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Risk Factors for Sepsis in Infected Diabetic Foot Patients

Risk Factors for Sepsis in Infected Diabetic Foot Patients. Alpharian , G.T. , Ismiarto , Y.D., Tiksnadi , B.T., Primadhi , A . Department of Orthopedics and Traumatology Faculty of Medicine Universitas Padjadjaran , Hasan Sadikin General Hospital Bandung. Introduction.

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Risk Factors for Sepsis in Infected Diabetic Foot Patients

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  1. Risk Factors for Sepsis in Infected Diabetic Foot Patients Alpharian, G.T., Ismiarto, Y.D., Tiksnadi, B.T., Primadhi, A. Department of Orthopedics and Traumatology Faculty of Medicine UniversitasPadjadjaran, HasanSadikin General Hospital Bandung

  2. Introduction • 25% of diabetic patients complicated by diabetic foot • WHO : • “The feet of a diabetic individual that is at risk for pathological processes such as infection, ulcer formation, and/or damage to deeper tissues (such as tendons, muscle, and bone) which may be accompanied by neurological derangement, peripheral vasculopathy, and/or other manifestations of diabetes in the extremities” • Shaw JA, Sicree RA, Zimmet PZ. Global Estimates of the Prevalence of Diabetes for 2010 and 2030. Diabetes Research and Clinical Practice 2010;87:4-14. • Frykberg RG, Zgonts T, Armstrong DG, Driver VR, Giurini JM, Kravitz SR, et al. Diabetic Foot Disorders: A Clinical Practice Guideline. The Journal of Foot and Ankle Surgery. [Supplement]. 2006;45(5):S2-66. • Wild S, Roglic G, Green A, Sicree R, King H. Global Prevalence of Diabetes. Diabetes Care. 2004;27(5):1047-53.

  3. Introduction • Diabetic foot ulcer is formed in the diabetic foot as an interaction between the pathological features of the diabetic foot : • peripheral neuropathy : dysfunction of the sensoric, motoric, and autonomic components of the foot • micro-and macroangiopathy, and • deformities of the footcausing abnormal pressure points • Trauma that occurs to this state of foot (usually minor trauma) precipitate the formation of a wound  chronic ulcer due to wound healing problems in the diabetic individual • East JM, Yeates CB, HP R. The Natural History of Pedal Puncture Wounds in Diabetics : A Cross Sectional Survey. BMC Surgery. 2011;11(27):1-24. • Frykberg, RG., Zgonis, T., Armstrong, DG., Driver, VR., Giurini, JM., Kravitz, SR., et.al. Diabetic Foot Guidelines : A Clinical Practice Guideline 2006 revision. The Journal of Foot & Ankle Surgery, 2006; 45(5): S1-S58

  4. Introduction • Ulceration  point of entry for microorganism  colonization  infection • Decreased wound healing + loss of protective sensation  unresolved wound & infection + spread of infection • Increased duration and severity of infection  risk for development of sepsis • Need of aggressive infection control to prevent life threatening sepsis • Frykberg, RG., Zgonis, T., Armstrong, DG., Driver, VR., Giurini, JM., Kravitz, SR., et.al. Diabetic Foot Guidelines : A Clinical Practice Guideline 2006 revision. The Journal of Foot & Ankle Surgery, 2006; 45(5): S1-S58 • Richard, JL, Sotto, A., Lavigne, JP. New Insights in Diabetic Foot Infections. World J Diabetes2011; 2(2): 24-32 • Hotchkiss RS, Karl IE. The Pathophysiology and Treatment of Sepsis. N Engl. J Med 2003, 348; 138 -50.

  5. Aim of study • Identify risk factors associated with sepsis in infected diabetic foot patients.

  6. Methods • Retrospective study on medical records of to identify infected diabetic foot patients treated in our center within period 2008 2013 • With sepsis • Without sepsis • Identification of infected diabetic feet : IDSA • Identification of infected diabetic feet with sepsis : infection + sepsis • Comparative analysis of clinical and laboratory characteristics • Categorical Data by Chi Square while numerical data by Mann-Whitney

  7. Results

  8. Results

  9. Results • Gender and age did not correlate with higher risk of sepsis • patients in the sepsis group had a significant higher proportion of Wagner type 4 (33.33%) and Wagner type 5 (52.78%) compared to those in the non-sepsis group (X2=16.41, p<0.05, OR 11.02, 95% CI [3.16, 38.42]) • Presence of ascending infection is significantly higher in the sepsis group compared to the non-sepsis group (29 vs 8, p<0.05, OR 8.8, 95% CI [2.71, 28.59]) • Average duration of wound (or ulcer) in the sepsis group (22.5±13 days) is significantly (p<0.05) longer than the non-sepsis group (10.9±3 days)

  10. Significant correlation (2 = 7.19, p<0,05) between lower than normal ABI values and sepsis in infected diabetic foot patients (OR 5.27, 95% CI [1.68,16.53]) • Laboratory : • Leukocyte levels values of patients in the sepsis group was higher compared to the non sepsis group (14.7 ± 5.7 vs 10.4 ± 2.5, p <0.05) • C-Reactive Protein (CRP) values of patients in the sepsis group was higher compared to the non-sepsis group (97.6 ± 32 vs 56.2 ± 48, p<0.05) • ESR values in the sepsis group was higher compared to the non sepsis group (113 ± 31 vs 88.2 ± 21, p<0.05) • Creatinine values of patients in the sepsis group was higher compared to the non-sepsis group (128.4±30.1 vs 98.7±21.4, p<0.05)

  11. Conclusion • Patients with infected diabetic foot with history of foot wound more than 20 days, presenting with ascending infection, below normal ABI, advanced Wagner grade (4 and above), and an increased Leukocyte, ESR, CRP and Creatinine levels are at a at a higher risk of subsequently developing sepsis.

  12. Strengths • Literature search found limited available literature describing diabetic foot infections associated with sepsis • May be one of few studies that attempt to correlate diabetic foot infections to sepsis Limitations • Small series of cases in this study • Retrospective data

  13. Thank you

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