Diagnosis of infection in the foot of patients with diabetes: A systematic review.

BACKGROUND: Securing an early accurate diagnosis of diabetic foot infections and assessment of their severity are of paramount importance since these infections can cause great morbidity and potential mortality and present formidable challenges in surgical and antimicrobial treatment. METHODS: In June 2022, we searched the literature using PubMed and EMBASE for published studies on the diagnosis of diabetic foot infection (DFI). On the basis of pre-determined criteria, we reviewed prospective controlled, as well as non-controlled, studies in English. We then developed evidence statements based on the included papers. RESULTS: We selected a total of 64 papers that met our inclusion criteria. The certainty of the majority of the evidence statements was low because of the weak methodology of nearly all of the studies. The available data suggest that diagnosing diabetic foot infections on the basis of clinical signs and symptoms and classified according to the International Working Group of the Diabetic Foot/Infectious Diseases Society of America scheme correlates with the patient's likelihood of the need for hospitalisation, lower extremity amputation, and risk of death. Elevated levels of selected serum inflammatory markers such as erythrocyte sedimentation rate (ESR), C-reactive protein and procalcitonin are supportive, but not diagnostic, of soft tissue infection. Culturing tissue samples of soft tissues or bone, when care is taken to avoid contamination, provides more accurate microbiological information than culturing superficial (swab) samples. Although non-culture techniques, especially next-generation sequencing, are likely to identify more bacteria from tissue samples including bone than standard cultures, no studies have established a significant impact on the management of patients with DFIs. In patients with suspected diabetic foot osteomyelitis, the combination of a positive probe-to-bone test and elevated ESR supports this diagnosis. Plain X-ray remains the first-line imaging examination when there is suspicion of diabetic foot osteomyelitis (DFO), but advanced imaging methods including magnetic resonance imaging (MRI) and nuclear imaging when MRI is not feasible help in cases when either the diagnosis or the localisation of infection is uncertain. Intra-operative or non-per-wound percutaneous biopsy is the best method to accurately identify bone pathogens in case of a suspicion of a DFO. Bedside percutaneous biopsies are effective and safe and are an option to obtain bone culture data when conventional (i.e. surgical or radiological) procedures are not feasible. CONCLUSIONS: The results of this systematic review of the diagnosis of diabetic foot infections provide some guidance for clinicians, but there is still a need for more prospective controlled studies of high quality.

IWGDF/IDSA guidelines on the diagnosis and treatment of diabetes-related foot infections (IWGDF/IDSA 2023).

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the management and prevention of diabetes-related foot diseases since 1999. The present guideline is an update of the 2019 IWGDF guideline on the diagnosis and management of foot infections in persons with diabetes mellitus. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used for the development of this guideline. This was structured around identifying clinically relevant questions in the P(A)ICO format, determining patient-important outcomes, systematically reviewing the evidence, assessing the certainty of the evidence, and finally moving from evidence to the recommendation. This guideline was developed for healthcare professionals involved in diabetes-related foot care to inform clinical care around patient-important outcomes. Two systematic reviews from 2019 were updated to inform this guideline, and a total of 149 studies (62 new) meeting inclusion criteria were identified from the updated search and incorporated in this guideline. Updated recommendations are derived from these systematic reviews, and best practice statements made where evidence was not available. Evidence was weighed in light of benefits and harms to arrive at a recommendation. The certainty of the evidence for some recommendations was modified in this update with a more refined application of the GRADE framework centred around patient important outcomes. This is highlighted in the rationale section of this update. A note is also made where the newly identified evidence did not alter the strength or certainty of evidence for previous recommendations. The recommendations presented here continue to cover various aspects of diagnosing soft tissue and bone infections, including the classification scheme for diagnosing infection and its severity. Guidance on how to collect microbiological samples, and how to process them to identify causative pathogens, is also outlined. Finally, we present the approach to treating foot infections in persons with diabetes, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and bone infections; when and how to approach surgical treatment; and which adjunctive treatments may or may not affect the infectious outcomes of diabetes-related foot problems. We believe that following these recommendations will help healthcare professionals provide better care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes-related foot disease.

Interventions in the management of diabetes-related foot infections: A systematic review.

