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PIE DIABETICO INFECTADO 2024

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Received: 28 August 2023
Revised: 8 January 2024
Accepted: 10 February 2024
DOI: 10.1111/wrr.13162
ORIGINAL ARTICLE-CLINICAL SCIENCE
The infected diabetic foot: Analysis of diabetic and
non-diabetic foot infections
Lawrence A. Lavery DPM, MPH 1 |
Mehmet A. Suludere MD 1
|
Easton Ryan MD 2 |
Peter A. Crisologo DPM 1 | Arthur Tarricone DPM, MPH 1 |
Matthew Malone DPM, PhD 3
| Orhan K. Oz MD, PhD 4
1
Department of Plastic Surgery, University of
Texas Southwestern Medical Center, Dallas,
Texas, USA
Abstract
The aim of this study was to compare outcomes of moderate and severe foot infec-
2
Resident Department of Orthopedics,
Harvard University Medical School, Boston,
Massachusetts, USA
3
tions in people with and without diabetes mellitus (DM). We retrospectively evaluated 382 patients (77% with DM and 23% non-DM). We collected demographic data,
School of Medicine, Infectious Diseases and
Microbiology, Western Sydney University,
Sydney, New South Wales, Australia
co-morbidities and one-year outcomes including healing, surgical interventions, num-
4
required more surgeries (2.3 ± 2.2 vs. 1.7 ± 1.3, p = 0.01), but did not have a longer
Department of Radiology, University of Texas
Southwestern Medical Center, Dallas,
Texas, USA
ber of surgeries, length of stay, re-infection and re-hospitalisation. DM patients
hospital length of stay during the index hospitalisation (DM 10.9 days ±9.2 vs. nonDM = 8.8 days ±5.8, p = 0.43). After the index hospitalisation, DM patients had
Correspondence
Lawrence A. Lavery, Department of Plastic
Surgery, University of Texas Southwestern
Medical Center, 5323 Harry Hines Blvd,
Dallas, TX, USA.
Email: larry.lavery@utsouthwestern.edu
increased rates of re-hospitalisation for any reason (63.3% vs. 35.2%, CI 1.9–5.2, OR
3.2, p < 0.01), re-infection at the index wound infection site (48% vs. 30.7%, CI 1.3–
3.5, OR 2.1, p < 0.01), re-hospitalisation for a foot pathology (47.3% vs. 29.5%, CI
1.3–3.6, OR 2.1, p < 0.01), and longer times to ulcer healing (151.8 days ±108.8
vs. 108.8 ± 90.6 days, p = 0.04). Patients with DM admitted to hospital with foot
infections have worse clinical outcomes during the index hospitalisation and are more
likely to have re-infection and re-admission to hospital in the next year.
KEYWORDS
amputation, diabetic foot, infection, osteomyelitis, outcomes
1
|
I N T RO DU CT I O N
all of which may increase the risk of lower extremity amputation.1 The
risk of ulcers, infections and amputation is much less common in
Persons with diabetes mellitus (DM) have high rates of foot complica-
adults without diabetes, although there are only a few studies that
tions such as ulcerations, infections of the skin, soft tissue and bone,
evaluate non-diabetic foot infections.2 Persons with DM requiring
hospitalisation for a foot infection, are associated with poor healing,
increased risks of re-infections, and repeated hospitalizations. There is
Abbreviations: AKA, above knee amputation; BKA, below knee amputation; CI, confidence
interval; CKD, chronic kidney disease; CRP, C-reactive protein; DM, diabetes mellitus; ESRD,
end-stage renal disease; HbA1c, glycosylated haemoglobin; IWGDF, International Working
Group on The Diabetic Foot; MRI, magnetic resonance imaging; OM, osteomyelitis; OR, odds
ratio; SIRS, systemic inflammatory response syndrome; SPEC-CT, single-positron emission
computed tomography; STI, soft tissue infection; WBC, white blood cell count.
scant evidence comparing clinical outcomes and resource utilisation in
patients with foot infections in people with and without DM. Suaya
et al.3 analysed 2,227,401 patients from insurance claims data and
reported that persons with DM were five times more likely to have a
This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any
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© 2024 The Authors. Wound Repair and Regeneration published by Wiley Periodicals LLC on behalf of The Wound Healing Society.
