Invasive Systemic Infection After Hospital Treatment for Diabetic Foot Ulcer: Risk of Occurrence and Effect on Survival

Abstract Background Diabetic foot ulcers (DFUs) threaten limbs and prompt hospitalization. After hospitalization, remote-site invasive systemic infection related to DFU (DFU-ISI) may occur. The characteristics of DFU-ISIs and their effect on mortality risk have not been defined. Methods We conducted a retrospective cohort study of 819 diabetic patients hospitalized for treatment of 1212 unique DFUs during a 9-year period. We defined the index ulcer as that present at the first (index) DFU admission to our hospital. We defined DFU-ISI as a nonfoot infection that occurred after the index hospitalization and was caused by a microorganism concomitantly or previously cultured from the index ulcer. We determined the frequency, risk factors, and mortality risk associated with DFU-ISIs. Results After 1212 index DFU hospitalizations, 141 patients had 172 DFU-ISIs. Of the initial 141 DFU-ISIs, 64% were bacteremia, 13% deep abscesses, 10% pneumonia, 7% endocarditis, and 6% skeletal infections. Methicillin-resistant Staphylococcus aureus (MRSA) caused 57% of the ISIs. Patients with initial DFU cultures yielding MRSA and protracted open ulcers had a high 24-month cumulative probability of DFU-ISI (31%) and all-cause mortality rate (13%). Analysis with Cox regression modeling showed that complicated ulcer healing (hazard ratio, 3.812; 95% confidence interval, 2.434–5.971) and initial DFU culture yielding MRSA (2.030; 1.452–2.838) predicted DFU-ISIs and that DFU-ISIs were associated with increased mortality risk (1.987; 1.106–3.568). Conclusions DFU-ISIs are important late complications of DFUs. Prevention of DFU-ISIs should be studied prospectively. Meanwhile, clinicians should aggressively incorporate treatment to accelerate ulcer healing and address MRSA into the care of diabetic patients with foot ulcers.

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Staphylococcus aureus strains isolated from diabetic foot ulcers. Identification of the antibiotic resistant phenotypes

Romanian Journal of Diabetes Nutrition and Metabolic Diseases ◽

10.2478/rjdnmd-2013-0038 ◽

2013 ◽

Vol 20 (4) ◽

pp. 389-393 ◽

Cited By ~ 2

Author(s):

Teodora Chiţă ◽

Delia Muntean ◽

Luminiţa Badiţoiu ◽

Bogdan Timar ◽

Roxana Moldovan ◽

...

Keyword(s):

Diabetes Mellitus ◽

Staphylococcus Aureus ◽

Diabetic Foot ◽

Foot Ulcer ◽

Foot Ulcers ◽

Resistance Pattern ◽

Diabetic Patients ◽

Diabetic Foot Ulcers ◽

Bacterial Strains ◽

Diabetes Clinic

Abstract Background and aims: Infected foot ulcer is one of the most feared complications of diabetes mellitus. Staphylococcus aureus is the most frequently isolated pathogen in diabetic foot infections. The aim of this study was to evaluate the prevalence of S. aureus strains involved in producing foot infections in diabetic patients and the antibiotic resistance pattern of these strains. Material and methods: The study included 33 S. aureus strains isolated from 55 diabetic foot ulcers. The subjects were selected from the 2465 patients with diabetes mellitus hospitalized in the Timişoara Diabetes Clinic, between 2011 and 2013. Germs’ identification relied on cultural and biochemical characteristics. Final identification and antimicrobial testing were performed using the Vitek 2 (Bio Merieux France) automatic analyzer. Results: All the 55 samples collected from diabetic foot ulcers were positive. We isolated 64 bacterial strains (some samples were positive for 2 microorganisms). The most frequently isolated germ was S. aureus, in 33 samples (51.56%). All these S. aureus strains showed resistance to benzylpenicillin, while only 33.33% were methicillin-resistant (MRSA). Conclusions: The most frequently isolated germ in the wound secretions from diabetic foot ulcers was S. aureus. The highest percentage of antimicrobial resistance was recorded to benzylpenicillin and erythromycin.

