Background:Confusion often arises in caring for diabetic foot infections and ulcers, especially with antimicrobials; we aim to shed light on this entity and alert healthcare workers to its stewardship. Methods:Records were reviewed between February 2016 and September 2023. Data for patients diagnosed with diabetes and foot ulcers, infected or not, were examined following ICD 9 search terms. Records for patients were included if they were prediabetic/diabetic adults with foot ulcers, more than 18 years old, and on antidiabetic treatment. Patients were excluded if they insulin resistant, with normal HgbA1c levels, wheel-chair dependent, bed-bound, non-diabetic patients, diabetic patients who had vascular lower limb surgery earlier to ulcers, diabetic patients who had aortocoronary bypass, deep venous thrombosis within six months, malignancy, and severe clinical depression. A modified IWGDF/IDSA guidelines definitions for DFI and DFU was considered. Statistical analysis was done using R programming. Statistical methods were employed as appropriate, and a significant P-value was considered for P < 0.05. Results:Most characteristics were well balanced between DFI and DFU, on imaging osteomyelitis and tissue swelling were significantly more in DFI. Endovascular radiological procedures showed angiograms to be considerably more in DFI, while angioplasty was more in DFU, in addition to smoking. Bacteremia was uncommon, and swab cultures were mostly polymicrobial in both ulcers; no clear association with blood bacteria was detected with the polymicrobial growth, though few were concordant. Antimicrobials prescribed for both ulcers were not statistically different except for carbapenems, which were more in DFI (P < 0.0001). Conclusion:Attention should be paid to best practices while caring for diabetic ulcers. These include swab culture interpretations, the use of antimicrobials, and plan management according to DFI or DFU to utilize either local care or combination with antimicrobials.
References
[1]
Boulton, A.J.M. (2004) The Diabetic Foot: From Art to Science. The 18th Camillo Golgi Lecture. Diabetologia, 47, 1343-1353. https://doi.org/10.1007/s00125-004-1463-y
[2]
Yousef AlAyed, M., Younes, N., Al-Smady, M., Saleh Khader, Y., Alwin Robert, A. and Ajlouni, K. (2017) Prevalence of Foot Ulcers, Foot at Risk and Associated Risk Factors among Jordanian Diabetics. Current Diabetes Reviews, 13, 182-191. https://doi.org/10.2174/1573399812666151210143140
[3]
Uysal, S., Arda, B., Taşbakan, M.I., Çetinkalp, Ş., Şimşir, I.Y., Öztürk, A.M., Uysal, A. and Ertam, İ. (2017) Risk Factors for Amputation in Patients with Diabetic Foot Infection: A Prospective Study. International Wound Journal, 14, 1219-1224. https://doi.org/10.1111/iwj.12788
[4]
Jbour, A.K., Jarrah, N.S., Radaideh, A.M., Shegem, N.S., Bader, I.M., Batieha, A.M. and Ajlouni, K.M. (2003) Prevalence and Predictors of Diabetic Foot Syndrome in Type 2 Diabetes Mellitus in Jordan. Saudi Medical Journal, 24, 761-764.
[5]
Ababneh, A., Bakri, F.G., Khader, Y., Lazzarini, P. and Ajlouni, K. (2020) Prevalence and Associates of Foot Deformities among Patients with Diabetes in Jordan. Current Diabetes Reviews, 16, 471-482. https://doi.org/10.2174/1573399815666191001101910
[6]
Lipsky, B.A. (2016) Diabetic Foot Infections: Current Treatment and Delaying the ‘Post-Antibiotic Era’. Diabetes/Metabolism Research and Reviews, 32, 246-253. https://doi.org/10.1002/dmrr.2739
[7]
Al Ramahi, J.W., Ajamieh, O.A., Marrar, N., Alalamat, L., Hasan, N., Jaber, A.E., Dodin, O. and Matar, A. (2020) The Rates of the Unnecessary Antimicrobial Use (UAU) and the Effect of the Infectious Disease Consultations: A Cross-Sectional Study. International Journal of Infectious Diseases and Therapy, 5, 56-63. https://doi.org/10.11648/j.ijidt.20200503.14
[8]
Lipsky, B.A., Armstrong, D.G., Citron, D.M., Tice, A.D., et al. (2005) Ertapenem versus Piperacillin/Tazobactam for Diabetic Foot Infections (SIDESTEP): Prospective, Randomised, Controlled, Double-Blinded, Multicentre Trial. The Lancet, 366, 1695-1703. https://doi.org/10.1016/S0140-6736(05)67694-5
[9]
Saltoglu, N., Surme, S., Ezirmik, E., Kadanali, A., Kurt, A.F., Sahin Ozdemir, M., et al. (2023) The Effects of Antimicrobial Resistance and the Compatibility of Initial Antibiotic Treatment on Clinical Outcomes in Patients with Diabetic Foot Infection. The International Journal of Lower Extremity Wounds, 22, 283-290. https://doi.org/10.1177/15347346211004141
