Infected Diabetic Foot Ulcers Research Articles

Differences in foot care practice between participants at risk for and with diabetic foot ulcers (DFUs) in community

The research aimed to investigate differences in foot care practice between participants at risk for and with diabetic foot ulcers (DFUs). The study design was quantitative with a cross-sectional approach. A total of 150 participants included in this study. Participants at risks for DFUs were measured using the 10g Semmes-Weinstein monofilaments for detecting neuropathy and the Ankle Brachial Index (ABI) Doppler for diabetic angiopathy. Data analyzed using chi-squared and Fisher's exact tests. There were significant differences in foot care between the risk for DFUs and DFUs groups, especially for foot washing, footwear inspection, and footwear usage domains (p<0.01). Those in the risk for DFUs group were more frequent and better in conducting foot care than those in the DFUs group. Performing routine foot care practices among people diagnosed with diabetes are essential for preventing the development and infection of DFUs.

Recognition of ischaemia and infection in diabetic foot ulcers: Dataset and techniques

Recognition and analysis of Diabetic Foot Ulcers (DFU) using computerized methods is an emerging research area with the evolution of image-based machine learning algorithms. Existing research using visual computerized methods mainly focuses on recognition, detection, and segmentation of the visual appearance of the DFU as well as tissue classification. According to DFU medical classification systems, the presence of infection (bacteria in the wound) and ischaemia (inadequate blood supply) has important clinical implications for DFU assessment, which are used to predict the risk of amputation. In this work, we propose a new dataset and computer vision techniques to identify the presence of infection and ischaemia in DFU. This is the first time a DFU dataset with ground truth labels of ischaemia and infection cases is introduced for research purposes. For the handcrafted machine learning approach, we propose a new feature descriptor, namely the Superpixel Colour Descriptor. Then we use the Ensemble Convolutional Neural Network (CNN) model for more effective recognition of ischaemia and infection. We propose to use a natural data-augmentation method, which identifies the region of interest on foot images and focuses on finding the salient features existing in this area. Finally, we evaluate the performance of our proposed techniques on binary classification, i.e. ischaemia versus non-ischaemia and infection versus non-infection. Overall, our method performed better in the classification of ischaemia than infection. We found that our proposed Ensemble CNN deep learning algorithms performed better for both classification tasks as compared to handcrafted machine learning algorithms, with 90% accuracy in ischaemia classification and 73% in infection classification.

Antibiotic profiles of Microbial Infection in Diabetic Foot Ulcers

Introduction and aim: Diabetic foot ulcers are a serious medical and economic worry. It is the most common reason for diabetic patients to be admitted to hospital. If not treated appropriately, the infection might lead to amputation of the infected foot. The current research aims to recognise the frequencies of isolated aerobic bacterial pathogens associated with diabetic foot ulcers and detect their antibiotic susceptibility and resistance patterns to reduce the risk of complications.&#x0D; Methodology: This cohort study included 140 swab samples from diabetic foot ulcers from patients referred to the surgery department at Al-Azhar University Hospital in New Damietta, Egypt, in the period between January and December 2018. All samples were processed for the identification of aerobic bacterial strains were identified using routine bacteriological culture methods and antimicrobial susceptibility by the Kirby-Bauer disc diffusion method.&#x0D; Results: Out of 140 pus and tissue samples obtained of diabetic foot ulcers, 120 (85.7%) exhibited aerobic organism growth, yielding a total of 132 isolates with an average of 1.1 isolates per specimen. Polymicrobial infection was 10%. Gram-negative isolates were prominent (62.88%), with Pseudomonas aeruginosa (26.5%) being the most common strain causing diabetic foot infections, followed by E. coli (20.5%). Staph aureus was the most common Gram-positive bacteria (8.9%). Out of 83 Gram-negative bacteria, 54 (65%) produced extended-spectrum lactamase (ESBL). The majority of Gram-negative isolates were resistant to levofloxacin, gentamicin, ampicillin-sulbactam, and gatifloxacin. All Gram-negative bacteria were sensitive to imipenem. Of the 25 Staph aureus, 15 (60%) were Methicillin Resistant Staphylococcus aureus (MRSA) and susceptible to vancomycin and linezolid.&#x0D; Conclusion: Pseudomonas sp. was the most prevalent cause of infections. Most isolates were multidrug resistant. In our study, Gram-negative bacteria were the main cause of diabetic foot infections. A significant number of MDR isolates were also observed. The inappropriate use of broad-spectrum antibiotics may be the main cause of the increase in the frequency of MDR isolates.

