Clinical Profile and Management of Diabetic Foot Infection at Hayatabad Medical Complex, Peshawar

Diabetes mellitus is a serious global health concern, affecting approximately 422 million individuals worldwide and leading to more than 2 million deaths annually (C​o​u​s​i​n​ ​e​t​ ​a​l​.​,​ ​2​0​2​2). Diabetic foot infection (DFI) is a chronic condition of ulceration of poorly controlled and long-term diabetic patients (R​a​j​a​ ​e​t​ ​a​l​.​,​ ​2​0​2​3). Among diabetic patients, 15% will develop foot ulcers. Foot infection is poorly treatable, and 14-24% will require amputation (C​D​C​,​ ​2​0​2​0). The psychological burden associated with potential limb loss has been reported to exceed even the fear of death in many patients (C​h​a​s​t​a​i​n​ ​e​t​ ​a​l​.​,​ ​2​0​1​9).

Once infection develops in diabetic patients, it is difficult to cure it, depending on the severity of infection (L​a​v​e​r​y​ ​e​t​ ​a​l​.​,​ ​2​0​0​6). The mortality rate of DFI is more than that of prostate and breast cancer (A​r​m​s​t​r​o​n​g​ ​e​t​ ​a​l​.​,​ ​2​0​0​7). Patients with severe infection have a substantial risk of mortality (W​u​k​i​c​h​ ​e​t​ ​a​l​.​,​ ​2​0​1​8).

Open wounds are the major cause of DFI in diabetic patients (G​l​e​n​n​ ​e​t​ ​a​l​.​,​ ​2​0​1​7; H​o​b​i​z​a​l​ ​&​ ​W​u​k​i​c​h​,​ ​2​0​1​2). According to some researchers, patients with wounds are more likely to get infections than those with intact skin (L​a​v​e​r​y​ ​e​t​ ​a​l​.​,​ ​2​0​0​6). Ulcerations are a common risk factor of DFI (W​a​l​s​h​ ​e​t​ ​a​l​.​,​ ​2​0​1​6), and other risk factors include neuropathy, nephropathy, vasculopathy, prior amputation, and walking barefoot (L​a​z​z​a​r​i​n​i​ ​e​t​ ​a​l​.​,​ ​2​0​1​8). Researchers have suggested that ulceration significantly increases mortality rate in this group (R​o​b​b​i​n​s​ ​e​t​ ​a​l​.​,​ ​2​0​0​8). DFI development and progression are multifactorial health concerns, breaching the skin and making it susceptible to microbes (L​a​v​e​r​y​ ​e​t​ ​a​l​.​,​ ​2​0​0​6). Staph. aureus, P. aeruginosa, E. coli, etc. are the common bacteria of DFI.

Anti-microbial resistance has further complicated the rising incidence of DFI. Common microbes, found in infected feet, have developed resistance to most of the antibiotics. New molecular techniques have solved the problem of uncultivable microbes but clinicians face challenges in treatment, i.e., which pathogen should be targeted (S​i​n​g​h​ ​e​t​ ​a​l​.​,​ ​2​0​2​3).

The incumbent study aims to examine the demographic factors of patients suffering from DFI and record clinical history, management strategies, and antibiotic prescribing patterns.

DFI remains a serious problem with prolonged hospitalization, high morbidity and high mortality rates, often leading to severe complications. There is a limited understanding of how demography, clinical records, and antibiotic prescribing patterns play roles in the care and management of DFI, despite advancement. Inappropriate antibiotic prescription leads to prolonged hospitalization and poor clinical outcomes. The current study focuses on carefully examining the demographic factor, clinical history, management strategies, and antibiotic prescribing patterns to improve the patients’ care and management.

A prospective and observational type of study was conducted at Hayatabad Medical Complex (HMC) and Peshawar. First, ethical approval was taken from the Post Graduate Medical Institute (PGMI), Hayat Abad Peshawar. Then, through a proper channel, permission was taken from the Medical Director (MD) and Deputy Medical Superintendent (DMS) of HMC, the Head of the Endocrinology Ward, and the Head of the Microbiology Section.

