الفهرس 
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Abstract
The current prospective case-controlled-hospital-based study recruiting two groups of individuals attending at elMansoura diabetic foot clinic and elMinia vascular surgery clinic between December 2019 to April 2020.
This study was conducted on 74 patients divided into 2 groups containing both control and patients groups.
PATIENTS’ GROUP
54Diabetic patients attending to the clinic for the first time with diabetic foot ulcer including 30 females and 224 males. Age within this groups wear ranged from 27 to 85
CONTROL GROUP
Consisted of 20 patients who are not diabetic presented with foot ulcer, Including 12 males and 8 females
Age within this groups wear ranged from 27 to 85
Inclusion criteria: patients with type or type 2 diabetes and have diabetec
foot ulcer attending to the diabetic foot clinic and willing to participate and giving written consent.
Exclusion criteria :
1: Grade 0 ulcer, pre or post ulcerative lesion that has healed.
2:patients already on anti microbial treatment.
All patients in our study were subjected to careful history taking, full examination including systemic and local examination for the ulcer, laboratory investigations ( cbc, urea and creatinine, fasting and pp blood sugar, lipid profile, CRP, ESR, A/C ratio) and culture and sensitivity from the wound.
The age of diabetic patients ranged from 27 to 85 years with mean of 55.8 years, while the mean age of non-diabetic patients was 46.4 year. More than half of diabetic patients was males 34 (63%) and in non- diabetic patients, male: female ratio was 1:1.
The aim of the study to assess the risk factors for diabetic foot ulcer, culture and sensitivity from the Wound to assess the appropriate antibiotics and assessment of multi drug resistant organisms.
Among the diabetic patients, 11 (20.4%) had type I diabetes mellitus and 43 (79.6%) had type II diabetes mellites. The mean duration of diabetes was 12.8 years. More than half of diabetic patients 3 (61.1 %) were on insulin while 27.8% were taking oral hypoglycemics.
The associated comorbidities found that 25.9% had hypertension, 92.6 had neuropathy, 3.3% had nephropathy and 29.6% had retinopathy. The associated comorbidities were significantly associated with diabetic patients compared to non-diabetics. There was no difference in percentage pf smokers between diabetic and non- diabetics.
Foot deformity occurred in 38.9% of diabetic patients while no deformity was found among non- diabetics (p= 0.001). The most frequent foot deformity among diabetic patients were high arched foot (11.1%), rocker bottom (11.1) then hammer toe (9.3%) and charcot foot (3.7%).
Approximately one fourth (25.9%) of diabetic patients had amputations. The amputation level was big toe in 50% of patients with amputation and below knee in 21.4%.
In comparison with non-diabetics, diabetic patients had higher ESR in the first and second hour (40.4±13.9 and 87.2±22 vs 32.5±10.6 and 68.7±24 respectively).
Regarding lipid profile, diabetic patients had higher total cholesterol and LDL than non-diabetics while there was no significant difference between the two groups regarding HDL.
Comparing patients infected with MDROs with patients infected with NMDROs among diabetic patients, it was found that CRP was higher in patients infected with MDROs 73.3±33.9 compared to 44.7±26.5 in patients infected with NMDROs (p= 0.020).
Regarding kidney function test, the mean creatinine was 1.4±0.9 (mg/dl) in diabetics and that was significantly higher than creatinine in non-diabetics (1 mg/dl) (p= 0.035).
Gram positive organism were isolated from 61.1% of diabetic foot ulcer while 33.3% were gram negative. Isolates were Staph aurous, 14.8% coagulase-negative staph, 11.1% for each of streptococci,pseudomonas and Klebsiella (MDRD); 5.6% for Klebsiella (ESBL) and E-coli.
Among non-diabetics the isolates were 60% staph aurous, 10% for each of pseudomonas, klebsiella (ESBL) and E-coli. While 5.6% of diabetics and 10% of non-diabetics were negative culture.
Staph aureus isolated from diabetic ulcers were sensitive to imipenem (100%), vancomycin (100%), Amikacin (94.7%), doxycycline, levofloxacin and Piperacillin/Tazobactam (84.2%). Coagulase-negative staphylococci (CoNS) were sensitive to Imipenem (100%), vancomycin (100%), Piperacillin/Tazobactam (100%), and Doxycycline (87.5%). Streptococci was sensitive to most of antibiotics except to nitrofurantoin, ceftazidime, ceftriaxone and cefoxitin. All gram-positive isolates were susceptible to imipenem and vancomycin (100%). Amoxicillin resistance was found in 100% staph aureus and CoNs.
Patients infected with MDROs were more likely to have history of previous ulcer (100%) compared to Patients infected with NMDROs (p <0.001). All patients infected with MDROs had diabetic foot ulcer of grade V, while most of patients infected with NMDROs had diabetic foot ulcer of grade III (71.1%) with statistically significant difference (p <0.001).
Staph aureus was found in 19 (46.3%) of diabetic foot ulcers of duration less than one month while Pseudomonas and Klebsiella (MDRO ) were found most frequently (46.2%) in ulcers more than one month and this result was statistically significant.
We recommend the following:
1. Educating The Patient, Family And Healthcare Providers about risk factors and prevention of diabetic foot ulceration
2. Ensuring Routine Wearing Of Appropriate Footwear
3. Treating Risk Factors For Ulceration: Pre-ulcerative signs on the foot, such as blisters, fissures or hemorrhage appear to be strong Predictors of future ulceration.
4. Tight control of blood sugar hyperlipidemia and blood pressure
5. Once diabetic foot infection start broad spectrum antibiotics before culture and sensitivity
6. from the wound, then change to the antibiotics according to the culture.
7. Staph aureus is the most common organism isolated from diabetic foot ulcer
8. Vancomycin. Amikacin and imipenem have broad spectrum activity against Gram positive and gram negative organisms.
9. MDRO associated with previous ulcer and previously treated ulcer with antibiotics and Duration of ulcer more than one month.