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wileyonlinelibrary.com/journal/wrr
Wound Rep Reg. 2024;32:360–365.
skin or soft tissue infection (STI). Similarly, Wukich et al.4 retrospec-
rates and mortality. Foot amputations include toe amputations up to
tively analysed post-operative foot infections to compare outcomes in
Chopart's amputations. Below the knee amputations involved ampu-
patients with and without DM and identified that persons with DM
tation through the tibia and fibula below the knee joint. Above the
were five times more likely to have a postoperative infection after
knee amputations involved amputation through the femur above
elective surgery than patients without DM.
the knee joint.
Lavery and colleagues reported that persons with ankle fractures
with DM were 2.8 times more likely to develop infection and 6.6
times more likely to require amputation than persons without DM.5
2.1
|
Statistical analysis
We identified two studies that compared diabetic and non-diabetic
patients with foot infections as a result of penetrating injuries.2,6 The
Clinical data were summarised using descriptive statistics. Median,
primary objective of this study was to compare risk factors and clinical
mean and standard deviation for continuous variables and frequency
outcomes in persons with and without DM admitted to hospital with
and percentages for categorical variables are presented. Clinical and
infected foot ulcers.
surgical outcomes between persons with and without DM were compared using parametric (Student t-test, χ2 test) and non-parametric
tests (Mann–Whitney U test, Fisher exact test) as appropriate. Odds
2
|
M E TH O DO LO GY
ratios (OR) and confidence intervals (CI) were calculated for dichotomous risk factor and outcome variables. In this article, we compare
This was a retrospective cohort study, approval was obtained from
risk factors and outcomes for patients with and without diabetes.
the IRB at the Parkland Hospital and University of Texas Southwest-
SPSS version 25, (IBM, Chicago, IL) was used in the analysis of
ern Medical Center. We evaluated the medical records of 382 patients
the data.
(294 with DM [77%] and 88 without DM [23%]) admitted to hospital
with moderate and severe foot infections over a period of 8 years. All
the patients were 18–90 years of age with at least 12 months follow-
3
|
RE SU LT S
up or until they were deceased. Infection was stratified based on; the
presence of osteomyelitis (OM) and/or soft tissue infection (STI), and
The medical records of 294 patients with DM and 88 patients without
on the severity of infection. STIs were defined by clinical signs
DM were evaluated. In the patient demographics, there were no dif-
and symptoms of infection in addition to ruling out OM through MRI,
ferences in age or gender between individuals with diabetes and those
single-positron emission computed tomography (SPECT CT), or a neg-
without diabetes (Table 1). (75.2% DM and 73.9% non-DM, CI 0.6 to
ative bone biopsy. The criteria for osteomyelitis were based on a posi-
1.8, p = 0.80). Persons with DM had more co-morbidities than people
tive bone culture or bone histopathology. The International Working
without DM such as ESRD (eGFR <15 mL/min) (DM 9.5% vs. non-DM
Group on the Diabetic Foot (IWGDF) foot infection classification was
0.0%, 1.1 to 313.3, OR 18.9, p = 0.04), retinopathy (DM 30.6%
used to define moderate and severe foot infection.7 Severe infection
vs. non-DM 0.0%, 4.8 to 1276.1, OR 78.3, p < 0.01), peripheral neu-
was identified by clinical recognition of two or more of the following
ropathy (DM 90.8% vs. non-DM 53.4%, CI 4.8–15.4, OR 8.6,
systemic inflammatory response syndrome (SIRS) criteria8: heart rate
p < 0.01), peripheral arterial disease (DM 70.1% vs. non-DM 37.5%,
>90 beats per minute, temperature >38 C or <36 C, respiratory rate
CI 2.4–6.4, OR 3.9, p < 0.01), previous foot ulcer (DM 63.9% vs. non-
>20 breaths per minute or white blood cell count (WBC)
DM 36.4%, CI 1.9–5.1, OR 3.1, p < 0.01), and previous amputation
>12,000 cells/mm3 or <4000 cells/mm3.
(DM 35.4% vs. non-DM 10.2%, CI 2.3–710.0, OR 4.8, p < 0.01). In
In our facility, emergency physicians routinely order standard lab-
addition, at the time of admission persons with DM had higher white
oratory tests including WBC's, erythrocyte sedimentation rate (ESR)
blood cell counts (DM 10.9 109/L ± 4.3 vs. non-DM 10.4 109/L
and C-reactive protein (CRP), and albumin at the time of admission.