[10]
Senneville, É., Albalawi, Z., Van Asten, S.A., Abbas, Z.G., Allison, G., et al. (2023) IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-Related Foot Infections (IWGDF/IDSA 2023). Diabetes/Metabolism Research and Reviews, 40, e3687. https://doi.org/10.1002/dmrr.3687
[11]
Von Elm, E., Altman, D.G., Egger, M., Pocock, S.J., Gøtzsche, P.C. and Vandenbroucke, J.P. (2007) The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) Statement: Guidelines for Reporting Observational Studies. The Lancet, 370, 1453-1457. https://doi.org/10.1016/S0140-6736(07)61602-X
[12]
Lipsky, B.A., Berendt, A.R., Cornia, P.B., Pile, J.C., Peters, E.J., Armstrong, D.G., Senneville, E., et al. (2012) Executive Summary: 2012 Infectious Diseases Society of America Clinical Practice Guideline for the Diagnosis and Treatment of Diabetic Foot Infections. Clinical Infectious Diseases, 54, 1679-1684. https://doi.org/10.1093/cid/cis460
[13]
Shin, L., Armstrong, D. and Sanders, L.J. (2023) Foot Ulcers. https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_Diabetes_Guide/547054/all/Foot_Ulcers#:~:text=Diabetic foot ulcer (DFU):,, or neuroischemic (mixed)
[14]
Agale, S.V. (2013) Chronic Leg Ulcers: Epidemiology, Aetiopathogenesis, and Management. Ulcers, 2013, Article ID: 413604. https://doi.org/10.1155/2013/413604
[15]
Armstrong, D.G., Tan, T.W., Boulton, A.J. and Bus, S.A. (2023) Diabetic Foot Ulcers: A Review. JAMA, 330, 62-75. https://doi.org/10.1001/jama.2023.10578
[16]
Syauta, D., Hendarto, J., Mariana, N., Kusumanegara, J. and Faruk, M. (2021) Risk Factors Affecting the Degree of Diabetic Foot Ulcers according to Wagner Classification in Diabetic Foot Patients. Medicina Clínica Práctica, 4, Article 100231. https://doi.org/10.1016/j.mcpsp.2021.100231
[17]
Ledoux, W.R., Shofer, J.B., Smith, D.G. and Sullivan, K. (2005) Relationship between Foot Type, Foot Deformity, and Ulcer Occurrence in the High-Risk Diabetic Foot. Journal of Rehabilitation Research and Development, 42, 665-672.
[18]
Sohn, M.W., Budiman-Mak, E., Lee, T.A., Oh, E. and Stuck, R.M. (2011) Significant J-Shaped Association between Body Mass Index (BMI) and Diabetic Foot Ulcers. Diabetes/Metabolism Research and Reviews, 27, 402-409. https://doi.org/10.1002/dmrr.1193
[19]
Biasucci, L.M., Graziani, F., Rizzello, V., Liuzzo, G., Guidone, C., De Caterina, A.R., Brugaletta, S., Mingrone, G. and Crea, F. (2010) Paradoxical Preservation of Vascular Function in Severe Obesity. The American Journal of Medicine, 123, 727-734. https://doi.org/10.1016/j.amjmed.2010.02.016
[20]
Karter, A.J., Stevens, M.R., Brown, A.F., Duru, O.K., Gregg, E.W., Gary, T.L., Ettner, S.L., et al. (2007) Educational Disparities in Health Behaviors among Patients with Diabetes: The Translating Research into Action for Diabetes (TRIAD) Study. BMC Public Health, 7, Article No. 308. https://doi.org/10.1186/1471-2458-7-308
[21]
Purwanti, O.S., Yetti, K. and Herawati, T. (2016) Duration of Diabetic Correlated Diseases with Diabetic Foot Ulcers at DR Moewardi Hospital of Surakarta. International Conference on Health and Well-Being, Surakarta, 27-28 May 2016, 359-363.
[22]
Stuermer, E.K., Besser, M., Terberger, N., Koester, V., Bachmann, H.S. and Severing, A.L. (2019) Side Effects of Frequently Used Oral Antidiabetics on Wound Healing in vitro. Naunyn-Schmiedeberg’s Archives of Pharmacology, 392, 371-380. https://doi.org/10.1007/s00210-018-01597-9
[23]
Sapico, F.L., Bessman, A.N. and Canawati, H.N. (1982) Bacteremia in Diabetic Patients with Infected Lower Extremities. Diabetes Care, 5, 101-104. https://doi.org/10.2337/diacare.5.2.101
[24]
Bizri, A.R., El-Fattah, A.A., Bazaraa, H.M., Al Ramahi, J.W., Matar, M., Ali, R.A.N., Aziz, M.A., et al. (2023) Antimicrobial Resistance Landscape and COVID-19 Impact in Egypt, Iraq, Jordan, and Lebanon: A Survey-Based Study and Expert Opinion. PLOS ONE, 18, e0288550. https://doi.org/10.1371/journal.pone.0288550
[25]
Al Ramahi, J.W. and Jamal, W. (2020) A Ten Years Study of the Rates and Resistance Trends of the ESKAPE Bacteria Isolated from Sterile Body Sites (2010 –2019) at a Single Hospital. The International Arabic Journal of Antimicrobial Agents, 10.