The study was carried out over a period of three months, from April 15, 2017 to July 15, 2017, during which a total of 341 patients diagnosed with DFI were examined. In this study, the inclusion criteria were specifically focused on patients diagnosed with diabetes mellitus and DFI. The primary aim was to assess the prevalence and characteristics of foot infections in individuals with diabetes, as these are common complications that can lead to severe health issues if left untreated. The study intentionally excluded patients who had other types of infections, such as upper and lower respiratory tract infections, urinary tract infections, or any other non-foot-related infections. This exclusion was essential to ensure that the study results were concentrated on DFI alone, revealing distinct pathophysiological mechanisms, risk factors, and treatment approaches. By narrowing the scope to just DFI, the research aimed to provide more specific insights into how the infection develops and progresses in diabetic patients. This also allowed for a clearer understanding of the impact of diabetes on foot health, ensuring that the outcomes are directly applicable to managing and preventing diabetic foot complications.

During observation, patients’ demography, clinical history, antibiotic prescription and management outcomes were recorded in a history sheet, including name, age, sex, address, type of diabetes, durations of diabetes and diabetic foot, hospital stay, diabetic shoes, imputation (whether advised or not), medication (whether insulin dependent or not), number of antibiotics used and effectiveness. All these were present in the questionnaire entitled “Clinical Record of Diabetic Foot”. Examinations of every patient were done 2-3 times and the observation, effectiveness and improvement of the infection were noted.

After collecting complete information on patients suffering from DFI, a statistical analysis was applied.

In this study, a total of 341 patients were examined at HMC, Peshawar, in a three-month period. In the current study, the incidence rate of DFI is 60.1% among the male patients and is 38.9% among the female ones. The p-value is about 0.003, which is statistically significant. In terms of age, the patients were divided into five groups, namely less than 30, 31-40, 41-50, 51-60, and above 60. The corresponding incidence rates are 5.27%, 16.12%, 36.65%, 27.27%, and 14.66%, respectively, and the p-value is less than 0.00001. However, patients using insulin account for 7.33%, and those not using insulin account for 92.66%, with the p-value being less than 0.00001. It demonstrates a significant result. The demographic details of the patients are given in Table 1.

Figure 1 demonstrates the duration of diabetes mellitus since onset and provides a visual representation. It shows how long each patient has been living with the condition. Figure 2 shows the current status of glycaemia. The bar chart represents the details of fasting blood sugar (FBS) and random blood sugar (RBS) levels of the diabetic patients with foot infections.

Upon careful examination of the patients, DFI duration was categorized since its onset, i.e., infected less than 1 month (46.33%), 1-2 months (25.21%), and more than 2 months (28.44%). The p-value is 0.002, which is statistically significant (p < 0.05). This suggests that the distribution across the infection duration categories is not uniform and potentially meaningful. In terms of prolonged hospitalization, 2.93% of patients stayed in the hospital for less than 1 month, 23.46% for 11-20 days, 47.8% for 21-30 days, and 25.80% for more than 30 days. The p-value is 4.23 × 10⁻¹⁸, which is highly significant, indicating a very strong difference in the distribution of hospital stay durations, as shown in Table 2.

Common DFI complications include neuropathy, nephropathy and vasculopathy, and their occurrences are shown in Figure 3.

DFI management includes insulin prescription, antibiotic therapy, surgical intervention and specific shoe usage for diabetic patients. The treatment and management of DFI depend upon its severity and duration. As shown in Table 3, the diabetic patients using insulin account for 89.14% and those not using insulin account for 10.85%. Different numbers of antibiotics were prescribed, such as 1 (35.19%), 2 (31.67%), 3 (19.06%), 4 (8.21%), and 5 (5.86%). Surgical intervention includes imputation. 44.07% of patients were advised for imputation while 63.93% were not. The diabetic shoes were advised for all diabetic patients.

In the current study, it can be noted that antibiotics were prescribed to individuals infected with diabetic foot. The most commonly prescribed antibiotic was Augmentin. It was given to most of the individuals (48 patients), with its effectiveness and non-effectiveness being recorded at 70.83% and 29.16%. Other antibiotics are Penro, Grasil, Tanzo, Moxiget, Cebac, Meropenem, Rocephin, Meroncan, Fuzidin, Cefzone, Calamox, Zyvox, Cleocin HCl, Colistin, Cipro, Abomox, Garamycin, Levaquin and Cefsol. Their effectiveness was recorded at 38.29%, 87.50%, 86.67%, 50%, 58.33%, 66.66%, 33.33%, 66.66%, 60%, 33.33%, 80%, 86.66%, 26.66%, 100%, 56.66%, 25%, 66.66%, 100%, and 75%, respectively. And their non-effectiveness was recorded at 61.7%, 14.28%, 13.33%, 50%, 41.66%, 33.33%, 66.66%, 33.33%, 40%, 66.66%, 20%, 13.33%, 73.33%, 0%, 44.33%, 75%, 33.33%, 0% and 25%, respectively. Flagyl is a protozoal antibiotic given to most of the patients. Its effectiveness was not mentioned in Figure 4. The test yielded a p-value of approximately 8.3 × 10⁻³⁵, which is highly significant (p < 0.05), indicating that the effectiveness of treatment varies significantly among the antibiotics.

