An evaluation of risk factors affecting amputation in patients with diabetic foot Infection

Year 2021, Volume: 4 Issue: 1, 49 - 54, 21.01.2021

Handan Alay Sinan Yılmaz Fatma Kesmez Can Mehmet Parlak

https://doi.org/10.32322/jhsm.809986

Cited By: 1

Abstract

Introduction: Diabetic foot infections are one of the most common complications of diabetes and generally result in lower extremity amputations.
Aim: The purpose of this study is to investigate risk factors affecting amputation in patients diagnosed with diabetic foot ulcer.
Materials and Methods: This prospective cohort study involved 137 patients diagnosed with diabetic foot infection in a university hospital diabetic foot clinic.
Results: The mean age of the participants was 60.5±10.1 years, and 70.8% (n=97) were men. The majority of patients (62.0%) were educated to elementary or middle school level, while 26.3% were illiterate. Mean duration of diabetes was 13.3±6.2 years. Hypertension was present in 48.2% of patients, hypercholesterolemia in 31.4%, cardiovascular disease (CVD) in 38%, peripheral artery disease (PAD) in 21.2%, peripheral venous insufficiency in 10.2%, and polyneuropathy in 70.1%, and 9.5% were receiving hemodialysis. According to the Infectious Diseases Society of America classification, moderate foot ulcers were present in 60.6% of patients, mild ulcers in 34.3%, and severe ulcers in 5.1%. Forty-six percent of patients were diagnosed with osteomyelitis during follow-up. Amputation was present in 28.5% (n=39) of the patients followed-up due to foot ulcers. PAD increased the risk of amputation 2.7-fold (95% CI: 1.02-7.14), osteomyelitis 2.6-fold (95% CI: 1.10-6.16), and repeated hospitalizations 5.9-fold (95% CI: 2.25-15.33). Growth was observed in 72.6% of patients without amputation, 76.5% were polymicrobial, and 65.9% of antibiogram results were multidrug resistant. No significant difference was observed among the patients in terms of multidrug resistance (p=0.468).
Conclusion: PAD, osteomyelitis, and history of repeated hospitalizations are separate risk factors for amputation in patients with diabetic foot ulcers.

