title: Changing microbiological profile of pathogenic bacteria in diabetic foot infections: time for a rethink on which empirical therapy to choose?
abstract: OBJECTIVE
  We studied the bacterial aetiology and antibiotic sensitivity pattern of diabetic foot ulcers in India.
  
  
  METHODS
  Records of 447 hospitalised patients between 1991 and 2008 were retrospectively analysed between two time periods (before and after 1999) to compare bacterial aetiology and antimicrobial sensitivity patterns. The first three consecutive cultures from the same wound during treatment were evaluated.
  
  
  RESULTS
  Of 1,632 cultures, 66% were polymicrobial, 23% monomicrobial and 11% sterile. In the monomicrobial group, 14% (n = 228) of cultures were Gram-negative, whereas 9% (n = 147) were Gram-positive. The most common pathogens in the first culture were Pseudomonas aeruginosa (20.1%), Staphylococcus aureus (17.2%) and Escherichia coli (16.3%). Results for the third cultures showed persistence of P. aeruginosa (15.3%) and E. coli (14.2%). Gram-negative isolates dominated over Gram-positive ones (25.3% vs 15.1%, p < 0.05). Antibiotic sensitivity patterns before and after 1999 were: piperacillin-tazobactam 74% vs 66% (p < 0.005), imipenem 77% vs 85% (NS), cefoperazone-sulbactam 47% vs 44% (p < 0.005), amikacin 62% vs 78% (NS), ceftriaxone 41% vs 36% (p < 0.005), amoxicillin-clavulanate 51% vs 43% (p < 0.05) and clindamycin 43% vs 36% (p < 0.005), respectively.
  
  
  CONCLUSIONS
  Unlike in the West, in India Gram-negative bacteria were found to have always been dominant in the wounds of patients with diabetic foot infections. Infection with polymicrobial multidrug-resistant Gram-negative bacilli is common. The policy of empirical antimicrobial therapy at tertiary care needs to be changed.
authors.affiliation: Department of Endocrine Surgery, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.
authors.forename: P
authors.initials: P
authors.lastname: Ramakant
authors.forename: A K
authors.initials: AK
authors.lastname: Verma
authors.forename: R
authors.initials: R
authors.lastname: Misra
authors.forename: K N
authors.initials: KN
authors.lastname: Prasad
authors.forename: G
authors.initials: G
authors.lastname: Chand
authors.forename: A
authors.initials: A
authors.lastname: Mishra
authors.forename: G
authors.initials: G
authors.lastname: Agarwal
authors.forename: A
authors.initials: A
authors.lastname: Agarwal
authors.forename: S K
authors.initials: SK
authors.lastname: Mishra
mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D001419:Bacteria / Q000187:drug effects / Q000472:pathogenicity*; D017719:Diabetic Foot / Q000188:drug therapy* / Q000382:microbiology*; D024901:Drug Resistance, Multiple, Bacterial; D005260:Female; D006801:Humans; D007194:India; D008297:Male; D008826:Microbial Sensitivity Tests; D008875:Middle Aged; D012189:Retrospective Studies
chemical_list: D000900:Anti-Bacterial Agents