Diabetic Foot: Epidemiological, Therapeutic and Evolutionary Aspects in the Department of Medicine and Endocrinology of the Hospital in Mali, Mali ()
1. Introduction
According to the WHO, the number of people with diabetes worldwide has increased from 108 to 422 million over the past 30 years [1]. In Belgium, this number increased from around 300,000 to over 500,000 individuals between 2001 and 2011 [2]. Projections for 2030 are over one million [3]. In Africa, the number of diabetics was estimated at 14.2 million people in 2015 and 34.2 million are expected in 2040 [4].
The diabetic foot is defined according to the international consensus on the diabetic foot (developed by IWGDF: International Working Group on Diabetic Foot) of 2007 as any Infection, ulceration or destruction of the deep tissues of the foot associated with neuropathy and/or peripheral arterial disease of the lower limbs in diabetics [5].
These lesions in ill-balanced patients, difficult and expensive to treat most often lead to amputation, which makes this pathology a major public health problem, especially noting that every 30 seconds, a lower limb will be lost due to the diabetes [6].
Diabetic foot is a frequent and serious complication of diabetes with a very high rate of amputations of the lower limbs and often dramatic socio-economic and psychological consequences [7].
In Africa, foot injuries in diabetics are unfortunately very common. Poverty, poor hygiene and barefoot walking interact to aggravate the impact of foot injuries caused by diabetes [8]. In Mali there are few studies on diabetic foot [9] and there is an increase in the number of cases in the department. The objective of this study was to describe the epidemiological, therapeutic and evolutionary profile of the diabetic foot in a hospital setting in Mali.
2. Methodology
We conducted a retrospective, descriptive, cross-sectional study between September 1, 2011 and December 31, 2015 among diabetic patients aged 14 and over who arrived in the endocrinology/medicine department of the hospital in Mali.
Inclusion criteria:
- Study: retrospective, descriptive, transversal.
- Duration: 4 years and 3 months.
- Be 14 years old and over.
- All diabetic patients who arrive in the endocrinology department of the hospital in Mali with a foot infection.
- We collected clinical, paraclinical and therapeutic data from these patients.
- Voluntary and informed consent was given in writing before being enrolled in the study.
Non-inclusion criteria:
We excluded from our series the incomplete files as well as the other causes apart from the diabetic foot.
Information was collected from patient charts using survey forms on which diabetic foot lesions were described according to the Texas classification (see Table 1). The questionnaires were entered and analyzed on Excel 2007 and SPSS version 20.0 software after data verification.
3. Results
We identified 94 cases of diabetic foot out of a total of 828 hospitalized patients, i.e. a prevalence of 11.35%. The age range 41 - 60 years represented (60.6%), the extreme ages were 14 and 81 years (Cf. Table 2). Men 36 cases (38.3%), women 57 cases (60.6%) with a sex ratio of 0.62%. Housewives 47 cases 50% (see Figure 1). Non-educated people 51 cases (54.3%) (see Figure 2). The economic standard of living was considered low in 40 cases (42.6%) and sufficient in 54 (57.4%). The presence of osteitis was observed in 40 cases (42.6%). Doppler ultrasound was abnormal in 48 patients (51%) (see Figure 3). Cytobacteriological examination of the pus was positive in 56 cases (59.6%). Staphylococcus aureus was found in 21 samples (22.4%) (see Table 3). The wounds were classified as stage D Grade 3 in 28 cases (29.8%) (see Table 4). Fifty-nine (61.7%) and 25.5% of the
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Table 1. University of Texas classification (UT).
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Table 2. Age distribution of patients.
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Table 3. Distribution according to the germs found in the culture.
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Table 4. Distribution of patients by Texas classification.
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Figure 1. Distribution of patients by occupation.
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Figure 2. Distribution of patients by education level.
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Figure 3. Distribution of patients by Doppler ultrasound findings.
patients were on insulin and oral anti-diabetic drugs respectively, while 12.8% had no anti-diabetic treatment. Medical treatment was mainly Amoxicillin + Metronidazole used in 36 cases (38.29%) and amputation was performed in 35 cases (37.2%) (Cf. Table 5, Table 6). The evolution was favorable in 85 cases (90.4%), 9.6% (5 patients) died of which the main causes were hypoglycemia in 4 cases and sepsis in 3 cases.
4. Discussion
The study included 94 cases out of a total of 828 hospitalized patients, for a prevalence of 11.35%. This hospital prevalence is close to those reported by Djim. F et al. [9] and Koffi D [10] respectively 16.37% and 15.29%. In Africa, it is estimated overall at 5.5% [11] and in France (ENTRED), the prevalence is 6% [12].