A study on diabetic foot ulcers in Central rural India to formulate empiric antimicrobial therapy.

Aim:This study was carried out on patients with diabetic foot ulcer (DFU) to assess the clinical characteristics, spectrum of microbial flora, antibiotic sensitivity, and devise an empiric antimicrobial therapy.Material Methods:Clinical data and tissue samples were collected from 105 diabetic foot ulcer patients between December 2018 and November 2019. The collected samples were processed as per Clinical and Laboratory Standards Institute guidelines and clinical and microbiological data was analyzed.Results:In this study of 105 patients, DFU was most common in males in 5th and 6th decade of life. Majority of patients had poor glycemic control and neuropathy. Of 110 bacterial isolates obtained from 97 samples, 73.7% were Gram-negative bacteria, and 27.3% were Gram-positive. Most of samples (48.6%) showed growth of single bacteria, growth of two bacteria and polymicrobial growth was seen in 28.6% and 15.2% of tissue samples respectively of which. Pseudomonas was predominant isolate (27.3%) sensitive to imipenem (90%), amikacin (86.6%), gentamicin (83.3%), and cefotaxime (80%) followed by Staphylococcus aureus (19.1%) sensitive to amikacin and gentamicin (100%), and ofloxacin (90%). Pseudomonas, E. coli, Proteus and Klebsiella were highly resistant to ampicillin and amoxicillin-clavulanic acid.Conclusion:This study showed DFU are common in 5th and 6th decades of life. Gram-negative bacteria are predominant infective organism. Most of both Gram-negative and Gram-positive bacteria are resistant to variable degrees to commonly used antibiotics and sensitive to aminoglycosides. Amikacin and gentamicin can be used as empiric antibiotics for treatment of DFU infections.

Procalcitonin as a marker of diabetic foot ulcer infection

BackgroundProcalcitonin (PCT), an amino acid protein precursor of calcitonin hormone released by thyroid C cells or other body cells, can be used as a marker for diagnosing infection. PCT has a suggestive role in diagnosing diabetic foot infection alone or in combination with other markers of infection.ObjectiveThe aim was to clarify the effectiveness of PCT as a marker for diagnosing of infection in Egyptian patients with diabetic foot ulcer (DFU) in comparison with other inflammatory markers such as C-reactive protein, white blood cell count, and erythrocyte sedimentation rate.Patients and methodsThis cross-sectional study was carried out at Menoufia University Hospitals, from the period of January 2018 to December 2018. In total, 90 patients were classified into three groups; each group contained 30 patients: group I served as diabetic control without foot ulcers, group II patients had noninfected DFU, and group III patients had infected diabetic foot ulcer (IDFU). Diagnosis of IDFU relied on Infectious Diseases Society of America-International Working Group on the Diabetic Foot classification of diabetic foot infection.ResultsSerum PCT levels were elevated in DFU groups, with significantly higher in infected more than noninfected DFU. In addition, PCT levels were significantly higher in patients with IDFU compared with traditional markers such as C-reactive protein, erythrocyte sedimentation rate, and white blood cell counts.ConclusionBased on our results, we conclude that PCT has a valuable role in diagnosing infection in DFUs.

Effect of Induced Membrane Formation Followed by Polymethylmethacrylate Implantation on Diabetic Foot Ulcer Healing When Revascularization Is Not Feasible.