Mostly antibiotics are given orally. But in the case of DFI, antibiotics were given either intravenously (IV) or intramuscularly (IM). Flagyl was mostly administered as IV and in few cases was orally. IV-administered antibiotics include Penro, Grasil, Tanzo, Augmentin, Cebac, Meronem, Rocephin, Merocan, Cefzone, Calamox, Zyvox, Cleocin, Colistin, Cipro, Garamycin, and Levaquin. Only Penro was administered as IM. It can be noted that Levaquin, Cleocin HCl and Calamox were also administered orally. Antibiotics administered only orally include Moxiget and Avelox. It can be noted that Fuzidin was the only topical antibiotic (Table 4).

DFI is a serious issue worldwide, as its prevalence continuously rises, leading to serious socio-economic challenges. The current study was conducted in various hospitals across KP. 341 patients were examined over a three-month period, and their clinical records and medications (antibiotic prescriptions) were documented.

According to G​a​d​e​p​a​l​l​i​ ​e​t​ ​a​l​.​ ​(​2​0​0​6​), male patients (85%) were predominant, whereas female ones accounted for 15%. However, in the current study, the proportion is slightly lower. The predominance of male patients in both studies may be attributed to the fact that the male is engaged in fieldwork and is more exposed to the infection than the female. Some researchers have suggested that slower healing in diabetic patients increases susceptibility to the infection (V​o​w​d​e​n​,​ ​1​9​9​7).

It can be noted that people of 40-60 years old have the highest risk, aligning with the findings of G​a​d​e​p​a​l​l​i​ ​e​t​ ​a​l​.​ ​(​2​0​0​6​), who recorded 57 ± 11.29 years. Similarly, the insulin-dependent diabetic patients’ proportion aligns with the study by A​s​s​a​a​d​-​K​h​a​l​i​l​ ​e​t​ ​a​l​.​ ​(​2​0​1​4​), who reported 96.75%.

The duration of diabetes since its onset is also a significant factor in the occurrence and development of DFI. The incumbent study shows a similar result to previous studies (54.5%) (G​a​d​e​p​a​l​l​i​ ​e​t​ ​a​l​.​,​ ​2​0​0​6). DFI often leads to prolonged hospitalization, depending on its severity. The clinical history shows 25 days of hospitalization on average, comparable to the study of G​a​d​e​p​a​l​l​i​ ​e​t​ ​a​l​.​ ​(​2​0​0​6​), who reported 20 ± 20 days.

Prolonged DFI leads to complications like neuropathy, nephropathy, vasculopathy, cardiopathy, etc. The percentage (41.6%) of the previous result is higher than that of the current study. However, this study shows a higher incidence in patients aged more than 65 years old (A​k​k​u​s​ ​&​ ​S​e​r​t​,​ ​2​0​2​2). Whereas nephropathy shows contrasting results with previous studies. The variation is maybe caused by the fact that the current study focuses on DFI while the previous research focuses on all diabetic patients (D​ò​r​i​a​ ​e​t​ ​a​l​.​,​ ​2​0​1​6). The vasculopathy result aligns with the study by I​k​e​m​ ​e​t​ ​a​l​.​ ​(​2​0​1​0​), and has few discrepancies with some previous reports (R​a​h​m​a​n​ ​e​t​ ​a​l​.​,​ ​2​0​0​9).

Poly-antibiotic therapy depends on the severity of infection. In this study, the participants were divided into five groups based on the numbers of prescribed anti-microbial drugs. However, in previous studies, the category includes a poly-antibiotic therapy with more than two antibiotics. The antibiotic prescription patterns in DFI in the incumbent study reveal a slight difference. The current study demonstrates that 64.81% of patients used more than two prescribed antibiotics compared to the previous results (57.3%). The slight difference depends on the severity of infection (N​a​g​a​y​a​ ​e​t​ ​a​l​.​,​ ​2​0​2​4).

