Outcomes after Emergency Admission with a Diabetic Foot Attack Indicate a High Rate of Healing and Limb Salvage But Increased Mortality: 18-Month Follow-up Study

Abstract

Aim The diabetic foot attack (DFA) is perhaps the most devastating form of diabetic foot infection, presenting with rapidly progressive skin and tissue necrosis, threatening both limb and life. However, clinical outcome data in this specific group of patients are not available.

Methods Analysis of 106 consecutive patients who underwent emergency hospitalisation for DFA (TEXAS Grade 3B or 3D and Infectious Diseases Society of America (IDSA) Class 4 criteria). Outcomes evaluated were: 1) Healing 2) major amputation 3) death 4) not healed. The first outcome reached in one of these four categories over the follow-up period (18.4±3.6 months) was considered. We also estimated amputation free survival.

Results Overall, 57.5% (n=61) healed, 5.6% (n=6) underwent major amputation, 23.5% (n=25) died without healing and 13.2% (n=14) were alive without healing. Predictive factors associated with outcomes were: Healing (age<60, p=0.0017; no Peripheral arterial disease (PAD) p= 0.002; not on dialysis p=0.006); major amputation (CRP>100 mg/L, p=0.001; gram+ve organisms, p=0.0013; dialysis, p= 0.001), and for death (age>60, p= 0.0001; gram+ve organisms p=0.004; presence of PAD, p=0.0032; CRP, p=0.034). The major amputation free survival was 71% during the first 12 months from admission, however it had reduced to 55.4% by the end of the follow-up period.

Conclusions In a unique population of hospitalised individuals with DFA, we report excellent healing and limb salvage rates using a dedicated protocol in a multidisciplinary setting. An additional novel finding was the concerning observation that such an admission was associated with high 18-month mortality, almost all of which was after discharge from hospital.

Key words

diabetic foot - diabetic foot attack - diabetic foot infection - outcomes - peripheral vascular disease - wound healing