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Prevention and treatment of diabetic foot ulcers

Journal of the Royal Society of Medicine ◽

10.1177/0141076816688346 ◽

2017 ◽

Vol 110 (3) ◽

pp. 104-109 ◽

Cited By ~ 40

Author(s):

Jonathan Zhang Ming Lim ◽

Natasha Su Lynn Ng ◽

Cecil Thomas

Keyword(s):

Diabetic Foot ◽

Healthcare Access ◽

Foot Ulcer ◽

Diabetic Foot Ulcer ◽

Foot Ulcers ◽

Diabetic Patients ◽

Diabetic Foot Ulcers ◽

Foot Care ◽

Healthcare Provision ◽

Foot Complications

The rising prevalence of diabetes estimated at 3.6 million people in the UK represents a major public health and socioeconomic burden to our National Health Service. Diabetes and its associated complications are of a growing concern. Diabetes-related foot complications have been identified as the single most common cause of morbidity among diabetic patients. The complicating factor of underlying peripheral vascular disease renders the majority of diabetic foot ulcers asymptomatic until latter evidence of non-healing ulcers become evident. Therefore, preventative strategies including annual diabetic foot screening and diabetic foot care interventions facilitated through a multidisciplinary team have been implemented to enable early identification of diabetic patients at high risk of diabetic foot complications. The National Diabetes Foot Care Audit reported significant variability and deficiencies of care throughout England and Wales, with emphasis on change in the structure of healthcare provision and commissioning, improvement of patient education and availability of healthcare access, and emphasis on preventative strategies to reduce morbidities and mortality of this debilitating disease. This review article aims to summarise major risk factors contributing to the development of diabetic foot ulcers. It also considers the key evidence-based strategies towards preventing diabetic foot ulcer. We discuss tools used in risk stratification and classifications of foot ulcer.

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Clinical Profile of Patients with Diabetic Foot Ulcer Treated Conservatively or Surgically and Effect of Risk Factors on Ulcer Healing

International Journal of Research and Review ◽

10.52403/ijrr.20210629 ◽

2021 ◽

Vol 8 (6) ◽

pp. 238-244

Author(s):

Ved Prakash

Keyword(s):

Risk Factors ◽

Peripheral Neuropathy ◽

Glycemic Control ◽

Ulcer Healing ◽

Diabetic Foot ◽

Foot Ulcer ◽

Diabetic Foot Ulcer ◽

Clinical Profile ◽

Diabetic Patients ◽

Duration Of Diabetes

Objective: The aim of this study was to assess the clinical profile of patients with diabetic foot ulcer treated conservatively or surgically and effect of risk factors on ulcer healing. Methods: This was a retrospective observational study conducted in tertiary medical teaching hospital where medical records of diabetic patients who were admitted with foot problem were evaluated. All diabetic patients who were aged >18 years and admitted with DFU were included in this study. A structured proforma was used to collect data from the medical record. SPSS version 20.0 was used to perform the statistical analysis. Result: 280 subjects with diabetic foot ulcer (DFU) were evaluated in this study. 71% ulcers were healed where as 11% were persisted unhealed. Patients who were undergone for amputation 12% were minor (Foot only) and 4% were major (above the ankle). A statistically significant association between age, duration of diabetes, glycemic control peripheral neuropathy, and ulcer size were found with diabetic foot ulcer healing. Conclusion: Modifiable factors like good glycemic control, early management of ulcers and early treatment of peripheral neuropathy can influence Diabetic foot ulcer outcomes. Special care should be provided to diabetic subjects who are aged and have longer duration of diabetes. Keywords: Diabetic foot ulcers, ulcer severity, clinical profile, Wagner’s Classification, outcome.

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Diabetic foot ulcers: Retrospective comparative analysis from Sicily between two eras

PLoS ONE ◽

10.1371/journal.pone.0259405 ◽

2021 ◽

Vol 16 (12) ◽

pp. e0259405

Author(s):

Valentina Guarnotta ◽

Stefano Radellini ◽

Enrica Vigneri ◽

Achille Cernigliaro ◽

Felicia Pantò ◽

...

Keyword(s):

