Cultivatable Bacteriota of Chronic Wound of Patients with Diabetic Foot Syndrome with Critical Limb Ischemia Based on Wound Biopsy in Peri-Revascularization Period

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

1. The introduction, a more in-depth explanation of the pathophysiology behind DF, particularly the mechanisms of neuropathy, ischemia, and infection, could benefit the reader. This could be achieved by linking these mechanisms with recent findings, such as inflammatory responses or immune dysregulation in DF wounds (Consider quoting: 10.1002/adfm.202308387).

2. The introduction could include a brief discussion on the specific ways in which revascularization impacts wound microbiota, oxygenation, immune response, and healing dynamics, particularly with regard to diabetic patients.

3. The introduction touches on the role of microorganisms in wound infections, a discussion of studies that analyze the microbiota composition before and after revascularization would be highly relevant here, as it bridges the microbiological findings with clinical outcomes. Moreover, it would be valuable to specify why the focus on cultivatable bacteriota is essential, considering the complexities of wound microbiota, including the role of anaerobes, biofilms, and polymicrobial infections.

4. The introduction should emphasize the clinical implications of understanding the wound microbiota dynamics, particularly how it could influence treatment strategies (e.g., targeted antibiotics or microbiome modulation).

5. While the inclusion criteria are well-defined, consider providing more details about exclusion criteria. For example, it would be important to specify whether patients with additional comorbidities (e.g., active infections, cancer, etc.) were excluded, as these might confound the results.

6. The age range (40-80 years) is appropriate, but it could benefit from a justification. Older patients often have more comorbidities, which could impact the interpretation of wound healing. Clarifying the rationale for selecting this age range is necessary.

7. To further explore whether the increase in bacterial density may be due to specific conditions (such as local environmental changes after blood flow restoration) that promote the proliferation of non-pathogenic microorganisms and thus mitigate their association with infection severity.

Author Response

Dear reviewers,

 

we are extremely grateful for the time you have devoted to reviewing this article. We are grateful for any comments that will help us improve the quality of the prepared text. We have made every effort to meet your expectations regarding the available data.

At the same time, we are aware of the limitations that science currently places before us, especially in the face of insufficient funds for conducting our own research. We thank you for your understanding in this regard.

 

Reviewer 1

The introduction, a more in-depth explanation of the pathophysiology behind DF, particularly the mechanisms of neuropathy, ischemia, and infection, could benefit the reader. This could be achieved by linking these mechanisms with recent findings, such as inflammatory responses or immune dysregulation in DF wounds (Consider quoting: 10.1002/adfm.202308387).

Response: Due to the wide scope of the subject matter, including ischemia, the problem of infections in patients with diabetic foot, we wanted to prepare the most concise introduction possible. Nevertheless, we used the suggestions and briefly developed the pathophysiology responsible for the individual elements

The introduction could include a brief discussion on the specific ways in which revascularization impacts wound microbiota, oxygenation, immune response, and healing dynamics, particularly with regard to diabetic patients.

Response: We briefly described this topic in more details

The introduction touches on the role of microorganisms in wound infections, a discussion of studies that analyze the microbiota composition before and after revascularization would be highly relevant here, as it bridges the microbiological findings with clinical outcomes. Moreover, it would be valuable to specify why the focus on cultivatable bacteriota is essential, considering the complexities of wound microbiota, including the role of anaerobes, biofilms, and polymicrobial infections.

Response: Microbiota composition before and after revascularization is poorly described in English literature, that’s why such studies are important. We mentioned about complexity of DF ulcer microbiological factors, challenging factors implicating the need of further studies.

The introduction should emphasize the clinical implications of understanding the wound microbiota dynamics, particularly how it could influence treatment strategies (e.g., targeted antibiotics or microbiome modulation).

Response: Added to introduction section

While the inclusion criteria are well-defined, consider providing more details about exclusion criteria. For example, it would be important to specify whether patients with additional comorbidities (e.g., active infections, cancer, etc.) were excluded, as these might confound the results.

Response: Its very important to clarify this - added

The age range (40-80 years) is appropriate, but it could benefit from a justification. Older patients often have more comorbidities, which could impact the interpretation of wound healing. Clarifying the rationale for selecting this age range is necessary.