The optimal approaches to managing diabetic foot infections remain a challenge for clinicians. Despite an exponential rise in publications investigating different treatment strategies, the various agents studied generally produce comparable results, and high-quality data are scarce. In this systematic review, we searched the medical literature using the PubMed and Embase databases for published studies on the treatment of diabetic foot infections from 30 June 2018 to 30 June 2022. We combined this search with our previous literature search of a systematic review performed in 2020, in which the infection committee of the International Working Group on the Diabetic Foot searched the literature until June 2018. We defined the context of the literature by formulating clinical questions of interest, then developing structured clinical questions (Patients-Intervention-Control-Outcomes) to address these. We only included data from controlled studies of an intervention to prevent or cure a diabetic foot infection. Two independent reviewers selected articles for inclusion and then assessed their relevant outcomes and methodological quality. Our literature search identified a total of 5,418 articles, of which we selected 32 for full-text review. Overall, the newly available studies we identified since 2018 do not significantly modify the body of the 2020 statements for the interventions in the management of diabetes-related foot infections. The recent data confirm that outcomes in patients treated with the different antibiotic regimens for both skin and soft tissue infection and osteomyelitis of the diabetes-related foot are broadly equivalent across studies, with a few exceptions (tigecycline not non-inferior to ertapenem [±vancomycin]). The newly available data suggest that antibiotic therapy following surgical debridement for moderate or severe infections could be reduced to 10 days and to 3 weeks for osteomyelitis following surgical debridement of bone. Similar outcomes were reported in studies comparing primarily surgical and predominantly antibiotic treatment strategies in selected patients with diabetic foot osteomyelitis. There is insufficient high-quality evidence to assess the effect of various recent adjunctive therapies, such as cold plasma for infected foot ulcers and bioactive glass for osteomyelitis. Our updated systematic review confirms a trend to a better quality of the most recent trials and the need for further well-designed trials to produce higher quality evidence to underpin our recommendations.

IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-related Foot Infections (IWGDF/IDSA 2023).

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the management and prevention of diabetes-related foot diseases since 1999. The present guideline is an update of the 2019 IWGDF guideline on the diagnosis and management of foot infections in persons with diabetes mellitus. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used for the development of this guideline. This was structured around identifying clinically relevant questions in the P(A)ICO format, determining patient-important outcomes, systematically reviewing the evidence, assessing the certainty of the evidence, and finally moving from evidence to the recommendation. This guideline was developed for healthcare professionals involved in diabetes-related foot care to inform clinical care around patient-important outcomes. Two systematic reviews from 2019 were updated to inform this guideline, and a total of 149 studies (62 new) meeting inclusion criteria were identified from the updated search and incorporated in this guideline. Updated recommendations are derived from these systematic reviews, and best practice statements made where evidence was not available. Evidence was weighed in light of benefits and harms to arrive at a recommendation. The certainty of the evidence for some recommendations was modified in this update with a more refined application of the GRADE framework centred around patient important outcomes. This is highlighted in the rationale section of this update. A note is also made where the newly identified evidence did not alter the strength or certainty of evidence for previous recommendations. The recommendations presented here continue to cover various aspects of diagnosing soft tissue and bone infections, including the classification scheme for diagnosing infection and its severity. Guidance on how to collect microbiological samples, and how to process them to identify causative pathogens, is also outlined. Finally, we present the approach to treating foot infections in persons with diabetes, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and bone infections; when and how to approach surgical treatment; and which adjunctive treatments may or may not affect the infectious outcomes of diabetes-related foot problems. We believe that following these recommendations will help healthcare professionals provide better care for persons with diabetes and foot infections, prevent the number of foot and limb amputations, and reduce the patient and healthcare burden of diabetes-related foot disease.

Interventions in the management of infection in the foot in diabetes: a systematic review.