Risk Factors ◽

Diabetic Foot ◽

Cox Regression ◽

Age Of Onset ◽

Age At Onset ◽

Foot Ulcer ◽

Diabetic Foot Ulcer ◽

Diabetic Patients ◽

Type 2 Diabetic Patients ◽

Risk Of Death

Aim The aim of this study was to analyze changes in the incidence, management and mortality of DFU in Sicilian Type 2 diabetic patients hospitalized between two eras, i.e. 2008–2013 and 2014–2019. Methods We compared the two eras, era1: 2008–13, era2: 2014–19. In era 1, n = 149, and in era 2, n = 181 patients were retrospectively enrolled. Results In the population hospitalized for DFU in 2008–2013, 59.1% of males and 40.9% of females died, whilst in 2014–2019 65.9% of males and 34.1% of females died. Moderate chronic kidney disease (CKD) was significantly higher in patients that had died than in ones that were alive (33% vs. 43%, p < 0.001), just as CKD was severe (14.5% vs. 4%, p < 0.001). Considering all together the risk factors associated with mortality, at Cox regression multivariate analysis only moderate-severe CKD (OR 1.61, 95% CI 1.07–2.42, p 0.021), age of onset greater than 69 years (OR 2.01, 95% CI 1.37–2.95, p <0.001) and eGFR less than 92 ml/min (OR 2.84, 95% CI 1.51–5.34, p 0.001) were independently associated with risk of death. Conclusions Patients with DFU have high mortality and reduced life expectancy. Age at onset of diabetic foot ulcer, eGFR values and CKD are the principal risk factors for mortality.

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The Effectiveness of the 15 Psi Irrigation Technique in Wound Cleansing to Reduce the Number of Bacteria on Patients with Diabetic Foot Ulcers

International Journal of Indonesian National Nurses Association (IJINNA) ◽

10.32944/ijinna.v1i1.22 ◽

2018 ◽

Vol 1 (1) ◽

pp. 88-97

Author(s):

Lestari Makmuriana (Corresponding author) ◽

Suriadi ◽

Yani Sofiani ◽

Fitrian Rayasari

Keyword(s):

Normal Saline ◽

Diabetic Foot ◽

Foot Ulcer ◽

Foot Ulcers ◽

Diabetic Patients ◽

Clinical Test ◽

Diabetic Foot Ulcers ◽

Double Blind ◽

Saline Irrigation ◽

Number Of Bacteria

The increasing population of diabetic patients leads to the increasing number of diabetic foot ulcer (DFU) cases. To avoid the expansion of the infection, the wound cleansing is conducted through the irrigation and pressure methods. The aim of this research was to identify the effectiveness of wound cleansing using 0.9% normal saline technique with the pressure of 15 Psi in reducing the number of bacteria. This research used the randomized control trial method with a double blind design which had been approved by the ethnical committee of Muhammadiyah University of akarta with the ethnical committee number 261/PMK-UMJ/IV/2017. There were as many as 31 samples in each group collected through consecutive sampling technique with randomization. It had been found that there was a signi fi cant difference in the number of bacteria before and after wound cleansing. Thus, it could be concluded that from the statistical test and clinical test, wound cleansing with normal 0.9% saline technique with the pressure of 15 Psi could decrease the number of bacteria in diabetic foot ulcers. Wound cleansing with 0.9% normal saline irrigation technique pressurized at 15 Psi was recommended as a safe wound cleansing method for diabetic foot ulcers.

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A prospective observation study on diabetic foot ulcer using diabetic ulcer severity score at tertiary care hospital

International Surgery Journal ◽

10.18203/2349-2902.isj20214744 ◽

2021 ◽

Vol 8 (12) ◽

pp. 3553

Author(s):

Bharti Saraswat ◽

Kapil Kumar Gill ◽

Ashok Yadav ◽

Krishan Kumar

Keyword(s):

Diabetic Foot ◽

Foot Ulcer ◽

Diabetic Foot Ulcer ◽

Scoring Systems ◽

Foot Ulcers ◽

Diabetic Patients ◽

Care Hospital ◽

Age Group ◽

Diabetic Foot Ulcers ◽

Diabetic Ulcer

Background: A number of scoring systems and classifications are available for diabetic foot ulcers with intention to compare the treatment modalities and future outcomes. Many of them are complex and don’t predict future outcome within the patients. Aim and objectives of current study were to establish a wound-based clinical scoring systems (DUSS) as daily clinical practice by assessing the efficacy of diabetic ulcer severity score.Methods: A total of 73 diabetic patients with foot ulcers were included in this prospective observational study conducted at Dr. S.N. Medical college, Jodhpur and attached hospitals from July 2018 to August 2020. Ulcers were assessed and DUSS score created. Patients were followed up for six months or until healing or amputation if either.Results: In this prospective study of 73 patients with diabetic foot ulcers, most common age group affected was between 51-70 years. Mean age group was 58.57±12.66 years. Mean duration of diabetes was 7.61±5.72 years. Most commonly ulcers were of DUSS score 2. Mean DUSS score was 1.97±1.15. Majority of diabetic foot ulcer patients (37 out of 51) with DUSS score 0, 1 and 2 healed by primary intention after wound debridement. Those with score 3 & 4 majority of them (20 out of 22) had amputation.Conclusions: This is a very simple scoring system that provides an easily accessible and a streamlined approach in the clinical setting without need of any advanced investigative equipment. Hence this can be applied in any set up.