No study has investigated the role of induced membrane (IM) formation in treating diabetic foot ulcer (DFU). This retrospective study was aimed (1) at evaluating the potential role of a two-staged surgical approach, comprising polymethylmethacrylate (PMMA) implantation and IM formation, in the treatment of DFU and (2) at comparing the results of those with routine wound debridement in patients with DFUs and nonrevascularized peripheral arterial disease (PAD). Fifty patients with infected DFUs who were not candidates for vascular interventions were enrolled between February 2016 and April 2018 and assigned to the PMMA group (n = 28) and conventional group (n = 22). The healing rate, major amputation rate, duration of healing, frequency of debridement procedures, patient survival rate, and reulceration of DFUs were determined. The Mann-Whitney U test, independent sample t-test, and χ2 or Fisher exact test were used in statistical analysis. Overall clinical outcomes were statistically different between the groups (Z = −2.495, P = 0.013). In the PMMA group, 16 patients (57.1%) with intact IM formation achieved ulceration healing at 13.1 ± 3.7 weeks with a mean number of debridements of 1.3 ± 0.4, which were significantly different compared to those values in 5 patients of the conventional group (22.7%, P = 0.014; healing duration: 26.4 ± 7.8 weeks, P = 0.016; mean number of debridements: 3.6 ± 0.5, P ≤ 0.001). At a mean 16.8 ± 4.3-month follow-up, patient survival rates were 92.9% and 68.2% in the PMMA and conventional groups, respectively (P = 0.032). The major amputation rate and reulceration of DFUs were similar between the groups. The two-staged surgical approach is an available, effective modality for improving healing of DFUs. This study provides preliminary information of IM formation followed by PMMA implantation in the management of DFUs in PAD when revascularization is not feasible.

Preoperative Prediction of Postoperative Physical Function in Infected Diabetic Foot Ulcer Patients

Category:DiabetesIntroduction/Purpose:Diabetic foot ulcers (DFU) is a prevalent problem that can lead to devastating results such as limb loss if left untreated. Nevertheless, the prolonged treatment course can limit the patient’s overall function and quality of life. Utilization of Patient-Reported Outcomes Measurement Information System (PROMIS) in Orthopaedic practice has previously shown that preoperative PROMIS scores can predict postoperative outcomes in foot and ankle surgeries. However, PROMIS assessment has not been used to determine the impact of surgical treatment for DFU on patients’ physical function. We sought to investigate the impact of preoperative PROMIS scores (Physical Function (PF), Pain Interference (PI), Depression (D)), demographic and laboratory values on postoperative PF in this unique patient population.Methods:From an academic orthopaedic surgeon’s practice, we identified infected DFU patients who underwent surgical interventions between February 2015 and November 2018 using ICD-10 code E11.621 (n=240). Patients with at least 3 consecutive visits, 3 month minimum post-surgical follow up and completed PROMIS Computer Adaptive Testing (CAT) assessments for each visit were included (n=92). Demographic data, BMI, medical comorbidities, Hemoglobin A1C, procedure performed, and wound healing status were collected. Amputation level was categorized as the following: 0 = irrigation & debridement (I&D) (n=39), 1 = forefoot amputations (n=46), 2 = mid/hindfoot amputations (n=14), 3 = Syme or above amputations (n=12). Uni- and multivariate analysis were performed to identify factors affecting the post-operative PF within the cohort. Spearman’s rank correlation coefficient, Chi-Squared tests and multidimensional modelling were applied to all variables’ pre-operative and post-operative time points. Based on the results, we formulated a numeric equation to predict post-surgical PROMIS PF.Results:The mean age was 60.5 (33-96) and 4.7 (3-12) months follow up. Mean preoperative PF, PI, and D changed from 34.4, 58.7, 51.4 to postoperative 36.1, 58.8, 51.1, respectively (ΔPF = 1.7, ΔPI=0.1, ΔD = -0.3). Preoperative PF (p < 0.01), PI (p < 0.01), depression (p < 0.01), chronic renal failure (p < 0.02) and amputation level (p < 0.04) showed significant univariate correlation with post-operative PF. Multivariate model (r = 0.6) revealed postoperative PF is predicted by initial PF (p = 0.094), depression (p= 0.008), amputation level (p = 0.002), and wound healing status (p = 0.001). The model had greater prediction power than the best univariate association (Δr = +0.17). Follow up length was not significant (p = 0.08).Conclusion:This study demonstrates that preoperative PROMIS scores combined with clinical factors can predict postoperative PF in DFU patients. Postoperative PF is predicted by: PFlongest_FU = 45.4 +0.20 PFinitial -0.21 Dinitial -6.1 (Heal =1) -2.9 (Amputation Category, 1-3). Additional diseased states not captured in this study and psychosocial variables may improve prediction power of the multivariate model. 70% of the patients’ initial PF were 1 to 2 standard deviations below the US population (n = 49; 28). Therefore, the reported model may serve as a valuable tool for patient education, setting expectations and post-surgical PF prediction in infected DFU patients.

