|Year : 2013 | Volume
| Issue : 2 | Page : 98-102
Factors associated with diabetic septic foot among patients attending the diabetic septic foot unit in the military hospital, Khartoum State, Sudan
Siham A Balla, Haidr A Ahmed, Suzan F Alhassan
Department of Community Medicine, Faculty of Medicine, University of Khartoum, Sudan
|Date of Web Publication||25-Dec-2013|
Siham A Balla
Department of Community Medicine, Faculty of Medicine, University of Khartoum
Context: Diabetic septic foot (DSF) is a serious outcome complication of diabetes mellitus. Patients having DSF are at a high risk of amputations and surgical hazards.
Aim: The aim of this study was to identify the self-care of foot and factors associated with DSF among diabetic patients attending the DSF unit in the Military Hospital.
Materials and Methods: A case-control study was conducted among diabetic patients attending the diabetic clinic in the Military Hospital during May-June 2012. Thirty DSF cases and 30 controls were interviewed using a structured questionnaire and DSF was observed and graded by Wagner's classification.
Statistical Analysis: Descriptive statistics of the cases was presented and Fisher's exact test was used to test the risk factors associated with DSF.
Results: The mean age for the study groups was 55.60 11.9 years. Based on the Wagner classification, 83.3% of septic feet were classified as grades 3, 4 and 5. Considering the delay in presentation with DSF to the hospital, 86.7% presented after 1 week up to more than 2 months from the start of the lesion. Low socioeconomic status, lack of self-care of foot, peripheral neuropathy and foot ischemia and deformity were associated with developing DSF (P-value < 0.05).
Conclusion: Most patients with DSF seek care late and present with advance grade lesions. Lack of self-care of foot, peripheral neuropathy and foot ischemia and deformity are the risk factors of DSF.
أجريت هذه الدراسة على مرضى السكري الذين يراجعون وحدة علاج القدم المتعفنة جراء داء السكري. وتم فيها إجراء مقابلات مع حالات مصابة وأخرى ضابطة باستخدام استبيان منظم وجرت ملاحظة المصابين بتعفن أقدامهم وتصنيفهم وفقا لمعيار.(Wagner)
بينت الدراسة أن معظم مرضى السكري الذين يعانون من تعفن في أقدامهم يتأخرون عن المراجعة مما يسبب إصابتهم بدرجات متقدمة. أما العوامل المرتبطة بتعفن أقدام مرضى السكري فهي انعدام العناية الذاتية بالقدم واعتلال الأعصاب الطرفية ونقص تدفق الدم إلى القدم خاصة عند وجود تشوه فيها.
Keywords: Diabetic septic foot, risk factors, self-care of foot, Wagner classification
|How to cite this article:|
Balla SA, Ahmed HA, Alhassan SF. Factors associated with diabetic septic foot among patients attending the diabetic septic foot unit in the military hospital, Khartoum State, Sudan. Saudi J Med Med Sci 2013;1:98-102
|How to cite this URL:|
Balla SA, Ahmed HA, Alhassan SF. Factors associated with diabetic septic foot among patients attending the diabetic septic foot unit in the military hospital, Khartoum State, Sudan. Saudi J Med Med Sci [serial online] 2013 [cited 2018 Dec 11];1:98-102. Available from: http://www.sjmms.net/text.asp?2013/1/2/98/123658
| Introduction|| |
Globally, it is estimated that every 30 seconds a lower limb is lost somewhere in the world as a consequence of diabetic septic foot (DSF).  It is a common complication of diabetes and frequently leads to amputation of the extremities.  Individuals with diabetes are at a 30-times higher risk for lower extremity amputation compared with those without diabetes. 
Patients with diabetes may present to the hospital with different levels of foot lesions. Wagner's classification is used as a grading system of DSF, and it is one of the classifications upon which the management may be determined. 
DSF contributes to the high morbidity rate among the affected population, especially in developing countries that have limited health care infrastructures, and most of the patients access the health care with advance ulcers.  The diabetic foot ulcer is a major public health problem in sub-Saharan Africa in general. The prevalence among the population of rural Sudan is about 3.9%, and it causes a high rate of bed occupancy in hospitals' admission. 
Foot complications of diabetic patients are the most frequent reason for hospitalization among diabetic patients. The main risk factors that strongly contribute to the occurrence of diabetic foot ulcer are neuropathy and micro as well as macrovascular occlusion. The valid preventive measures for early detection and management of foot ulcers are the patients' knowledge about diabetes and practicing foot care, including wearing soft leather shoes and examination of the feet for minor abrasions. 
