Determinants of wound healing in patients hospitalized for diabetic foot ulcer: results from the MEDFUN study

Abstract

Objective. The high amputation rates from diabetic foot ulcer (DFU) in Nigeria and prolonged hospitalization due to poor wound healing is a source of concern. Furthermore, factors that affect wound healing of DFUs have not yet been well studied in Nigeria, whereas knowing these factors could improve DFU outcomes. Therefore, the objective of this study was to determine the factors that are associated with the wound healing in patients hospitalized for DFU.Methods. The Multi-Center Evaluation of Diabetic Foot Ulcer in Nigeria (MEDFUN) was an observational study involving 336 diabetic patients hospitalized for DFU and managed by a multi-disciplinary team until discharge or death. Demographic, clinical, and biochemical characteristics were documented. Test statistics used were chi square, t-test, univariate, and multivariate logistic regression. The study endpoints were ulcer healing, LEA, duration of hospitalization, and mortality. Here we present data on wound healing.Results. The mean ± SD age was 55.9±12.5 years. Univariate predictors of wound healing were ulcer duration more than 1 month prior to hospitalization (p<0.001), peripheral arterial disease (PAD) (p<0.001), foot gangrene (p<0.001), Ulcer grade ≥3 (p=0.002), proteinuria (p=0.005), anemia (p=0.009), renal impairment (p=0.021), glycated hemoglobin ≥7% (0.012), and osteomyelitis (p<0.001). On multivariate regression, osteomyelitis was the strongest independent predictor of wound healing after adjusting for all other variables (OR 0.035; 95% CI 0.004–0.332). This was followed by PAD (OR 0.093; 95% CI 0.028–0.311), ulcer duration >1 month (OR 0.109; 95% CI 0.030–0.395), anemia (OR 0.179; 95% CI 0.056–0.571).Conclusion. Presence of osteomyelitis, duration of ulcer greater than 1 month, PAD, Wagner grade 3 or higher, proteinuria, presence of gangrene, anemia, renal impairment, and HbA1c ≥7% were the significant predictors of wound healing in patients hospitalized for DFU. Early identification and prompt attention to these factors in a diabetic foot wound might significantly improve healing and reduce adverse outcomes such as amputation and death.

Factors Associated with Healing Outcomes in Primary Care Patients with Diabetic Foot Ulcers: A Retrospective Study in a Multiethnic Sample

“…This is consistent with several other studies on DFUs. 15,[27][28][29] The present study also found that fewer ischemic ulcers (18.7%) healed within 3 months compared with neuropathic (41.1%) and neuroischemic ulcers (26.7%). Univariate analysis showed that ischemic and neuroischemic ulcers were negatively associated with healing within 3 months.…”

Diabetic Wound-Healing Science

“…A meta-analysis found that increasing anemia severity was associated with DFU severity and could serve as a predictor of amputation and mortality [ 45 ]. Retrospective cohort studies identified anemia as significantly associated with larger, deeper ulcers, more severe infections, high amputation risk, and increased mortality rates [ 46 , 47 ], while observational studies in Nigeria have found anemia to be associated with poor wound healing, amputation, and increased mortality [ 48 , 49 ]. Conversely, other studies found anemia to be a non-significant predictor of clinical outcome for patients with DFUs [ 50 , 51 , 52 ]; thus, the context under which anemia may be a prognostic factor for DFU wound healing is still debatable and requires further elucidation.…”

“…The increased prevalence of S. aureus colonization of intact diabetic skin and DFUs contributes to the high rate of diabetic foot ulcers infections [ 74 ] and subsequent spread of infection to the bone and bloodstream. In fact, osteomyelitis was identified as a significant predictor of wound healing [ 48 ] and amputation [ 79 ] in a Nigerian multi-center observational study. Unfortunately, systemic antibiotics have limited delivery to chronic wound sites, especially in the presence of a bacterial biofilm, so new therapies have been focused on topical delivery of drugs with varied release mechanisms [ 80 , 81 ].…”

Evolving spectrum of diabetic wound: Mechanistic insights and therapeutic targets

“…A higher prevalence of S. aureus colonization in DFUs and intact diabetic skin lead to systemic infection and osteomyelitis[ 63 ]. Indeed, in a Nigerian observational multi-center study, it was reported that the presence of osteomyelitis is an important predictor of wound healing in hospitalized patients with DFUs[ 68 ]. The expression of proteolytic factors by Streptococcus and Staphylococcus are believed to be the disruptor of skin barrier.…”