Operative Intervention Does Not Change Pain Perception in Diabetic Foot Ulcer Patients

Category:Diabetes, Midfoot/ForefootIntroduction/Purpose:Most diabetic foot ulcer (DFU) patients have peripheral neuropathy (PN), which presents with numbness, pain and weakness. DFU patient’s perceived pain and other clinical factors affecting their pain level have not been reported. Although high prevalence of depression among diabetes patients have been reported, its correlation with perception of pain has not been investigated in patients with ulcers. PROMIS (Patient-Reported Outcomes Measurement Information System) allows accurate quantification of patient’s physical function (PF), pain interference (PI) and Depression. We aimed to investigate 1) if DFU patient’s pre- and postoperative pain level correlate with demographic data/ laboratory values/surgical procedure and 2) if depression level and/or surgical intervention impacts pain.Methods:Prospectively collected PROMIS (PF, PI, D) assessments were obtained for patients who underwent surgical intervention for infected DFU between February 2015 and November 2018 (n=240). Patients who had at least 3 consecutive visits with a minimum follow up of 3 months and had completed all assessments for each visit were included (n=92). Demographic data, BMI, medical comorbidities, Hemoglobin A1C (A1C), procedure performed, wound healing status, PN, depression, and amputation level were collected. The mean follow-up duration was 4.7 (3-12) months. T-score distribution of initial PROMIS scores were calculated and compared to the US population. Chi-Square test and Minimum clinically important differences (MCID) were calculated to assess the co-occurrence of different PROMIS domains. We also analyzed other clinical factors and their influences on MCID changes in PROMIS domains.Results:The 92 patients were 80.4% male (n=74) and had an average age of 60.5 (33-96) and BMI of 34.1 (22.0-57.5). Irrigation and debridement (n=39), forefoot amputations (n=46), mid/hindfoot amputations (n=14) and Syme or above amputations (n=12) were performed. Mean pre-operative PF, PI, and depression PROMIS scores were 34.4, 58.7, and 51.4, respectively. Average scores at final follow up increased 1.7, decreased 0.1, and increased 0.2, respectively. Depression and PI were the most strongly associated co-occurrences (p=0.03) pre-operatively and remained significant (p<0.01) with respect to post-operative MCID. PF and PI also strongly co-occurred pre-operatively (p=0.04) and with post-operative MCID assessment (p=0.02). PF was affected by initial A1C (p=0.03) and wound healing status (p=0.03). PN was the only clinical factor found to affect PI (p=0.03).Conclusion:DFU patients with PN experience a significant amount of pain. Contrary to previous studies, we did not find a higher prevalence of depression in our DFU cohort compared to the average United States population. The study results do not indicate the origin of pain, which can be further investigated using other measures, such as PROMIS Neuropathic Pain Quality Scale. Surgical intervention did not significantly relieve pain in DFU patients. These findings may be referenced for pre-operative patient education and setting expectation for surgery.

MiR-23c regulates wound healing by targeting stromal cell-derived factor-1α (SDF-1α/CXCL12) among patients with diabetic foot ulcer

