Page 7 - Vasoclick emagazine Issue2

Four major factors associated with a
improved by revascularization in patients with
significantly shorter OS
6
ischemic infection. Thus, timely management of
6

ischemic wound and early access to vascular
Major amputation(s) during hospitaliza-
tion
(P<0.001;
HR
surgery for limb salvage in diabetic patients is
2.836–15.700)
strongly recommended.
6
Wound ischemia: due to an infected
ulcer [(vs. non-ischemic wound; P=0.046;
e) Infection
a) Patient characteristics
b) The LRINEC-score
HR 1.598; CI 1.008–2.532)
1) Indicative of severe infection, high CRP
The LRINEC -score had no effect on the OS or
Overall 324 patients were enrolled (237 males,
Age: over 67 years (P<0.001; HR 1.055;
levels were found to be associated with a
87 females; mean age, 66.8 years, SD 12.8)
AFS.
6
CI 1.035–1.076)
worse AFS.
with 404 periods of hospitalization.
6
6
2) AFS was also associated with a deep wound
Impaired renal functions: eGFR under
The Laboratory Risk Indicator for Necrotizing
Materials and methods
60 ml/min (P<0.001; HR 0.989; CI
(penetrating to the bone or joint) and high
Fasciitis score (LRINEC score):
The retrospective cohort study enrolled adult
0.982–0.995)
blood leukocytes.
6
It is a sensitive scoring system to identify
patients presenting with acute DFI at the
3) Long-lasting and multiple foot ulcers were
necrotizing fasciitis and distinguish it from other
Tampere University Hospital during 2010
Therefore, a diabetes patient presenting with an
also associated with a worse outcome as
soft tissue infections. An LRINEC score of >8
-2014.
8
6,7
acute infection can undergo a minor amputation
reported previously.
2, 6
has been found to be sensitive for patients with
to restrict the infection, and this way a major
diabetes.
was
Following
patient-related
9
information
amputation can be avoided, saving both limb and
c) Survival of patients with DFI
The study therefore emphasized on the

collected from the hospital records:
life of the patient.
The present study showed that survival of
importance of early detection and treatment of
The present study assessed the utility of LRINEC
Patient demographics (age and gender)
patients after a DFI was poor within one-year
the infection for diabetic foot ulcers.
6
score to diagnose severe DFI and a poor
Registered diagnoses (ischemic heart disease,
d) Effect of revascularization
(81.2%), and almost 50% of patients died within
prognosis. LRINEC score with a cutoff of >8 was
chronic obstructive pulmonary disease, con-
The AFS was greatly reduced in patients with
5-years after a DFI. The risk of death was almost
6
f) Hypertension
chosen to identify necrotizing fasciitis.
gestive heart failure and dyslipidemia, microbi-
6
ischemic wounds. 16.1% of the cases had
six-fold after the infection among patients that
The study demonstrated that use of a
ological and clinical chemistry findings, surgi-
revascularization within 1 month of admission
with
underwent
than
those
amputation
hypertensive medication was associated with an
A specialist in plastic surgery staged the wounds
cal revisions and amputations, open and endo-
and in most cases within 1 week.
6
infections but treated without amputation. After
increased AFS, however the observation requires
according to the University of Texas Staging
vascular revascularization procedures, wound

a 5-year follow-up, only 1 of 12 patients (8.3%)
further validation.
6
System for Diabetic Foot Ulcers (UT scale).
status, and the length of hospital stay).
6,10
6
Revascularization
(open
survived.
6

endovascular) had no effect on survival of
Vasoclick, Edition 2 procedure 6.673; CI or patients, however, AFS was significantly
06
CASSINI trial showed that rivaroxaban (10 mg Duration of anticoagulation for CAT:
Conclusion 7) LaaksoM, Kiiski J, KarppelinM, HelminenM, Kaartinen I. once daily) is associated with a lower Owing to the lack of randomized clinical studies
Pathogens causing diabetic foot infection and the
Patients with DFI have high morbidity and reliability of the superficial culture. Surg Infect. 2020. doi: incidence of recurrent VTEs and major to investigate different durations of
poor survival outcomes despite advanced 10.1089/sur.2020.072. bleeding in high-risk ambulatory patients with anticoagulation in cancer patients, the optimal

