Malaysian Orthopaedic Journal 2014 Vol 8 No 1 SD Balakrishnan, et al

Doi: http://dx.doi.org/10.5704/MOJ.1403.017

‘Does the National Antibiotic Guideline- 2008 remain

applicable for treating diabetic foot infection?’ A new
evidence-based regional study on culture and sensitivity
patterns in Terengganu population

SD Balakrishnan, MBBS (MAHE), NJ Shahid, MD (UKM), TM Fairuz, MBBS (NCL),

IMA Ramdhan, M Med Orth
Department of Orthopaedics, Hospital Sultanah Nur Zahirah, Kuala Terengganu, Malaysia

ABSTRACT years now. Therefore, the objective of this study was to look
into patterns of bacteriology among diabetic foot patients in
Diabetic foot infections make up a significant number of
our hospital with the focus to identify the commonly
orthopaedic ward admissions. The recommended choice of
isolated microorganisms from diabetic foot infection and to
empirical antibiotics used in Malaysia for diabetic foot
assess the response of the patients to the antibiotics as per the
infections is based on the National Antibiotic Guidelines
National Antibiotic Guidelines. This is important because,
2008. The pattern of bacteriology and the effectiveness of the
with time, the spectrum of organisms involved in the locality
treatment of diabetic foot infections based on this guideline
may change and the empirical choice of antibiotic treatment
were analyzed through a retrospective study in our hospital.
for these patients may not be applicable as recommended.
Data over a period of one year (May 2012- April 2013) was
By doing this, we attempt to prevent the misuse of antibiotics
analyzed, and 96 patients were included in this study.
which can cause emergence of multi-resistant organisms and
Polymicrobial growth (58%) was mainly isolated, followed
superinfection 2.
with an almost equal percentage of gram-negative (22%) and
gram-positive organisms (20%). The empirical antibiotics
based on the national antibiotic guidelines were used as
MATERIALS AND METHODS
definitive antibiotics in 85% of the cases. Although there
was slight variation in the pattern of organisms as compared A retrospective study was conducted using the data from the
to other studies conducted in this country, the high rate of Diabetic Foot Registry of HSNZ, from May 2012 till April
positive clinical response proved that the antibiotic guideline 2013. The data comprised of all in-patient diabetic foot
was still effective in diabetic foot infection treatment. patients that have been admitted for diabetic foot related
infections with a first positive intraoperative tissue culture
Key Words: (e.g. deep tissues, curetted bone). As proposed by Citron et
Diabetic foot infections, National Antibiotic Guidelines, al, post debridement specimens were obtained, as it would
Culture and Sensitivity help a better yield of positive cultures 3. The samples were
transported using sterile bottles to the microbiology lab and
cultured using Mueller-Hinton agar. Our exclusion criterion
INTRODUCTION was, diabetic patients with foot infections that have been
managed in the in non-orthopaedic wards. Thus out of 182
Diabetic foot complications, especially infections such as
patients over that one-year period, only 96 fulfilled our
wet gangrene, infected ulcers, abscess and necrotizing
criteria. This data was counter-checked using the Hospital
fasciitis are - the leading causes of non-traumatic
Information System (HIS).
amputations in Malaysia 1. Apart from surgical intervention,
the appropriate choice of antibiotics is an important part in
Patients were categorized into mild, moderate and severe
the management of these wounds. In Malaysia, we have been
infection based on clinical features described in the national
using the National Antibiotic Guideline that was published in
antibiotic guidelines 2008 4 which was originally adapted
2008 as a main guideline for the empirical antibiotic choice
from the Infectious Disease Society of America (IDSA)
for diabetic foot infections. Up to date, there are no recent
PEDIS classification 5, and the antibiotics were started as per
studies done in our country regarding microorganism growth
protocol for each group (Table I). The response to the
pattern and its response to the treatment as recommended by
treatment was observed based on clinical improvement and
this Guideline. Thus, it is important to evaluate the efficacy
the sensitivity to the antibiotics started. The empirical
of this guideline as it has been adhered to for about five
Corresponding Author: Sashi Darshan Balakrishnan, Department of Orthopaedics, Hospital Sultanah Nur Zahirah, Jalan Sultan Mahmud,
20400 Kuala Terengganu, Terengganu
Email: [email protected]

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 Diabetic foot infections

Table I: Summarized National Antibiotic Guideline 2008 [4]

Infection/Condition & Likely Organism Preferred Treatment Comments

Mild Infections:
Presence of > 2 markers of inflammation Cloxacillin 500mg PO q6h Duration of treatment:
(purulence or erythema, pain, tenderness, warmth, Or 1-2 weeks
or induration) with any cellulitis/erythema extending Amoxycilin/Clavulanate
less than 2 cm around the ulcer; infection is limited 625mg PO q12h
to the skin or superficial subcutaneous tissues;
no systemic toxicity

Moderate Infections:
Features of mild infection, no systemic toxicity or Ampicillin/Sulbactam 1.5g Duration of treatment:
metabolic instability and > 1 of the following: IV q8h usually 2-4 weeks.
cellulitis extending more than 2 cm around an ulcer, Or Modify according to
lymphangitic streaking, spread beneath the superficial Cefuroxime 750mg IV q8h clinical response
fascia, deep tissue abscess, gangrene, or involvement PLUS/MINUS If proven
of muscle, tendon, joint, or bone Metronidazole 500mg IV q6h osteomyelitis:
at least4-6 weeks.
However, a shorter
duration (3 weeks)
is sufficient if the
entire infected
bone is removed
Severe Infections:
Infection plus systemic toxicity or metabolic Ceftazidime 2g IV q8h Duration of
instability (e.g. fever, chills, tachycardia, PLUS treatment: as in
hypotension, confusion, vomiting, leukocytosis, Metronidazole 500mg IV q6h moderate
metabolic acidosis, severe hyperglycemia, infection
or azotemia above baseline)