Keywords

Diabetic foot, amputation, risk factors, infection, multidrug resistance

References

• International Diabetes Federation, IDF Diabetes Atlas, International Diabetes Federation, Brussels, Belgium, 8th edition, 2017.
• Zhang P, Lu J, Jing Y, Tang S, Zhu D, Bi Y. Global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis (dagger). Ann Med 2017; 49: 106-16.
• Apelqvist J, Larsson J. What is the most effective way to reduce incidence of amputation in the diabetic foot? Diabetes Metab Res Rev 2000; 16: S75-83.
• Chronic Complications of Diabetes, Diabetes and Foot. National Diabetes Consensus Group. TURKDIAB Diabetes Diagnosis and Treatment Guideline 2019; 121-30.
• Brownrigg JRW, Griffin M, Hughes CO, et al. Influence of foot ulceration on cause-specific mortality in patients with diabetes mellitus. J Vasc Surg 2014; 60: 982–6.
• Turhan V, Mutluoglu M, Acar A, et al. Increasing incidence of Gram-negative organisms in bacterial agents isolated from diabetic foot ulcers. J Infect Dev Ctries 2013; 7: 707-12.
• Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med 2017; 376: 2367.
• Lipsky BA, Berendt AR, Cornia PB, et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2012; 54: 132-73.
• Neves J, Matias R, Formiga A, et al. O pé diabético com infecção aguda: tratamento no Serviço de Urgência em Portugal. Rev Port Cir 2013; 27: 19-36.
• Sánchez-Sánchez M, Cruz-Pulido WL, Bladinieres-Cámara E, AlcaláDurán R, Rivera-Sánchez G, Bocanegra-García V. bacterial prevalence and antibiotic resistance in clinical isolates of diabetic foot ulcers in the Northeast of Tamaulipas, Mexico. Int J Low Extrem Wounds 2017; 16: 129-34.
• Spicler A, Hurwitz BL, Armstrong DG, Lipsky BA. Microbiology of diabetic foot infections: from Luis Pasteur to ‘crime scene investigation’. BMC Med 2015; 13: 1-13.
• Magiorakos AP, Srinivasan A, Carey RB, et al. Multidrug-resistant, extensively drugresistant and pandrug-resistant bacteria: an international expert proposal for interim standard definitions for acquired resistance. Clin Microbiol Infect 2012; 18: 268–81.
• Barwell ND, Devers MC, Kennon B, et al. Scottish diabetes foot action group. Diabetic foot infection: antibiotic therapy and good practice recommendations. Int J Clin Pract 2017; 71: 10.1111/ijcp.13006.
• Apelqvist J, Larsson J. What is the most effective way to reduce incidence of amputation in the diabetic foot? Diabetes Metab Res Rev 2000; 16: 75-83.
• Baba M, Davis WA, Norman PE, Davis TME. Temporal changes in the prevalence and associates of diabetes-related lower extremity amputations in patients with type 2 diabetes: the Fremantle Diabetes Study. Cardiovasc Diabetol 2015; 14: 1-10.
• De Jesus-Silva SG, De Oliveira JP, Colepicolo Brianezi MH, De Moraes Silva MA, Krupa AE, Cardoso RS. Analysis of risk factors related to minor and major lower limb amputations at a tertiary hospital. J Vasc Bras 2017; 16: 16-22.
• Namgoong S, Jung S, Han SK, Jeong SH, Dhong ES, Kim WK. Risk factors for major amputation in hospitalised diabetic foot patients. Int Wound J 2016; 13: 13-9.
• Moon KC, Kim SB, Han SK, Jeong SH, Dhong ES. Risk factors for major amputation in hospitalized diabetic patients with forefoot ulcers. Diabetes Res Clin Pract 2019; 158: 107905.
• Al-Mahroos F, Al-Roomi K. Diabetic neuropathy, foot ulceration, peripheral vascular disease and potential risk factors among patients with diabetes in Bahrain: a nationwide primary care diabetes clinic-based study. Ann Saudi Med 2007; 27: 25-31.
• Bruun C, Siersma V, Guassora AD, Holstein P, de Fine Olivarius N. Amputations and foot ulcers in patients newly diagnosed with type 2 diabetes mellitus and observed for 19 years. The role of age, gender and co-morbidity. Diabet Med 2013; 30: 964-72.
• Larsson LG, Baum J, Mudholkar GS. Hypermobility: features and differential incidence between the sexes. Arthritis Rheum. 1987; 30: 1426-30.
• Cheng YJ, Gregg EW, Kahn HS, Williams DE, De Rekeneire N, Narayan KM. Peripheral insensate neuropathy-a tall problem for US adults? Am J Epidemiol 2006; 164: 873-80.
• Hjelm K, Nyberg P, Apelqvist J. Gender influences beliefs about health and illness in diabetic subjects with severe foot lesions. J Adv Nurs 2002; 40: 673-84.
• Orneholm H, Apelqvist J, Larsson J, Eneroth M. High probability of healing without amputation of plantar forefoot ulcers in patients with diabetes. Wound Repair Regen 2015; 23: 922-31.
• Al-Rubeaan K, Youssef AM, Ibrahim HM, et al. All-cause mortality and its risk factors among type 1 and type 2 diabetes mellitus in a country facing diabetes epidemic. Diabetes Res Clin Pract 2016; 118: 130-9.
• Boyko EJ, Ahroni JH, Stensel V, Forsberg RC, Davignon DR, Smith DG. A prospective study of risk factors for diabetic foot ulcer. The Seattle Diabetic Foot Study. Diabetes Care 1999; 22: 1036-42.
• Shatnawi NJ, Al-Zoubi NA, Hawamdeh HM, Khader YS, Garaibeh K, Heis HA. Predictors of major lower limb amputation in type 2 diabetic patients referred for hospital care with diabetic foot syndrome. Diabetes Metab Syndr Obes 2018; 11: 313-9.
• Pscherer S, Dippel FW, Lauterbach S, Kostev K. Amputation rate and risk factors in type 2 patients with diabetic foot syndrome under real-life conditions in Germany. Prim Care Diabetes 2012; 6: 241-6.
• Selvin E, Marinopoulos S, Berkenblit G, et al. Meta-analysis: glycosylated hemoglobin and cardiovascular disease in diabetes mellitus. Ann Intern Med 2004; 141: 421–31.
• Winkley K, Stahl D, Chalder T, Edmonds ME, Ismail K. Risk factors associated with adverse outcomes in a population-based prospective cohort study of people with their first diabetic foot ulcer. J Diabetes Complications 2007; 21: 341–9.
• Cardoso HC, Zara ALSA, Rosa SSRF, et al. Risk factors and diagnosis of diabetic foot ulceration in users of the Brazilian public health system. J Diabetes Res 2019; 2019: 5319892.
• Namgoong S, Jung S, Han SK, Jeong SH, Dhong ES, Kim WK. Risk factors for major amputation in hospitalised diabetic foot patients. Int Wound J. 2016 Mar; 13 Suppl 1: 13-9.
• Al-Rubeaan K, al Derwish M, Ouizi S, et al. Diabetic foot complications and their risk factors from a large retrospective cohort study. PLoS One 2015; 10: e0124446.
• Khawaja N, Abu-Shennar J, Saleh M, Dahbour SS, Khader YS, Ajlouni KM. The prevalence and risk factors of peripheral neuropathy among patients with type 2 diabetes mellitus; the case of Jordan. Diabetol Metab Syndr. 2018; 10: 8.
• Nelson RG, Gohdes DM, Everhart JE, et al. Lower-extremity amputations in NIDDM. 12-yr follow-up study in Pima Indians. Diabetes Care 1988; 11: 8–16.
• Chaturvedi N, Stevens LK, Fuller JH, Lee ET, Lu M. Risk factors, ethnic differences and mortality associated with lower-extremity gangrene and amputation in diabetes. The WHO Multinational Study of Vascular Disease in Diabetes. Diabetologia 2001; 44: S65-S71.
• Faglia E. Characteristics of peripheral arterial disease and its relevance to the diabetic population. Int J Low Extrem Wounds 2011; 10: 152–66.
• Oliveira AFD, Oliveira Filho HD. Microbiological species and antimicrobial resistance profile in patients with diabetic foot infections. J Vasc Bras 2014; 13: 289-93.
• Oliva A, Giacobbe DR, Di Luca M, Miller NS. New ınsights into ınfections due to multidrug resistant gram negative bacteria: the ınterplay between lab and clinic. Biomed Res Int 2018; 2018: 8905874.