IDF21-0128 Diabetic Foot Ulcers: Factors Related to Greater Clinical Severity at Presentation

Abstract

Background: Diabetic foot ulcer (DFU) is an important diabetes complication associated to higher mortality and lower quality of life. DFU severity strongly depends on depth and the presence of infection. Previous studies have tried to identify factors related to DFU severity, most of them using the Wagner classification as the discriminative criteria. A number of factors have already been pointed out: smoking, higher body mass index, older age, insulin therapy, ulcer’s duration and localization. There are no data published on this subject in the Portuguese population, although it has already been stated that greater clinical severity at presentation is associated with increased risk of short-term amputation. Aim: To evaluate the factors related to infected and deep (and thus more severe) DFU at presentation. Method: Cross-sectional study including patients that attended a first diabetic foot appointment at our unit during the year of 2018. Only adult patients with an active DFU were included. Ulcers were classified as infected if they were graded a score ≥2 on the PEDIS classification and/or a stage B or D on the Texas classification; deep if they were graded a score ≥2 on the Texas classification and/or a grade ≥2 on the Wagner classification. Results: 435 patients were included, most of which were men (62.1%). Their median age was 70.0 (IQR 58.0-79.0) years and the mean diabetes duration was 20.0 (IQR 10.0-25.0) years. DFU infection was associated to poor nail care, both according to PEDIS (p=0.004) and Texas (p=0.005) classifications (OR≈2.000). The same association was found with peripheral artery disease (p=0.025 and p=0.009; OR≈1.800), lesion duration shorter than one month (p=0.023 and p=0.029; OR≈1.700) and dorsal and interdigital ulcer location (p=0.022 and p=0.018). Structural deformities were associated with infected DFU according to Texas classification (p=0.045). Diabetes duration over 10 years was associated with deeper wounds, both according to Texas (p=0.030) and Wagner (p=0.031) classifications (OR≈2.700). Being already on antibiotics at the time of the first appointment was associated with both infected and deep DFU. No association was found with patients’ age, HbA1c level (<7 vs ≥7%), neuropathy, education level or insulin therapy. Discussion: As other authors have described, we found that peripheral artery disease and dorsal ulcers are associated with increased lesion severity. We also found an association between interdigital ulcer location and infection, meaning that DFU in this location also tend to be more severe. This might be due to the fact that this area typically accumulates humidity and is often neglected in diabetic foot examination. Individuals with infected DFU are twice more likely to have poor nail care. Toenails may be a reservoir for bacterial and fungal colonization and thus may be associated to DFU severity. We also point out structural deformities and longer diabetes duration to be associated with more severe lesions. Previous medication with antibiotics by primary care physicians and need for quicker referral to our center also seem to be a sign of severity.