Response: Added justification

7. To further explore whether the increase in bacterial density may be due to specific conditions (such as local environmental changes after blood flow restoration) that promote the proliferation of non-pathogenic microorganisms and thus mitigate their association with infection severity.

Response: We agree that this is crucial, we hope that in the future we can get some funding to conduct studies including more sophisticated methods to better assess clinically significant pathogens. However the distribution among different species didn’t change significantly and despite for example S. aureus density increase healing was achieved. Probably the clue thing is balance favoring healing then pathology in wound, but still there is a lot to know. Thank You

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors,

 

The title of your work is: "Cultivable Bacteriota of Chronic Wounds in Patients with Diabetic Foot Syndrome and Critical Limb Ischemia Based on Wound Biopsy in the Peri-Revascularization Period."

 

However, the methods and results presented do not align with the title. While you cite the analysis of cultivable bacteria, only Staphylococcus aureus, Pseudomonas, and the Enterobacteriaceae family are identified. Since this refers to cultivable microbiota, as indicated in the title, the authors should explore more thoroughly the primary species found in wounds. They should also investigate the correlation between endogenous colonization and whether these microorganisms originate from the external environment. Additionally, it would be beneficial to include phenotypic characteristics, such as the virulence profile and sensitivity to antimicrobials.

 

This is an important subject, but the current presentation lacks the necessary depth for publication.

 

 

Best Regards.

Author Response

Reviewer 2

However, the methods and results presented do not align with the title. While you cite the analysis of cultivable bacteria, only Staphylococcus aureus, Pseudomonas, and the Enterobacteriaceae family are identified. Since this refers to cultivable microbiota, as indicated in the title, the authors should explore more thoroughly the primary species found in wounds.

Response: Thank you for this significant comment. Due to very complex case of patients with DM combined with PAD and infection its easy to omit some important data. We added information about the results of culture and rest of strains isolated and also about polyetiology in result section

They should also investigate the correlation between endogenous colonization and whether these microorganisms originate from the external environment.

Response: We added paragraph in discussion section with comment to situation of DM patients.

Additionally, it would be beneficial to include phenotypic characteristics, such as the virulence profile and sensitivity to antimicrobials.

Response: We are aware of importance of such data, unfortunately our study had no significant founds to achieve all goals, we decided to get good identification and quantitative assessment, so additional PCR, AMR were out of our range – this is space to continuation of such studies after covering appropriate funding.

Reviewer 3 Report

Comments and Suggestions for Authors

In manuscript ID: microbiolres-3313229, the authors have evaluated the impact of improved blood supply on the change of the clinical status and culturable bacteriota of chronic wounds. This study addresses a clinically significant topic, offering valuable insights into the interplay between vascular health and microbial dynamics in chronic wound management. However, the authors should address the following minor comments before the manuscript can be considered for publication.

 

1.    Given the findings that long-term smoking cessation does not fully reverse its effects, what strategies could be explored to mitigate the residual vascular damage and enhance wound healing in former smokers?

2.    Based on the study's findings, what recommendations could be made for managing diabetic foot wounds in former smokers with chronic limb-threatening ischemia (CLTI)?

3.    Authors must define the abbreviation (for example SINBAD: Site, Ischemia, Neuropathy, Bacterial Infection, and Depth) when it appears for the first time in the manuscript.

4.    How does the degree of immune response impairment differ between current smokers, former smokers, and non-smokers in the context of wound healing?

Author Response

Reviewer 3

Given the findings that long-term smoking cessation does not fully reverse its effects, what strategies could be explored to mitigate the residual vascular damage and enhance wound healing in former smokers?

Response: Current data are not covering this topic in detail due to microcirculation regulations on which we have limited ways to get significant impact. Relevant paragraph was added in discussion section

 

Based on the study's findings, what recommendations could be made for managing diabetic foot wounds in former smokers with chronic limb-threatening ischemia (CLTI)?

Response: At the same place conclusion was made

Authors must define the abbreviation (for example SINBAD: Site, Ischemia, Neuropathy, Bacterial Infection, and Depth) when it appears for the first time in the manuscript.

Response: Corrected and checked again for the first mention of abbreviations

 

4. How does the degree of immune response impairment differ between current smokers, former smokers, and non-smokers in the context of wound healing?

 

Response: Mentioned based on Nature study about immunology in context of smoking status.