|Year : 2013 | Volume
| Issue : 1 | Page : 3-7
Clinical and microbiological profile of diabetic foot in patients admitted at a tertiary care center in Mangalore
K Ashwin Alva1, P Sathyamoorthy Aithala1, Rakesh Rai1, B Rekha2
1 Department of General Surgery, Father Muller Medical College, Kankanady, Mangalore, Dakshina Kannada, Karnataka, India
2 Department of Microbiology, Father Muller Medical College, Kankanady, Mangalore, Dakshina Kannada, Karnataka, India
|Date of Web Publication||20-May-2013|
K Ashwin Alva
Department of General Surgery, Father Muller Medical College, Kankanady, Mangalore, Dakshina Kannada, Karnataka - 575 006
Source of Support: None, Conflict of Interest: None
Background: Worldwide diabetes affects more than 194 million people and the figure is expected to reach 333 million by 2025. India is considered as the diabetic capital of the world. Diabetic foot is the most common complication of diabetes. Amputation which is the end result of diabetic foot disease is associated with significant morbidity and mortality. Since it is crucial to identity those at an increased risk of diabetic foot complications, a detailed study of the natural history of diabetic foot, various clinical characteristics, the role of micro-organisms and their contribution toward worsening of ulcerations was undertaken in our hospital. Materials and Methods: A prospective study was carried out on 100 diabetic patients with foot ulcers for a period of one and half years at Father Muller Medical college Hospital, Mangalore. Results: The data analysis of 100 patients yielded the following results. Diabetic foot was very common in the elderly age group (>55 years) 54% and male dominant (87%). Majority of them had diabetes for more than 5 years (41%) and complications of diabetes were present on admission in 15% of them. Presentation of diabetic foot in the form of single/multiple toe disarticulation/above knee/below knee amputation accounted for a quarter (23%) of surgical interventions in our hospital. The glycemic control in most of the patients was very poor with random blood sugar >200 mg/dl (70%) and glycosylated hemoglobin >7 g% (74%) of them. One-fourth of the patients stayed for at least a month in the hospital (25%). In culture, Gram-negative organisms were predominant (11%). The most common bacteria isolated were Staphylococcus aureus (20.6%), Pseudomonas (16.2%), Escherichia coli (14.7%), and Klebsiella (11.8%). Conclusion: Based on the results of our study, it can be concluded that diabetic foot in various forms accounts for significant morbidity in the surgical wards. The factors contributing mainly are poor glycemic control at the time of admission, presence of gangrene, complications of diabetes (nephropathy, neuropathy), and associated comorbidities (peripheral vascular disease, hypertension, ischemic disease). There is a lot of scope for improvement in the approach to treatment of diabetic foot in our set-up which needs urgent attention. This article is presented to highlight the colossal neglect in the management of diabetic foot in most of the tertiary care centers in and around this part of the world.
Keywords: Bacteria, complications, diabetes, foot
|How to cite this article:|
Alva K A, Aithala P S, Rai R, Rekha B. Clinical and microbiological profile of diabetic foot in patients admitted at a tertiary care center in Mangalore. Muller J Med Sci Res 2013;4:3-7
|How to cite this URL:|
Alva K A, Aithala P S, Rai R, Rekha B. Clinical and microbiological profile of diabetic foot in patients admitted at a tertiary care center in Mangalore. Muller J Med Sci Res [serial online] 2013 [cited 2023 Mar 20];4:3-7. Available from: https://www.mjmsr.net/text.asp?2013/4/1/3/112259
| Introduction|| |
Diabetes mellitus affects more than 194 million people worldwide and the figure is expected to reach 333 million by the year 2025. With the maximum number of cases being in developing countries, diabetes is a global problem. India has the highest number of diabetic patients and is considered as the "diabetic capital of the world." 
Diabetic foot is the most common complication of diabetes and is greater than retinopathy, nephropathy, heart attack, and stroke combined. Diabetic foot is one of the most feared complications of diabetes. The ultimate result of diabetic foot disease is amputation and is associated with significant morbidity and mortality.  It also has immense social, psychological and financial consequences for the patient and the family.