The optimal approaches to managing diabetic foot infections remain a challenge for clinicians. Despite an exponential rise in publications investigating different treatment strategies, the various agents studied generally produce comparable results, and high-quality data are scarce. In this systematic review, we searched the medical literature using the PubMed and Embase databases for published studies on the treatment of diabetic foot infections as of June 2018. This systematic review is an update of previous reviews, the first of which was undertaken in 2010 and the most recent in 2014, by the infection committee of the International Working Group of the Diabetic Foot. We defined the context of literature by formulating clinical questions of interest, then developing structured clinical questions (PICOs) to address these. We only included data from controlled studies of an intervention to prevent or cure a diabetic foot infection. Two independent reviewers selected articles for inclusion and then assessed their relevant outcomes and the methodological quality. Our literature search identified a total of 15 327 articles, of which we selected 48 for full-text review; we added five more studies discovered by means other than the systematic literature search. Among these selected articles were 11 high-quality studies published in the last 4 years and two Cochrane systematic reviews. Overall, the outcomes in patients treated with the different antibiotic regimens for both skin and soft tissue infection and osteomyelitis of the diabetic foot were broadly equivalent across studies, except that treatment with tigecycline was inferior to ertapenem (±vancomycin). Similar outcomes were also reported in studies comparing primarily surgical and predominantly antibiotic treatment strategies in selected patients with diabetic foot osteomyelitis. There is insufficient high-quality evidence to assess the effect of various adjunctive therapies, such as negative pressure wound therapy, topical ointments or hyperbaric oxygen, on infection related outcomes of the diabetic foot. In general, the quality of more recent trial designs are better in past years, but there is still a great need for further well-designed trials to produce higher quality evidence to underpin our recommendations.

Diagnosis of infection in the foot in diabetes: a systematic review.

BACKGROUND: Securing an early accurate diagnosis of diabetic foot infections and assessment of their severity are of paramount importance since these infections can cause great morbidity and potentially mortality and present formidable challenges in surgical and antimicrobial treatment. METHODS: In June 2018, we searched the literature using PuEbMed and EMBASE for published studies on the diagnosis of diabetic foot infection. On the basis of predetermined criteria, we reviewed prospective controlled, as well as noncontrolled, studies in any language, seeking translations for those not in English. We then developed evidence statements on the basis of the included papers. RESULTS: From the 4242 records screened, we selected 35 papers that met our inclusion criteria. The quality of all but one of the evidence statements was low because of the weak methodology of nearly all of the studies. The available data suggest that diagnosing diabetic foot infections on the basis of clinical signs and symptoms and classified according to the International Working Group of the Diabetic Foot scheme correlates with the patient's likelihood of ulcer healing, of lower extremity amputation, and risk of death. Elevated levels of selected serum inflammatory markers are supportive, but not diagnostic, of soft tissue or bone infection. In patients with suspected diabetic foot osteomyelitis, both a positive probe-to-bone test and an elevated erythrocyte sedimentation rate are strongly associated with its presence. Culturing tissue samples of soft tissues or bone, when care is taken to avoid contamination, provides more accurate microbiological information than culturing superficial (swab) samples. Plain X-ray remains the first-line imaging examination when there is suspicion of diabetic foot osteomyelitis, but advanced imaging methods help in cases when either the diagnosis or the localization of infection is uncertain. CONCLUSION: The results of this first reported systematic review on the diagnosis of diabetic foot infections provide some guidance for clinicians, but there is a need for more prospective controlled studies of high quality.

Guidelines on the diagnosis and treatment of foot infection in persons with diabetes (IWGDF 2019 update).

The International Working Group on the Diabetic Foot (IWGDF) has published evidence-based guidelines on the prevention and management of diabetic foot disease since 1999. This guideline is on the diagnosis and treatment of foot infection in persons with diabetes and updates the 2015 IWGDF infection guideline. On the basis of patient, intervention, comparison, outcomes (PICOs) developed by the infection committee, in conjunction with internal and external reviewers and consultants, and on systematic reviews the committee conducted on the diagnosis of infection (new) and treatment of infection (updated from 2015), we offer 27 recommendations. These cover various aspects of diagnosing soft tissue and bone infection, including the classification scheme for diagnosing infection and its severity. Of note, we have updated this scheme for the first time since we developed it 15 years ago. We also review the microbiology of diabetic foot infections, including how to collect samples and to process them to identify causative pathogens. Finally, we discuss the approach to treating diabetic foot infections, including selecting appropriate empiric and definitive antimicrobial therapy for soft tissue and for bone infections, when and how to approach surgical treatment, and which adjunctive treatments we think are or are not useful for the infectious aspects of diabetic foot problems. For this version of the guideline, we also updated four tables and one figure from the 2016 guideline. We think that following the principles of diagnosing and treating diabetic foot infections outlined in this guideline can help clinicians to provide better care for these patients.

