Diabetic foot ulcers: a growing global health emergency in the COVID-19 era

A recently published article describes care practice patterns and risk factors in patients hospitalized with diabetic foot ulcers (DFU) at a North American institution. In that institution, DFU is present in 2.4% of hospitalized patients. Over the nearly 2-year study period, patients had an overall mortality of 13% and a 25% incidence rate of limb amputation. High rates of osteomyelitis and readmission were found. Care practices for hospitalized patients with DFU at this center were highly variable. Arterial studies were not frequently requested, despite the recommendations. The physiotherapist was also not frequently consulted despite the prominent role he plays in proper wound healing. Most of the antibiotics were empirically prescribed. Antibiotic prescription occurred in 77% of patients with osteomyelitis and was not based on culture. According to the authors, the prescription rates for anti-MRSA and antipseudomonal antibiotics were probably higher than necessary [1].

The field of diabetes care is changing rapidly as new anti-diabetic treatments emerge; however, chronic diabetes-related complications, especially DFUs, remain a major global public health problem. The latest Diabetes Atlas reports that the global prevalence of diabetes has reached 10.5%, with almost half (44.7%) of adults undiagnosed. Their projections are that by the year 2045, 783 million adults will be living with diabetes, or one in eight adults. This would mean an increase of 46%. This relentless increase in the prevalence of this disease puts a lot of pressure on the health system, making it difficult, in many cases, for people with diabetes to access the information and care they need. One of its most important complications is DFU, which predicts a higher mortality rate [2].

What is the reality of the UPD in the world? In African countries, the prevalence of DFU ranged between 10.0 and 30.0%, and the prevalence of amputations between 3.0 and 35.0%, according to hospital reports. In contrast, in the South East Asia Region, the proportion of people with diabetes who developed DFU was typically less than 15.0% and the proportion who experienced a recurrence was less than 14.0%. In some high-income regions, such as Europe, the prevalence of DFU ranged from 1.0% (Denmark) to 17.0% (Belgium), and recurrence from 7.0% (Germany and Italy in 2012) to 42%. (Italy in 2017). In the United States of America, the frequency of DFU recurrence ranged from 8.0% in 2013 to 52.0% in 2018. In the Middle East and North Africa region, the prevalence of DFU mainly ranged from 5.0 to % and 20.0% [3]. It is estimated that in middle- and high-income countries, up to 50% of patients with diabetes and ulcers have peripheral arterial disease. Many of these cases remain undiagnosed until the patient presents with a significant ulcer due to a lack of history of prior disease, claudication, or rest pain. People with diabetes present peripheral arterial disease more frequently, are usually younger with a multisegmental, bilateral presentation, much more distal, with faster progress and higher risk of amputation [4]. Diabetic foot infection remains the most common complication in diabetic patients requiring hospitalization, often leading to lower extremity amputation. They only heal 46% of ulcers. 10% of these recur, 15% of patients die and 17% require amputation [5].

The evidence base for many aspects of foot ulcer treatment in people with diabetes is weak and good-quality research is needed, especially studies for routine clinical care such as the one discussed [1]. The principles of good standard care include a formal assessment of the ulcer and surrounding skin at each clinical review; the necessary discharge, with a detailed description of the type and an evaluation of its effectiveness; debridement of the wound surface, which can be surgical (either in the clinic or in an operating room) or non-surgical; selection of appropriate care products; appropriate antimicrobial therapy (only for clinically infected wounds); attention to nutrition and self-care; try to achieve optimal glycemic control; evaluation of peripheral arterial disease, with consideration of revascularization when appropriate; and close observation continues with appropriate management adjustment [6]. Successful management of the DFU requires coordination between multidisciplinary specialists to prevent foot amputations and reduce the risk of ulcer recurrence by implementing a holistic approach to address all comorbidities.

Another study in primary care provides ‘real world evidence’, highlighting the consequences of inefficient and inappropriate management of DFUs in clinical practice in the UK. The annual cost attributable to managing these ulcers was estimated to be between £524 and £728 million. The average cost of wound care over 12 months was approximately £7800 per DFU, of which 13% was attributed to amputations. The cost of managing an amputated wound was £16,900 per DFU amputee, but these costs exclude rehabilitation after amputation. Assessment of peripheral perfusion allows for stratification, but only 5% of all patients had an ankle-brachial pressure index (ABPI) or Doppler study recorded within the first 3 months of initial presentation. Of all DFUs, 35% were healed within 12 months and the median healing time was 4.4 months. 48% of the wounds remained unhealed at 12 months and 17% of the wounds led to amputation. 45% of all DFUs were considered at risk of infection or infected at the time of presentation [7]. The problem is out of control. As in many other pathologies, good clinical practice guidelines are prepared but poorly applied [8–10].

An individualized approach to the patient with diabetes is required according to personal preferences with vascular risk assessments at each consultation, assessing the need to suspend medications and considering new interventions [11]. Foot examination of all diabetic patients is recommended annually even in the absence of foot ulceration. When an ulcer does not heal well in a period of four or 6 weeks, it will be advisable to perform an imaging study (Doppler ultrasound, Tomography or MRI). Intensive control of vascular risk should be carried out, giving support for smoking cessation, control of hypertension, glycemia, the use of statins and antiplatelet drugs [12]. To assess suspicion of osteomyelitis of the foot, we must use a combination of bone probe testing, serum inflammatory markers (C-reactive protein, sedimentation rate, or procalcitonin) along with a plain radiograph as the initial test to diagnose osteomyelitis [13, 14]. Hospital care for a person with DFU requires a multidisciplinary team with documentation of the size, depth, and position of the ulcer using a standardized system [15]. Suspicion of diabetic foot infection requires an adequate sample of soft tissue or bone at the base of the wound. Skin samples are not useful. The choice of antibiotic should be based on microbiological results [16]. There is also strong evidence supporting the use of offloading devices in diabetic patients who have developed an ulcer. They prevent mechanical stress on a callous foot from progressing or developing an ulcer [17].

Another basic element of quality is continuity of care, where there are often gaps. When analyzing attendance at the clinic after discharge in patients with DFU, a rate of attendance at the clinic 30 days after discharge was only 53.8%. Interventions are needed to increase posthospital care for the prevention of complications [18]. DFUs not only influence the patient’s quality of life, but also reduce life expectancy. The DFU offers an excellent window into the inadequacies of current diabetes care systems and the global trend of population aging. Despite numerous management guidelines, there appears to be significant deviation from standard care recommendations, reflecting the complex nature of these patients in real world practice. Future interventions should aim at standardization to improve outcomes [1].

We are facing a true public health emergency. Overcoming these barriers requires a paradigm shift from stratified care, to personalized medicine, to get the right treatment for the right patient at the right time [19, 20]. The COVID pandemic in which we are still immersed is further complicating the problem. Many people with DFU can be cared for remotely and/or at home with telemedicine, but people whose lesions have increased in size, or who have moderate to severe ischemia and/or infection, should be cared for face-to-face: the infection should be drained or debrided urgently with adequate vascular evaluation. To guarantee equity, continuity, and homogeneity in access to health quality services for all citizens with diabetic foot, disease management requires strong integration between the hospital and primary care, with socio-health integration and continuity of the entire process [21–23].

Data Availability

This work is a clinical commentary and is not based on clinical or experimental data. This work did not receive specifc funding.

Conflict of Interest

The authors declare that he has no confict of interest.

Human and animal rights statement

This research did not involve humans and/or animals.