treatment resources. 8) Wong C-H, Khin L-W, Heng K-S, Tan K-C, Low C-O. The cancer as well as lower rates of duration of treatment remains elusive. Based on
6
2
LRINEC (Laboratory Risk Indicator for Necrotizing
High CRP levels are associated with a Fasciitis) score: a tool for distinguishing necrotizing discontinuation due to adverse events. 13 existing evidence, patients with active cancer
reduced AFS. fasciitis from other soft tissue infections. Crit Care Med. and metastatic cancer undergoing therapy are
6
2004; 32:1535–41. doi:
Ischemic infections in deep wounds with 10.1097/01.CCM.0000129486.35458.7D A growing body of clinical and real-world data posed to high risk of recurrent VTE. According to
2
high CRP levels suggest severity of the 9)Tan JH, Koh BTH, Hong CC, Lim SH, Liang S, Chan GEH, continues to support the use of rivaroxaban different guidelines, the duration of
disease and must be prevented early. 6 et al. A comparison of necrotising fasciitis in diabetics for the treatment of CAT based on its safety anticoagulation may range from 3-6 months. 3,7,8
and non-diabetics: a review of 127 patients. Bone Joint J.
A major amputation is a strong predictor of (2016) 98-B:1563–8. doi: and efficacy 9, 13 . The COSIMO study using a The guidelines emphasized that the duration of
10.1302/0301-620X.98B11.37526
death in patients with DFI. non-interventional approach demonstrated therapy should be routinely evaluated based on
6
Thus, early identification and treatments of 10) Lavery LA, Armstrong DG, Harkless LB. Classification that patients with CAT who switched from the patient’s clinical profile, risks and benefits of
of diabetic foot wounds. J Foot Ankle Surg. 1996; 35:528–
DFI are critical to improve both the AFS and 31. doi: 10.1016/S1067-2516(96)80125-6 LMWH, fondaparinux, or VKA therapy to therapy, and patient preferences. 2
OS. rivaroxaban experienced an improvement in
6
treatment satisfaction in reducing Overall, the recently published guidelines are
References: patient-reported anticoagulation burden. 14 consistent in their recommendations for CAT
1) Armstrong DG, Swerdlow MA, Armstrong AA, Conte MS, management as summarized in table 1. They
Padula WV, Bus SA. Five year mortality and direct costs of In line with these findings, rivaroxaban has provide unanimous advice to reassess the
care for people with diabetic foot complications are
comparable to cancer. J Foot Ankle Res. 2020;13:16. doi: been recommended for the treatment of CAT duration of therapy depending on the patient’s
10.1186/s13047-020-00383-2 Guideline recommendations for treat- Rivaroxaban for treatment of CAT: across all the international guidelines for
ment of cancer-associated thrombosis: Rivaroxaban was the first DOAC approved by clinical condition and preferences, as well as the
2) Ndosi M, Wright-Hughes A, Brown S, Backhouse M, cancer patients, having a low risk of bleeding risks/benefits of the therapy. 2
Lipsky BA, Bhogal M, et al. Prognosis of the infected All the guidelines are consistent in the US Food and Drug Administration (FDA)
diabetic foot ulcer: a 12-month prospective observational and no drug-drug interactions. 2
9
study. Diabet Med. 2018; 35:78–88. doi: recommending direct oral anticoagulants for the treatment of VTE in 2012. Though, the
10.1111/dme.13537 initial approval did not selectively address
(DOAC) in their treatment for CAT. DOACs and Table 1. Guideline recommendations for treatment of cancer-associated VTE 2
3) Huang Y-Y, Lin C-W, Yang H-M, Hung S-Y, Chen I-W. low-molecular-weight heparin (LMWH) are the cancer patients with CAT, the EINSTEIN and
Survival and associated risk factors in patients with
diabetes and amputations caused by infectious foot agents of choice for long-term therapy (over EINSTEIN-PE trials that led to the approval Guideline Initial Anticoagulation Long term Optimal Incidental/
gangrene. J Foot Ankle Res. 2018; 11:1. doi: included ~5.6% of cancer patients in the Anticoagulation Duration Recurrent VTE
2
10.1186/s13047-017-0243-0 Vitamin K antagonist (VKA)) . Guidelines,
however, recommend cautious use of DOACs in rivaroxaban treatment arm. 9,10,11 American Society Rivaroxaban, LMWH, UFH, or Rivaroxaban or edoxaban 6 months Incidental VTE: Treated in the
4) Raspovic KM, Wukich DK. Self-reported quality of life of Clinical fondaparinux (preferred over VKA), LMWH same manner as symptomatic
and diabetic foot infections. J Foot Ankle Surg. 2014; patients with gastrointestinal (GI) and Oncology VTE.
4
53:716–9. doi: 10.1053/j.jfas.2014.06.011 SELECT-D, the first randomized comparison 2020
gastro-urinary (GU) malignancies until more
5) Peters EJ, Childs MR, Wunderlich RP, Harkless LB, evidence is available. Inferior vena cava (IVC) of rivaroxaban (15mg twice daily for 3 weeks, International Rivaroxaban and edoxaban for
2
Armstrong DG, Lavery LA. Functional status of persons Society of patients with cancer with acute
with diabetesrelated lower-extremity amputations. filters can be offered in case the anticoagulation then 20 mg once daily for a total of 6 months) Thrombosis and VTE, a low risk of bleeding, and no
Hemostasis
drug-drug interactions.
Diabetes Care. 2000; 24:1799-804. doi: versus dalteparin (200 IU/kg daily during 2018 5
10.2337/diacare.24.10.1799 is contraindicated or if there is progressive LMWH for patients with acute VTE
at high risk for bleeding, including
thrombosis despite optimal anticoagulation. The month 1, then 150 IU/kg daily for months 2-6) those with luminal GI malignancy
6) Vuorlaakso M, Kiiski J, Salonen T, Karppelin M, with intact primaries, GU malignan-
Helminen M, Kaartinen I. Major Amputation Profoundly filter should be retrieved once the for the treatment of CAT in cancer patients, cies, nephrostomy tubes, or GI
Increases Mortality in Patients With Diabetic Foot showed non-inferior efficacy and safety of mucosal abnormalities.
Infection. Front Surg. 2021;8:655902. Published 2021 Apr anticoagulation is safe to resume. 2
30.doi:10.3389/fsurg.2021.655902 rivaroxaban compared to LMWH. 12