Publication History

Received: 11 August 2020
Received: 10 November 2020

Accepted: 25 November 2020

Article published online:
22 December 2020

• References

• 1 Armstrong DG, Boulton AJM, Bus SA. Diabetic foot ulcers and their recurrence. N Engl J Med 2017; 376: 2367-2375 DOI: 10.1056/NEJMra1615439
• 2 Uckay I, Gariani K, Dubois-Ferriere V. et al. Diabetic foot infections: recent literature and cornerstones of management. Curr Opin Infect Dis 2016; 29: 145-152
• 3 Lavery LA, Armstrong DG, Wunderlich RP. et al. Risk factors for foot infections in individuals with diabetes. Diabetes Care 2006; 29: 1288-1293
• 4 Vas PRJ, Edmonds M, Kavarthapu V. et al. The Diabetic Foot Attack: “Tis Too Late to Retreat!”. Int J Low Extrem Wounds 2018; 17: 7-13
• 5 Uccioli L, Meloni M, Giurato L. et al. Emergency in diabetic foot. Emergency Med 2013; 160
• 6 Dorr S, Schlecht M, Chatzitomaris A. et al. Predictive effect of inflammatory response and foot ulcer localization on outcome in younger and older individuals with infected diabetic foot syndrome. Exp Clin Endocrinol Diabetes 2020;
• 7 Game F. Classification of diabetic foot ulcers. Diabetes/Metabolism Research and Reviews 2016; 32: 186-194
• 8 Lipsky BA, Berendt AR, Cornia PB. et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clinical Infectious Diseases 2012; 54: e132-e173
• 9 Gershater MA, Londahl M, Nyberg P. et al. Complexity of factors related to outcome of neuropathic and neuroischaemic/ischaemic diabetic foot ulcers: A cohort study. Diabetologia 2009; 52: 398-407
• 10 Uccioli L, Gandini R, Giurato L. et al. Long-term outcomes of diabetic patients with critical limb ischemia followed in a tertiary referral diabetic foot clinic. Diabetes Care 2010; 33: 977-982
• 11 Lipsky BA, Aragon-Sanchez J, Diggle M. et al. IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes. Diabetes Metab Res Rev 2016; 32: 45-74
• 12 Nelson A, Wright-Hughes A, Backhouse MR. et al. CODIFI (Concordance in Diabetic Foot Ulcer Infection): a cross-sectional study of wound swab versus tissue sampling in infected diabetic foot ulcers in England. BMJ Open 2018; 8: e019437
• 13 Bowling FL, Jude EB, Boulton AJM. MRSA and diabetic foot wounds: Contaminating or infecting organisms?. Current Diabetes Reports 2009; 9: 440-444 DOI: 10.1007/s11892-009-0072-z
• 14 Aragón-Sánchez J, Lázaro-Martínez JL, Quintana-Marrero Y. et al. Are diabetic foot ulcers complicated by MRSA osteomyelitis associated with worse prognosis? Outcomes of a surgical series. Diabetic medicine 2009; 26: 552-555
• 15 Manas AB, Taori S, Ahluwalia R. et al. Admission time deep swab specimens compared with surgical bone sampling in hospitalized individuals with diabetic foot osteomyelitis and soft tissue infection. The International Journal of Lower Extremity Wounds
• 16 Boyko EJ, Seelig AD, Ahroni JH. Limb- and person-level risk factors for lower-limb amputation in the prospective seattle diabetic foot study. Diabetes Care 2018; 41: 891-898 DOI: 10.2337/dc17-2210
• 17 Aziz Z, Lin WK, Nather A. et al. Predictive factors for lower extremity amputations in diabetic foot infections. Diabetic Foot & Ankle 2011; 2: 7463
• 18 Pickwell K, Siersma V, Kars M. et al. Predictors of lower-extremity amputation in patients with an infected diabetic foot ulcer. Diabetes Care 2015; 38: 852-857
• 19 van Battum P, Schaper N, Prompers L. et al. Differences in minor amputation rate in diabetic foot disease throughout Europe are in part explained by differences in disease severity at presentation. Diabet Med 2011; 28: 199-205
• 20 Holman N, Young RJ, Jeffcoate WJ. Variation in the incidence of amputation in the lower limb in England. Diabetologia 2012; 55 DOI: 10.1007/s00125-012-2468-6
• 21 Ndip A, Rutter MK, Vileikyte L. et al. Dialysis treatment is an independent risk factor for foot ulceration in patients with diabetes and stage 4 or 5 chronic kidney disease. Diabetes Care 2010; 33: 1811-1816
• 22 Meloni M, Giurato L, Izzo V. et al. Long term outcomes of diabetic haemodialysis patients with critical limb ischemia and foot ulcer. Diabetes Res Clin Pract 2016; 116: 117-122
• 23 Lavery LA, Lavery DC, Hunt NA. et al. Amputations and foot-related hospitalisations disproportionately affect dialysis patients. Int Wound J 2015; 12: 523-526
• 24 Klaphake S, de Leur K, Mulder PG. et al. Mortality after major amputation in elderly patients with critical limb ischemia. Clin Interv Aging 2017; 12: 1985-1992
• 25 van Netten JJ, Fortington LV, Hinchliffe RJ. et al. Early post-operative mortality after major lower limb amputation: A systematic review of population and regional based studies. Eur J Vasc Endovasc Surg 2016; 51: 248-257
• 26 Jupiter DC, Thorud JC, Buckley CJ. et al. The impact of foot ulceration and amputation on mortality in diabetic patients. I: From ulceration to death, a systematic review. Int Wound J 2016; 13 -892 903
• 27 Thewjitcharoen Y, Krittiyawong S, Porramatikul S. et al. Outcomes of hospitalized diabetic foot patients in a multi-disciplinary team setting: Thailand's experience. J Clin Transl Endocrinol 2014; 1: 187-191
• 28 Meloni M, Izzo V, Giurato L. et al. Procalcitonin Is a prognostic marker of hospital outcomes in patients with critical limb ischemia and diabetic foot infection. J Diabetes Res 2019; 2019: 4312737
• 29 Ince P, Game FL, Jeffcoate WJ. Rate of healing of neuropathic ulcers of the foot in diabetes and its relationship to ulcer duration and ulcer area. Diabetes Care 2007; 30: 660-663
• 30 Monteiro-Soares M, Russell D, Boyko EJ. et al. Guidelines on the classification of diabetic foot ulcers (IWGDF 2019). Diabetes Metab Res Rev 2020; 36: e3273
• 31 Vassallo IM, Gatt A, Cassar K. et al. Healing and mortality rates following toe amputation in type 2 diabetes mellitus. Exp Clin Endocrinol Diabetes 2019;
• 32 Ahluwalia R, Vainieri E, Tam J. et al. Surgical diabetic foot debridement: improving training and practice utilizing the traffic light principle. Int J Low Extrem Wounds 2019; 18: 279-286
• 33 Sung JA, Gurung S, Lam T. et al. A 'Speed-Dating' Model of Wound Care? Rapid, High-Volume Assessment of Patients With Diabetes in a Multidisciplinary Foot Wound Clinic. Exp Clin Endocrinol Diabetes 2020;
• 34 Vig S, Waite KH. The Role of the Multidisciplinary Team in the Management of Diabetic Foot Complications. In: Shearman PC. Management of Diabetic Foot Complications. London: Springer London; 2015: 201-213