Rat bite as a cause of diabetic foot ulcer in sub-Saharan Africa.

There have been relatively few reports of foot ulcers in diabetes resulting from rat bite. The findings were derived from people attending a single specialist service in Dar es Salaam for diabetic foot ulcers (DFUs) between 1 January 1999 and 31 December 2016. Details from people presenting for the first time with an ulcer judged to be caused by rat bite were compared with those with from other causes of foot ulcer. There were 426 first recorded foot ulcer episodes (in 179 people) judged to be caused by rat bite. The affected population was significantly younger (mean 55.9 vs 57.5 years, P = .037) and had a lower body mass index (26.5 vs 27.9, P = .008) than controls with other types of foot ulcer. They also presented significantly sooner (7.8 vs 18.2 days, P < .001) and were more likely to heal (85.8 vs 5.5%, P < .001), even though there was also a trend towards an increased risk of death (9.1% vs 5.3%, P = .032). Rat bite is an uncommon cause of DFU, but is not rare. Although the incidence of ulcer healing is higher than in a general foot ulcer population, the incidence of death is also higher.

Antibiotic Stewardship in the Management of Infected Diabetic Foot Ulcer Disease in Less Developed Countries.

BACKGROUND: Diabetic foot ulcers in developing countries often become infected. The healthcare systems are often not equipped to conduct the culture and the sensitivity tests required for prescribing a targeted antibiotic treatment for diabetic foot infection (DFI). METHODS: We evaluate antibiotic stewardship programmes for DFIs, at every level of health care, with an emphasis on resource-poor settings such as in Africa. RESULTS: The management of DFI very often is adapted to the financial and practical realities of the resource-poor regions. The application of the point-of-care Gram stain of deep tissue samples is efficient, rapid, low cost and ubiquitously available. Upon the identification of the predominant pathogen in the Gram stain, a semi-quantitative preemptive antibiotic treatment can be started in accordance with the World Health Organization Aware, Watch and Restrict Essential Medicine List. This list is catered to every country and is a powerful tool. However, some basic knowledge of the local microbiological epidemiology is necessary to choose the most appropriate agent. We report our experience on using the rapidly available Gram stain for narrowing the preemptive choice of listed antibiotic agents, as an economic tool for antibiotic stewardship in DFIs. CONCLUSIONS: In the practical and resource-saving management of DFI, the 'therapeutic' use of Gram stains is not common in resource-rich countries but should be added to the arsenal of the general efforts for antibiotic stewardship.

What characteristics are most important in stratifying patients into groups with different risk of diabetic foot ulceration?

AIMS/INTRODUCTION: This study aimed to assess if patients can be divided into different strata, and to explore if these correspond to the risk of diabetic foot complications. MATERIALS AND METHODS: A set of 28 demographic, vascular, neurological and biomechanical measures from 2,284 (1,310 men, 974 women) patients were included in this study. A two-step cluster analysis technique  was utilised to divide the patients into groups, each with similar characteristics. RESULTS: Only two distinct groups: group 1 (n = 1,199; 669 men, 530 women) and group 2 (n = 1,072; 636 men, 436 women) were identified. From continuous variables, the most important predictors of grouping were: ankle vibration perception threshold (16.9 ± 4.1 V vs 31.9 ± 7.4 V); hallux vibration perception threshold (16.1 ± 4.7 V vs 33.1 ± 7.9 V); knee vibration perception threshold (18.2 ± 5.1 V vs 30.1 ± 6.5 V); average temperature sensation threshold to cold (29.2 ± 1.1°C vs 26.7 ± 0.7°C) and hot (35.4 ± 1.8°C vs 39.5 ± 1.0°C) stimuli, and average temperature tolerance threshold to hot stimuli at the foot (43.4 ± 0.9°C vs 46.6 ± 1.3°C). From categorical variables, only impaired sensation to touch was found to have importance at the highest levels: 87.4% of those with normal sensation were in group 1; whereas group 2 comprised 95.1%, 99.3% and 90.5% of those with decreased, highly-decreased and absent sensation to touch, respectively. In addition, neuropathy (monofilament) was a moderately important predictor (importance level 0.52) of grouping with 26.2% of participants with neuropathy in group 1 versus 73.5% of participants with neuropathy in group 2. Ulceration during follow up was almost fivefold higher in group 2 versus group 1. CONCLUSIONS: Impaired sensations to temperature, vibration and touch were shown to be the strongest factors in stratifying patients into two groups with one group having almost 5-fold risk of future foot ulceration compared to the other.