In Sudan, diabetes mellitus is becoming a common public health problem. DSF-related mortality varied among different hospitals of Sudan. Khartoum hospitals reported that 35-40% of inpatients had a major lower limb amputation during the '80s, and it is estimated at 7.4% in public hospitals in the western part of the country. , The lower limb amputations among inpatients with a diabetic foot in Khartoum hospitals increased in recent years in Sudan.  Recently, DSF accounted for 10.2% of all complications reported from private clinics in Khartoum state. 
The increase in diabetic foot could be due to inadequate information about diabetes and its complications that should be disseminated to the public. It could be attributed to some traditions and social habits that delay the presentation to health care, leading to deterioration of the wounds. Almost all the studies of DSF in Sudan addressed the neurological and vascular risk factors rather than the behavior of self-care of foot. The aim of this study was to identify the foot self-care measures and its association with DSF among diabetic patients.
| Materials and Methods|| |
This is a case - control study conducted among patients with diabetes presented with or without DSF in the Military Hospital. The hospital is located in Omdurman locality, Greater Khartoum in Sudan. A DSF unit was established in the Military Hospital since 2008. It receives military and non-military patients from Greater Khartoum and from different parts of the country. Cases were selected from diabetic patients with foot ulcer. The controls were selected from the diabetic patients attending the outpatient clinic without foot ulcers, neither in the past history nor currently. Previous studies showed that age, duration of diabetes and insulin therapy were independently associated with DSF.  In this study, these factors were matched for cases and controls to emphasize the association of foot self-care measures and its related factors. Written consent was signed by the patients, and they were interviewed by a structured questionnaire. The DSF was observed for lesions and deformity, and classified by Wagner's classification [Table 1].  Pulsation of the arties of both feet was examined for both groups to assess the ischemic status of the feet. Loss of sensation (neuropathy) was assessed by light touch. Socioeconomic status of the study groups was determined by the type of housing (residents in the urban center of Sudan capital or in the peripheral semiurban areas) and the income (household expenditure per day as below 20 SDG or above). Accordingly, they were classified as either low or high socioeconomic status.
The sample size was calculated by an Open Epi calculator.  The power of the study was chosen at 80%, alfa 0.05 and case-control ratio equal 1.  Considering the pre-intervention exposure of wearing protective shoes in a randomized controlled study, the exposure of the control was estimated at 20%.  The calculated minimum sample size was 60 (30 controls and 30 cases).
Data were cleaned, entered and analyzed by SPSS version 18. Descriptive statistics of the cases were presented regarding classification of the DSF, time of presentation to the hospital and history of previous foot ulcer. Fisher's exact test was used to determine the association of DSF with the following foot factors: Measures of self-care of foot, foot deformity and ischemia, peripheral neuropathy, socioeconomic status and family history.
| Results|| |
Regarding the total study groups, the mean age was 55.60 ± 11.9 years (min: 38; max: 85). The matched variables are sex (male:female ratio equal 2.7:1) and type of treatment (20% insulin and 80% oral hypoglycemic drugs), and 66.7% cases and controls had a duration of diabetes of more than 10 years.
Approximately 83.3% of the cases presented with DSF as grades 3, 4 and 5 (30%, 30% and 23.3%, respectively) [Table 2]. Regarding patient's behavior for taking treatment, 13.3% of the cases with foot ulcer presented to the hospitals at the same day of noticing the ulcer, whereas 70% presented to the hospital after 1-2 weeks, 10% after 1 month and 6.7% after 2 months. Less than half of the cases with DSF (46.67%) had a past history of foot ulcer or some degree of amputation [Table 2].
Walking barefoot (OR: 3.8) and wearing open shoes (OR: 3.3) were significantly associated with DSF. Wearing special shoes and daily self-examination of the feet are protective factors from developing DSF (OR: 7.9 and 4.6, respectively). Foot deformity, absence of arterial pulse of the feet and peripheral neuropathy were strongly associated with DSF (OR: 9.3, 9 and 5, respectively). The study showed a significant association between DSF and low socioeconomic status (OR: 5), whereas family history of diabetes (OR: 1.7) was not associated with DSF [Table 3].
| Discussion|| |
Previous studies showed that age, duration of diabetes and insulin therapy were independently associated with DSF.  In this study, we focused on testing the association of DSF with factors related to self-care of foot, foot deformity and ischemia and peripheral neuropathy as well as socioeconomic and family history.
