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

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: [email protected];
Prof. P. Price, Wound Healing Research Unit, Cardiff University - email: [email protected]
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.
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
Wound Location
60
50
40
frequency 30
20
10
0
Forefoot, Midfoot region Heel region Plantar aspect
hallux, digits,
apices
Malleolar
region
Lateral border Amputation
site
Combination
of sites
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.
Criteria for successful outcomes and unsuccessful outcomes - Note: Each patients’ case was followed through
until their last entry within their hospital record for that specific hospital admission. Any subsequent relapses, readmissions or deaths within 1 year from the original recorded admission were captured
Good / successful
Poor / unsuccessful
 No amputation at any level
 Amputation at any level
 Patient discharged from hospital
 Wound not healed within a year
 Wound healed within a year
 Relapse and readmitted for diabetic foot infection within 1 year
 Patient died during treatment or within a year in the community
 No further admittance
34 Patients (26.6%)
94 Patients (73.4%)
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 predetermined 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.