| Abstract [eng] |
Background / objective More than 60% of lower extremity amputations are due to diabetes mellitus. In Lithuania, in-hospital mortality after amputations varies from 5 to 37%. The main causes of invalidity and mortality are foot infection or gangrene, sepsis and complications of the heart and lungs. A combination of peripheral neuropathy, ischemic vascular disease and infection facilitate diabetic ulcer development, which can lead to gangrene and amputation. However, in many cases foot ulcers and amputation can be prevented. The work of prevention begins with the initial diagnosis of diabetes. Attempts to reduce the incidence of lower extremity amputations have shown that multi-disciplinary team management is one of the more effective means of accomplishing this goal. A complex multi-disciplinary team, including vascular surgeon, endocrinologist, general surgeon, podiatrist consultations and continuous control are vital for patients with diabetic foot syndrome. The topics were analyzed from general surgeon's point of view. The objective of this analysis was to find the experience of treatment of diabetic foot syndrome, factors inducing gangrene of lower extremity, dominant microorganisms and their susceptibility to antibiotics in diabetic foot wounds. Methods At Vilnius City University Hospital departments of general surgery, from 1992 to 2002 441 patients with diabetic foot syndrome were hospitalized. The data were collected by filling in a questionnaire. Results The main goal in the treatment of diabetic foot syndrome is to save the extremity or in the case of life-threatening infection to save the patient's life. Treatment of diabetic foot syndrome could be categorized into general and local. For the general treatment of diabetic foot we resort first of all to glycemic control and in the case of infection to antibiotic therapy. If a life-threatening infection, sepsis occurs, radical surgical intervention – amputation of lower extremity – is performed. For the local treatment of diabetic foot we resort to foot surgery including dreinage, lavage and debridement. Also other therapies such as adjuvant means of treatment, e.g., hyperbaric oxygen therapy, are applied at Vilnius City University Hospital departments of general surgery. Of all the patients hospitalized for diabetic foot syndrome 71.7% were operated on. We analyzed the prevalence of microorganisms in diabetic foot wounds. Microbiological tests were taken only from 46% of all diabetic wounds. In total, 323 pathogens were isolated. One pathogen was found in 54.5%, two in 29.6%, three in 11.1%, four and more in 4.8% of all swabs. According to the data, in almost half of all swabs two or more pathogens were found. The most common species were Staphylococcus, Proteus, Streptococcus and Enterococcus. The predominant pathogenic organisms were Gram-positive aerobes found in 61.9% of swabs. Of the Gram-positive aerobes, St. aureus was found most frequently (36.2% of all swabs), and 12% were MRSA. We analyzed the outcomes of diabetic foot syndrome. Of all hospitalized patients, 31.1% had been ill with diabetic foot complications before hospitalization. At the departments of general surgery, 7.7% of hospitalized patients' extremities were amputated above the knee and 23.4% below the knee; 59.6% of patients were cured. We found that 9.3% of patients died during hospitalization; their mean age was 68.4 years. Three main causes of the lethal outcome were sepsis and septicemia, myocardial infarction and heart failure. Other causes were lung artery embolism, terminal insufficiency of renal function, hypoglycemic coma, perforated ulcer of the duodenum. Conclusions Approximately 0.5% of all patients of Vilnius City University Hospital departments of general surgery are hospitalized with diabetic foot syndrome every year. About 60% of patients were cured, but some patients were not: their extremities were amputated above the knee in 7.7% and 9.3% of patients died during hospitalization. Eleven cases of lethal outcome were directly associated with diabetic foot syndrome (sepsis, septicemia), one case with diabetes mellitus (hypoglycemic coma), and the other cases with concomitant and conterminous diseases. Only a multi-disciplinary team (including endocrinologists, vascular and general surgeons) applying a combined management of diabetic foot syndrome can reduce the prevalence of amputations and mortality in diabetic foot patients. In diabetic foot wounds polymicrobic flora was dominant. St.aureus was the sole pathogen most sensitive to oxaciline, gentamycine, erythromycine, cefazoline and 12% were MRSA. |
