June 17, 2010
School of Medicine, Kochi
 

Long hours of hospitalization coupled with fear of amputation? Yes, if ignored, diabetes can be lethal to body parts.
 

“Fifteen percent of patients with diabetes develop lower-extremity ulcers during their lifetimes. Diabetes is the most common cause for non-traumatic amputation of lower extremities.”
 

These facts were presented in Dr. Gopi Chellan’s research paper titled Spectrum and Prevalence of Fungi Infecting Deep Tissues of Lower Limb Wounds in Type 2 Diabetic Patients.
 

The paper was published in the June 2010 issue of the Journal of Clinical Microbiology, an international journal that publishes current research on microbiological aspects of infections and infestations.
 

The paper was based on original research carried out at the Amrita School of Medicine. The study was led by Dr. Gopi, currently pursuing his Ph.D. at the Dept. of Endocrinology, Diabetes and Podiatric Surgery and in association with the Dept of Microbiology.
 

“518 patients, 382 male and 136 female, that were diagnosed with Type 2 diabetes and hospitalized due to infected lower limb wounds were enlisted in the study,” Dr. Gopi explained.
 

“We determined the incidence of fungal infections in patients with diabetic foot wounds. Deep tissue (0.5 cm x 0.5 cm) taken per-operatively from the wound bed was cultured for fungi.”
 

What did the team find?
 

“Fungal prevalence was found in 27.2 % (141/518) of the study population. 79.7% (413/518) of the population had bacterial infection in deep tissue. Mixed fungal and bacterial infections were seen in 21.4% of patients …” Read Complete Abstract »
 

Why was this finding important?
 

“Clinicians and surgeons treating diabetic foot wounds suspect only bacterial infections and treat them with antibacterial agents. They do not routinely send deep tissue from the wound bed for fungal culture and sensitivity.”
 

“We speculate that opportunistic fungi may invade deep into the wounds and contribute to delayed wound healing in some of the diabetic patients who are otherwise immune-compromised compared to non-diabetics.”
 

This study, the first of its kind in the world, assumes greater significance when one considers the fact that among 191 WHO member states, India has the largest number of people living with diabetes.
 

“In the context of delayed wound healing and amputation rates due to diabetic lower-limb wounds (DLWs), it is important to study the pathogenicity of fungi in deep tissues and their possible contribution to delayed wound healing,” the team finally recommended.
 

“The role of antifungal agents in wound management needs to be evaluated further.”
 

 

PAPER ABSTRACT
Five hundred and eighteen (382 male and 136 female) consecutive Type 2 diabetic patients hospitalized due to infected lower limb wounds were enlisted in the study. Deep tissue (approximately 0.5 X 0.5 cm size) taken per-operatively from wound bed was cultured for fungi. Fungal prevalence was found in 27.2 % (141/518) of the study population. Candida parapsilosis (25.5%), Candida tropicalis (22.7%), Trichosporon asahii (12.8%), Candida albicans (10.6%) and Aspergillus species (5.0%) were the most predominant fungal isolates. 17.7% of the fungal isolates were resistant to itraconazole, 6.9% to amphotericin b, 6.9% to voriconazole, 3.9% to fluconazole and 1.5% to flucytosine respectively. 79.7% (413/518) of the population had bacterial infection in deep tissue. The predominant isolates were Enterococcus faecalis (14.1%), Staphylococcus aureus (12.2%) and Pseudomonas aeruginosa (10.8%). Mixed fungal and bacterial infections were seen in 21.4% of patients, while 5.8% had only fungal infection and 58.3% had only bacterial infections. 14.5% had neither bacteria nor fungi in the deep tissue. Patients with higher glycosylated hemoglobin level had significantly more fungal infections. The study revealed that deep-seated fungal infections are high in DLWs. In the context of delayed wound healing and amputation rates due to DLWs, it is important to study the pathogenicity of fungi in deep tissues of DLWs and their possible contribution to delayed wound healing. The role of antifungal agents in wound management needs to be evaluated further.