Past history of foot ulcer is known as a potential factor for the recurrence of DSF. In this study, 46.67% of the cases had a past history of foot ulcer. This high prevalence rate among cases might be due to some recall bias. Previous studies of longitudinal designs showed a relative risk of 3.05 and recurrence rate of 23.2% for DSF. , The low recurrence rate in these longitudinal studies could be due to follow-up, health consciousness of the diabetic patients involved and frequently reporting to those caring centers, the close monitoring of patients and the quality of services provided.
The classification of DSF showed that 83.3% of the DSF cases were classified as grades 3, 4 and 5 (30%, 30% and 23.3%, respectively). The advance DSF grades are due to patients' care-seeking behavior and reporting late to the diabetic care units. The time of presenting to care was a risk factor for advanced grades. It was found that 13.3% of the patients seek treatment at the same day they notice the ulcer and that 86.7% present to the clinic after 1 week to more than 1 month. Similar findings were reported in studies in Sudan where records of DSF were reviewed and the frequent presentations of DSF were grades 3 and 4; this was explained by late access to treatment and access to traditional healers prior to hospital admission. ,
Neuropathy and ischemia
In this study, peripheral neuropathy and absence of arterial pulse of the feet are significantly associated with DSF (OR: 5 and 9, respectively). This is similar to studies with different designs, which showed a strong relation of foot ulcers with neuropathy, peripheral vascular diseases and ischemia. , Our findings showed that foot deformity has an eight-fold increased risk in cases than in controls (OR: 9.3). Limited joint mobility, foot deformities and trauma are causative factors of foot ulceration among diabetic patients.  However, previous studies recommended further researches regarding foot deformity and type of footwear as a predictor for DSF. ,
Self-care of foot
Our study focuses on footcare, which showed an association of DSF with walking barefoot (OR: 3.8) and wearing open shoes (OR: 8.3), while wearing special shoes (OR: 7.9) and daily self-examination of the feet (OR: 4.6) were-less frequent among the cases. This might be explained by available poor educational programs in Sudan, the inadequately available number of trained educators and the pooled services for diabetic patients within the general outpatient's clinics. Our findings are supported by previous studies, which showed the frequent and regular self-inspection of the feet, the patient's education and the wearing of proper shoes are cost-effective and play significant roles in the prevention of foot ulcer. ,,, Although some studies had inadequate research methods, nevertheless, it showed the effect of group education on the decrease of foot ulcer and amputation. 
Adherence to daily examination of foot in both cases and controls in our study is 36.7%. This is not far different from a survey conducted at eight centers in New Jersey, where 32.2% of the participants reported looking at the bottom of their feet daily.  In our study, wearing special shoes among cases and controls is 28.3%, reflecting limited knowledge and behavior toward wearing special shoes as far as they are diabetic. In a previous study, the trauma due to rubbing from custom shoes was 21%. 
Socioeconomic and family history
In this study, the low socioeconomic status is significantly associated with DSF (OR: 5). Similarly, a non-randomized case study of two cohort groups with and without DSF showed a significant association of DSF with low socioeconomic status (OR: 4.39 by multivariate analysis).  Regarding the family history of diabetes, it was found to be positive in a recent case study,  while in our study and due to the small sample size, the association was not significant (P > 0.05).
| Conclusion|| |
The increased risk for developing DSF is associated with self-care of foot, peripheral neuropathy and foot ischemia and deformity. Low socioeconomic status is associated with DSF, and delay in time presentation with DSF results in advanced grades of the lesions. Disseminating information about diabetes and self-care is recommended. Strengthening the health education programs addressing the diabetes problems will assist the diabetic patients to care for their feet and decrease the potentials for developing any complications as well as DSF.
| Acknowledgment|| |
Many thanks are extended to Dr. Mohammed Mahmoud. He is the Consultant and Head of the Diabetic Septic Foot Unit - Military Hospital, for his valuable support.
