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A RETROSPECTIVE ANALYSIS OF THE OUTCOMES OF TREATMENT ASSOCIATED WITH FOOT INFECTIONS IN A COHORT OF HOSPITALISED DIABETIC PATIENTS. L. Rambour, School of Health Professions & Rehabilitation Sciences, University of Southampton - email: lr7@soton.ac.uk ;

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A RETROSPECTIVE ANALYSIS OF THE OUTCOMES OF TREATMENT ASSOCIATED WITH FOOT INFECTIONS IN A COHORT OF HOSPITALISED DIABETIC PATIENTS

L. Rambour, School of Health Professions & Rehabilitation Sciences, University of Southampton - email: lr7@soton.ac.uk;

Prof. P. Price, Wound Healing Research Unit, Cardiff University - email: pricepe@whru.co.uk

Introduction:

The National Service Framework for Diabetes has advised key interventions necessary to raise the standard of diabetes care throughout the NHS. These standards proposed utilising effective diagnostic, prognostic and therapeutic strategies to help reduce amputation and mortality rates (1). The outcome of diabetic foot ulcers has been shown to be influenced by specific patient data and characteristics recorded at presentation to hospital by several authors in recent years (2,3,4). Systematically recording these data may be crucial when planning treatment regimes, monitoring treatment effectiveness and predicting clinical outcomes.

Aim of study:

To explore the outcome of treatment for a cohort of patients with diabetes and foot infections. To consider patient factors present at admission and examine potential associations with outcomes.

Results Continued:

  • Number discharged into the community for ongoing treatment of unhealed wounds was 113 (88.2%).
  • At the end point of the study 96 (75%) of the original wounds had eventually healed within 1 year (with / without amputation) and 11 (8.5%) patients were readmitted for new diabetic foot infection/s or breakdown of the old wound site (the remainder had not healed or had died).
  • Following statistical analysis using logistical regression, peripheral ischaemia (p=0.021) and infection severity (p=0.003) were variables that were found to be most associated with poor / unsuccessful outcome.
  • Method:
  • The Department of Health’s National Casemix Office ICD codes were accessed for patient record identification purposes. A 5 year study period was utilised.
  • Inclusion criteria:
    • Patients with Type I or II Diabetes Mellitus, + / - co-morbidities
    • Admitted to hospital with a foot ulceration / accompanying infection
    • Male or Female – over 16 years
  • Results:
  • 128 primary wounds were investigated
  • Larger ratio of males to females - Mean age was 68.8 years
  • Mean duration of diabetes of 13.3 years
  • Complications mainly included PVD, hypertension and neuro-ischaemia
  • Mean HbA1c levels were 8.3% on admission
  • A large number of wound descriptors were used to describe the wounds
  • 85% patients wounds were classified as moderate to severe (potentially limb

threatening) - Wounds were contaminated with polymicrobial species

  • 26 (20.3%) cases of confirmed osteomyelitis
  • Combination antibiotic therapy was the favoured course of treatment (mean duration =

17.6 days

  • The mean hospital stay was 32.4 days
  • 41% required surgical procedures i.e. angioplasty, bypass grafting, exploration,

drainage and / or debridement

  • 72 (56.2%) patients underwent amputation at some level

Conclusion:

Infectious ulceration is a major step on the path to lower limb amputation and increases morbidity and mortality in people with diabetes mellitus. This necessitates more hospital admissions, length of hospital stay and increased NHS costs (5,6,7). There were variable approaches to treatment of the diabetic infected foot ulcers in this cohort of patients, with which wound healing was achieved. However, the overall outcome of treatment, judged with the pre-determined criteria in this study, proved relatively poor.

Infection severity and ischaemia were both found to be strongly associated with poor outcome as with other similar studies (2,4). Recording data on admission to hospital and tracking patients’ progress is complex and extremely time consuming however, this information may prove essential when evaluating treatment and predicting accurate outcomes. Large multi-centre retrospective / prospective studies on treatment outcomes may prove advantageous for future research.

1. Department of Health (2001) National Service Framework for Diabetes: Standards.

2. Oyibo, S.O., Jude, E.B., Tarawneh, I., Nguyen, H.C., Armstrong, D.G., Harkless, L.B., and Boulton, A.J.M. (2001) The effects of ulcer size and site, patient’s age, sex and type and duration of diabetes on the outcome of diabetic foot ulcers. Diabetic Medicine. 18: 133-138.

3. Pittet, D., Wyssa, B., Herter-Clavel, C., Kursteiner, K., Vaucher, J. and Lew, D.P. (1999) Outcome of Diabetic Foot Infections Treated Conservatively. Archives of International Medicine. 159: 851 - 856.

4. Campbell, W.B., Ponette, D. and Sugiono, M. (2000) Long-term results following operation for diabetic foot problems: arterial disease confers a poor prognosis. European Journal of Vascular and Endovascular Surgery. 19 (2): 174 – 177.

5. Shearer, A., Scuffman, P., Gordois, A., Oglesby, A. (2003) Predicted costs and outcomes of reduced vibration detection in the UK. The Diabetic Foot. 6 (1): 30 – 37.

6. Reiber, G. E., Pecoraro, R.E. and Kocpsell, T.D. (1992) Risk factors for amputation in patients with diabetes mellitus: A case control study. Annals of Internal Medicine. 117: 97 - 105.

7. Berendt, T. and Lipsky, B.A. (2003) Should Antibiotics be used in the treatment of the Diabetic Foot. The Diabetic Foot. 6 (1): 18 – 28.

Correspondance to:

Lorraine Rambour

School Of Health Professions

and Rehabilitation Sciences,

University of Southampton.

Building 45, Highfield, Southampton. SO17 1BJ.