Bacterial Resistance in Patients with Infected  Diabetic Foot without Major Amputation Outcome in a Peruvian National Hospital

Presentation Number: LB SUN 78
Date of Presentation: April 2nd, 2017

Marlon Yovera-Aldana*1, Antuané Rodríguez2, Mariela Vargas2, Manuel O. Huaman2, Paula Lucero2, Claudia Yalan2, Jesús Vargas-Vilca2 and Eduardo García-Orbegoso3
1National University of Piura, Piura, Peru, 2Ricardo Palma University, Lima, Peru, 3Edgardo Rebagliati Martins National Hospital, Lima, Peru

Abstract

OBJECTIVE: To determine bacterial resistance among patients with infected diabetic foot without major amputation outcome treated with Early Ambulatory Surgical Debridement (EASD).

MATERIALS AND METHODS: Cross-sectional study, review of medical records of patients attending the diabetic foot area during the period 2010-2014 at the Edgardo Rebagliati Martins National Hospital. The EASD is the excision of non-viable tissues (skin, subcutaneous cellular tissue, muscle, tendons or bones) plus drainage of secretions, in a procedure room with a minimum frequency of 3 times a week, performed by the endocrinologist from the first contact. Only cultures of aerobic bacteria were evaluated. The samples (mainly bone and tendons) were taken from the base of the ulcer after being debrided. No patient resulted in major lower limb amputation and all presented complete epithelization.

RESULTS: 128 bacterial isolated from 88 patient’s cultures were included in the analysis. The subjects were males in 81.8% and average age of 60.6 + 12.6 years. The median time for diabetes was 15 years and only 18.7% had HbA1c less than 7%. According to the Meggitt-Wagner classification, 39.8% were grade 3, 40.9% were grade 4 and 1.1% were grade 5. The infection severity, agreed to the Infectious Diseases Society of America (IDSA), was mild in 11.4%, moderate in 80.7% and severe in 7.9%.
Of the 88 cultures, 42% were polymicrobial and 3.5% were negative. Gram-negative bacteria prevailed with 69.5%. The most frequent isolated bacteria were Escherichia coli 33.7%, Enterococcus faecalis 14.1%, Staphylococcus aureus 13.3%; Proteus mirabilis 10.2%, Morganella morganii 7.0%, Citrobacter freundii 5.5% and Pseudomonas aeruginosa 4.7%. In Gram-negative bacteria, 32% of Enterobacteriaceae were positive extended spectrum beta-lactamase (ESBL). There was no resistance to carbapenems in Enterobacteriaceae but P. aeruginosa had resistance between 80% to 100%. Among negative ESBL Enterobacteriaceae, 69% were resistant to ciprofloxacin and 56% were resistant to ceftriaxone. Acinetobacter baumannii showed 100% resistance to all antibiotics evaluated but was only found in 2.3% of the cases. In Gram-positive bacteria, 70.5% of S. aureus were methicillin resistant (MRSA). S. aureus non-resistant methicillin showed resistance to ciprofloxacin and clindamycin of 66% and 50% respectively; increasing to 100 and 89% in MRSA. Vancomycin showed resistance of 0% in all Gram-positive bacteria.

CONCLUSIONS: Among patients, whose diabetic foot amputation was avoided by EASD, there was a high frequency of positive ESBL Enterobacteriaceae, MRSA and high resistance to empirical most commonly used antibiotics such as ciprofloxacin, ceftriaxone and clindamycin. According this profile, a carbapenem with vancomycin is the least resistant initial combination to use until the ulcer culture result.

 

Nothing to Disclose: MY, AR, MV, MOH, PL, CY, JV, EG