PRESCRIPTION PATTERN AND USAGE OF ANTIMICROBIAL AGENTS FOR TREATING DIABETIC FOOT INFECTIONS AT TERTIARY CARE CENTRE
Keywords:Diabetic foot infections, Meggit-Wagner`s classification, Bacterial profiles, Antibiotics
Objective: Due to the uncertainty about optimal antibiotic treatment, and probably substantial variation in practice, the present study was carried out to determine the bacterial profiles of infected diabetic foot ulcers (DFUs) and also to analyze the prescribing pattern of antibiotics used.
Methods: A prospective observational study was carried out in the department of General surgery at a tertiary care teaching hospital, Mangalore. Demographic details and treatment data of 78 patients were collected in a specially designed Proforma, and the data were analyzed using Microsoft Excel.
Results: According to Meggit-Wagner's classification, patients admitted with DFUs predominantly belonged to WAGNER 1 category (36%), followed by WAGNER 4 (26%) and WAGNER 2 (22%) categories. Out of 66 culture-positive specimens, 21 (31.8%) had monomicrobial flora, and 45 (68.2%) had polymicrobial flora. A total of 148 organisms were obtained from the specimens. The most common isolates were Staphylococcus aureus (22.3%) and Pseudomonas aeruginosa (17.5%). Ceftriaxone was the most commonly prescribed empirical antibiotic (29%), followed by linezolid (20%), piperacillin-tazobactam (20%), amoxicillin-clavulanic acid (13%), cefoperazone-sulbactam (11%). After the culture and sensitivity (C/S) results, antimicrobials were changed in 74.61% of patients in the preference of Linezolid (51%), Amikacin (27%), Levofloxacin (19%), Ciprofloxacin (17%), Piperacillin-tazobactam (13%), Cefixime (15%), Ceftriaxone (11%) among others. Clindamycin and metronidazole were used to cover anaerobic microorganisms.
Conclusion: Most of the microorganisms isolated from DFUs were resistant to many types of antibiotics. Gram-positive organisms were largely sensitive to linezolid and vancomycin, while Gram-negative organisms to amikacin and imipenem. Local treatment of wounds is essential.
Whiting DR, Guariguata L, Weil C, Shaw J. IDF diabetes atlas: global estimates of the prevalence of diabetes for 2011 and 2030. Diabetes Res Clin Pract 2013;94:311-21.
Ramsey SD, Newton K, Blough D, McCulloch DK, Sandhu N, Reiber GE, et al. Incidence, outcomes, and cost of foot ulcers in patients with diabetes. Diabetes Care 1999;22:382-7.
Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA 2005;293:217-28.
Ang C, Lim Y. Recurrent admissions for diabetic foot complications. Malays Orthop J 2013;7:21-6.
Khoharo HK, Ansari S, Qureshi F. Diabetic foot ulcers: common isolated pathogens and in vitro antimicrobial activity. Prof Med J 2009;16:53-60.
Mansilha A, Brandão D. Guidelines for treatment of patients with diabetes and infected ulcers. J Cardiovasc Surg (Torino) 2013;54:193-200.
Lipsky BA, Aragon Sanchez J, Diggle M. IWGDF guidance on the diagnosis and management of foot infections in persons with diabetes. Diabetes Metab Res Rev 2016;32 Suppl 1:45‐74.
Wagner FW Jr. The dysvascular foot: a system for diagnosis and treatment. Foot Ankle 1981;2:62-122.
Armstrong DG, Lavery LA, Harkless LB. Validation of a diabetic wound classification system. The contribution of depth, infection, and ischemia to risk of amputation. Diabetes Care 1998;21:855-9.
Jayasinghe SA, Atukorala I, Gunethilleke B, Siriwardena V, Herath SC, De Abrew K. Is walking barefoot a risk factor for diabetic foot disease in developing countries? Rural Remote Health 2007;7:692.
Gadepalli R, Dhawan B, Sreenivas V, Kapil A, Ammini AC, Chaudhry R. A clinico-microbiological study of diabetic foot ulcers in an Indian tertiary care hospital. Diabetes Care 2006;29:1727-32.
Gregg EW, Sorlie P, Paulose Ram R, Gu Q, Eberhardt MS, Wolz M, et al. prevalence of the lower-extremity disease in the US adult population>=40 y of age with and without diabetes: 1999-2000 national health and nutrition examination survey. Diabetes Care 2004;27:1591-7.
Jyothylekshmy V, Menon AS, Abraham S. Epidemiology of diabetic foot complications in a podiatry clinic of a tertiary hospital in South India. Indian J Health Sci 2015;8:48-51.
Sharma VK, Khadka PB, Joshi A, Sharma R. Common pathogens isolated in diabetic foot infection in Bir hospital. Kathmandu University Med J 2006;4:295-301.
Bansal E, Garg A, Bhatia S, Attri AK, Chander J. Spectrum of microbial flora in diabetic foot ulcers. Indian J Pathol Microbiol 2008;51:204-8.
Citron DM, Goldstein EJ, Merriam CV, Lipsky BA, Abramson MA. Bacteriology of moderate to severe diabetic foot infections and in vitro activity of antimicrobial agents. J Clin Microbiol 2007;45:2819-28.
Shankar EM, Mohan V, Premlatha G, Srinivasan RS, Usha AR. Bacterial etiology of diabetic foot infections in South India. Eur J Intern Med 2005;16:567-70.
Peter N, Cherian N, Thomas S, George S, Sundresh JN. Study of prescribing pattern and use of antibiotics in the management of wound infection. Asian J Pharm Clin Res 2017;10:210-3.
Tiwari S, Pratyush DD, Dwivedi A, Gupta SK, Rai M, Singh SK. Microbiological and clinical characteristics of diabetic foot infection in northern India. J Infect Dev Ctries 2012;6:329-32.
Tentolouris N, Petrikkos G, Vallianou N, Zachos C, Daikos GL, Tsapogas P, et al. Prevalence of methicillin-resistant staphylococcus aureus in infected and uninfected diabetic foot ulcers. Clin Microbiol Infect 2006;12:186-9.
Akhi MT, Ghotaslou R, Asgharzadeh M, Varshochi M, Pirzadeh T, Memar MY, et al. Bacterial etiology and antibiotic susceptibility pattern of diabetic foot infections in tabriz, Iran. GMS Hyg Infect Control 2015;10:Doc02. DOI:10.3205/ dgkh000245
Raja NS. Microbiology of diabetic foot infections in a teaching hospital in Malaysia: a retrospective study of 194 cases. J Microbiol Immunol Infect 2007;40:39-44.
Lipsky BA, Hoey C. Topical antimicrobial therapy for treating chronic wounds. Clin Infect Dis 2009;49:1541-9.
Chopra I. The increasing use of silver-based products as antimicrobial agents: a useful development or a cause for concern? J Antimicrob Chemother 2007;59:587-90.
Roeder B, Van Gils CC, Maling S. Antibiotic beads in the treatment of diabetic pedal osteomyelitis. J Foot Ankle Surg 2000;39:124-30.
BB D, Unnikrishnan B, Kulkarni V, Thapar R, Mithra P, Kumar N, et al. Knowledge and practice regarding foot care among type 2 diabetes mellitus patients at a tertiary care hospital in coastal South India. Asian J Pharm Clin Res 2015;8:175-8.