Review articleDiabetic lower extremity infection: Influence of physical, psychological, and social factors☆
Introduction
Diabetes continues to be one of the most common underlying causes of amputation of the foot and leg in postindustrialized countries. (Most & Sinnock, 1983, National Institute of Health, 1980) For most patients, an infection is a pivotal event that leads to additional lower extremity complications, such as ulcers, amputation of the (contralateral) limb, and/or death.
Amputation is one of the complications of diabetes that can be prevented successfully. Several studies suggest that amputations can be reduced by 40–85% when high-risk patients are identified and provided with a multispecialty treatment approach that focuses on preventive strategies (Apelqvist et al., 1994, Edmonds, 1987, Gibbons et al., 1984, Levin, 1988, Reiber, 1992, Tan et al., 1987). These amputations are most often preceded by a severe foot infection; however, most published data on risk factors for lower extremity amputations are limited to descriptive reports of surgical case series. There are only a few studies that evaluate risk factors for infection and amputation, and many of these systemically eliminate patients with a history of amputation or concentrate on systemic variables such as glucose control and hyperlipidemia (Humphrey et al., 1996, Moss et al., 1992, Moss et al., 1999, Nelson et al., 1988, Selby & Zhang, 1995), a combination of systemic and local factors (Hämäläinen, Halonen, Rönnemaa, & Toikka, 1999), or only address lower extremity variables (Adler, Ahroni, Boyko, & Smith, 1999). To our knowledge, there have been only two studies that assessed the influence of socioeconomic factors together with systemic medical parameters for diabetic complications (Nicolucci et al., 1996, Flores Rivera, 1998). One of these studies did not specifically investigate foot infection or amputation and did not include local extremity factors like neuropathy or vasculopathy (Nicolucci et al., 1996). The other study investigated amputations and socioeconomic factors, but unfortunately, the author did not describe any of the operational definitions (Flores Rivera, 1998).
Although evidence is scarcely available, poor socioeconomic status has been empirically accepted as a risk factor for diabetic foot complications, even in the recently developed International Consensus on the Diabetic Foot by the International Working Group on the Diabetic Foot (Apelqvist et al., 2000, International Working Group on the Diabetic Foot, 1999). Therefore, the purpose of this study was to evaluate the socioeconomic, psychosocial, systemic, and specific lower extremity risk factors for severe foot infection possibly necessitating an amputation among patients with diabetes.
Section snippets
Methods
This study was designed as a case-control study at the University of Texas Health Science Center at San Antonio. The institutional review boards of this university teaching institution approved the research protocol. Sixty-eight cases and 44 controls with diabetes mellitus based on World Health Organization (1980) criteria, aged 18 to 80 years, were consecutively enrolled. Cases were defined as subjects that were admitted to hospital for a foot infection, deemed by the treating physician to be
Results
As summarized in Table 1, patients with a severe foot infection had significantly a longer duration of diabetes, a higher peak plantar pressure, and a higher prevalence of neuropathy. In the initial univariate analysis of the data, the presence of severe diabetic foot infection was significantly associated with several factors. These data are outlined in Table 2. Using a stepwise logistic regression model, we evaluated the potential interactions of the univariate associations. These data are
Discussion
This study evaluates several potential risk factors for diabetic foot infection. The results suggest that previous amputation, peripheral vascular disease, and neuropathy are significant risk factors for diabetic foot infection. This implies the great influence of physical factors to diabetic foot infection. The additional risk of socioeconomic status, knowledge of the foot, years of education, and systemic medical parameters, such as glycemic control, is limited in this population. These
References (51)
- et al.
Is there a critical level of plantar foot pressure to identify patients at risk for neuropathic foot ulceration?
Journal of Foot and Ankle Surgery
(1998) - et al.
Relative performance of the MAST, VAST, and CAGE versus DM-III-R criteria for alcohol dependence
Journal of Clinical Epidemiology
(1993) - et al.