The 41 - 60 age group was the most represented, 60.6%, Djim. F et al. [9] found 59.6%. The average age was 42.66 years, other African studies: SANI.R et al. [13], Nghario L et al. [14], Gueye D.D et al. [15], Dr Merad M S et al. [16], Mohaman Djibril et al. [17] found respectively 53 years, 54 years, 57 years, 60.5 years, 60.74 years. That reported in European literature varies between 67 years
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Table 5. Distribution of patients according to the type of antibiotics used.
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Table 6. Distribution of patients according to surgical management.
and 73 years [18]. This age difference can be explained by the young age of onset of diabetes in African populations, but above all by poor treatment compliance by our patients. The reasons for this poor compliance are multiple: the non-acceptance of diabetes, traditional therapy, beliefs and especially poverty [19].
Women were in the majority (61.7%) against 38.3% for men with a sex ratio of 0.62%. This female predominance has been noted by some authors such as Samaké D [20]. On the other hand, the male predominance which has been studied by Dr Merad M S et al. [16] (sex ratio M/F 2.33) is a phenomenon confirmed by several authors. Sani et al. [13] found a sex ratio of 2.46; it is 2.5 for Amoussou-Guenou [21]. The generally recognized poor adherence to therapy in men explained this male predominance [22].
Housewives were the most represented in our study (50%). This same predominance was observed by Djim F et al. [9] 53.3%.
The majority of our patients were not educated with 54.3%. This same result was observed by Traoré D.Y [23] 55.5% and Nghario L et al. [14] 47%. In fact, ignorance of the diabetic status due to illiteracy has also been reported in a variable proportion in the African literature: 13.1% in Niger [24]; 27.9% in Tanzania [25].
The socio-economic level was low in 42.6%, Nghario L et al. [14] found a low level in 66.10% of patients. The Doppler ultrasound was abnormal in 51% of our patients. Djim F C. et al. [9] had 48.6% arteriopathy of the lower limbs and 20% obliteration.
The presence of germs was noted in 59.6% of samples taken from wounds. Nghario L et al. [14] had reported in 50% of his samples.
Among the germs isolated, staphylococcus aureus was found more in 22.4%, the same germ was the most isolated in 16.13% in Djim F C. et al. [9]. On the other hand, in the Aouam study [26], the most frequently found germ was Pseudomonas aeruginosa. A study done in India and published in 2017 found poly-microbial infections in 54% with other mono-microbial in 43%. [27]. In Morocco the bacteriological sample carried out had objectified the multisensitive Staphylococcus aureus in 28.23% [28].
According to the University of Texas classification, the foot was classified as stage D Grade 3 in (29.8%), Guèye D.D et al. [15] found grade 1b lesions which represented 34.0%, followed by 26.4% by grade 2d lesions and 24.5% by grade 3d lesions. Also, Dr Merad M S et al. [16], had found osteitis at Stage 3D in 46% of patients.
During hospitalization, insulin therapy alone was started in 61.7% of cases. This result was with Djim F et al. [9] in Mali with 95.7% insulin therapy and Dr L. Elazizi et al. [29] had performed insulin therapy in 77.20% of patients. The most widely used antibiotic therapy was the combination Ciprofloxacin + Metronidazole in 38.29% of cases, the same combination found in Djim F et al. [9] at 37.8%. Similarly, this antibiotic therapy was generally introduced by Dr L. Elazizi et al. [29] in 89.20%.
Amputation was performed in 37.2% of our patients including 24.3% in the lower 1/3 of the leg, 16.3% in the upper 1/3 of the leg and a disarticulation of the big toe in 24, 3% of cases. SANI.R et al. [13] found amputation in 37 cases (41.1%), of which the amputation site was the foot in 23 cases (62.2%) followed by the leg in 11 cases (29, 7%) and the thigh in 3 cases. Case (8.1%), as well as authors such as Sidibé AT et al. [30] and Merad M S et al. [16] reported respectively 41.36% and 34% of amputations in their studies.
The outcome was favorable in 90.4% of cases, other favorable results have been reported by authors such as Koffi D [10] which reported 91.70% and 71% of cases in Assia EL Ouarradi [31].
We recorded a mortality rate of 9.6% during the study period. This rate was reported at Djim. F et al. [9], Sidibé AT et al. [30], Gueye D.D et al. [15], SANI.R et al. [13], Djibril et al. [17] respectively 10.6%; 5.75%; 16.9%; 16.7%; 6.45%. Hypoglycemia in 4.3% of cases was the leading cause of death. Djim. F et al. [9] found that sepsis was the cause of death (60%) and for Nghario L et al. [14] sepsis and hyperglycemia were the main causes of death in 50% of cases.
5. Conclusion
Foot lesions are relatively frequent in our diabetic patients, and are responsible for high mortality and morbidity. A delay in management with lesions received at advanced stages is always noted. The management of the diabetic foot must be multidisciplinary.