Four out of ten uninfected diabetic foot ulcers develop infection

New unique research from Queensland has been published in the journal PLoS One, showing that four out of ten uninfected diabetic foot ulcers develop infection during the first twelve months of treatment. The researchers analyzed long-term data from >850 patients presenting with an uninfected diabetic foot ulcers from the Queensland High Risk Foot Form database. The study is the first-ever worldwide to present such data, and the result of relentless efforts in Queensland to routinely collect the clinical data  and outcomes of their patients with diabetic foot ulcers.

While it is well-known that foot infection is a major predictor of poor health outcomes (such as prolonged healing, hospitalization, amputation and death), this information predominantly comes from studies following patients who presented with an infected foot ulcer. However, we know in clinical practice that many patients present with an uninfected foot ulcer but still develop an infection during the course of treatment. Such infection significantly disrupts the healing of the foot ulcer and changes treatment, and is most unwanted by both patients and clinicians. Despite its clinical importance, the development of these infections in foot ulcers has not been studied before.

The Queensland data now show that 40% of uninfected ulcers become infected before they heal even with a good standard of clinical care: 32% in ulcers that heal within 3 months, and 56% in ulcers that take more than 3 months to heal. The first clinical message is (again) the importance of short healing times. As a clinician, one should try to get ulcers healed as quickly as possible, and patients should be made aware of the importance of quicker healing to help prevent infection and subsequent poor outcomes. However, it is not reported in the study when the infections developed as that information was not available to the researchers. It may be possible that most infections occurred in the first 3 months, and were actually the cause of prolonged healing times, rather than a complication of non-healing ulcers. Despite that, with nearly all foot infections starting in a foot ulcer, shorter healing times can always be expected to reduce the risk of foot infection.

The study also presents interesting findings on risk factors for developing foot infection in patients presenting with an uninfected foot ulcer (such as deep ulcers, previous ulcers, peripheral neuropathy and foot deformities). To do this study justice, I would encourage you to read the paper in full. It’s open access and freely available here. For clinicians everywhere, the paper confirms the importance of continuous infection vigilance, as 40% of your uninfected diabetic foot ulcer patients will develop one during treatment, and the importance of trying everything to speed up healing.

In conclusion, this is the first paper from the Queensland Statewide Diabetes Clinical Network’s High Risk Foot Form database, and it lives up to its expectations. It is a fine example of how valuable the collection of routine clinical data by many clinicians in everyday practice can be to research and in turn back to informing everyday clinical practice. It is hoped that clinicians in Queensland will continue to capture the routine clinical data of their patients and add to this database, for researchers to analyse and further advance our clinical understanding. Lastly, it is hoped that a national database is established soon so all Australian clinicians can collect this valuable clinical data as recommended by Diabetic Foot Australia’s Australian Diabetic Foot Ulcer Minimum Dataset.