Diabetic Foot Ulcer (DFU) is the most common in patients who have diabetic peripheral neuropathy and angiopathy as well as a foot deformity. The delayed process of wound healing in diabetic condition is mainly due to reduced expression of the growth factors, persistent inflammatory response and endothelial dysfunction. Emerging evidence indicate that miRNAs play a crucial role in regulating angiogenesis, collectively called as “angiomiRs”. The present study aimed to screen the expressions of angiomiRs particularly miR23 family and its association with the various angiogenic factors including SDF-1α in the tissue biopsies isolated from DFU patients. Among the 40 enrolled subjects for this study, 10 were subjected in each group as healthy controls, type 2 diabetic subjects (T2DM), T2DM subjects with uninfected DFU, and T2DM subjects with infected DFU. The expression of both the miR23 family such as hsa-miR-23a, hsa-miR-23b, hsa-miR-23c and angiogenic factors such as SDF-1α, HIF-1α, VEGF, eNOS were investigated in peripheral blood mononuclear cells and tissue biopsy samples using qPCR. We found that the angiogenic factor SDF-1α was significantly decreased in both the circulation and tissue biopsies of patients with T2DM and infected DFU. The SDF-1α at the 3′-untranslated region pairs with target miRNAs namely hsa-miR-23a-3p, hsa-miR-23b-3p and hsa-miR-23c as established using miRNA target prediction algorithm. Further, the tissue-specific expressions of miR-23a and miR-23b were found to be low whereas miR-23c was increased in patients with infected DFU. Moreover, correlation analysis showed that SDF-1α was found to have a significant inverse association with miR-23c. In conclusion, miR-23c may function as a new regulator to inhibit angiogenesis by targeting SDF-1α.

Effect on total microbial load and community composition with two vs six-week topical Cadexomer Iodine for treating chronic biofilm infections in diabetic foot ulcers.

This study compares two vs six weeks of topical antimicrobial therapy with Cadexomer Iodine in patients with diabetic foot ulcers (DFUs) complicated by chronic biofilm infections. Patients with non-healing DFUs with suspected chronic biofilm infections were eligible for enrolment. Patients were randomised to receive either two or six weeks of treatment with topical Cadexomer Iodine. Tissue biopsies from the ulcers were obtained pre-and-post treatment and underwent DNA sequencing and real-time quantitative polymerase chain reaction (PCR) to determine the total microbial load, community composition, and diversity of bacteria. Scanning electron microscopy confirmed biofilm in all 18 ulcers with suspected chronic biofilm infections. Cadexomer Iodine resulted in 14 of 18 (78%) samples achieving a mean 0.5 log10 reduction in microbial load. Regardless of treatment duration, there was no statistical difference in the reduction of total microbial loads. No difference in the rate of wound healing in the two groups was seen at 6 weeks. Cadexomer Iodine reduces the total microbial load in DFUs with chronic biofilm infections and affects microbial community composition and diversity. All ulcers in both groups showed an initial reduction in wound size with application of Cadexomer Iodine, which might reflect its effect on biofilms.

Fungal isolates from diabetic amputations: Histopathologic spectrum and correlation with culture

Fungal isolates from diabetic amputations: Histopathologic spectrum and correlation with culture - IJMR- Print ISSN No: - 2394-546X Online ISSN No:- 2394-5478 Article DOI No:- 10.18231/j.ijmr.2019.028, Indian Journal of Microbiology Research-Indian J Microbiol Res

The Microflora of Chronic Diabetic Foot Ulcers Based on Culture and Molecular Examination: A Descriptive Study

This prospective, descriptive study was conducted to evaluate clinical wound parameters and to determine the aerobic and anaerobic microflora of DFUs with 1 or more clinical signs of infection using culture and molecular methods. Patients with a DFU and clinical signs of infection receiving care at a tertiary care hospital in Varanasi, India, were consecutively enrolled. Patient and wound characteristics were assessed, and the cultures obtained were analyzed quantitatively to detect aerobes/facultative anaerobes and by polymerase chain reaction for common anaerobes. If no organisms were found using these methods, sequence analysis of bacterial 16S ribosomal RNA (16SrRNA) was used. Clinical, demographic, and microbial flora variables were compared using the chi-squared test, and predictors of culture results were ascertained using multiple logistic regressions. Forty (40) patients participated. Of those, 30 (75%) had positive culture results with a total of 64 isolates (2.13 isolates/ulcer). The ratio of aerobes to anaerobes was 1.24:1 (35/29); Peptococcus spp was the most frequent isolate (15, 23.4%). Proteobacteria and Firmicutes were detected by 16SrRNA in 6 of the 10 samples (60%), their presence not detected by other methods. Ulcer size <11.84 cm2 (OR: 4.71; 95% CI: 0.93-23.68) and ulcer on the dorsum of the foot (OR: 0.92; 95% CI: 0.05-16.42) were significantly associated (P <.05) with monomicrobial microflora. Gram-negative aerobic/facultative anaerobes predominated in the 30 DFUs that exhibited clinical signs of infection. Further experimental studies are required to understand the diverse microorganisms present in DFUs and their potential role in wound infections.