± 4.01, p = 0.04), more severe infection based on SIRS criteria
Broad demographic and clinical data were collected including medical
(DM 37.4% vs. no DM 25.0%, CI 1.0–3.0, OR 1.8, p = 0.03), erythro-
history, wound characteristics, laboratory tests and clinical and surgi-
cyte sedimentation rates (ESR) (DM 72.5 mm/h ± 36.3 vs. non-DM
cal outcomes. Data on sensory neuropathy, peripheral arterial disease,
38.2 mm/h ± 24.9,
previous foot ulcerations and lower extremity amputations, and cur-
(DM 7.34 mg/L ± 8.5 vs. non-DM 4.74 mg/L ± 7.0, p < 0.01). How-
rent dialysis status were collected. The diagnosis of diabetes was
ever, there was no difference in the proportion of people with a white
based on the American Diabetes Association criteria.7 Peripheral arte-
blood cell count higher than 12.0 109/L in both groups (DM 47.3
rial disease was defined as non-compressible vessels at the ankle, an
vs. non-DM 39.8, CI 0.8 to 2.2, OR 1.4, p = 0.22).
p < 0.01),
and
C-reactive
protein
(CRP)
ankle-brachial index <0.9, claudication symptoms, or history of vascu-
Many adverse clinical outcomes were more common in persons
lar surgery in the extremity. Sensory neuropathy was defined as
with DM compared to those without DM (Table 2). Persons with DM
abnormal vibration sensation or abnormal sensation with 10 g
required more surgical procedures during the index admission
Semmes-Weinstein monofilament. We evaluated the need for sur-
(DM 2.3 ± 2.4 vs. non-DM 1.7 ± 1.3, CI 2.0–2.4, p = 0.01), and had
gery, the number of procedures, the need for lower extremity amputa-
more lower limb amputations (DM 56.8% vs. non-DM 44.3, CI 1.0–
tions, amputation level, duration of anti-microbials, hospital length of
2.7, OR 1.7, p = 0.04). There was no difference in the hospital length
stay, wound healing, time to healing, re-infection rates, re-admission
of stay during the index hospitalisation (DM 10.9 days ±9.2 vs.
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361
LAVERY ET AL.
LAVERY ET AL.
TABLE 1
Demographics and co-morbidities.
Diabetes (N = 294)
No diabetes (N = 88)
Odds ratio
1.1
Male
221 (75.2)
65 (73.9)
Age (years)
53.0, 52.73 (10.85)
52.0, 50.22 (15.13)
95% CI
p-value
0.6–1.8
0.80
51.0–53.4
0.61
Retinopathy
90 (30.6)
0 (0.0)
78.3
4.8–1276.1
<0.01
Peripheral neuropathy
267 (90.8)
47 (53.4)
8.6
4.8–15.4
<0.01
Peripheral arterial disease
206 (70.1)
33 (37.5)
3.9
2.4–6.4
<0.01
Nephropathy
129 (43.5)
17 (19.3)
3.3
1.8–5.8
<0.01
CKD I–IV
101 (34.4)
17 (19.3)
2.2
1.2–3.9
0.01
ESRD/dialysis
28 (9.5)
0 (0.0)
18.9
1.1–313.3
0.04
Previous foot ulcer
188 (63.9)
32 (36.4)
3.1
1.9–5.1
<0.01
Previous amputation
104 (35.4)
9 (10.2)
4.8
2.3–10.0
<0.01
IWGDF – Severe
110 (37.4)
22 (25.0)
1.8
1.0–3.0
0.03
Osteomyelitis
157 (53.4)
45 (51.1)
1.1
0.7–1.8
0.71
8.9, 9.2 (2.5)
5.5, 5.4 (0.47)
8.1–8.7
<0.01
10.0–10.8
0.04
0.8–2.2
0.22
Infection severity
Laboratory values
Glycated haemoglobin
WBC
9.6, 10.9 (4.3)
8.8, 10.4 (4.0)
WBC > 12,000
139 (47.3)
35 (39.8)
1.4
Note: Dichotomous variables presented as N (%). Continuous variables presented as median, mean (SD).
Abbreviations: A1c, glycosylated haemoglobin; CKD, chronic kidney disease; CRP, C-reactive protein; ESRD, end-stage renal disease; WBC, white blood
cell count.
TABLE 2
1-year outcomes. Foot amputations included toe amputations up to Chopart's amputation.
