Has been changed numbers and characteristics of patients with major amputations indicated for the diabetic foot in our department during last decade?
Authors:
Vladimíra Fejfarová 1; Alexandra Jirkovská 1; Vladimír Petkov 2; Ludmila Řezaninová 1; Robert Bém 1; Michal; Dubský 1; MUDr. Veronika Wosková 1; Andrea Němcová 1; Jelena Skibová 1
Authors‘ workplace:
Centrum diabetologie IKEM, Praha
1; Oddělení klinické mikrobiologie IKEM, Praha
2
Published in:
Vnitř Lék 2016; 62(12): 969-975
Category:
Original Contributions
Overview
Introduction:
One of the most serious complications of the diabetic foot (DF) is a major amputation, which is associated with poor patient prognosis. The occurrence of major amputations may be influenced by a variety of factors including deep infection caused by resistant pathogens.
The aims of our study were to compare the incidence of major amputations in podiatric center, characteristics of amputated patients with the DF and other factors contributing to major amputations in last decade.
Methods:
We included into our study all patients hospitalized for the DF in our center whose underwent major amputations from 9/2004 to 9/2006 (group 1) and from 9/2013 to 9/2015 (group 2). Risk factors such as severity of DF ulcers based on Texas classification, duration of previous antibiotic therapy, the presence and severity of peripheral arterial disease (PAD) according to Graziani classification, the number of revascularizations, renal failure/hemodialysis, osteomyelitis, infectious agents found before amputations and their resistance were compared between the study groups.
Results:
During the 1st study period (9/2004–9/2006) 373 patients were hospitalized for the DF, of whom 3.2 % underwent major amputation (12/373 – group 1), during the 2nd study period (9/2013–9/2015) 376 patients, of whom 5.1 % absolved major amputation (19/376 – group 2). As the numbers of major amputations as their indications were similar in both study groups. The study groups did not differ significantly in the age, BMI, duration and type of diabetes, duration of DF and severity of DF ulcers, the presence of renal failure/hemodialysis, osteomyelitis and PAD. Group 2 had milder forms of PAD by Graziani classification (4.4 ±1.4 vs 5.7 ± 0.9; p = 0.012) and a higher number of revascularizations before major amputations (2.5 ± 1.5 vs 1 ± 1; p = 0.003) compared to the group 1. These patients were significantly longer treated by antibiotics (5.4 ± 2.4 vs 2.5 ± 2 months; p = 0.002) and underwent more resections and minor amputations (3.1 ± 2.1 vs 0.9 ± 0.5; p = 0.0004) before major amputations in contrast to the group 1. There was a trend to higher incidence of Gram-negatives (65.1 % vs 61.5 %; NS) with a predominance of Enterobacteriacae species (60.7 % vs 56 %; NS) and a trend to the increase of Pseudomonas (25 % vs 18.8 %; NS) and Enterococci sp. (46.7 % vs 20 %; NS) in the group 2 compared to the group 1. The incidences as of MRSA, multidrug resistant Pseudomonas sp. of other resistant microbes were similar in both study groups.
Conclusions:
The incidence of major amputations in patients hospitalized for the DF remains unchanged during the last decade. The therapy of factors leading to amputations has evidently intensified. This is in accordance with the latest international recommendations for the therapy of DF. In the future, it is appropriate to focus on the improvement of detection and treatment of infection and ischemia in such risk group of patients.
Key words:
diabetic foot – major amputation
Sources
1. Tuttolomondo A, Maida C, Pinto A. Diabetic foot syndrome as a possible cardiovascular marker in diabetic patients. J Diabetes Res 2015; 2015: 268390. Dostupné z DOI: <http://dx.doi.org/10.1155/2015/268390>.
2. Naidoo P, Liu VJ, Mautone M et al. Lower limb complications of diabetes mellitus: a comprehensive review with clinicopathological insights from a dedicated high-risk diabetic foot multidisciplinary team. Br J Radiol 2015; 88(1053): 20150135. Dostupné z DOI: <http://dx.doi.org/10.1259/bjr.20150135>.