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Does intensive glycaemic control promote healing in diabetic foot ulcers? – a feasibility study

BMJ Open ◽

10.1136/bmjopen-2019-029009 ◽

2020 ◽

Vol 10 (1) ◽

pp. e029009 ◽

Cited By ~ 1

Author(s):

Ajith Dissanayake ◽

Alain C Vandal ◽

Veronica Boyle ◽

Diane Park ◽

Bobbie Milne ◽

...

Keyword(s):

Glycaemic Control ◽

Insulin Therapy ◽

Intensive Insulin Therapy ◽

Ulcer Healing ◽

Diabetic Foot ◽

Foot Ulcer ◽

Diabetic Foot Ulcer ◽

Foot Ulcers ◽

Ulcer Area ◽

Diabetes Patients

IntroductionOne in four diabetes patients will develop a foot ulcer over their lifetime. The role of glycaemic control in the healing of foot ulcers in diabetes patients is not supported by randomised controlled trial (RCT) data.ObjectivesTo determine the feasibility of an RCT of glycaemic control with intensive insulin therapy in diabetic foot ulcer, by assessing: entry criteria, fasting capillary blood glucose (FCBG) medication satisfaction and sensitivity of different ulcer-healing endpoints to glycaemic control.DesignTwo substudies: one cross-sectional and one single-arm prospective.SettingSingle-centre secondary care diabetic foot clinic in New Zealand.ParticipantsSubstudy 1: 78 participants consisting of all people ≥18 years with a diabetic foot ulcer presenting to the clinic over 35 weeks in 2015.Substudy 2: 15 participants from Substudy 1 consenting to intensive insulin therapy.InterventionSubstudy 1: None.Substudy 2: Intensive insulin therapy with standard podiatry care over 24 weeks.OutcomeSubstudy 1: Proportion of participants satisfying potential RCT entry criteria; medication satisfaction (Diabetes Medication Satisfaction).Substudy 2: FCBG, index ulcer healing time, index ulcer size, health-related quality of life (HRQoL; EuroQol 5 Dimensions 5 Levels and Diabetic Foot Ulcer Scale-Short Form).ResultsProportion in Substudy 1 satisfying all entry criteria was 31% (95% CI 21 to 42). FCBG values decreased between baseline and study end (difference −3.7 mmol/L, 95% CI −6.5 to −0.8); 83% (95% CI 44 to 95) of ulcers healed by 24 weeks. FCBG correlated negatively with medication satisfaction. Ulcer area logarithm was most sensitive to FCBG changes, displaying significant negative correlation with HRQoL outcomes. Detecting a 30% between-group difference in this outcome (80% power, α=5%) requires 220 participants per arm, achievable within 1 year with 15 centres similar to study setting.ConclusionsAn adequately powered RCT requires cooperation between a large number of centres. Ulcer area logarithm should be primary endpoint.Trial registration numberANZCTR ACTRN12617001414303

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Reducing the burden of chronic wounds: Prevention and management of the diabetic foot in the context of clinical guidelines

Journal of Health Services Research & Policy ◽

10.1258/jhsrp.2008.008011 ◽

2008 ◽

Vol 13 (3_suppl) ◽

pp. 82-91 ◽

Cited By ~ 13

Author(s):

Aidan Searle ◽

Lone Gale ◽

Rona Campbell ◽

Mark Wetherell ◽

Karen Dawe ◽

...

Keyword(s):

Decision Making ◽

Shared Decision Making ◽

Diabetic Foot ◽

Clinical Guidelines ◽

Chronic Wounds ◽

Foot Ulcer ◽

Foot Ulcers ◽

Diabetic Patients ◽

Shared Decision ◽

Behavioural Factors

Objectives: Chronic wounds such as diabetic foot and venous leg ulcers are a major burden for health services. Our programme was developed to explore the psychological and behavioural factors that may influence both the incidence of chronic wounds and their progression. The present article focuses on two particular aspects of the programme: patient knowledge of diabetic foot ulceration and factors influencing foot-related behaviour in patients with and without foot ulcers; and patient and podiatrist perspectives of consultations for diabetic foot ulcers. Methods: Two independent qualitative studies were undertaken: one with diabetic patients without a history of ulceration; and the other with diabetic patients with active ulceration and podiatrists treating these patients. Results: We found that patients may find it difficult understanding the rationale underlying prevention and treatment of foot ulcers; ulcerated patients may find it difficult to engage in the management of their foot ulcer outside consultations; and some podiatrists feel frustrated and unsupported in their attempts at empowering and building partnerships with patients. Conclusion: Patient and practitioner factors may contribute to the effective implementation of clinical guidelines regarding education, partnership building and shared decision-making. These findings are discussed in relation to patient education, partnership building and shared decision-making as recommended in NICE guidelines.

