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Diabetes mellitus (DM) is one of the most common metabolic disorders, considered as a major health problem increasing globally at an alarming rate. Approximately 425 million people are suffering from DM worldwide (2016). The DM patients are more prone to have associated complications hindering the quality of life, financial burden, comorbidities and even mortality. The cost of diabetic foot complications is much higher than the management of many cancers (Armstrong, Boulton et al. 2017). It is assumed that 148 million of them will once develop DFUs as one of the major complications in their lifetime and around 50% of DFUs are infected (Lazzarini, Pacella et al.
2018). The complications of the DFUs
DFI is clinically defined as an invasion of pathological microorganisms and multiplication in the soft tissue or bone anywhere below the malleoli inducing host inflammatory responses. Approximately 15 to 25 percent of people with diabetes experience foot ulcers with the amputation rate of 10-15 times higher than that of non-diabetic patients. Almost 60% of DFUs are complicated by infection and infection spreading from soft tissue to bone leading to osteomyelitis which is a higher risk of amputation (Singh, Armstrong et al.
2005). Around 84 percent of lower limb amputations have a history of ulceration and half of them only survive for more than 2 years. The patients with diabetic foot diseases (foot ulcers and infection) have reached estimated 5- year mortality rate up to 50%, which is higher than of some cancers; prostate cancer, colon cancer, Hodgkin Lymphoma and breast cancer (Robbins, Strauss et al. 2008). The majority (60–80%) of foot ulcers will heal, while 10–15% of them will remain active and 5–24% of them will finally lead to limb amputation within a period of 6–18 months after the first evaluation (Alexiadou and Doupis 2012).
DFIs are usually poly-microbial often caused by 6 to 7 different specific organisms; aerobic gram-positive cocci like Staphylococcus aureus, gram-negative bacilli (Escherichia coli, Klebsiella pneumonia, Pseudomonas aeruginosa), and anaerobes (Caputo, Cavanagh et al. 1994), (Vagholkar and Shirabhatti. 1994) [Google Scholar], (Delbridge, Appleberg et al. 1983). Many studies from different countries with geographical variation have revealed different DFI-related microbial compositions and drug susceptibilities (Belefquih, Frikh, et al. 2016), (Perim, Borges Jda et al. 2015), (Guira, Tieno et al. 2015) and the ratios of patients associated with multidrug resistance (MDR), methicillin-resistant Staphylococcus (MRS), and extended-spectrum β-lactamase (ESBL) bacterial infections have increased every year, suggesting that administration of empirical anti-infective regimens increasing the chances of treatment failure (Wu, Pan et al. 2018).
A part of culture-proven and different radiographic diagnostic tests available, the assessment of infection by the inflammatory markers (ESR, CRP, PCT, IL-6, WBC, and Neutrophils) have been coming in clinical practice since a long time. Even though the tests of these markers are not regarded as confirmatory diagnostic tests, but will obviously help the clinician in a feasible and economical way to predict level of infection and aid the diagnosis and also useful for deciding whether to start empirical antibiotic therapy. Different studies have shown the role of these inflammatory markers in the evaluation of diabetic foot infections, their severity and their treatment response.
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