Diabetes associated problems are the second most common cause of lower limb amputations in India. Foot disorders such as ulcerations, infection, gangrene are the leading causes of hospitalization in patients with diabetes mellitus.  Diabetic foot and its sequel account for billions of dollars in direct medical expenditure as well as lengthy hospital stay and period of disability.  Majority of amputations are preceded by foot ulcerations.
| Materials and Methods|| |
A prospective study was carried out on 100 diabetic patients with foot ulcers for a period of one and half years at Father Muller Medical College hospital. Principles of convenience sampling were applied for collecting data in the study.
Diabetic foot infection is defined as the presence of ulcers (superficial to deep) on examination or evidence of inflammation, i.e., cellulitis or purulent discharge, or evidence of necrosis, with or without osteomyelitis or systemic toxicity.
Diabetics were diagnosed on the basis of fasting plasma glucose of 126 mg/dl and above or if symptoms were present (i.e., polyuria, polydipsia, polyphagia, weight loss, and blurred vision) and a random plasma concentration of 200 mg/dl or more, on two different occasions.
A semi-structured questionnaire was developed to record the medical history, examination details, and investigation reports. Detailed medical history and physical examination included demographic data, duration of diabetes, treatment compliance, method of glycemic control, history of previous amputation, awareness about complications, personal habits such as smoking and alcohol consumption, history of ischemic heart disease, hypertension or cerebrovascular disease, nephropathy, neuropathy, duration of wound, history of antibiotic intake prior to admission. Neuropathy was assessed with tuning fork, ischemia by pulsations of dorsalis pedis and posterior tibialis, osteomyelitis (to assess bone involvement) was diagnosed on X-rays, categorization of foot ulcers into five types based on Wagner's classification.
The extent of foot infection was assessed based on Wagner's classification as follows:
Grade 1: Ulceration involving only the dermis
Grade 2: Ulceration involving tendons and/or joint capsules
Grade 3: Extending to bone, usually causing osteomyelitis
Grade 4: Localized gangrene
Grade 5: Gangrene involving a major part of the foot.
Wound was thoroughly washed with saline to remove the slough and the local antiseptic application applied during previous dressing. Specimen was collected from the edge of the wound and sent to the lab immediately. Gram's staining was done followed by culture on 5% sheep blood agar, Mac Conkeys agar. After 24-48 h of incubation, bacterial growth was identified by colony morphology, Gram's staining and biochemical reactions. Antibacterial susceptibility test was done by Kirby Bauer's method for appropriate antibiotics.
| Results|| |
Most of the patients accrued in the study were of more than 45 years of age with 34% being in the 46-55 years, 33% in between the age of 56 years and 65 years and about 21% of >65 years of age. Most of the patients were ignorant in expressing the precise duration of diabetes mellitus. However, from the best of their knowledge it was expressed that the average duration available, was 29% (1-5 years), 13% (6-10 years), and 13% (10-15 years) respectively. Demographic data suggested that 56% of the patients belonged to proper Mangalore region, 7% arrived from Malnad region and 5% were from Uttara Kannada district of Karnataka. Additionally, a considerable population 32% was also from the northern most parts of the Kerala state.
Nearly 28% of the patients with the diabetic foot also had neuropathy, 22% had diabetic retinopathy, 15% had nephropathy at the time of admission. Diabetic foot complications manifests in myriad forms and in this study it was observed that 27% patients presented with abscess, 21% with cellulites, 25% with gangrene of one or more toes including forefoot along with abscess/cellulitis/ulcer, 19% with ulcer foot in various forms and 5% with necrotizing fasciitis.
Incision and drainage (24%) and wound debridement/slough excision (27%) formed the major chunk of surgical intervention in the hospital, which goes with the common mode of presentation. 19% of them underwent toe disarticulation (single/multiple) and also 2% had below knee amputation and above knee amputation each, while 8% of them were treated with split thickness skin grafting.
It was observed that nearly 58% of the patients needed hospitalization for nearly a month while 10% stayed for more than a month. However, stay of nearly 32% was unclear.
Microbiological studies performed represented a mosaic of pathogenic organisms. It was observed that out of the 55% patients in whom the wound swab was taken, 36% had isolated single bacteria, while 19% showed polymicrobial growth. Differential staining indicated that 55% of the organisms were Gram-negative, while the remaining were Gram-positive.
