriately, is significant. And I think the big idea here is that, you know, we think of just feeding someone an antibiotic and we're going to help them. And this is somehow, just a really simple thing and, you know, we're treating ourselves just like we're treating our patient, but, you know, these antimicrobials, it's like chemotherapy and it affects people, uh, and it can hurt people.

I think many of the people watching this know that on their service, there are probably any number of patients on their inpatient service that have acute kidney injury, that have C. difficile colitis. And these problems are not just, morbid, they increase the risk for mortality. And so I would just ask, and I think the moral of this broader story is to understand, to think before you give your patient an antimicrobial, try to be as narrow as possible or try to narrow that spectrum as soon as possible, and you'll be doing your patient a service. In summary, shorter, better, and if you can help it, oral is probably just as good as parenteral. Again, I want to credit, Dr. Brian Schmidt and coworkers for a lot of this, but what I would say is don't just take it for granted. Don't just start someone on a broad spectrum agent and set it and forget it. This is not cruise control. Get it out of cruise control. Grab the wheel and steer.