Diabetes (N = 294)
No diabetes (N = 88)
Odds ratio
95% CI
p-value
Index outcomes
Index length of stay (days)
8.0, 10.9 (9.2)
8.0, 8.8 (5.8)
9.6–11.3
0.43
Antibiotic duration (days)
22.0, 39.0 (43.0)
23.0, 34.1 (30.4)
33.7–10.8
0.32
Surgical intervention
232 (78.9)
72 (83.0)
0.5–1.5
0.55
Number of surgeries
2.0, 2.3 (2.4)
2.0, 1.7 (1.3)
2.0–2.4
0.01
0.83
Lower limb amputation
167 (56.8)
39 (44.3)
1.7
1.0–2.7
0.04
Foot amputation
139 (47.3)
38 (43.2)
1.2
0.7–1.9
0.50
BKA & AKA
28 (9.5)
1 (1.1)
9.2
1.2–68.3
0.03
0.9
1-year outcomes
Healed
205 (69.7)
64 (72.7)
Time to heal (days)
115.0, 151.8 (108.8)
73.0, 108.8 (90.6)
Re-infection
141 (48.0)
27 (30.7)
Re-admission for foot
139 (47.3)
26 (29.5)
Re-admission, all cause
186 (63.3)
31 (35.2)
Length of stay for foot (days)
13.0, 18.8 (13.7)
10.0, 13.7 (11.5)
Mortality
9 (3.1)
0 (0.0)
0.5–1.5
0.59
129.0–154.4
0.04
2.1
1.6–3.5
<0.01
2.1
1.3–3.6
<0.01
3.2
1.9–5.2
<0.01
16.0–19.3
0.01
0.3–102.2
0.22
5.9
Note: Dichotomous variables presented as N (%). Continuous variables presented as median, mean (SD), the p-value was calculated by comparison of the
means. The length of stay during the 1-year study period, represents the days hospitalised for study foot related complications, including the index
procedure.
Abbreviations: AKA, above knee amputation; BKA, below knee amputation.
non-DM 8.8 days ±5.8, CI 9.6 to 11.3, p = 0.43). After the index hospitalisation,
DM
patients
had
worse
outcomes
and
3.2, p < 0.01), re-infection at the index wound site (48.0% vs. 30.7%,
more
CI 1.3–3.6, OR 2.1, p < 0.01), re-hospitalisation for a foot pathology
complications over a 12-month period (Figure 1); increased rates of
(either new problem or at index wound site) (47.3% vs. 29.5%, CI 1.9–
re-hospitalisation for any reason (63.3% vs. 35.2%, CI 1.9–5.2, OR
5.2, OR 3.2, p = 0.01), and longer times to ulcer healing (151.8 days
1524475x, 2024, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/wrr.13162 by Cochrane Mexico, Wiley Online Library on [26/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
362
F I G U R E 1 Outcomes during the year
following the index hospitalisation in
people with and without diabetes. This
bar chart compares the outcomes of foot
infections in people with and without
diabetes. The outcomes are from the
study period of 1-year after the initial
hospitalisation. There was a significant
difference between the two groups. AKA,
above knee amputation; BKA, below knee
amputation.
F I G U R E 2 Kaplan–Meier function for time to heal comparing people with and without diabetes. Kaplan–Meier survival curve showing the
days to heal trajectories in people with and without diabetes. People with diabetes had a significantly longer mean number of days to wound
healing compared to people without diabetes.
±108.8 vs. 108.8 days ±90.6, CI 129.0–154.0, p = 0.04) (Figure 2).
with DM admitted to hospital for a foot infection in comparison to
There were no significant differences in the proportion of wounds
those without DM. The population with DM had more co-morbidities,
that healed, foot amputations, surgical interventions, length of the
risk factors for foot complications, and poor outcomes during the
index hospitalisation and 1 year mortality (Table 2).
index hospitalisation including re-infection and re-hospitalisation
within 12 months post-discharge.
There are few studies that have compared the type of infection,
4
|
DISCUSSION
the severity of infection, and clinical outcomes among people with
and without diabetes. One of the limitations to the work by Suaya
To the best of our knowledge, this is the first study to compare out-
and colleagues is that it is from a large administrative database and
comes in persons with and without DM with infected foot ulcers. The
does not report consistent operational definitions for risk factors or
results illustrate the poor outcomes and recurrent infections in people
procedures. They provide a very broad look at foot infections by
1524475x, 2024, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/wrr.13162 by Cochrane Mexico, Wiley Online Library on [26/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
363
LAVERY ET AL.