Circulatory levels of B-cell activating factor of the TNF family in patients with diabetic foot ulcer: Association with disease progression.

Enhanced and prolonged expression of tumor necrosis factor alpha (TNF-α), a potent pro-inflammatory cytokine is evidenced during the chronic wound healing process of infected diabetic foot ulcer (IDFU). B-cell activating factor (BAFF) is the member of TNF-α family, which implicit in B-cell dysfunction. This study was aimed to evaluate the role of BAFF in diabetic foot ulcer (DFU) patients and to correlate its association with other family of inflammatory cytokines. Circulating levels of BAFF and other cytokines were measured in IDFU (n = 44) and non-IDFU patients (n = 40) using multiplexed bead-based cytokine immunoassay. A stepwise significant increase was observed in both circulatory BAFF and C-reactive protein (CRP) during the disease progression. The area under the receiver operating characteristic curve (AUCROC ) for BAFF was found to be high (0.89; [95% CI: 0.73-1.0]), when compared to CRP (0.68; [95% CI: 0.61-0.76]). Optimum diagnostic cutoff level for BAFF was found to be ≥2.35 pg/mL with 62.0% sensitivity and 85.7% specificity. Further, BAFF levels showed a significant positive correlation with CRP among IDFU patients. With respect to other family cytokines, BAFF levels were positively correlated with TNF-α, interferon family cytokines such as IFN-α2, IL-28A/IFN-λ2, IFN-γ, and IL-10 family cytokines such as IL-19, IL-22, and IL-26 and negatively correlated with IL-6 receptor family such as gp130/sIL-6Rβ. Hence, our data suggest that devising therapeutic strategies to reduce the levels of BAFF may contribute in amelioration of IDFU.

A neglected causative agent in diabetic foot infection: a retrospective evaluation of 13 patients with fungal etiology

Background/aimClinicians often neglect fungal infections and do not routinely investigate deep tissue from the wound for fungal culture and sensitivity due to insufficient information in the literature. In this study, we aimed to evaluate fungal etiology of invasive fungal diabetic foot which is rarely reported in the literature.Materials and methodsThe patients who were unresponsive to antibiotic therapy and those with positive fungal in bone or deep tissue culture were enrolled in the study. Detailed hospital records were retrieved for demographics and clinical features. Results A total of 13 patients who were diagnosed with invasive fungal diabetic foot (ten females, three males, mean age 59.8 ± 9 years) were included. All of the patients had type-2 diabetes mellitus. Eleven (84.6%) patients had mixed infection. The most common cause of fungal infections of diabetic foot ulcers was the Candida species. Ten (76.9%) patients underwent amputation, two (15.4%) patients refused amputation, and one patient died before surgery. ConclusionInvasive fungal infections may also be a causative pathogen in deep tissue infections. Therefore, fungal pathogens should be considered in patients unresponsive to long-term antibiotic therapy. Early detection of fungal infections in high-risk individuals is critical for the prevention of severe consequences such as foot amputation.

Evaluation of biofilm formation, cell surface hydrophobicity and gelatinase activity in Acinetobacter baumannii strains isolated from patients of diabetic and non-diabetic foot ulcer infections

Abstract Diabetic foot ulcer infections (DFIs) are one of the most complicated diseases worldwide. DFIs are a significant public health concern and may lead to high rates of amputations. The complications of DFIs depend on clinical characteristics of the patients, drug susceptibility and virulence factors of bacteria. Acinetobacter baumannii is one of the virulent pathogens which causes DFIs. The present study was conducted to compare the virulence factors of A. baumannii strains isolated from diabetic and non-diabetic foot ulcer infections (non-DFIs). The virulence factors such as cell surface hydrophobicity (CSH), gelatinase activity and biofilm formation were tested. Confocal laser scanning microscopy (CLSM) was adopted to monitor the biofilm architecture. Out of 480 cases tested, 70 patients were infected with A. baumannii. Biofilm formation was detected in 31.43% of the isolates. We found a significant difference in the biofilm formation and CSH in isolates from the patients with DFIs and non-DFIs (P

Emergence of Fluconazole-resistant Candida Infections in Diabetic Foot Ulcers: Implications for Public Health.

