Complex Foot Infection can be treated With Surgical Debridement and Antibiotic Loaded Calcium Sulfate: study

UK: Complex foot infections involving bone and soft tissue in patients with co-morbidities such as diabetes and peripheral arterial disease (PAD) are a cause of significant hospital admission. They are associated with substantial economic costs to health services worldwide. Historically, severe foot infection has been treated with surgical debridement and prolonged courses of systemic antibiotics. Prolonged systemic antibiotic use increases the risk of drug side effects, antimicrobial resistance and Clostridium difficile infection.

R. Morley et al. conducted a study to investigate whether surgical debridement and implantation of antibiotic loaded calcium sulphate (ALCS) is effective in the resolution of foot infection and wound healing.

A retrospective cohort study of 137 consecutive cases of osteomyelitis (127) or significant soft tissue infection (10) over 62 months from 02/2013 to 04/2018 was conducted following local ethical approval.

All cases of infection were treated with surgical debridement and local antibiotic-loaded calcium sulfate.

The primary outcomes of infection resolution, time to healing and duration of postoperative antibiotics were measured.

Results:

• In 137 cases, 88.3% of infections resolved.

• Infection was eradicated in 22 patients without postoperative systemic antibiotics.

• About 82.5% of wounds healed, with an average healing time of 11.3 weeks.

• Healing time was significantly increased for the co-morbidities of diabetes and PAD (p =< .05) and for those requiring prolonged systemic postoperative antibiotics.

• no adverse reactions including any local or systemic toxicity but it was noted that dissolution of ALCS did cause some skin maceration in some cases to varying degrees which may have affected healing times.

The authors concluded that - a combination of conservative surgical debridement and implantation of ALCS would appear to be safe and effective in managing complex foot infection, and may reduce the requirement for prolonged postoperative courses of systemic antimicrobials potentially reducing the associated financial cost, adverse reactions and often toxic effects of these drugs. The authors would advocate early surgical intervention in appropriate cases, to prevent deeper tissue involvement preserving lower limb structure and function.

Further studies, particularly randomized controlled trials would be useful to compare surgical debridement, thorough irrigation and use of ALCS to surgical debridement and thorough irrigation alone.

Level of Clinical Evidence: 3

Key Words: diabetes foot, ulceration, local antibiotics, osteomyelitis, peripheral arterial disease

Further reading:

Complex Foot Infection Treated With Surgical Debridement and Antibiotic Loaded Calcium Sulfate—A Retrospective Cohort Study of 137 Cases

Robert Morley, Matt Rothwell, John Stephenson, Liza McIlvenny, Frank Webb, Aaron Barber.

The Journal of Foot & Ankle Surgery 61 (2022) 239−247

https://doi.org/10.1053/j.jfas.2021.07.014