The progression of DFI and related complications leads to amputations. The amputation incidence rate in the current study is 44.07% compared to earlier research (31%). The discrepancies may be caused by delayed presentations, poor response to the prescribed antibiotics, advanced infection stage or the effectiveness of early surgical intervention strategies (L​u​o​ ​e​t​ ​a​l​.​,​ ​2​0​2​4).

In this study, the most commonly prescribed anti-microbial drug was Augmentin. Its efficacy was 70.83%, aligning with its established role as the first-line treatment for mild and moderate infection (G​a​r​i​a​n​i​ ​e​t​ ​a​l​.​,​ ​2​0​1​9). On the other hand, the non-effectiveness shows antibiotic resistance, a significant concern in chemotherapy of DFI (P​e​t​e​r​-​R​i​e​s​c​h​,​ ​2​0​1​6). The variation in antibiotic prescription demonstrates the poly-microbial nature of infection, requiring broad-spectrum antibiotics to completely cover gram-positive and gram-negative strains. Prescribed antibiotics included Penro, Grasil, Moxiget, and Meropenem.

The variation in efficacy of prescribed anti-microbial drugs like Penro (38.29%) and Cefzone (33.33%) emphasizes the importance of local surveillance of antibiotic resistance and is considered a growing concern in diabetic patients, specifically with the extensive use of broad-spectrum antibiotics like Cefepime and Meropenem. The 100% efficacy rate of Zyvox and Levaquin suggests that these may be the promising and drugs of choice for the treatment of poly-microbial and multi-drug-resistant infections (B​o​u​z​a​,​ ​2​0​0​9).

For treating DFI, the most common routes of antibiotic administration were IV and IM as these require vigorous and intensive management. This aligns with previous reports that Penro, Grasil, and Meropenem antibiotic are administered IV, particularly in severe and complicated infections. For mild and moderate infections, Moxiget and Avelox were administered orally and Fuzidin was used for localized wound care as a topical antibiotic (M​o​u​g​a​k​o​u​ ​e​t​ ​a​l​.​,​ ​2​0​2​3; O​l​i​d​ ​e​t​ ​a​l​.​,​ ​2​0​1​5).

The current study highlights the importance of a critical need for proper antibiotic therapy in treating DFI, as misuse of antibiotics can lead to high antibiotic resistance that could worsen the issue. Previous reports emphasize the antibiotic stewardship program to guide clinical practitioners in choosing effective therapeutic treatment to minimize resistance concerns (M​a​c​D​o​u​g​a​l​l​ ​&​ ​P​o​l​k​,​ ​2​0​0​5). The inefficacy of anti-microbial drugs like Cefzone and Penro further stresses the need for continuous surveillance of local resistance patterns. Furthermore, the frequent use of IV antibiotic administration underscores the importance of infection control measures to prevent nosocomial infection and multi-drug-resistant strain spreading. It is emphasized that the region-specific treatment guideline should be developed based on local resistance data to optimize and control resistance development.

This study highlights the growing severity and socio-economic burden of DFI, which continues to present significant challenges to healthcare systems worldwide. The findings, which align with and diverge from previous research, emphasize the importance of age, gender, and insulin dependency as significant risk factors for DFI. The study underscores the need for effective management strategies, particularly given the complications and prolonged hospitalization associated with advanced stages of DFI. Compared to previous reports, the higher incidence of amputations observed in this study (44.07%) reflects the critical need for early intervention and better antibiotic stewardship.

The findings also point to a concerning trend of antibiotic resistance, particularly with commonly prescribed drugs like Penro and Cefzone, which highlights the need for vigilant surveillance of local resistance patterns. The predominance of IV and IM antibiotic administration in severe cases further emphasizes the intensive nature of treatment required for DFI. These results underscore the urgent need for region-specific treatment guidelines to combat multi-drug-resistant infections and optimize patient care.

Looking to the future, it is crucial to implement more robust antibiotic stewardship programs aimed at reducing the misuse of antibiotics and preventing the development of resistance. Regular monitoring of antibiotic efficacy and resistance patterns is essential for adapting treatment strategies to local needs. Additionally, improving early diagnosis and timely intervention could prevent the progression of DFI, reducing the incidence of amputations and associated complications. Lastly, ongoing research should focus on the development of more effective, localized therapies that address the poly-microbial nature of DFI, ensuring better patient outcomes and reduced healthcare costs.