Table II: Duration of diabetes Table III: Spectrum of monomicrobials isolated

Duration (Years) No. of patients (%) Monomicrobials Number of patients (%)

0-5 38 (40%) Staphylococcus Aureus 11 (27%)

5 - 10 30 (31%) Streptococcus spp. 6 (15%)
10 - 15 16 (17%) MRSA 2 (4%)
> 15 12 (12%) Enterobacter spp. 4 (10%)
Pseudomonas spp. 5 (12%)
Klebsiella pneumonia 9 (22%)
Proteus mirabilis 4 (10%)

Fig. 1: Overall pattern of microbials isolated. Fig. 2: The response of patients to treatment based on National
Antibiotic Guidelines 2008.

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Malaysian Orthopaedic Journal 2014 Vol 8 No 1 SD Balakrishnan, et al

antibiotics started based on the national antibiotic guidelines contributing factors to the variation in the isolate patterns.
were changed if there was no positive clinical response or if Another contributing factor to the organism types isolated
the organism was resistant to the particular antibiotic maybe the fact that the patients in this study were mainly
chosen. those with moderate to severe infections that required
inpatient treatment 3.

RESULTS The choice of empirical antibiotics started in our centre was

based upon the National Antibiotic Guideline 2008. Once the
A total of 96 patients were evaluated, 68 males (70%) and 28
patients were started on the empirical antibiotics, they were
females (30%). Most of the patients who presented (40%)
assessed for clinical response and the antibiotic sensitivity of
were diagnosed with diabetes only five years previously -,
the culture taken intra-operatively was traced. As our results
while 31% and 17% patients had been diagnosed previously
show, 85 % of patients responded to the antibiotics chosen
with diabetes ranging from 5-10 years and 10-15 years
initially and only 15% needed a change in antibiotics due to
respectively. Only 12% of them had been diagnosed more
resistance of organisms or unfavourable clinical response.
than 15 years ago. (Table II). The majority of the organisms
This positive outcome was seen because the antibiotic
isolated were polymicrobials (58%), followed by an almost
coverage of moderate to severe infections was relatively
equal percentage of gram negative organisms (22%) and
broad spectrum and was important especially in-patients
gram positive organisms (20%) (Figure 1). Among the
who were immunocompromised.
monomicrobials isolated, the majority was Staphylococcus
aureus ( 27%), followed by Klebsiella ( 22%) and
Early recognition of the severity of infection, medical
Streptococcus spp( 15%). (Table III). Clinically, most of the
stabilization, appropriate antibiotic selection, early surgical
patients (86%; n=83) had moderate infections, majority of
intervention and plans for delayed reconstruction are crucial
which did not require antibiotic change from the empirical
components of managing diabetic foot infections. The
therapy that was started. The mild and severe cases, which
empirical antibiotic therapy is started for coverage of
made up of four and ten patients respectively, responded
pathogens, while patient is being stabilized metabolically
successfully to the empirical antibiotics that were started
and hemodynamically, and while timing surgical
(Figure 2). Thus, the overall percentage of patients who were
intervention, when appropriate. Once the patient is medically
continued on the empirical antibiotics as definitive therapy
stabilized, initial surgical debridement is performed with the
was 85%.
goal of resecting all non-viable tissue and decompressing
gross abscess. This is of utmost importance for successful
control of the infection8.
DISCUSSION
Our demographic data showed that the vast majority of the In recent times, the role of biofilm has been studied as a
patients were males. This may be due to the fact that in cause of chronic diabetic foot wounds. Studies have well
Terengganu most males in the lower socioeconomic groups documented the presence of biofilm as an important barrier
are manual labourers or fishermen and tend to have a higher to effective treatment. A study by James et al showed that
incidence of foot injuries, which is an important risk factor 60% of chronic wounds contained biofilm as compared to
for diabetic foot infections. The diabetic foot infections were only 6% of acute wounds9. With this new knowledge related
also most common in the group diagnosed less than five to diabetic foot wounds, we should include synergy of
years ago. This is possibly due to late diagnosis of diabetes different antibiotics for better biofilm penetration and
mellitus or poor foot care knowledge in this population. eradication in a revision of the National Antibiotic
Guidelines of this country.
The data accumulated in this study was compared to other
recent studies. We compared the bacteriology pattern of
diabetic foot infection in our hospital with a recent study CONCLUSION
from India by Girish et al. They reported predominance of
The culture and sensitivity pattern of the microorganisms
polymicrobial growth, and among the monomicrobials,
isolated in our hospital is consistent with studies done in
majority was gram negative organisms 6. Our country
other centres, and the empirical antibiotic therapy as
showed that monomicrobial infection was more common.
recommended by the National Antibiotic Guideline 2008 of
Nadeem et al in a study 2005 in a teaching hospital our
Ministry of Health of Malaysia is effective in the treatment
country, reported a predominant gram negative growth 7. In
of diabetic foot infections. We suggested some modification
2006, Yoga et al from another hospital in the state of Kedah
to increase effectiveness against biofilm producing
found that gram positive organisms were more common 2.
organisms in future editions. Based on this study, apart from
These different patterns of isolates possibly depend on the
surgical intervention, the proper identification of causative
severity of the infection and geographical variations 5. Based
organisms and the appropriate antibiotic therapy of diabetic
on our observation, patients in our hospital tended to present
foot infections are key contributors to the achievement of
late for treatment of diabetic foot infections, as they usually
successful outcome.
sought traditional healers initially. This may be one of the

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