Background:It is well documented in the literature that fungal infections are common in diabetic foot ulcers (DFUs). This has led to an overuse of antifungal agents, namely fluconazole, with a consequent risk of emergence of resistance to this drug. Previous studies have shown a 3.9% prevalence of fluconazole resistance in DFU, but limited data exist regarding the change in resistance pattern over the last decade.Objectives:Our aim was to study the prevalence of resistance to fluconazole in patients with DFU and culture-proven fungal infections.Materials and Methods:We retrospectively studied 1438 patients with type 2 diabetes and nonhealing foot ulcers who had fungal cultures performed during the course of their treatment. The data were collected for all patients who presented to our foot clinic over a period of 18 months.Results:The prevalence of positive fungal culture was 17.38% (250/1438). 151/200 positive cultures belonged to Candida species. Resistance to fluconazole was observed in 9.3% (17/200). The most common organism with resistance to fluconazole was Candida auris (10/17).Conclusions:High prevalence of fluconazole resistance is a potential cause of concern, and the rational use of this drug is important in the community. The above results could have an impact on public health, as fluconazole is one of the safest and effective oral antifungal agents available. The spread of resistance could have implications for its use in other situations including systemic fungal infections.

Platelet-rich plasma plays an antibacterial, anti-inflammatory and cell proliferation-promoting role in an in vitro model for diabetic infected wounds.

AimThis study was designed to examine the potential mechanism underlying these roles of platelet-rich plasma in treating diabetic foot ulcers (DFUs).MethodsStaphylococcus aureus and HaCaT were co-cultured under high glucose conditions to serve as an in vitro model for infected cells in DFUs. Platelet-rich gel (PRG) or extract liquid of platelet-rich gel (EPG) were used to interfere with the model to observe the growth of HaCaT cells and S. aureus, and the effect of miR-21 changes in HaCaT cells on PDCD4, NF-κB activity and related inflammatory factors.ResultsIncubation of HaCaT cells with S. aureus promoted the decline of cell proliferation. Under this condition, the level of PDCD4 and the activity of NF-κB were increased in HaCaT cells with concomitant increased of IL-6, TNF-α and decreased IL-10, TGF-β1 in cultured supernatant. Both of PRG and EPG exhibited specific anti-S. aureus activity where they protect HaCaT cells from bacterial damage and promote cell proliferation. Meanwhile, EPG was observed to increase intracellular miRNA-21 while reduce PDCD4 expression and inhibit NF-κB activity to suppress the inflammation in HaCaT cells.ConclusionThis in vitro model provides a valuable tool for study of wound healing in the treatment of DFUs. Our results suggest that miRNA-21 may regulate the expression of NF-κB through PDCD4 where it plays an anti-inflammatory role and promote proliferation in infected DFUs treated by PRP. These findings could provide novel therapeutic targets for refractory wounds.

A Prospective, Experimental Study to Assess the Effectiveness of Home Care Nursing on the Healing of Peristomal Skin Complications and Quality of Life

The authors examined the effect of specialized ostomy care in the home on peristomal skin complications and patient quality of life (QOL). A prospective, experimental study was conducted among 35 people >18 years old with a colostomy or ileostomy and peristomal skin complications who were listed in 2 ostomy supplier databases. Participants were alternatively allocated to 6 home care visits (intervention [IG], n = 18) or 2 outpatient/clinic care [CG] visits (control, n = 17). Demographic and patient variables were assessed at the initial visit in both groups. The Ostomy Skin Tool (OST) and the Stoma-Quality of Life instrument were used to assess study characteristics; data were statistically analyzed. The Discoloration, Erosion, Tissue Overgrowth scores of the OST of the 2 groups were similar in the first assessment (IG = 6.22 ± 1.47; CG= 6.11 ± 1.96; P = .776), but a statistically significant difference was noted between groups at the end of study (IG = 0.44 ± 0.85, CG = 4.76 ± 2.30; P = .00). At the first assessment, QOL scores of the IG and CG groups were 72.63 ± 11.48 and 66.73 ± 17.52, respectively (P = .197). At the final assessment, QOL scores were 78.12 ± 9.66 and 71.83 ± 18.37 for IG and CG, respectively (P = .390). Home nursing care was found to be effective in treating peristomal skin complications. The QOL scores achieved at the final assessment were significantly improved compared with the initial assessment. The results demonstrated the importance of follow-up after stoma surgery.

