Risk factors for foot ulcers in patients with diabetes mellitus - a short report from vellore, South India

Bacteriological Profile of Diabetic Foot Ulcer With Special Reference to Biofilm Formation

Introduction Diabetes mellitus is a metabolic disorder characterized by abnormally high sugar levels in the blood for prolonged periods of time. The world's largest number of diabetics resides in India, making it the world's diabetic capital, with a diabetic foot ulcer (DFU) incidence of around 8-17%. Due to the polymicrobial and multidrug resistant (MDR) nature of DFUs, antimicrobial susceptibility testing is of high importance to help treat patients effectively and prevent the development of MDR bacteria. The ability to form biofilms is a significant additive to virulence of an organism that causes an able strain to be resistant to more antibiotics as compared to a free-living strain, thereby further delaying the healing of DFUs. Materials and methods This study included 74 samples collected from patients with DFUs, out of which 69 (93.24%) yielded growth on culture. Gram staining was done for the direct microscopy, isolation, and determination of organism, and the detection of biofilm formers using Congo Red Agar plates. Data were tabulated and statistically analyzed. Results Out of 74 samples collected, 69 (93.24%) yielded growth on culturing, with 5 (6.76%) cultures coming back negative. On Gram staining, 42 (56.8%) samples showed Gram-positive cocci and 53 (71.6%) showed Gram-negative bacilli. On isolating organisms from the samples, 16 (21.7%) samples had Pseudomonas aeruginosa, followed by Klebsiella pneumoniae at 13 (17.6%) and Proteus mirabilis and Escherichia coli at 11 each (14.9%), indicating a Gram-negative bacteria predominance. Of the Gram-positive bacteria isolated, Staphylococcus aureus stands at two (2.7%) and Streptococcus pyogenes at one (1.4%). The prevailing monomicrobiality could be attributed to antibiotic administration prior to sample collection. On antibiotic sensitivity of organisms tested against each antibiotic, more than 75% of tested samples were resistant to ampicillin, cefuroxime, and erythromycin, and around 70% and more of tested samples were sensitive to ertapenem, meropenem, amikacin, gentamicin, benzylpenicillin, vancomycin, and clindamycin. Out of the 69 positive cultures, 29 (42.03%) yielded biofilm formers. Pseudomonas aeruginosa was the predominant biofilm former with 10 (34.48%) of 29 of total biofilm-forming isolates, followed by E. coli and K. pneumoniae with five each (17.24%) and Proteus mirabilis with three samples (10.34%). Regarding strains forming biofilms according to bacterium species, S. aureus was predominant, with 100% (two out of two samples) of isolates forming biofilms. Staphylococcus aureus was followed by Pseudomonas aeruginosa with 62.5% (10 out of 16 samples), Acinetobacter baumannii (two out of four samples) and Enterobacter cloacae (one out of two samples) with 50% each, E. coli with 45.45% (5 out of 11 samples), and K. pneumoniae with 38.46% (5 out of 13 samples) of isolates forming biofilms. It should be noted that only two S. aureus, four A. baumannii, and two Enterobacter cloacae samples were isolated in comparison to a larger number of Gram-negative bacteria. This study has found that 100% of multidrug-resistant organisms (MDROs) are biofilm formers. Conclusion The ability to form biofilms adds immensely to the virulence and antibiotic resistance. Detection of biofilm formers is non-invasive and convenient to measure and would help provide insight into antibiotics to be administered to the patient, thereby reducing development of MDROs and reducing healing time.

Assessment of diabetic foot ulcers: back to basics

Diabetic foot ulceration affects up to 34% of the global diabetic population as a result of poor glycaemic control. Complications resulting from diabetic foot ulceration can be complex, expensive and challenging. It is important for risk factors to be recognised early and for regular assessment to take place. Streamlining a coordinated approach that enhances communication and guides treatment approaches can help to improve wound outcomes.

