title: High burden of diabetic foot infections in the top end of Australia: An emerging health crisis (DEFINE study).
abstract: BACKGROUND
  The risk of diabetes mellitus is increasing worldwide, and is particularly high in Indigenous Australians. Complicated foot infection is one of the most common sequelae of diabetes. We describe the incidence and associations of Indigenous and non-Indigenous inpatients with diabetic foot infections at Royal Darwin Hospital.
  
  
  METHODS
  All adult Royal Darwin Hospital inpatients with diabetic foot infections were enrolled prospectively from September 2012 to November 2013. Incidence, demographics, microbiology, management and clinical outcomes were analysed by Indigenous status, and association with methicillin resistant Staphylococcus aureus and Pseudomonas aeruginosa.
  
  
  RESULTS
  There were 245 separate hospital admissions in 177 patients with an incidence of 79 admissions per 100,000 person years. Patients occupied a mean of 19.4 hospital beds each day. Compared to the non-Indigenous population, Indigenous patients had a greater incidence of admission (Rate Ratio (RR)=5.1, [95%CI=3.8, 7.0]), were younger (mean difference of 11.1 years; p<0.001), and more likely to undergo major and minor amputations (RR=4.1 [95%CI=1.6, 10.7], and 6.2 [95%CI=3.5, 11.1] respectively). Non-multiresistant methicillin resistant S. aureus was present in 44.7% of wounds from Indigenous patients versus 20.6% of non-Indigenous patients (Odds Ratio (OR)=3.1, [95%CI=1.5, 6.4]), whereas P. aeruginosa presence was significantly lower (15.8% versus 46.0%; OR=0.22; [95%CI=0.11, 0.45]). Methicillin resistant S. aureus or P. aeruginosa infections were associated with longer antibiotic courses and durations of stay.
  
  
  CONCLUSIONS
  This study highlights a rising burden of diabetic foot infections in the Top End of Australia, with a four-fold increase in bed days since 2002 and an overrepresentation in the Indigenous population.
authors.affiliation: Department of Infectious Diseases, Royal Darwin Hospital, PO Box 41326, Casuarina, Northern Territory, Australia. Electronic address: robert.commons@gmail.com.
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Commons
authors.affiliation: High Risk Foot Service, Royal Darwin Hospital, PO Box 41326, Casuarina, Northern Territory, Australia.
authors.forename: Claire H
authors.initials: CH
authors.lastname: Robinson
authors.affiliation: Division of Surgery, Royal Darwin Hospital, PO Box 41326, Casuarina, Northern Territory, Australia.
authors.forename: David
authors.initials: D
authors.lastname: Gawler
authors.affiliation: Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Northern Territory, Australia.
authors.forename: Joshua S
authors.initials: JS
authors.lastname: Davis
authors.affiliation: Department of Infectious Diseases, Royal Darwin Hospital, PO Box 41326, Casuarina, Northern Territory, Australia; Global and Tropical Health Division, Menzies School of Health Research and Charles Darwin University, PO Box 41096, Casuarina, Northern Territory, Australia; Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, OX3 7LJ, UK.
authors.forename: Ric N
authors.initials: RN
authors.lastname: Price
mesh_terms: D017719:Diabetic Foot / Q000150:complications* / Q000453:epidemiology; D005260:Female; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D015876:Northern Territory / Q000453:epidemiology; D011446:Prospective Studies; D014946:Wound Infection / Q000453:epidemiology* / Q000209:etiology
keywords: Australia; Diabetes mellitus; Diabetic foot infection; Indigenous; Methicillin resistant Staphylococcus aureus; Pseudomonas aeruginosa