European Journal of Cardiovascular Medicine

Diabetes mellitus (DM) has emerged as one of the most significant global health challenges of the 21st century, affecting over 400 million individuals worldwide, with projections indicating a rise to 642 million by 2040 [1]. In India alone, over 77 million people are living with diabetes, and this number is expected to escalate dramatically in the coming decades [2,3]. Among the many complications associated with diabetes, diabetic foot ulcers (DFUs) represent one of the most debilitating and costly, contributing to limb loss, reduced quality of life, and increased mortality [4].

The lifetime risk of a diabetic patient developing a foot ulcer is estimated at 15–25% [5]. DFUs are often polymicrobial and complicated by delayed wound healing due to peripheral neuropathy, ischemia, and impaired immunity [6]. Infections are frequent and represent the leading cause of hospital admissions and amputations in diabetic patients [7]. Proper microbiological assessment and antimicrobial therapy are essential for guiding clinical management. However, bacterial flora in DFUs vary significantly by geography, antimicrobial resistance patterns, and patient comorbidities, making empirical treatment often inadequate [8]. Rising prevalence of multidrug-resistant (MDR) organisms, including extended-spectrum β-lactamase (ESBL) producers and carbapenem-resistant strains, further complicates treatment and increases healthcare burden [9]. Understanding the local microbiological profile and its correlation with clinical severity (e.g., Wagner grade), glycemic control, and surgical outcomes is critical for timely intervention and limb salvage. Despite numerous regional studies, data from central India remain limited.

This study was conducted to (i) identify the spectrum of organisms isolated from DFUs, (ii) assess their antimicrobial susceptibility, and (iii) correlate microbiological and clinical parameters with outcomes such as surgical intervention and ulcer healing.

Study Design and Setting

This prospective observational study was conducted in the Department of General Surgery at Rajmata Shrimati Devendra Kumari Singhdeo Government Medical College, Ambikapur, Chhattisgarh, over a period of 12 months from May 2023 to April 2024. The study was approved by the institutional ethics committee, and informed consent was obtained from all participants prior to enrollment.

Study Population

A total of 100 adult patients aged 18–65 years with clinically diagnosed diabetic foot ulcers (DFUs) were included. Patients were recruited from the surgery outpatient department and inpatient wards. Inclusion criteria comprised confirmed cases of diabetes mellitus (type 1 or type 2) presenting with foot ulceration of Wagner grade 2 or above. Patients with non-diabetic ulcers, immunocompromised states unrelated to diabetes, or those unwilling to provide consent were excluded.

Study Objectives

The primary objective of this study was to evaluate the microbiological profile of diabetic foot ulcers and determine the antibiotic sensitivity patterns of the isolated organisms. Secondary objectives included assessing clinical outcomes following management and identifying correlations between microbiological findings, ulcer severity (Wagner grading), glycemic control (HbA1c levels), and surgical interventions.

Clinical Assessment and Data Collection

Detailed demographic information, medical history, and clinical parameters were recorded at baseline. Each ulcer was graded using the Wagner classification system and measured to assess size. Blood samples were obtained to determine HbA1c levels, fasting and postprandial glucose, and other routine investigations.

Wound swabs or deep tissue specimens were collected from the base of the ulcer after appropriate debridement and sent for aerobic bacterial culture and sensitivity testing. Standard microbiological techniques were used for organism identification and antimicrobial susceptibility profiling, following Clinical and Laboratory Standards Institute (CLSI) guidelines.

Treatment and Follow-up

All patients received appropriate medical and surgical management based on wound severity, glycemic status, and microbiological results. Empirical antibiotic therapy was initiated on admission and modified post-culture as necessary. Surgical interventions included wound debridement, minor amputations (toe or forefoot), or major amputations (below-knee or above-knee) as clinically indicated. Patients were followed until ulcer healing or discharge.

Statistical Analysis

Data were compiled using Microsoft Excel and analyzed with SPSS version 25. Descriptive statistics were used to summarize demographic and clinical variables. Categorical variables were expressed as percentages. One-way analysis of variance (ANOVA) was used to assess the relationship between Wagner grades and HbA1c levels. The association between Wagner grade and surgical intervention was evaluated using the chi-square test. A p-value of <0.05 was considered statistically significant.

Patient Demographics and Clinical Characteristics

A total of 100 patients with diabetic foot ulcers were enrolled in this prospective observational study. The majority of patients were male (62%), with females accounting for 38% of the cohort. Most participants (84%) were between 46 and 65 years of age, with a mean age of 54.38 ± 11.61 years. Clinical grading using the Wagner classification revealed that the majority of ulcers were Grade 2 (63%), followed by Grade 3 (22%). More severe grades (Grades 4 and 5) were less common, observed in 8% and 7% of patients, respectively. The distribution of Wagner grades is summarized in Table 1.