The utility of Gram stains and culture in the management of limb ulcers in persons with diabetes.

In Tanzania, limited laboratory services often preclude routine identification of microorganisms that cause infections in persons with diabetes. Thus, we carried out this study to determine the utility of a Gram stain alone versus culture in guiding appropriate antimicrobial therapy. During February 2006 to December 2007 (study period), deep tissue biopsies were obtained from persons with diabetes presenting to the Muhimbili National Hospital (MNH) with infected limb ulcers. Specimens were Gram-stained then cultured for bacteria and fungi. Biopsies were obtained from 128 patients. Of 128 cultures, 118 (92%) yielded bacterial or fungal growth; 59 (50%) of these 118 cultures yielded mixed growth (80% included Gram-negative organisms); 38 (32%) and 20 (17%) yielded Gram-negative and Gram-positive organisms alone, respectively. The predictive value positive of a Gram stain for bacterial growth was 93% (110/118); a Gram-positive stain was 75% (15/20) predictive of growth of Gram-positive organisms whereas a Gram-negative stain was 82% (31/38) predictive of growth of Gram-negative organisms. In regions with limited resources, a Gram stain of an ulcer biopsy that is carefully procured is largely predictive of the type of microorganism causing infection. Gram staining of deep tissue biopsies might have a potential role to play in the management of infected diabetic limb ulcers.

Diabetic foot ulcer disease in African continent: 'From clinical care to implementation' - Review of diabetic foot in last 60 years - 1960 to 2020.

The prevalence of diabetes mellitus is increasing globally and the greatest potential increases in diabetes will occur in Africa. Data suggest that these increases is associated with rapid demographic, sociocultural and economic transitions. There will be a parallel increase in the complications of diabetes and among the various complications those related to diabetic foot disease are associated with the highest morbidity and mortality. Diabetic Peripheral neuropathy (DPN) is the most common cause of diabetic foot complications in African countries; however, peripheral arterial disease (PAD) appears to increase, possibly a result of rising urbanization. Search done for the past six decades (1960 to 2020) on all foot complications. Rates of complications of diabetic foot in last six decades varied by country as follow: DPN: 4-90%; PAD: 0-77%; foot ulcers: 4-61%; amputation rates: 3-61% and high mortality rates reaching to 55%, patients who presented late with infection and gangrene. Educational and prevention programmes are required to curb the growing complications of diabetic foot ulcers in Africa among patients and health care workers. Secondly, it is imperative that governments across the African continent recognise the clinical and public health implications of diabetic foot disease in persons with diabetes.

Predicting the risk of amputation and death in patients with diabetic foot ulcer. A long-term prospective cohort study of patients in Tanzania.