Further characteristics indicated the infection to be mostly by Staphylococcus (20.6%), Pseudomonas (16.2%), Escherichia More Details coli (14.7%), Klebsiella (11.8%), Methicillin Resistant Staphylococcus aureus (MRSA) and Enterococcus (10.3%). Culture sensitivity studies showed that E. coli was sensitive to Gatifloxacin (100%), Levofloxacin (60%), Amikacin (100%), and Gentamicin (60%). Klebsiella species were sensitive to imipenem, meropenem, gatifloxacin. Streptococcus was sensitive to ampicilin and amoxicillin. Pseudomonas was sensitive to amikacin (78%), cefaperazone-sulbactam (50%), imipenem, meropenem (43%). Proteus bacteria was sensitive to ceftriaxone (33%), imipenem (100%), meropenem (100%), piperacillin (100%), cefaperzone-sulbactam (100%). Staphylococcus was commonly sensitive to ceftriaxone, co trimoxizole, amoxyclav, vancomycin, ofloxacin while the drug resistant MRSA was sensitive to teicoplanin, vancomycin, amikacin, and gatifloxacin.
In our study, it was observed that 31 patients (31%) had to undergo amputation. Additionally, it was also observed that patients in whom the amputations had to be performed had diabetic nephropathy (34.4%), neuropathy (18.8%), and peripheral vascular disease (18.8%).
| Discussion|| |
Most of the patients belong to age group 46-55 years (34%), 56-65 years (33%), >65 years (21%). In Bansal et al.,  among those with diabetic foot ulcer 56.31% were in the age group of 51-70 years, which is comparable to our study. More than half of the patients were residents of Mangalore region and about 1/3 came from Kerala (Kasaragod, Kanhangad, Kannur) as our hospital is a tertiary care center and referral center for the coastal Karnataka and parts of the northern Kerala.
The duration for which patient is suffering from diabetes is directly related to the degree of wounds and also indirectly making the patient more vulnerable due to the complications of diabetes like nephropathy, neuropathy, and retinopathy in long-term disease. 29% suffered from diabetes mellitus for 1-5 years followed by 6-10 years and 10-15 years accounting for 13% each respectively.
In Bansal et al.,  48.54% had diabetes mellitus for than 10 years, which is more than three times our study. This can be substantiated by the fact that most of the patients were ignorant in expressing the precise duration of diabetes mellitus leading to inaccuracy in the duration of diabetes.
22% of the patients had neuropathy, equal proportion had retinopathy. Nephropathy was also quite common constituting 15%.
In Bansal et al.,  76% had neuropathy which does not match with our study.
In another observation byLevin,  the incidence of neuropathy is in 10-20%, which is comparable with our study. 25% had gangrene of one or more toes at the time of admission itself.
It was noted that one-fourth of the patients already had gangrene of one or more toes at the time of admission that inevitably ended up in amputation.
Another feature noted in our study was that none of the patients with peripheral vascular disease underwent any surgical intervention to improve the vascularity of the vessel, which is a major drawback in the treatment strategy for limb salvage in diabetic foot.
In the article by Robert G Frykberg, it is stressed that arterial reconstruction surgery forms an important part in the strategy for the limb salvage therapy.
68% of the patients had random blood sugar, more than 200 mg/dl and glycosylated hb% >7 in 74% (43) patients out of 58 patients.
These results are comparable with Bansal et al.  where random blood sugar >200 mg/dl was found in 67% and glycosylated hb% in 64% of the patients. Data available for 70% of patients among whom majority stayed up to one month (58%) and 10% stayed for more than a month.
Type and Number of the Organism Isolated Per Culture
- Gram-negative organism (55.8%) were the major isolates in our study
- 36% had grown single organism on culture
- Staphylococcus was the most common bacteria isolated
- MRSA accounted for 10.3% of all organisms, which forms a major chunk
- Bansal et al.  found that Gram-negative comprised 76% and Pseudomonas was the most common isolate followed by Staphylococcus (18.18%)
- In Catherine et al.,  more than half (65%) presented with single organism
- Proteus, being the most organism (13%) followed by E. coli (12%)
- MRSA accounted for 33% of staphylococcal infection in our study, whereas in Bansal et al. and Catherine et al.  it was quite high amounting to 56% and 69% respectively.