Table 1. Distribution of Wagner Grades Among Study Participants (N = 100)

Ulcer Characteristics Before and After Treatment

At the time of enrollment, ulcer size was less than 5 cm in 45% of patients and between 5–10 cm in 50%, while only 5% had ulcers exceeding 10 cm. After three months of treatment, significant wound improvement was observed in most patients. Complete ulcer healing was documented in 5% of cases, while 83% had ulcers reduced to the 2.5–5 cm range. Only 12% had ulcers remaining larger than 5 cm. The size distribution of ulcers before and after treatment is presented in Tables 2a and 2b.

Table 2a. Ulcer Size before Treatment (N = 100)

Table 2b. Ulcer Size after Treatment (N = 100)

Glycemic Control (HbA1c Distribution)

HbA1c levels were used to assess glycemic control among participants. A majority of patients (61.5%) had well-controlled diabetes (HbA1c <7%), while 21.8% had mildly elevated values (7.1–8%). Moderately to poorly controlled diabetes (HbA1c 8.1–10%) was seen in 15.6% of patients, and only 1.07% had severely uncontrolled glycemia (HbA1c >10%). The distribution is summarized in Table 3.

A statistically significant correlation was observed between higher Wagner grades and elevated HbA1c levels (p < 0.05, one-way ANOVA), suggesting that poor glycemic control may be associated with more severe ulceration.

Microbiological Profile of Infected Ulcers

Of the 100 patients included in the study, 82% had culture-positive diabetic foot ulcers. The vast majority (81%) had monomicrobial infections, while only 1% had polymicrobial growth. Gram-negative organisms were more frequently isolated than gram-positive organisms.

Escherichia coli was the most commonly isolated pathogen (26.8%), followed by Pseudomonas aeruginosa and coagulase-negative staphylococci (CONS), both accounting for 17.1% of cases. Other isolates included Klebsiella (12.2%), Proteus (9.8%), Citrobacter (4.9%), Staphylococcus aureus (3.7%), Staphylococcus albus (3.7%), and Acinetobacter (2.4%). The distribution of isolates is shown in Table 4.

Table 4. Microbiological Isolates from Diabetic Foot Ulcer Cultures (N = 100)

Surgical Management and Outcomes

Surgical intervention was required in the majority of patients with diabetic foot ulcers. Debridement was the most frequently performed procedure, carried out in 73% of cases. Minor amputations, including toe or forefoot removal, were required in 22% of patients. Major amputations, such as below-knee (BKA) or above-knee amputations (AKA), were necessary in only 5% of cases.

A statistically significant association was observed between increasing Wagner grade and the need for more

extensive surgical intervention (p = 0.001, chi-square test), indicating that higher ulcer severity is predictive of poor surgical outcomes.

Table 5. Surgical Interventions Performed (N = 100)

This prospective observational study evaluated the clinical, microbiological, and surgical aspects of diabetic foot ulcers (DFUs) in a cohort of 100 adult patients in central India. The findings highlight a predominance of moderate-grade ulcers, a microbiological profile led by gram-negative organisms, and a high rate of debridement with limited major amputations—patterns largely consistent with both national and international literature. Most patients in this study were between 46 and 65 years of age, aligning with other Indian studies that report peak DFU prevalence in middle-aged adults [10]. Male predominance (62%) was also consistent with findings from Gadepalli et al. and Roy et al., who attributed this to greater occupational exposure, delayed health-seeking behaviour, and under-recognition of foot care in men [11,12].

The majority of patients presented with Wagner grade 2 ulcers (63%), a pattern similar to the cohort studied by Shanmugam et al., where grades 2 and 3 accounted for most cases [13]. The severity of ulcers in our study showed a statistically significant correlation with HbA1c levels (p < 0.05), reinforcing the importance of glycemic control in ulcer progression. This correlation supports the work of Siddharth Rai et al., who documented poor glycemic control as a key risk factor for ulcer depth and infection severity [14]. Microbiologically, the study found that 82% of ulcers were culture-positive, with Escherichia coli being the most commonly isolated organism (26.8%), followed by Pseudomonas aeruginosa and coagulase-negative staphylococci (CONS). These findings are consistent with studies from Teku et al. and Venkatesan et al., both of which reported a predominance of gram-negative bacilli in Indian DFU patients [15,16]. However, this differs from Western literature, where gram-positive cocci such as Staphylococcus aureus are often the primary isolates [17]. Antibiotic sensitivity testing revealed high responsiveness to gentamicin, imipenem, and amikacin, while resistance to third-generation cephalosporins and fluoroquinolones was frequent. This matches regional trends reported by Bhaskar et al. and suggests an alarming rise in multidrug-resistant (MDR) organisms, likely driven by widespread empirical antibiotic use and poor compliance [18].

Surgical intervention was common in this study, with 73% of patients undergoing wound debridement and 22% requiring minor amputations. Only 5% required major amputations, a relatively lower rate compared to similar studies by Rajput et al. and Roy et al., where major amputations were performed in up to 10–15% of cases [12,19]. Notably, a strong statistical association was observed between higher Wagner grades and the need for surgical intervention (p = 0.001), emphasizing the clinical utility of ulcer grading in prognostication and planning. Although most patients showed ulcer size reduction with treatment, only 5% achieved complete healing within the study period. This modest healing rate underscores the chronic and multifactorial nature of DFUs, requiring comprehensive management beyond short-term medical and surgical therapy.