3. Fejfarová V, Jirkovská A, Dragomirecká E et al. Has the diabetic foot a significant impact on selected psychological or social characteristics of patients with diabetes mellitus? J Diabetes Res 2014; 2014: 371938. Dostupné z DOI: <http://dx.doi.org/10.1155/2014/371938>.
4. Al-Rubeaan K, Al Derwish M, Ouizi S et al. Diabetic foot complications and their risk factors from a large retrospective cohort study. PLoSOne 2015; 10(5): e0124446. Dostupné z DOI: <http://dx.doi.org/10.1371/journal.pone.0124446>.
5. Edmonds M. Modern treatment of infection and ischaemia to reduce major amputation in the diabetic foot. Curr Pharm Des 2013; 19(27): 5008–5015.
6. Jirkovská A et al. Syndrom diabetické nohy: komplexní týmová péče. Maxdorf Jessenius: Praha 2006. ISBN 80–7345–095-X.
7. Fejfarová V, Jirkovská A et al. Léčba syndromu diabetické nohy odlehčením. Maxdrof Jessenius: Praha 2015. ISBN 978–80–7345–436–4.
8. Leese B. Diabetes mellitus and the St Vincent Declaration. The economic implications. Pharmacoeconomic 1995; 7(4): 292–307.
9. Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care 1998; 21(5): 855–859.
10. Brownrigg JR, Hinchliffe RJ, Apelqvist J et al. On behalf International Working Group on the Diabetic Foot (IWGDF). Performance of prognostic markers in the prediction of wound healing or amputation among patients with foot ulcers in diabetes: a systematic review. Diabetes Metab Res Rev 2016; 32(Suppl 1): 128–135. Dostupné z DOI: <http://dx.doi.org/10.1002/dmrr.2704>.
11. Fejfarová V, Jirkovská A Ischemická choroba dolních končetin u pacientů s diabetes mellitus. Postgraduální medicína 2013; 15(2): 169–175.
12. Hardman RL, Jazaeri O, Yi J et al. Overview of classification systems in peripheral artery disease. Semin Intervent Radiol 2014; 31(4): 378–388. Dostupné z DOI: <http://dx.doi.org/10.1055/s-0034–1393976>.
13. Akbari A, Clase CM, Acott P et al. Canadian Society of Nephrology commentary on the KDIGO clinical practice guideline for CKD evaluation and management. Am J Kidney Dis 2015; 65(2): 177–205. Dostupné z DOI: <http://dx.doi.org/10.1053/j.ajkd.2014.10.013>.
14. Bakker K, Apelqvist J, Lipsky BA et al. [International Working Group on the Diabetic Foot (IWGDF)]. The 2015 IWGDF Guidance documents on prevention and management of foot problems in diabetes: development of an evidence-based global consensus. Dostupné z WWW: <http://iwgdf.org/guidelines/>
15. Frykberg RG, Zgonis T, Armstrong DG et al. American College of Foot and Ankle Surgeons Diabetic foot disorders. A clinical practice guideline (2006 revision). J Foot Ankle Surg 2006; 45(5 Suppl): S1-S66.
16. Fejfarová V, Jirkovská A, Skibová J et al. Pathogen resistance and other risk factors in the frequency of lower limb amputations in patients with the diabetic foot syndrome. Vnitř Lék 2002; 48(4): 302–306.
17. Hoffmann M, Kujath P, Flemming A et al. Survival of diabetes patients with major amputation is comparable to malignant disease. Diab Vasc Dis Res 2015; 12(4): 265–271. Dostupné z DOI: <http://dx.doi.org/10.1177/1479164115579005>.
18. Prompers L, Huijberts M, Schaper N et al. Resource utilisation and cosi associated with the treatment of diabetic foot ulcers. Prospective data from the Eurodiale Study. Diabetologia 2008; 51(10): 1826–1834. Dostupné z DOI: <http://dx.doi.org/10.1007/s00125–008–1089–6>.
19. Lazzarini PA, O‘Rourke SR, Russell AW et al. Reduced Incidence of Foot-Related Hospitalisation and Amputation amongst Persons with Diabetes in Queensland, Australia. PLoSOne 2015; 10(6): e0130609. Dostupné z DOI: <http://dx.doi.org/10.1371/journal.pone.0130609>.