Effectiveness of the diabetic foot risk classification system of the International Working Group on the Diabetic Foot
Diabetes Care
(2001) - et al.
Lower extremity amputation in diabetes. The independent effects of peripheral vascular disease, sensory neuropathy, and foot ulcers
Diabetes Care
(1999) - et al.
International consensus and practical guidelines on the management and the prevention of the diabetic foot
Diabetes/Metabolism Research and Reviews
(2000) - et al.
Diabetic foot ulcers in a multidisciplinary setting—An economic analysis of primary healing and healing with amputation
Journal of Internal Medicine
(1994) - et al.
Amputation and reamputation of the diabetic foot
Journal of the American Podiatric Medical Association
(1997) - et al.
Choosing a practical screening instrument to identify patients at risk for diabetic foot ulceration
Archives of Internal Medicine
(1998) - et al.
Arteriosclerosis obliterans and associated risk factors in insulin-dependent and non-insulin dependent diabetes
Diabetes
(1980) - et al.
The insensitive foot
A prospective study of risk factors for diabetic foot ulcer
Diabetes Care
Additional factors associated with plantar ulcers in diabetic neuropathy
Diabetic Medicine
Effect of near normoglycemia for two years on progression of early diabetic retinopathy, nephropathy, and neuropathy: The Oslo study
British Medical Journal
Experience in a multidisciplinary diabetic foot clinic
Risk factors for amputation in diabetic patients: A case-control study
Archives of Medical Research
Improved quality of diabetic foot care. 1984 vs. 1990: Reduced length of stay and costs. Insufficient reimbursement
Archives of Surgery
The fate of the second leg in the diabetic amputee
Diabetes
Factors predicting lower extremity amputations in patients with type 1 or type 2 diabetes mallitus: a population-based 7-year follow-up study
Journal of Internal Medicine
Effects of acculturation and socioeconomic status on obesity and diabetes in Mexican Americans
American Journal of Epidemiology
Chronic renal failure in non-insulin dependent diabetes mellitus
Annals of Internal Medicine
Diabetes and nontraumatic lower extremity amputations. Incidence, risk factors, and prevention—A 12-year follow-up study in Nauru
Diabetes Care
International consensus on the diabetic foot
Diabetic foot infections: fate of the contralateral foot
Plastic and Reconstructive Surgery
Semmes-Weinstein monofilaments: a simple, effective and inexpensivc screening device for identifying diabetic patients at risk of foot ulceration
Diabetes Research and Clinical Practice
Cited by (75)
Clinical practice recommendations for infectious disease management of diabetic foot infection (DFI) – 2023 SPILF
2024, Infectious Diseases NowOsteomyelitis in Charcot neuroarthropathy
2022, The Essentials of Charcot Neuroarthropathy: Biomechanics, Pathophysiology, and MRI FindingsGlucose control and infection of diabetic foot ulcer
2021, Journal of Diabetes and its ComplicationsThe diabetic foot microbiota: A review
2017, Human Microbiome JournalCitation Excerpt :One prospective and multifocus study identified bone contact on probing, foot ulcer duration of longer than 30 days, a history of recurrent foot ulcers, traumatic etiology of the ulcer and peripheral vascular disease as independent risk factors for DFIs from a multivariate analysis [8]. Another retrospective study of DFI reported that risk factors for DFIs were previous amputation, peripheral vascular disease and neuropathy but not the socioeconomic status nor the patient’s knowledge of foot care [9]. Recent studies using molecular methods have confirmed that chronic wounds, including DFUs, have a polymicrobial nature that largely exceeds the identification capabilities of traditional culture methods [10–13].
IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023)
2024, Diabetes/Metabolism Research and Reviews
- ☆
This paper was presented as an oral presentation at the 4th International Symposium on the Diabetic Foot, Noordwijkerhout, The Netherlands, May 2003. No funding was received for this study.