INTRODUCTION: This prospective cohort study aimed to identify the characteristics of patients with diabetic foot ulcer who are at higher risk of amputation and at increased risk of death. METHODS: About 103(M/F:60/43) participants, with active foot ulcer at baseline, participated in this study and followed for 22 years till death or lost to follow-up. Ten clinical measures were collected at baseline. During the follow-up of 4.2 ± 5.4 years, 22(M/F:14/8) participants had an amputation and 50(M/F:32/18) participants passed away during 5.5 ± 5.8 years follow-up period. RESULTS: Cox Proportional Hazard regression (HR[95%CI]) indicated neuropathy (6.415[1.119-36.778]); peripheral arterial disease (PAD) (9.741[1.932- 49.109]); current smoking (16.148[1.658-157.308]); diabetes type- 1 (3.228[1.151-9.048]) and longer delay attending appointment after ulcer (1.013[1.003-1.023]) were significantly (p < .05) associated with increased risk of amputation. In addition, death was significantly associated with the risk of amputation (3.458[1.243-9.621]). Three parameters (HR[95%CI]) including neuropathy (3.058[1.297-7.210]); PAD (5.069[2.113-12.160]); amputation history (3.689[1.306-10.423]) and retinopathy (2.389[1.227-4.653]) were all significantly associated with increased risk of death. Kaplan-Meier survival analyses indicates that the time to amputation in years for participants who eventually died was significantly shorter (11.122 ± 1.507) vs those who stayed alive (15.427 ± 1.370). CONCLUSION: Neuropathy and PAD were the only two characteristics that increased both the risk of amputation and death. Amputation showed to contribute to an increased risk of death and those participants who eventually died had a higher risk of amputation. Delay in attending appointments after ulceration is shown to increase the risk of amputation. In addition, the participants with PAD showed a significantly shorter time to both amputation and death while neuropathy was only associated with decreased time to death. Amputation history and death during follow-up decrease the time to death and amputation respectively.

Tunga penetrans causing a rapidly progressing foot ulcer in a patient with uncontrolled type 2 diabetes mellitus.

Tungiasis is a parasitic disease resulting from infestation by a female flea Tunga penetrans. The parasites are endemic in the tropics and can infect patients with diabetes mellitus (DM). Augmented by uncontrolled hyperglycemia and pre-existing neuropathy, the parasite may trigger a locally spreading inflammation, which may aggravate the trauma introduced during its extraction, leading into a rapidly progressing foot ulcer. To the best of our knowledge, no such cases in patients with type 2 diabetes have ever been published from Tanzania and likely none worldwide. This case report shows that, in diabetic patients, the wound resulting from the extraction of T. penetrans may get infected and aggravated by the ongoing inflammatory reaction, rapidly evolve into limb-threatening condition and mortality. Preventive measures are necessary and should be emphasized in patients with DM. Studies are needed to increase our understanding of the pathophysiology, proper management and sequalae of ulcers of this nature.

The 'Step by Step' Diabetic Foot Project in Tanzania: a model for improving patient outcomes in less-developed countries.

Foot complications cause substantial morbidity in Tanzania, where 70% of leg amputations occur in diabetic patients. The Step by Step Foot Project was initiated to train healthcare personnel in diabetic foot management, facilitate transfer of knowledge and expertise, and improve patient education. The project comprised a 3-day basic course with an interim period 1-year of for screening, followed by an advanced course and evaluation of activities. Fifteen centres from across Tanzania participated during 2004-2006 and 12 during 2004-2007. Of 11,714 patients screened in 2005, 4335 (37%) had high-risk feet. Of 461 (11%) with ulcers, 45 (9·8%) underwent major amputation. Of 3860 patients screened during 2006-2007, there was a significant increase in the proportion with ulcers and amputations compared with 2005 (P < 0·001), likely a result of enhanced case finding. During 2005-2008, there was a fall in the incidence of foot ulcers in patient referrals to the main tertiary care centre in Dar es Salaam and a parallel fall in amputation among these referrals. In conclusion, the Step by Step Foot Project in Tanzania improved foot ulcer management for persons with diabetes and resulted in permanent, operational foot clinics across the country. This programme is an effective model for improving outcomes in other less-developed countries.

The Charcot Foot: An Emerging Public Health Problem for African Diabetes Patients.

Background: Although the awareness, diagnosis, management of the complications associated with diabetes have improved in African countries over the past decade, surveillance activities in Tanzania and anecdotal reports from other African countries have suggested an increased prevalence of Charcot Neuroarthropathy (CN) over the past few years. Aim: To characterize the epidemiology and the clinical burden of CN in a large diabetes population in Tanzania, and to evaluate outcomes of persons with the condition. Methods: This was a prospective analytic cohort study conducted between January 2013 through December 2015. Following informed consent, patients were followed at the outpatient clinic. Detailed clinical assessments and documented presence of diabetic peripheral neuropathy (DPN), macrovascular disease and microvascular disease were recorded. Education and counseling were part of the follow-up program. Results: 3271 ulcerations were presented at the clinic during the 3-year study period. 571 (18%) met the case definition for CN; all patients had Type 2 diabetes. The prevalence for each of the years 2013, 2014, and 2015 was 19/1192 (1.6%), 209/1044 (20%), and 343/1035 (34%), respectively; the increases in the slope of the trendline was statistically significant (P < .001). Conclusion: The prevalence of CN is increasing in the Tanzanian diabetes patient population, and is strongly associated with neuropathy. CN can lead to severe deformity, disability, and amputation. Due to the risk of limb amputation, patients with diabetes must seek immediate care if signs or symptoms appear and avoid delay in seeking medical attention. Early diagnosis of CN by caregivers is extremely important for successful outcomes.