20. Wiessman MP, Liberty IF, Segev RW et al. Clinical characteristics and survival of patients with diabetes mellitus following non-traumatic lower extremity amputation. Isr Med Assoc J 2015; 17(3): 145–149.
21. Piťhová P, Honěk P, Dušek L et al. Incidence of amputations among patients with diabetes mellitus in the Czech Republic from 2010 to 2014. Vnitř Lék 2015; 61(11 Suppl 3): 3S21–3S24.
22. 22 Gregg EW, Li Y, Wang J, et al. Changes in diabetes-related complications in the United States, 1990–2010. N Engl J Med 2014; 370(16): 1514–1523. Dostupné z DOI: <http://dx.doi.org/10.1056/NEJMoa1310799>.
23. Tabur S, Eren MA, Çelik Y et al. The major predictors of amputation and length of stay in diabetic patients with acute foot ulceration. Wien Klin Wochenschr 2015; 127(1–2): 45–50. Dostupné z DOI: <http://dx.doi.org/10.1007/s00508–014–0630–5>.
24. Ricco JB, Thanh Phong L, Schneider F et al. The diabetic foot: a review. J Cardiovasc Surg (Torino) 2013; 54(6): 755–762.
25. Lipsky BA, Peters EJ, Senneville E et al. Expert opinion on the management of infections in the diabetic foot. Diabetes Metab Res Rev 2012; 28(Suppl 1): 163–178. <http://dx.doi.org/10.1002/dmrr.2248>.
26. Belefquih B, Frikh M, Benlahlou Y et al. Diabetic Foot Infection in Morocco: Microbiological Profile. Wounds 2016; 28(3): 89–98.
27. Commons RJ, Robinson CH, Gawler D et al. High burden of diabetic foot infections in the top end of Australia: An emerging health crisis (DEFINE study). Diabetes Res Clin Pract 2015; 110(2): 147–157. Dostupné z DOI: <http://dx.doi.org/10.1016/j.diabres.2015.09.016>.
28. Hagel S, Scheuerlein H. Perioperative Antibiotic Prophylaxis and Antimicrobial Therapy of Intra-Abdominal Infections. Viszeral medizin 2014; 30(5): 310–316. Dostupné z DOI: <http://dx.doi.org/10.1159/000368582>.
29. Seth AK, Geringer MR, Hong SJ et al. Comparative analysis of single-species and polybacterial wound biofilms using a quantitative, in vivo, rabbitear model. PLoSOne 2012; 7(8): e42897. Dostupné z DOI: <http://dx.doi.org/10.1371/journal.pone.0042897>.
30. Fejfarová V, Jirkovská A, Petkov V et al. Comparison of microbial findings and resistance to antibiotics between transplant patients, patients on hemodialysis, and other patients with the diabetic foot. J Diabetes Complications 2004; 18(2): 108–112.
31. James GA, Zhao AG, Usui M et al. Microsensor and transcriptomic signatures of oxygen depletion in biofilms associated with chronic wounds. Wound Repair Regen 2016; 24(2): 373–383. Dostupné z DOI: <http://dx.doi.org/10.1111/wrr.12401>.
32. Callahan D, Keeley J, Alipour H et al. Predictors of Severity in Diabetic Foot Infections. Ann Vasc Surg. 2016; 33: 103–108. Dostupné z DOI: <http://dx.doi.org/10.1016/j.avsg.2016.01.003>.
33. Amin N, Doupis J. Diabetic foot disease: From the evaluation of the “foot at risk” to the novel diabetic ulcer treatment modalities. World J Diabetes 2016; 7(7): 153–164. Dostupné z DOI: <http://dx.doi.org/10.4239/wjd.v7.i7.153>.
Labels
Diabetology Endocrinology Internal medicineArticle was published in
Internal Medicine
2016 Issue 12
Most read in this issue
- Thrombophilia
- Oral antidiabetic drugs in treatment of type 1 diabetes mellitus
- Takotsubo cardiomyopathy: incidence, etiology, complications, therapy and prognosis
- Coffee as hepatoprotective factor