- E. coli - Sensitive to gatifloxacin (100%), amikacin (100%), and gentamicin (60%)
- MRSA - All are sensitive to linezolid, vancomycin, and teicoplanin (100%)
- Kleibsiella - All are sensitive to imipenem (100%) and meropenem (100%)
- Staphylococcus - Mostly sensitive to ceftriaxone (100%), cotrimoxazole (53.8%), amoxiclav (41.7%), vancomycin (100%), ofloxacin (58.3%)
- Pseudomonas - Sensitive to amikacin (77.7%), cefoperazone-sulbactam (50%), imipenem (42.9%), and meropenem (25%)
- Proteus - Sensitive to imipenem (100%), meropenem (100%), piperacillintazobactam (36%), cefoperazone-sulbactam (50%), and ceftriaxzone (33%)
- In Bansal et al.,  >75% of Gram-positive strains were sensitive to cephalosporins
- Pseudomonas - Sensitive to amikacin, cefoperazone-sulbactam, and imipenem
- All these are comparable to our study
- All MRSA strains were sensitive to vancomycin (100%) and resistant to ampicillin, cotrimoxazole and gentamicin, which is similar to our findings
- 34.4% of all amputation done in our study was presided by foot ulcers in various forms [Table 1]
|Table 1: The percentage of amputations preceded by ulcer and associated complications of diabetes per se like neuropathy, nephropathy, and retinopathy|
Click here to view
- 34.4% of these patients (amputation) had nephropathy and 18.8% had neuropathy and peripheral vascular disease each [Table 1]
- 85% of foot amputations are presided by foot ulcer according to Trautner et al.
Most of the micro organisms isolated were associated with Wagner grade 1 and 2 diabetic ulcers [Table 2].
|Table 2: Correlation between various micro‑organisms isolated from the ulcers and the Wagner grading of the diabetic foot Wagner|
Click here to view
A critical analysis showed that 34.4% of the amputations were preceded by an ulcer indicating that effective treatment of the ulcer can prevent amputation.
| Conclusion|| |
The lack of multi-disciplinary approach in the treatment of diabetic foot is quite obvious and there is a lot of scope of improvement in the form of holistic approach to a patient with diabetic foot rather than just treating the FOOT.
- Majority of the patients belong to age group >55 years and males are predominant
- Most of the patients come from Mangalore region and neighboring districts of Kerala
- Duration of diabetes for most of the patients is at least 5 years at the time of admission and complications in the form of neuropathy, nephropathy, and retinopathy are quite common
- Most common mode of presentation in our study is abscess followed by cellulitis and foot ulcers
- Amputations in the form of single, multiple toe disarticulations are rampant, contributing to significant morbidity, however, the notable feature is that 8% of these patients have undergone complete treatment for diabetic foot in the form of skin grafting at the first admission itself
- Peripheral arterial occlusive disease, hypertension, and ischemic heart disease add to the morbidity of diabetic foot and contribute to prolonged hospital stay and financial burden to the patient
- The glycemic control in majority of the patients is very poor, which again adds on to the delayed wound healing and worsening of the wound/gangrene
- Culture and sensitivity from the wounds plays an important role in prescribing the appropriate antibiotic at the time of admission itself rather than starting empirical treatment.
| References|| |
|1.||Murugan S, Mani KR, Devi U. Prevalence of MRSA among diabetic patients with foot ulcers and their antimicrobial susceptibility pattern. J Clin Diagn Res 2008;2:979-84. [Last cited 2009 Jun 2]. |
|2.||Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA 2005;293:217-28. |
|3.||Sadikot SM. The diabetic foot: Treatment, Available from: http://www.diabetesindia.com/diabetes/updates.htm#foot problem. [Last accessed on 2009 Aug 15] |
|4.||Frykberg RG. Diabetic foot ulcers: Pathogenesis and management. Am Fam Physician 2002;66:1655-62. |
|5.||Bansal E, Garg A, Bhatia S, Attri AK, Chander J. Spectrum of microbial flora in diabetic foot ulcers. Indian J Pathol Microbiol 2008;51:204-8. |
|6.||Levin EM. An overview of the diabetic foot: Pathogenesis, management and prevention of lesions. Int J Diabetes Dev Ctries 1994;14:39-47. |
|7.||Amalia SC, Colayco, Myrna T, Mendoza, Marissa M, Alejandria, et al. Microbiologic and clinical profile of anaerobic diabetic foot infections. Phil J Microbiol Infect Dis 2002;31:151-60. |
|8.||Trautner C, Haastert B, Giani G, Berger M. Incidence of lower limb amputations and diabetes. Diabetes Care 1996;19:1006-9. |
[Table 1], [Table 2]