Baseline characteristics of infected foot ulcers in patients with diabetes at a tertiary care hospital in Pakistan

Studies on diabetic foot ulcers (DFU) involving a representative sample of patients in Pakistan are scarce. This study aimed to determine baseline characteristics of infected DFUs in patients hospitalised at the Pakistan Institute of Medical Sciences Islamabad. In this cross-sectional study, carried out during May 2015 and June 2016, foot ulcer characteristics of patients with DFUs were investigated and documented. From infected DFUs, aerobic bacterial pathogens were isolated, identified and evaluated for antimicrobial susceptibility. A total of 214 patients were recruited to the study, 62.6% of which were male, 90.2% were aged ≥40 years, 76.2% had type 1 diabetes and 78.5% had poor glycaemic control at time of presentation to hospital. Most patients had grade 3/moderate ulceration (based on the Wagner and International Working Group on the Diabetic Foot/Infectious Diseases Society of America criteria). Over half of the DFUs (57.9%) were of ≤3 months' duration and 70.1% were ≥3 cm2. Of the patients with deep infection grade ulcers, 26.6% underwent amputation, accounting for their prolonged hospital stay (≥20 days). Significant differences were observed between patients with type 1 and type 2 diabetes with DFUs in relation to gender (p≤0.0001), ulcer size (p=0.0421) and duration of hospital stay (p=0.0253). The most significant predictors for lower extremity amputation were osteomyelitis (p=0.0114), retinopathy (p=0.0001) and neuropathy (p=0.0001. Piperacillin/tazobactam was found to be an effective antibiotic against the most commonly isolated Staphylococcus non-aureus (35.48%), Pseudomonas aeruginosa (22.26%), and Staphylococcus aureus (20.96%) species indentified in the DFU infections. The findings of this study may be helpful in the optimal management and appropriate treatment of patients with infected DFUs.

COMPARATIVE STUDY OF GELATINASE ACTIVITY AND PELLICLE FORMATION AMONG EXTENDED-SPECTRUM BETA-LACTAMASE AND NON-EXTENDED-SPECTRUM BETA-LACTAMASE PRODUCING ACINETOBACTER BAUMANNII FROM DIABETIC FOOT ULCER INFECTIONS

Objective: The aim of the study was to assess and compare the gelatinase activity and pellicle formation in extended-spectrum beta-lactamase (ESBL) and non-ESBL producing Acinetobacter baumannii isolates from diabetic foot ulcer infection (DFI).Methods: A total of 42 isolates of A. baumannii recovered from patients of DFI from September 2016 to February 2018. Isolates were identified by the standard microbiological method and confirmed by the BD Phoenix 100 system. The antimicrobial susceptibility test was performed by the Kirby–Bauer disk diffusion method and ESBL was detected by double disk diffusion synergy test method. Gelatinase production was determined by the Luria Bertani agar supplemented with 30 g/L gelatin, and pellicle formation was determined by the Mueller-Hinton broth which is incubated at two different temperatures.Results: A total of 42 A. baumannii isolates were multidrug resistant. Among 21 isolates, each was ESBL and non-ESBL producers. Pellicle formation at 25°C in ESBL and non-ESBL producer isolates was 47.61% (10/21) and 28.57% (06/21). Pellicle formation at 37°C in ESBL and non-ESBL producer isolates was 57.14% (12/21) and 42.85% (09/21), respectively. Gelatinase production was present in 38.09% ESBL and 28.57% in non-ESBL producers. ESBL strains were more virulent compared to non-ESBL producers among patients of DFIs.Conclusion: This study showed that pellicle formation at 37°C was highly virulent due to ESBL producers. Gelatinase production was elevated in ESBL compared to non-ESBL producer isolates. This attribute of the isolates could render ESBL positive more pathogenic. Colistin and polymyxin B are the only choices of treatment for multidrug-resistant Acinetobacter baumannii infections.