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Topically Applied Connective Tissue Growth Factor/CCN2 Improves Diabetic Preclinical Cutaneous Wound Healing: Potential Role for CTGF in Human Diabetic Foot Ulcer Healing

Journal of Diabetes Research ◽

10.1155/2015/236238 ◽

2015 ◽

Vol 2015 ◽

pp. 1-10 ◽

Cited By ~ 20

Author(s):

F. R. Henshaw ◽

P. Boughton ◽

L. Lo ◽

S. V. McLennan ◽

S. M. Twigg

Keyword(s):

Wound Healing ◽

Granulation Tissue ◽

Ulcer Healing ◽

Diabetic Foot ◽

Healing Rate ◽

Foot Ulcer ◽

Foot Ulcers ◽

Diabetic Foot Ulcers ◽

Wound Fluid ◽

Diabetic Wounds

Aims/Hypothesis. Topical application of CTGF/CCN2 to rodent diabetic and control wounds was examined. In parallel research, correlation of CTGF wound fluid levels with healing rate in human diabetic foot ulcers was undertaken.Methods. Full thickness cutaneous wounds in diabetic and nondiabetic control rats were treated topically with 1 μg rhCTGF or vehicle alone, on 2 consecutive days. Wound healing rate was observed on day 14 and wound sites were examined for breaking strength and granulation tissue. In the human study across 32 subjects, serial CTGF regulation was analyzed longitudinally in postdebridement diabetic wound fluid.Results. CTGF treated diabetic wounds had an accelerated closure rate compared with vehicle treated diabetic wounds. Healed skin withstood more strain before breaking in CTGF treated rat wounds. Granulation tissue from CTGF treatment in diabetic wounds showed collagen IV accumulation compared with nondiabetic animals. Woundα-smooth muscle actin was increased in CTGF treated diabetic wounds compared with untreated diabetic wounds, as was macrophage infiltration. Endogenous wound fluid CTGF protein rate of increase in human diabetic foot ulcers correlated positively with foot ulcer healing rate (r=0.406;P<0.001).Conclusions/Interpretation. These data collectively increasingly substantiate a functional role for CTGF in human diabetic foot ulcers.

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Factors Associated With Ulcer Healing and Quality of Life in Patients With Diabetic Foot Ulcer

Angiology ◽

10.1177/0003319716651166 ◽

2016 ◽

Vol 68 (3) ◽

pp. 242-250 ◽

Cited By ~ 11

Author(s):

Konstantinos Spanos ◽

Vasileios Saleptsis ◽

Athanasios Athanasoulas ◽

Christos Karathanos ◽

Alexandra Bargiota ◽

...

Keyword(s):

Quality Of Life ◽

Ulcer Healing ◽

Diabetic Foot ◽

Foot Ulcer ◽

Diabetic Foot Ulcer ◽

Major Amputation ◽

Diabetic Patients ◽

Factors Associated ◽

Minor Amputation

A prospective nonrandomized cohort study on consecutive diabetic patients with foot ulcer was undertaken to assess the factors associated with the healing process or limb salvage and evaluate the impact of their treatment on their quality of life. Quality of life was evaluated using Diabetic Foot Ulcer Scale–Short Form (DFS-SF) questionnaire before and after treatment. A total of 103 diabetic patients with ulcer (mean age 69.7 ± 9.6 years, 77% male) were treated and followed up for 12 months. Ulcer healing, minor amputation, and major amputation rates were 41%, 41%, and 18%, respectively, while the mortality rate was 18%. Ulcer healing was associated with University of Texas wound grade 1 and the Study of Infections in Diabetic feet comparing Efficacy, Safety and Tolerability of Ertapenem versus Piperacillin/Tazobactam trial’s diabetic foot infection wound score. Limb loss was associated with nonpalpable popliteal artery, longer in-hospital stay, and delay until referral. Quality of life was improved in all domains of DFS-SF ( P < .0001) throughout the cohort of our patients regardless of their outcome, and no outcome (healing, minor amputation, or major amputation) was superior to other. Significant improvement was observed in all domains of hygiene self-management after consultation during the follow-up period.

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