Ranjini, C Y (2006) A Microbial Study of Diabetic Foot Ulcer Infections. Masters thesis, Madras Medical College, Chennai.
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Abstract
INTRODUCTION : Diabetes mellitus with its multisystem affliction has emerged as the scourge of the 21st century, reaching pandemic proportion and causing devastating consequences. Foot ulcers are a significant complication of diabetes mellitus and often lead to lower-extremity amputation. Approximately 85 percent of all diabetes-related lower-extremity amputations are preceded by foot ulcers84.They are the most common cause of disability and hospitalization in patients with diabetes and are the disease’s most expensive complication. The WHO defines diabetic foot as “Infection, ulceration and/or destruction of deep tissues associated with neurological abnormalities and various degrees of peripheral vascular disease in the lower limb”. The underlying etiologies are neuropathy, trauma, deformity, high plantar pressures, infection, impaired wound healing, limited joint mobility and peripheral arterial disease. These factors lead to foot ulceration, gangrene and, finally, amputation if appropriate intervention is not applied. Diabetic ulcers are at high risk of infection secondary to impaired leukocyte chemotaxis and phagocytosis. High glucose levels and poor tissue perfusion may compound this condition. Decreased ability to fight off infection combined with tissue hypoxia creates an ideal environment for a necrotizing infection. Limb-threatening diabetic infections are usually polymicrobial involving multiple aerobic and anaerobic infections. Staphylococcus aureus, Streptococcus spp., Enterobacteriaceae, Bacteroides fragilis, Peptococcus spp. and Peptostreptococcus spp. may be cultured from diabetic ulcers. AIMS AND OBJECTIVES : 1. To evaluate the precipitating cause, severity and complications of foot ulcers of patients with diabetic foot treated in our hospital. 2. To identify the aerobic, anaerobic and fungal pathogens involved in the different grades of diabetic foot ulcers. 3. To establish an effective antimicrobial regimen for empirical treatment of diabetic foot infections. MATERIALS AND METHODS : This is a cross-sectional study conducted at the Institute of Microbiology at Madras Medical College, Chennai for a period of one year from December 2004 to December 2005.Samples of wound isolates taken from 104 patients with diabetic foot ulcer attending as outpatients in the Diabetology OP and those admitted in the surgical wards of the Diabetology Department were collected and processed. 30 outpatients and 74 inpatients were included in the study. Inclusion criteria: Male and female Diabetic patients in the age range of 20 to 90 having type 1 or type 2 diabetes and presenting with grade 1 to grade 5 foot ulcers were selected in the study. Each patient was included only once in the study. Exclusion criteria: Patients presenting with just callus and no foot ulcer (grade 0) were excluded from the study. RESULTS : Males were more commonly affected. Male: female ratio =1.53:1. The age ranges of the patients varied from 25 to 82 years. Majority (44.23%) of the patients were in the 51-60 age group. Mean age of patients = 54.93. (Standard deviation = 10.926). Right foot (62.5%) was more involved than the left. Majority of the patients had Grade 4 ulcers. (40.38%) Since ours is a tertiary care hospital catering to the poor socioeconomic group, patients presented with the advanced stage of the disease more frequently. Patients were predominantly suffering from type 2 diabetes (93.26%). Duration of diabetes mellitus was another important risk factor and it varied from as less as 4 months to 17 years. Thirteen of them were diagnosed as diabetic only on admission. Most (42.30%) of the patients had DM for 6-10 years. Trauma (33.65%) and smoking (30.76%) were the most common risk factors, followed by alcohol intake and previous ulcer. None of the risk factors assessed were significant ( p value >0.05) for the development of foot ulcer. Neuropathy was seen in 67.30% of patients. Most of them had Mild neuropathy (37.5%).Neuropathy was significant for the development of foot ulcer. (p <0.05) N=74.Vascular assessment using Doppler was done for the in-patients. Impaired vascularity was seen in 27 patients. (25.96%) Nine patients (12.16%) had purely ischemic while 18 (24.32%) had neuro-ischemic ulcers. The morbidity of the disease is increased by other associated medical illnesses. Coronary heart disease and hypertension were present in eight patients each, while renal dysfunction was present in 5 patients. CONCLUSION : The study revealed that • Peripheral neuropathy and longer duration of diabetes are the factors that predispose to foot ulcers while polymicrobial infection and increasing grade of foot ulcer aggravated the chance of amputation. • The most common microorganisms were gram-negative aerobes, and the isolation pattern, according to the grade of ulcer was primarily Staphylococcus aureus in Wagner I diabetic foot. Gram-negative organisms, majority of which were Proteus mirabilis sp. and Escherichia coli sp., were isolated as the foot grade advanced to gangrene. Significant anaerobic growth was observed in Wagner’s IV and V lesions. • Management of early stages include treatment with oral quinolones / cloxacillin / Cephalosporins. Ampicillin- Sulbactam and Cefaperazone-Sulbactam were found to be very effective drugs. Imipenem monotherapy or third-generation Cephalosporins with beta lactamase inhibitors plus an anti-anaerobe drug are attractive regimens for the advanced stage of the disease.
| Item Type: | Thesis (Masters) |
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| Uncontrolled Keywords: | Microbial ; Diabetic Foot Ulcer Infections. |
| Subjects: | MEDICAL > Microbiology |
| Depositing User: | Subramani R |
| Date Deposited: | 16 Aug 2017 00:35 |
| Last Modified: | 16 Aug 2017 01:27 |
| URI: | http://repository-tnmgrmu.ac.in/id/eprint/1773 |
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