Predicting the risk of future diabetic foot ulcer occurrence: a prospective cohort study of patients with diabetes in Tanzania.

OBJECTIVES: The aim of this study was to identify the parameters that predict the risk of future foot ulcer occurrence in patients with diabetes. RESEARCH DESIGN AND METHODS: 1810 (male (M)/female (F): 1012/798) patients, with no foot ulcer at baseline, participated in this study. Data from a set of 28 parameters were collected at baseline. During follow-up, 123 (M/F: 68/55) patients ulcerated. Survival analyses together with logistic regression were used to identify the parameters that could predict the risk of future diabetic foot ulcer occurrence. RESULTS: A number of parameters (HR (95% CI)) including neuropathy (2.525 (1.680 to 3.795)); history of ulceration (2.796 (1.029 to 7.598)); smoking history (1.686 (1.097 to 2.592)); presence of callus (1.474 (0.999 to 2.174)); nail ingrowth (5.653 (2.078 to 15.379)); foot swelling (3.345 (1.799 to 6.218)); dry skin (1.926 (1.273 to 2.914)); limited ankle (1.662 (1.365 to 2.022)) and metatarsophalangeal (MTP) joint (2.745 (1.853 to 4.067)) ranges of motion; and decreased (3.141 (2.102 to 4.693)), highly decreased (5.263 (1.266 to 21.878)), and absent (9.671 (5.179 to 18.059)) sensation to touch; age (1.026 (1.010 to 1.042)); vibration perception threshold (1.079 (1.060 to 1.099)); duration of diabetes (1.000 (1.000 to 1.000)); and plantar pressure at the first metatarsal head (1.003 (1.001 to 1.005)), temperature sensation (1.019 (1.004 to 1.035)) and temperature tolerance (1.523 (1.337 to 1.734)) thresholds to hot stimuli and blood sugar level (1.027 (1.006 to 1.048)) were all significantly associated with increased risk of ulceration. However, plantar pressure underneath the fifth toe (0.990 (0.983 to 0.998)) and temperature sensation (0.755 (0.688 to 0.829)) and temperature tolerance (0.668 (0.592 to 0.0754)) thresholds to cold stimuli showed to significantly decrease the risk of future ulcer occurrence. Multivariate survival model indicated that nail ingrowth (4.42 (1.38 to 14.07)); vibration perception threshold (1.07 (1.04 to 1.09)); dry skin status (4.48 (1.80 to 11.14)); and temperature tolerance threshold to warm stimuli (1.001 (1.000 to 1.002)) were significant predictors of foot ulceration risk in the final model. The mean time to ulceration was significantly (p<0.05) shorter for patients with: dry skin (χ2=11.015), nail ingrowth (χ2=14.688), neuropathy (χ2=21.284), or foot swelling (χ2=16.428). CONCLUSION: Nail ingrowth and dry skin were found to be strong indicators of vulnerability of patients to diabetic foot ulceration. Results highlight that assessments of neuropathy in relation to both small and larger fiber impairment need to be considered for predicting the risk of diabetic foot ulceration.

Diabetic foot ulcers and ethnicity in Tanzania: a contrast between African and Asian populations.

