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Diabetic Foot Infection and Major Amputation increases Mortality in Diabetes Patients 01

Clinical Research

Diabetic Foot Infection and Major Amputation increases Mortality in Diabetes
Patients

Endorsed by: Dr. (COL) Kumud Rai, Principal Director-Vascular Surgery, Max Super Speciality
Hospital, New Delhi

Background

Diabetes patients are predisposed to high risk of foot ulceration that may lead to a never-ending trail
of foot infections, prolonged hospitalizations, lower-extremity amputations, or even death. The 5-year
1
overall survival of patients with diabetic foot ulcers (DFUs) has been estimated to be 70%, and after a patients, however, AFS was significantly

major amputation, it was reduced to only 43%. Foot infections are critical complications of DFUs. Four major factors associated with a improved by revascularization in patients with
1
However, studies focusing on acute diabetic foot infections (DFIs) are limited in number. The two significantly shorter OS 6 ischemic infection. Thus, timely management of
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major outcomes for DFI patients are overall survival (OS) and amputation-free survival (AFS; survival Major amputation(s) during hospitaliza- ischemic wound and early access to vascular
without amputations above the ankle). Recent reports indicate that DFIs severely compromise the tion (P<0.001; HR 6.673; CI surgery for limb salvage in diabetic patients is

quality of life of patients. If presented with an infectious gangrene, the chance of patient survival over 2.836–15.700) strongly recommended. 6

5 years is around 40%. 2,3,4 Major amputation due to diabetic complications is the most feared Wound ischemia: due to an infected
outcome, and has been reported to be an independent predictor of premature death. Thus, the a) Patient characteristics b) The LRINEC-score ulcer [(vs. non-ischemic wound; P=0.046; e) Infection
1,5
HR 1.598; CI 1.008–2.532)
present study retrospectively investigated the long-term survival and risk factors for OS and AFS in Overall 324 patients were enrolled (237 males, The LRINEC -score had no effect on the OS or 1) Indicative of severe infection, high CRP
patients with DFI. 6 87 females; mean age, 66.8 years, SD 12.8) AFS. 6 Age: over 67 years (P<0.001; HR 1.055; levels were found to be associated with a
CI 1.035–1.076)
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with 404 periods of hospitalization. 6 worse AFS.
Materials and methods The Laboratory Risk Indicator for Necrotizing Impaired renal functions: eGFR under 2) AFS was also associated with a deep wound
60 ml/min (P<0.001; HR 0.989; CI
The retrospective cohort study enrolled adult Fasciitis score (LRINEC score): 0.982–0.995) (penetrating to the bone or joint) and high
patients presenting with acute DFI at the It is a sensitive scoring system to identify blood leukocytes. 6

Tampere University Hospital during 2010 necrotizing fasciitis and distinguish it from other Therefore, a diabetes patient presenting with an 3) Long-lasting and multiple foot ulcers were
8
-2014. 6,7 soft tissue infections. An LRINEC score of >8 acute infection can undergo a minor amputation also associated with a worse outcome as
has been found to be sensitive for patients with to restrict the infection, and this way a major reported previously. 2, 6

Following patient-related information was diabetes. 9 c) Survival of patients with DFI amputation can be avoided, saving both limb and

collected from the hospital records: The present study showed that survival of life of the patient. The study therefore emphasized on the
Patient demographics (age and gender) The present study assessed the utility of LRINEC patients after a DFI was poor within one-year importance of early detection and treatment of

Registered diagnoses (ischemic heart disease, score to diagnose severe DFI and a poor (81.2%), and almost 50% of patients died within d) Effect of revascularization the infection for diabetic foot ulcers. 6
chronic obstructive pulmonary disease, con- prognosis. LRINEC score with a cutoff of >8 was 5-years after a DFI. The risk of death was almost The AFS was greatly reduced in patients with
6
gestive heart failure and dyslipidemia, microbi- chosen to identify necrotizing fasciitis. 6 ischemic wounds. 16.1% of the cases had f) Hypertension
six-fold after the infection among patients that The study demonstrated that use of a
ological and clinical chemistry findings, surgi- underwent amputation than those with revascularization within 1 month of admission

cal revisions and amputations, open and endo- A specialist in plastic surgery staged the wounds infections but treated without amputation. After and in most cases within 1 week. 6 hypertensive medication was associated with an
vascular revascularization procedures, wound according to the University of Texas Staging a 5-year follow-up, only 1 of 12 patients (8.3%) increased AFS, however the observation requires

status, and the length of hospital stay). 6 System for Diabetic Foot Ulcers (UT scale). 6,10 Revascularization procedure (open or further validation. 6
survived. 6

endovascular) had no effect on survival of

Conclusion 7) LaaksoM, Kiiski J, KarppelinM, HelminenM, Kaartinen I.
Pathogens causing diabetic foot infection and the
Patients with DFI have high morbidity and reliability of the superficial culture. Surg Infect. 2020. doi:
poor survival outcomes despite advanced 10.1089/sur.2020.072.

treatment resources. 8) Wong C-H, Khin L-W, Heng K-S, Tan K-C, Low C-O. The
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LRINEC (Laboratory Risk Indicator for Necrotizing
High CRP levels are associated with a Fasciitis) score: a tool for distinguishing necrotizing
reduced AFS. fasciitis from other soft tissue infections. Crit Care Med.
6
2004; 32:1535–41. doi:
Ischemic infections in deep wounds with 10.1097/01.CCM.0000129486.35458.7D
high CRP levels suggest severity of the 9)Tan JH, Koh BTH, Hong CC, Lim SH, Liang S, Chan GEH,
disease and must be prevented early. 6 et al. A comparison of necrotising fasciitis in diabetics
and non-diabetics: a review of 127 patients. Bone Joint J.
A major amputation is a strong predictor of (2016) 98-B:1563–8. doi:
10.1302/0301-620X.98B11.37526
death in patients with DFI.
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Thus, early identification and treatments of 10) Lavery LA, Armstrong DG, Harkless LB. Classification
of diabetic foot wounds. J Foot Ankle Surg. 1996; 35:528–
DFI are critical to improve both the AFS and 31. doi: 10.1016/S1067-2516(96)80125-6

OS.
6

References:

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Padula WV, Bus SA. Five year mortality and direct costs of
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Helminen M, Kaartinen I. Major Amputation Profoundly
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Infection. Front Surg. 2021;8:655902. Published 2021 Apr
30.doi:10.3389/fsurg.2021.655902