Risk factors of diabetic foot ulcer in patients with type 2 diabetes: a retrospective cohort study

The aim of this study is to investigate the risk factors of diabetic foot ulcer (DFU) in patients with Type 2 diabetes. Baseline characteristics of DFU-free patients with Type 2 diabetes were retrospectively collected and DFU was identified during the follow-up. Incidence of DFU was calculated and cumulative incidence was estimated by Kaplan-Meier method. Cox regression model was used to explore factors associated with DFU. A total of 980 patients were included with a median follow-up time of 28.7 months. 259 (26.4%) patients developed DFU with an incidence rate of 11.3 per 100 person-years. The cumulative incidences of DFU at 1 year and 2 years during the follow-up were 5.4% (95% CI 3.9-6.9%) and 14.1% (95% CI 11.7-16.5%), respectively. Cox regression analysis indicated that factors associated with developing DFU included age (hazard ratio (HR)=1.06, 95% CI 1.05-1.07, per 1-year increase), body mass index (HR=1.05, 95% CI 1.02-1.07), higher level of education (HR=0.77, 95% CI 0.60-0.98), hypertension (HR=1.90, 95% CI 1.47-2.45), hyperlipidemia (HR=2.63, 95% CI 2.02-3.43), coronary heart disease (HR=2.88, 95% CI 2.22-3.75), heart failure (HR=2.47, 95% CI 1.91-3.20), stroke (HR=2.44, 95% CI 1.86-3.19), diabetic retinopathy (HR=1.86, 95% CI 1.40-2.48), diabetic kidney disease (HR=1.89, 95% CI 1.41-2.53), diabetic neuropathy (HR=1.73, 95% CI 1.31-2.30), poor glycemic control (HR=1.13, 95% CI 1.07-1.19, per 1% glycosylated hemoglobin increase), and course of diabetes (HR=1.01, 95% CI 1.00-1.01, per 1-month increase). The results showed a relatively high incidence of DFU, and revealed several baseline characteristics identified as risk factors of developing DFU.

Diabetes-related foot disorders among adult Ghanaians

Background: Diabetic foot remains a challenge in most low-middle-income countries (LMICs). A severe deficit in data exists on them in sub-Saharan Africa (SSA). Up-to-date data on the longitudinal trajectories and determinants can provide a benchmark for reducing diabetic foot complications in SSA. Objective: The primary objective of this study was to estimate trends in the incidence of diabetic foot and determine predictors in an adult Ghanaian diabetes cohort. Design: The study is a retrospective longitudinal study over a 12 year period. Methods: We applied Poisson regression analysis and Cox proportional hazard models to demographic and clinical information obtained from patients who enrolled in a diabetes specialist clinic in Ghana from 2005 to 2016 to identify longitudinal trends in incidence and predictors of diabetic foot. Results: The study comprised 7383 patients (63.8% female, mean follow-up duration: 8.6 years). The mean incidence of foot disorders was 8.39% (5.27% males and 3.12% females). An increase in the incidence of diabetic foot ranging from 3.25% in 2005 to 12.57% in 2016, p < 0.001, was determined. Diabetic foot, with adjusted hazard ratio (HR; 95% confidence interval (CI)), was predicted by disease duration, that is, for every 5-year increase in diabetes duration: 2.56 (1.41-3.06); male gender: 3.51 (1.41-3.06); increased body mass index (BMI), that is, for every 5 kg/m2: 3.20 (2.51-7.52); poor glycaemic control, that is, for every percentage increase in HbA1c: 1.11 (1.05-2.25), hypertension: 1.14 (1.12-3.21); nephropathy: 1.15 (1.12-3.21); and previous foot disorders: 3.24 (2.12-7.21). Conclusions: We have found a trend towards an increased incidence of diabetic foot in an outpatient tertiary diabetes setting in Ghana. Systemic and individual-level factors aimed at preventive foot screening as well as vascular risk factor control should be intensified in diabetic patients in Ghana and other LMICs. Abbreviations: BMI: Body Mass Index, BP: Blood Pressure, CI: Confidence Interval, HR: Hazard Ratio, HbA1c: Glycated Hemoglobin, PAD: Peripheral Arterial Disease, NCDs: Non Communicable Disease, SSA: Sub Saharan Africa.

Community based study to assess the prevalence of diabetic foot syndrome and associated risk factors among people with diabetes mellitus

BACKGROUND

Diabetic foot is one of the most significant and devastating complication of diabetes. The objective of this study was to assess the prevalence of diabetic foot syndrome (DFS) and the associated risk factors among people with diabetes mellitus.

METHODS

A community based cross-sectional study was carried out among 620 subjects with diabetes mellitus (DM) in rural areas of Udupi district. The Michigan Neuropathy Screening Instrument was used to identify peripheral neuropathy. Ankle brachial index was used to identify peripheral arterial disease (PAD). Subjects with diabetic foot syndrome were classified according to the International Working Group on Diabetic Foot (IWGDF) classification system.

RESULTS

The overall prevalence of DFS was 51.8%. Among them 31.3, 11.9 and 8.5% belonged to category 1, 2 and 3 respectively. Multivariate logistic regression analysis showed advancing age, low socio-economic status, sedentary physical activity and longer duration of DM were significant independent correlates of DFS.

