Clinical Characteristics and Risk Factor Analysis for Lower-Extremity Amputations in Diabetic Patients With Foot Ulcer Complicated by Necrotizing Fasciitis

Abstract

Patients with diabetes are at a higher risk of having diabetic foot ulcers (DFUs) or necrotizing fasciitis (NF). The present study aims to examine the clinical characteristics and associated risk factors for lower-extremity amputation (LEA) in patients with DFU complicated by NF.We retrospectively reviewed patients treated at a major diabetic foot center in Taiwan between 2009 and 2014. Of the 2265 cases 110 had lower-extremity NF. Limb preservation outcomes were classified as major LEA, minor LEA, or limb-preserved. Clinical characteristics, laboratory data, and bacterial culture results were collected for analysis.Of the 110 patients with NF, 100 had concomitant DFUs (NF with DFU) and the remaining 10 had no DFU (NF without DFU). None of the NF patients without DFU died nor had their leg amputated. Two NF patients with DFU died of complications. The amputation rate in the surviving 98 NF patients with DFU was 72.4% (46.9% minor LEA and 25.5% major LEA). Seventy percent of the NF patients without DFU had monomicrobial infections (60% with Streptococcus species), and 81.4% NF patients with DFU had polymicrobial infections. Anaerobic organisms were identified in 66% of the NF patients with DFU. Multinomial logistic regression analysis revealed an association between high-grade Wagner wound classification (Wagner 4 and Wagner 5) and LEA (adjusted odds ratio [aOR] = 21.856, 95% confidence interval [95% CI] = 1.625–203.947, P = 0.02 and aOR = 20.094, 95% CI = 1.968–205.216, P = 0.01 for major and minor LEA, respectively) for NF patients with DFU. In addition, a lower serum albumin level was associated with major LEA (OR = 0.066, P = 0.002).In summary, once DFUs were complicated by NF, the risk of amputation increased. Empirical treatment for NF patients with DFU should cover polymicrobial infections, including anaerobic organisms. The high-grade wound classification and low serum albumin level were associated with LEA.

Análise dos fatores de risco relacionados às amputações maiores e menores de membros inferiores em hospital terciário

“…It is estimated that necrotizing fasciitis affects up to 4.9% of diabetics, and that the probability of amputation reaches 72.4% in patients who also have plantar ulcers. 25 The same study detected that hypoalbuminemia was a determinant factor for amputation, observing that albumin levels were lower in patients who underwent major amputations than in patients who had minor amputations (2.3 g/dL vs. 2.6 g/dL, p = 0.002) and that high grades on the Wagner Classification (stages 4 and 5) had a stronger association with loss of the limb.…”

Diabetes-related foot disorders among adult Ghanaians

“…Diabetic foot defined as the foot of a diabetic patient with ulceration, infection and destruction of the deep tissues, associated with neurological abnormalities and various degrees of peripheral vascular disease (PVD) in the lower limb [1]. It is associated with both short- and long-term increase in morbidity, mortality and lower limb amputation [2,3]. Besides, management involves significant cost inputs regarding investigations and therapy [4].…”

The relevance of a fast and early diagnosis of necrotizing fasciitis in the Emergency Department: a case report

“…In a recent study 9 authors considered the association between diabetic foot ulcers in DM and NF, leading to lower extremity amputation. Among 2265 diabetic patients analyzed in the period between 2009 and 2014 in Chang Gung Memorial Hospital in Taiwan, 110 (4.9%) had lower extremity NF and DM type 2.…”