LAVERY ET AL.
evaluating claims data for skin and soft tissue infections. In contrast
was evaluated. Our group has used the same structured examination,
to our single centre, retrospective study during the one-year evalua-
imaging and surgical approach for the duration of this study, so opera-
tion period, they used a large repository database that included
tional definitions are likely to have better consistency than if many,
2,227,401 episodes of skin and soft tissue infections, with 10% of
independent physicians provided assessments and treatments. The
the population with a diagnosis of DM. In the ambulatory setting,
patients included in this study were seen at a safety net hospital that
the incidence of infection in people with diabetes was five times
disproportionately treats people of lower social economic status
higher than people without DM (4.9% vs. 0.8%). In the hospital, set-
that are under- and uninsured. The study population may not reflect
ting the same trend was observed. The incidence of infection was
patients' characteristics in different clinical settings. This patient pop-
4.9% in people with diabetes and 1.1% in persons without DM.3 In
ulation probably suffers health care disparities and less access to
contrast, we used patient level data based on standardised assess-
health care than other populations. The uneven group sizes could
ment and treatment protocols.
pose a limitation. Specifically, the diabetes (DM) group had signifi-
We have previously compared the incidence of osteomyelitis, sur-
cantly more patients, which could impact the statistical robustness of
gery and amputations in persons with and without DM with foot
the study's findings. However, traditional statistical approach rou-
infections as a result of a puncture wound injury.2,6 The mechanism of
tinely addresses this issue, and it should not have impacted our results
injury in this population may predispose these patients to worse clini-
and conclusions.
cal outcomes. Puncture wounds often initiate a deeper infection than
To conclude, we found that patients with moderate to severe
those that result from foot ulcers, because the puncturing object
foot infections with DM had significantly worse outcomes than
pushes foreign materials such as pieces of shoes, stockings, and dirt
patients without diabetes, with higher risk for re-infection, re-
into deeper anatomic structures that are closed off within d these
admission, more surgery and longer healing times.
compartments. In a study of 77 persons with DM and 69 people without DM, DM subjects were 3.6 times more likely to develop OM, five
CONFLIC T OF INTER E ST STATEMENT
times more likely to require multiple operations, and 46 times more
The authors declare no conflicts of interest.
likely to require amputation than non-DM patients. Truong evaluated
114 people with infected puncture wounds (83 DM and 31 no DM).
DATA AVAILABILITY STAT EMEN T
Like our study, DM patients had a higher prevalence of co-morbidities
The data that support the findings of this study are available from the
such as PAD, neuropathy and CKD, and they were 9 times more likely
corresponding author, upon reasonable request.
to have OM, 2.7 times more likely to require surgery, and 14 times
more likely to require amputation than people without DM.2 The
comparison of patients with infected punctures wounds have larger
odds ratios for clinical outcomes than our evaluation of infected foot
ulcers.
This study has several advantages and limitations that warrant
discussion. First, it is one of the largest studies that compares foot
infections in people with and without diabetes. In addition, this study
used strong operational definitions for osteomyelitis and soft tissue
infections. We used bone culture or histopathology to confirm the
diagnosis of OM. When radiographs or clinical examination was suggestive of osteomyelitis, we obtained bone for culture and histology
for two reasons. First, bone biopsy is the gold standard to confirm that
there is in fact a bone infection. Second, if the culture is positive, we
have antibiotic sensitivity results to help direct antibiotic therapy.
Other studies usually use a mix of clinical criteria such as “probe to
bone” or imaging with radiographs or clinical signs, and do not confirm
the diagnosis with bone culture/histology. In addition, a negative OM
diagnosis was confirmed based on a negative MRI, SPECT/CT, or
bone biopsy result. When we did not suspect osteomyelitis, we did
not routinely obtain bone to prove a negative MRI or SPECT CT. It is
uncommon to have a false negative using these studies,9 and we did
not want to disrupt the integrity of the joint capsule, periosteum or
cortex if it was not necessary. The retrospective design of the study
may have suffered from selection bias, and the operational definitions
may have varied among providers. However, we have had a dedicated
limb salvage service for several years before this retrospective cohort
OR CID
Mehmet A. Suludere
Matthew Malone
https://orcid.org/0000-0002-2285-0909
https://orcid.org/0000-0002-2946-8841
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2019.08.013
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How to cite this article: Lavery LA, Suludere MA, Ryan E, et al.
The infected diabetic foot: Analysis of diabetic and nondiabetic foot infections. Wound Rep Reg. 2024;32(4):360‐365.
doi:10.1111/wrr.13162
1524475x, 2024, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/wrr.13162 by Cochrane Mexico, Wiley Online Library on [26/07/2024]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
365
LAVERY ET AL.
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