This study has several limitations. The sample was drawn from a single tertiary centre, limiting generalizability. Polymicrobial and anaerobic cultures were not systematically pursued, and follow-up was limited to inpatient stay or short-term outpatient visits. Nevertheless, the findings provide valuable insight into the microbiological trends and clinical management of DFUs in central India.

This study highlights the complex and multifactorial nature of diabetic foot ulcers, with most patients presenting at a moderate ulcer grade and with suboptimal glycemic control. The predominance of gram-negative bacterial infections, particularly Escherichia coli, and the high rate of antibiotic resistance underscore the importance of microbiological surveillance and culture-guided therapy in this population.

Timely surgical intervention, especially debridement, remains central to management, with more extensive procedures such as amputation closely correlated with ulcer severity. The observed association between poor glycemic control and advanced Wagner grades reinforces the need for integrated glycemic and wound care strategies.

These findings emphasize the value of early diagnosis, targeted antimicrobial therapy, and aggressive local wound management in reducing complications and limb loss. Future multicentric studies with larger cohorts and long-term follow-up are warranted to further clarify microbial trends and optimize intervention strategies in diabetic foot care.

1.       International Diabetes Federation. IDF Diabetes Atlas, 9th ed. Brussels, Belgium: IDF; 2019.

2.       Teku RF, Karri R. Bacteriological profile and antibiotic sensitivity patterns in diabetic foot ulcer: a retrospective study. Int Surg J. 2023;10(5):1665–9.

3.       Rai S, Thomas R, Giri PA. Prevalence of diabetic foot ulcers and associated risk factors in patients with type 2 diabetes mellitus. Int J Res Med Sci. 2021;9(1):241–6.

4.       Lavery LA, Armstrong DG, Wunderlich RP, Mohler MJ, Wendel CS, Lipsky BA. Risk factors for foot infections in individuals with diabetes. Diabetes Care. 2006;29(6):1288–93.

5.       Boulton AJM, Armstrong DG, Albert SF, Frykberg RG, Hellman R, Kirkman MS, et al. Comprehensive foot examination and risk assessment. Diabetes Care. 2008;31(8):1679–85.

6.       Lipsky BA, Berendt AR, Cornia PB, Pile JC, Peters EJ, Armstrong DG, et al. 2012 IDSA clinical practice guideline for diagnosis and treatment of diabetic foot infections. Clin Infect Dis. 2012;54(12):132–73.

7.       Roy PG, Srinivasan S, Prabhu V, Rajagopal T, Udayabhaskar M, Vignesh K. Clinical profile and outcomes of patients with diabetic foot infections. J Assoc Physicians India. 2017;65(3):17–21.

8.       Gadepalli R, Dhawan B, Sreenivas V, Kapil A, Ammini AC, Chaudhry R. A clinico-microbiological study of diabetic foot ulcers in an Indian tertiary care hospital. Diabetes Care. 2006;29(8):1727–32.

9.       Shanmugam P, Jeya M, Linda S, Selvam M, Rajendran P. Bacteriological profile and antibiotic resistance pattern in diabetic foot ulcer patients. Asian J Pharm Clin Res. 2017;10(12):148–50.

10.    Siddharth Rai, Thomas R, Giri PA. Prevalence of diabetic foot ulcers and associated risk factors. Int J Res Med Sci. 2021;9(1):241–6.

11.    Gadepalli R, Dhawan B, Sreenivas V, et al. Clinico-microbiological study of diabetic foot ulcers. Diabetes Care. 2006;29(8):1727–32.

12.    Roy PG, Srinivasan S, Prabhu V, et al. Clinical profile and outcomes of patients with diabetic foot infections. J Assoc Physicians India. 2017;65(3):17–21.

13.    Shanmugam P, Jeya M, Linda S, et al. Bacteriological profile and resistance pattern in diabetic foot ulcer. Asian J Pharm Clin Res. 2017;10(12):148–50.

14.    Siddharth Rai, Thomas R, Giri PA. Ibid.

15.    Teku RF, Karri R. Bacteriological profile and sensitivity pattern in diabetic foot ulcer. Int Surg J. 2023;10(5):1665–9.

16.    Venkatesan P, Gnanadesigan N, Govindarajan S. Clinical and microbiological study of diabetic foot infections. Int J Res Med Sci. 2015;3(11):3246–9.

17.    Lipsky BA, Berendt AR, Cornia PB, et al. 2012 IDSA guideline on diabetic foot infections. Clin Infect Dis. 2012;54(12):132–73.

18.    Bhaskar H, Veeresh B, Chandanwale A. Antibiogram of diabetic foot ulcer pathogens. J Clin Diagn Res. 2012;6(9):1523–5.

19.    Rajput H, Sharma P, Khatri P, et al. Surgical outcomes in diabetic foot infections. Int J Surg Sci. 2020;4(2):272–6.