| References|| |
|1.||Jeffcoate WJ, Harding KG. Diabetic foot ulcers. Lancet 2003;361:1545-51. |
|2.||Rooh Ul Muqim SG, Ahmed M, Griffin S. Evaluation and management of diabetic foot according to Wagner's classification: A study of 100 cases. Skin 2003;66:22-9. |
|3.||Chalya PL, Mabula JB, Dass RM, Kabanqila R, Jaka H, Mchembe MD, et al. Surgical management of Diabetic foot ulcers, a Tanzanian university teaching hospital experience. BMC Res Notes 2011;4:365. |
|4.||Adam MA, Hamza AA, Ibrahim AE. Diabetic Septic Foot in Omdurman Teaching Hospital. Sudan J Med Sci. 2009;4:129-132. Available from: http://www.ajol.info/index.php/sjms/article/view/44898. |
|5.||Frykberg RG. Diabetic foot ulcers: Pathogenesis and management. Am Fam Physician 2002;66:1655-62. |
|6.||El Bushra A. Diabetic Septic Foot Lesions in El Obeid, western Sudan. Sudan J Med Sci 2008;2:119-121. Available from: http://www.ajol.info/index.php/sjms/article/view/38476. |
|7.||Yahya AR, El Mahadi MA, Ahmed ME. The risk factors for development of a diabetic foot in asymptomatic diabetics. Sud Med J 2008;44:19-23. |
|8.||KMOH. The complications of diabetic patients attended the private sectors during 2011,annual report. Statistics department. Khartoum Ministry of Health. 2012. |
|9.||Sämann A, Tajiyeva O, Müller N, Tschauner T, Hoyer H, Wolf G, et al. Prevalence of the diabetic foot syndrome at the primary care level in Germany: A cross-sectional study. Diabet Med 2008;25:557-63. |
|10.||Akther JM, Khan IA, Shahpurkar VV, Khanam N, Syed ZQ. Evaluation of the diabetic foot according to Wagner's classification in a rural teaching hospital. Br J Diabetes Vasc Dis 2011;11:74-9. |
|11.||Kelsey JL, Whittemore AS, Evans AS, Thompson WD. Methods in observational epidemiology, 2 nd ed. USA: Oxford University Press; 1996. |
|12.||Corbett CF. A randomized pilot study of improving foot care in home health patients with diabetes. Diabetes Educ 2003;29:273-82. |
|13.||Abbott CA, Carrington AL, Ashe H, Bath S, Every LC, Griffiths J, et al. The North West Diabetes Foot Care Study: Incidence of, and risk factors for, new diabetic foot ulceration in a community based patient cohort. Diabet Med 2002;19:377-84. |
|14.||Lavery LA, Armstrong DG, Wunderlich RP, Mohler MJ, Wendel CS, Lipsky BA. Risk factors for foot infections in individuals with diabetes. Diabetes Care 2006;29:1288-93. |
|15.||Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA 2005;293:217-28. |
|16.||Crawford F, Inkster M, Kleijnen J, Fahey T. Predicting foot ulcers in patients with diabetes: A systematic review and meta-analysis. QJM 2007;100:65-86. |
|17.||Corbett CF. A Randomized pilot study of improving foot care in home health patients with diabetes. Diabetes Educ 2003;29:273-82. |
|18.||Ramachandran A. Specific problems of the diabetic foot in developing countries. Diabetes Metab Res Rev 2004;20:S19-22. |
|19.||Ragnarson Tennvall G, Apelqvist J. Health-economic consequences of diabetic foot lesions. Clin Infect Dis 2004;39:S132-9. |
|20.||Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph WS, Karchmer AW, et al. Diagnosis and treatment of diabetic foot infections. Clin Infect Dis 2004;39:885-910. |
|21.||Norris SL, Engelgau MM, Narayan KM. Effectiveness of self-management training in type 2 diabetes: A systematic review of randomized controlled trials. Diabetes Care 2001;24:561-87. |
|22.||Johnston MV, Pogach L, Rajan M, Mitchinson A, Krein SL, Bonacker K, et al. Personal and treatment factors associated with foot self-care among veterans with diabetes. J Rehabil Res Dev 2006;43:227-38. |
|23.||Nather A, Siok Bee C, Keng Lin W, Qi Odelia KS, Yiong Huak C, Xinyi L, et al. Socioeconomic profile of diabetic patients with and without foot problems. Diabet Foot Ankle. 2010;1:1-5. |
|24.||Botek G, Anderson MA, Taylor R. Charcot neuroarthropathy: An often overlooked complication of diabetes. Cleve Clin J Med 2010;77:593-9. |
[Table 1], [Table 2], [Table 3]