Correlation between the Treatment Result and Causative Bacteria in Amputation of Diabetic Foot Department of Orthopaedic Surgery, College of Medicine, Dong-A university, Busan, Korea Myoung Jin Lee M.D., Ki Woong Kim, M.D.
<Correlation between the Treatment Result and Causative Bacteria in Amputation of Diabetic Foot> < Myoung Jin Lee M.D., Ki Woong Kim, M.D.> My disclosure is in the Final AOFAS Mobile App. I have no potential conflicts with this presentation.
Purpose To evaluate correlation between the clinical results and causative bacteria in diabetic foot patients with lower extremity amputation
Materials and Methods Jan. 2008 ~ Jan. 2012 129 patients, 131 feet - Male : 81 / Female : 48 - Rt. foot : 72 / Lt. foot : 59 Mean Age : 68.3 years (51~89) Mean F/U : 31 months (12~64) Mean duration of diabetes : 14.1 years (1~28) Mean preop. BST : 212 mg/dl (105~514) Mean preop. HbA1c : 8.65% (5.6~15.9) Medication - Oral : 74 patients, - Insulin inject : 34 patients - Combination : 21 patients
Materials and Methods Severe systemic disease was excluded - sepsis, malignant neoplasm, severe heart failure, severe grade of chronic kidney disease & liver cirrhosis Angio CT - for evaluation of lower limb vascularity - 12 patients excluded d/t arterial stenosis or occlusion Tissue specimens or material obtained from the bottom of a washed wound Abscess aspiration Gram staining and Culture for microbial sensitivity
Materials and Methods In culture, MSSA : 34 MRSA : 24 Enterobacter cloacae : 12 Pseudomonas aeruginosa : 10 Enterococcus faecalis : 12 Mixed infection : 14 Escherichia coli (3) Acinetobacter baumanni (2) Serratia marcescens (1) Klebsiella pneumonia (2) Proteus vulgaris (1) Enterobacter aerogenes (2) Other microorganisms : 8
Materials and Methods Mixed infection : 14 cases Acinetobacter baumannii + Enterococcus faecalis : 3cases Acinetobacter baumannii + Proteus mirabilis : 2 cases Acinetobacter baumannii + Serratia marcescens : 2 cases Staphylococcus aureus + Klebsiella pneumoniae : 2cases Acinetobacter baumannii + Streptococcus pneumoniae : 2 cases MRSA + Enterobacter cloacae : 1case Staphylococcus aureus + Enterobacter cloacae : 1case Escherichia coli + Enterobacter cloacae : 1case
Results Amputation level Complication Additional amputation Duration of treatment Patient s satisfaction Death More major amputation in mixed infection group Microorganism Major (n) Minor (n) Total P-value MSSA 2 32 34 > 0.05 MRSA 4 19 24 > 0.05 Mixed infection 6 8 14 < 0.05 Enterobacter cloacae 0 12 12 > 0.05 Pseudomonas aeruginosa 0 10 10 > 0.05 Enterococcus faecalis 0 8 8 > 0.05 No growth 0 17 17 > 0.05
Results Amputation level Complication Additional amputation Duration of treatment Patient s satisfaction Death More complication in mixed infection group Microorganism Necrosis /Reinfection (n) Total P-value MSSA 2/5 34 > 0.05 MRSA 4/8 24 > 0.05 Mixed infection 4/6 14 < 0.05 Enterobacter cloacae 0/1 12 > 0.05 Pseudomonas aeruginosa 0/2 10 > 0.05 Enterococcus faecalis 0/1 8 > 0.05 No growth 0/1 17 > 0.05
Results Amputation level Complication Additional amputation Duration of treatment Patient s satisfaction Death Longer duration of treatment in mixed infection group Microorganism Duration of treatment (days) Total P-value MSSA 37.5 34 > 0.05 MRSA 41.5 24 > 0.05 Mixed infection 53.4 14 < 0.05 Enterobacter cloacae 36.8 12 > 0.05 Pseudomonas aeruginosa 35.5 10 > 0.05 Enterococcus faecalis 34.7 8 > 0.05 No growth 32.5 17 > 0.05
Discussion & Conclusion In this study, Mixed infection - treatment duration longer than other microorganism groups : 53.4 days Incidence of major amputation, complication More in mixed infection group The predominance of S.aureus is in agreement with the results of previous reported studys S.aureus : 58/114 (50.9%) - MSSA : 34 cases (29.8%) - MRSA : 24 cases (21.1%) The most common pathogen in diabetic foot patients with lower extremity amputation was Methicillinsensitive Staphylococcus aureus Mixed bacterial infected patients have higher major amputation and complication rate, longer duration of treatment than the other bacterial infected patients group
References 1. Reiber GE, Ledoux WR. Epidemiology of foot ulcers and amputations in people with diabetes: Evidence for prevention. In: Herman WH, Kinmonth AL, Wareham NJ, Williams R, ed. Chichester, UK: John Wiley & Sons; 2010. 403-17. 2. Brodsky JW. Evaluation of the diabetic foot. Instr Course Lect. 1999;48:289-303. 3. Lee JS, Lu M, Lee VS, Russel ld, Bahr C, Lee ET. Lower-extremity amputation. Incidence, risk factors, and mortality in the Oklahoma Indian Diabetes Study. Diabetes. 1993;42:876-82. 4. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293:217-28. 5. Bild DE, Selby JV, Sinnock P, Browner WS, Braveman P, Showstack JA. Lower-extremity amputation in people with diabetes. Epidemiology and prevention. Diabetes Care. 1989;12:24-31. 6. Boulton AJ, Vi leikyte L, Ragnarson-Tennval lg, Apelqvist J. The global burden of diabetic foot disease. Lancet. 2005;366:1719-24. 7. Chow I, Lemos EV, Einarson TR. Management and prevention of diabetic foot ulcers and infections: a health economic review. Pharmacoeconomics. 2008;26:1019-35. 8. Abdulrazak A, Bitar ZI, Al-Shamali AA, Mobasher LA. Bacteriological study of diabetic foot infections. J Diabetes Complications. 2005;19:138-41. 9. Sharma VK, Khadka PB, Joshi A, Sharma R. Common pathogens isolated in foot infection in Bir Hospital. Kathman-du Univ Med J(KUMJ). 2006;4:295-301. 10. Pinzur MS, Sage R, Stuck R, Osterman H. Amputations in the diabetic foot and ankle. Clin Orthop. 1993;296:64-7. 11. Burgess EM, Romano RL, Zettl JH, Schrock RD Jr. Amputations of the leg for peripheral vascular insufficiency. J Bone Joint Surg Am. 1971;53-A:874-90.