CONCLUSION

The overall prevalence of DFS was high among the study population; hence the screening for foot complications should start at the time of diagnosis of diabetes integrated with sustainable patient education at primary care level by training of health care providers at primary care level.

Assessment of chronic wounds in adults: an integrative review

OBJECTIVE

To identify the main aspects that should be assessed in adults with chronic wounds.

METHOD

This was an integrative review of the scientific literature published between 2010 and early 2015 in the PubMed and Web of Science databases.

RESULTS

Few studies exclusively address wound assessment. However, the review found many aspects to consider when assessing individuals with ulcers, grouped as follows: factors that significantly affect healing or the development of new wounds (age, nutritional status, functional capacity, or comorbidities), pyschosocial factors, and wound characteristics (location, size, depth, type of tissue, time of evolution).

CONCLUSION

The literature search did not result in any one aspect that must be considered when assessing chronic wounds, but a complex interaction of factors that include both physiological and social and psychological elements. Professionals should be aware of this multifactorial approach to achieve early detection of the development and evolution of ulcers and to intervene accordingly.

A study of risk factors and foot care behavior among diabetics

Background:

Diabetic foot results in considerable morbidity and mortality in developing countries and the prevalence of diabetes is expected to increase further in the next decades in these countries. Diabetic ulcers are the most common foot injuries leading to lower extremity amputation. Family physicians have a pivotal role in the prevention or early diagnosis of diabetic foot complications. Patient education regarding foot hygiene, nail care and proper footwear is crucial to reducing the risk of an injury that can lead to ulcer formation.

Materials and Methods:

This is a prospective study carried out from July 2013 to September 2015. Fifty patients of Diabetes with foot ulcer and two hundred without foot ulcers were examined. Risk factors and clinical profile of patients were studied which included age, gender, duration of diabetes, BMI, smoking, random BSLs history, hypertension, glycated haemoglobin levels, lipid profile, history of loss of sensation and history of amputation. MNSI questionnaire and MNSI practical assessment for neuropathy were administered to diabetic patients along with a pre-structured questionnaire regarding foot care practices.

Results:

In this study significant risk factors were peripheral neuropathy, peripheral vascular disease, gender, loss of sensation, duration of diabetes and smoking. MNSI questionnaire and practical assessment scores were higher in foot ulcer patients. Poor foot care practices were observed in patients with diabetic foot ulcer patients.

Conclusion:

Diabetic foot ulcers were more common in elderly males. Peripheral neuropathy, peripheral vascular disease, Smoking, trauma, duration of diabetes mellitus and high levels of glycated haemoglobin had significant association with occurrence of foot ulcers. MNSI scores had a high predictive value for development of foot ulcers amongst diabetics. Awareness regarding foot care was poor which underlines need to promote practice of foot care amongst diabetic population.

Spectrum of bacteria associated with diabetic foot ulcer and biofilm formation: A prospective study

BACKGROUND

India has the world's largest number of diabetics. Non-traumatic lower limb amputation is the most common devastating complication of diabetes, primarily due to diabetic foot ulcers (DFU) and diabetic foot infections (DFI). In India, the incidence of foot ulcers ranges from 8-17 per cent. DFIs are predominantly polymicrobial and multidrug-resistant (MDR) with the ability to form biofilm, which is an important virulence factor and results in treatment failure.

AIMS

The main objectives of the study are to identify the spectrum of multidrug-resistant bacteria associated with these infections, their antibiotic sensitivity pattern, and to detect the biofilm formation.

METHODS

This was a prospective study at a tertiary care hospital. One hundred patients over the age of 18, having chronic diabetic foot ulcer, and attending the surgery outpatient department were included. Samples of pus were collected from deep wounds and processed using standard techniques for culture and sensitivity. Biofilm detection was done. Results were compiled and statistically analysed.

RESULTS

One hundred samples were processed and 82 yielded positive cultures. Staphylococcus aureus was the predominant organism, followed by Pseudomonas aeruginosa. Biofilm formation was seen in 38 (46.34 per cent) of the organisms. Biofilms were formed predominantly by Staphylococcus aureus (20 per cent).

CONCLUSION

The organisms causing chronic diabetic foot ulcers were commonly multidrug-resistant; this was also observed among biofilm formers. Therefore, screening for biofilm formation, along with the usual antibiogram, needs to be performed as a routine procedure in chronic diabetic ulcers to formulate effective treatment strategies for these patients.