To characterise the role of ethnicity in the occurrence of foot ulcer disease in persons with diabetes, we analysed prospectively collected data for persons attending the diabetes clinic at Muhimbili National Hospital (MNH), Dar es Salaam, Tanzania. A case was defined as any adult presenting to MNH with an ulcer at or below the ankle joint during July 1998-June 2005. We documented clinical and epidemiologic characteristics, progress, interventions and outcome. Seven hundred and eight persons met the case definition - 570 (80%) ethnic Africans and 138 (20%) Asian Indians. Ethnic Africans were more likely to present with gangrene (P < 0.01); Indians were more likely to be obese (P < 0.001) or have large vessel disease (P < 0.001). For Africans, intrinsic complications (neuro-ischaemia or macrovascular disease) delayed ulcer healing; for Asian Indians, mode of intervention (e.g. sloughectomy or glycaemic control with insulin or oral agents) determined the same outcome. Indigenous ethnic African and Asian Indian populations with diabetes display contrasting foot ulcer epidemiology. Peripheral vascular disease and gangrene are playing a larger role in ulcer pathogenesis and outcomes for both ethnic groups than was previously thought. Preventive efforts and interventions should be tailored to the two ethnic groups to achieve complete ulcer healing.

Can a combination of lifestyle and clinical characteristics explain the presence of foot ulcer in patients with diabetes?

AIMS: The aim of this study was to identify the biomechanical, neurological and clinical parameters along with other demographics and lifestyle risk factors that could explain the presence of foot ulcer in patients with diabetes in Africa. METHODS: A total of 1270 (M/F:696/574) patients; 77(M/F:53/24) with ulcerated vs 1193 (M/F: 643/550) with non-ulcerated feet; participated in this study. A set of 28 parameters were collected and compared between the participants with and without active foot ulcers. Multivariate logistic regression was utilised to develop an explanatory model for foot ulceration. RESULTS: Foot swelling (χ2(1,n = 1270) = 265.9,P = 0.000,Phi = 0.464) and impaired sensation to monofilament (χ2(2,n = 1270) = 114.2,P = 0.000,Cramer'sV = 0.300) showed strong association with presence of ulceration. A lower Temperature sensitivity to cold stimuli and limited ankle joint mobility were observed to be significant (P < 0.05) contributors to ulceration. The logistic regression model can justify the presence of foot ulceration with 95.3% diagnostic accuracy, 99.1% specificity and 37.3% sensitivity. CONCLUSION: Participants with ulcerated foot show distinct characteristics in few foot related parameters. Swollen foot, limited ankle mobility, and peripheral sensory neuropathy were significant characteristics of patients with diabetic foot ulcer. One out of three patients with ulcerated foot showed common characteristics that could be justified by the model.

Challenges for management of the diabetic foot in Africa: doing more with less.

Diabetes mellitus reached epidemic proportions in much of the less-developed world over a decade ago. In Africa, incidence and prevalence rates of diabetes are increasing and foot complications are rising in parallel. The predominant risk factor for foot complications is underlying peripheral neuropathy, although there is a body of evidence that confirm the increasing role of peripheral vascular disease. Gangrene and infections are two of the more serious sequelae of diabetic foot ulcer disease that cause long-standing disability, loss of income, amputation or death. Unfortunately, diabetes imposes a heavy burden on the health services in many African countries, where resources are already scarce or cut back. Reasons for poor outcomes of foot complications in various less-developed countries include the following: lack of awareness of foot care issues among patients and health care providers alike; very few professionals with an interest in the diabetic foot or trained to provide specialist treatment; non existent podiatry services; long distances for patients to travel to the clinic; delays among patients in seeking timely medical care, or among untrained health care providers in referring patients with serious complications for specialist opinion; lack of the concept of a team approach; absence of training programs for health care professionals; and finally lack of surveillance activities. There are ways of improving diabetic foot disease outcomes that do not require an exorbitant outlay of financial resources. These include implementation of sustainable training programmes for health care professionals, focusing on the management of the complicated diabetic foot and educational programmes that include dissemination of information to other health care professionals and patients; sustenance of working environments that inculcate commitment by individual physicians and nurses through self growth; rational optimal use of existing microbiology facilities and prescribing through epidemiologically directed empiricism, where appropriate; and using sentinel hospitals for surveillance activities. Allied with the golden rules of prevention (i.e. maintenance of glycaemic control to prevent peripheral neuropathy, regular feet inspection, making an effort not to walk barefooted or cut foot callosities with razors or knives at home and avoidance of delays in presenting to hospital at the earliest onset of a foot lesion), reductions in the occurrence of adverse events associated with the diabetic foot is feasible in less-developed settings.