Microbiological Characterization of Neuropathic Diabetic Foot Infection: a Retrospective Study at a Portuguese Tertiary Hospital

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Adequate patient management with effective antibiotic therapy is crucial. This retrospective cohort study aimed to characterize the microbiology and resistance patterns of moderate to severe neuropathic diabetic foot infection in patients hospitalized at a tertiary referral hospital between January 2020 and June 2023. Deep tissue specimens from ulcers were collected for culture. Sixty inpatients were included (62% male, mean age 59.1 ± 11.5 years). Osteomyelitis was present in 90% of the patients. Among 102 microorganisms (average of 1.91 ± 1.25 pathogens per patient), 60.8% were gram-positive bacteria, 31.4% were gram-negative, 3.92% were anaerobic bacteria, and 3.92% were fungi. Staphylococcus aureus (19%) and Enterococcus faecium (17%) were the most common. Pseudomonas aeruginosa (8%) and bacteria of the Enterobacterales family (24%) accounted for all the isolated gram-negative bacteria. Sixteen percent of Staphylococcus aureus and 67% of coagulase-negative Staphylococci were resistant to methicillin. Resistance to ampicillin was found in 11% of Enterococci . All Pseudomonas aeruginosa isolates were sensitive to piperacillin-tazobactam, ceftazidime, or cefepime. Among the Enterobacterales , resistance rates were 35% for piperacillin-tazobactam, 35% for ceftazidime, 17% for cefepime, and 13% for carbapenems. Although the prevalence of methicillin-resistant staphylococci was lower than that in other studies, carbapenem resistance among gram-negative bacteria warrants attention. This study highlights the importance of understanding local epidemiology for effective diabetic foot infection management and resistance mitigation. Diabetic foot infection Diabetic foot ulcer Microbiology Epidemiology Antibiotics 1. Introduction Diabetes mellitus (DM) is a significant global health issue that affects approximately 10.5% of the adult population worldwide [ 1 ]. Diabetic foot disease is recognized as one of the most serious complications of DM. The estimated lifetime incidence of diabetic foot ulcers (DFUs) ranges from 15–34% [ 2 – 4 ]. DFUs arise from a complex interplay of risk factors, including diabetic neuropathy and peripheral artery disease. The combination of loss of protective sensitivity, foot deformities, and limited joint mobility leads to abnormal foot loading, thereby increasing the likelihood of ulceration [ 4 ]. Bacterial colonization occurs due to skin breakdown and can lead to infection, facilitated by immunosuppression related to DM [ 3 , 5 ]. DFUs are the most frequent cause of disability among individuals with DM and are the main cause of nontraumatic lower limb amputations. In Portugal, in 2021, 2,445 lower limb amputations were performed in patients with DM [ 6 ], resulting in substantial burdens on healthcare systems in terms of hospitalizations and costs. Additionally, DFUs are associated with a 5-year mortality rate of approximately 50% [ 2 – 4 ]. The management of neuropathic diabetic foot infection (NDFI) requires crucial interventions, including offloading, appropriate antibiotic therapy, debridement surgery, and optimal glycemic control [ 4 ]. Current guidelines recommend collecting specimens for microbiological culture before initiating empiric antibiotic therapy [ 4 ]. The selected antibiotics should effectively target all potential pathogens while minimizing the risk of antibiotic resistance [ 2 , 4 ]. Therefore, knowledge of local microbiological epidemiology is crucial for adjusting empirical antibiotic therapy and improving patient outcomes. The aim of our study was to characterize the microbiological profile and susceptibility pattern of NDFI in patients requiring hospitalization at our centre. 2. Methods 2.1. Study design and participants We performed a retrospective observational study evaluating all patients with moderate to severe NDFI who were hospitalized in the Endocrinology Department of a tertiary hospital in Portugal between January 2020 and June 2023. All patients were treated by the same multidisciplinary team, including Endocrinology, Infectious Diseases and Orthopedics, all of whom had expertise in the treatment of NDFI, following national and international guidelines and recommendations. Peripheral arterial disease was excluded by the Vascular Surgery team. 2.2. Data collection and definitions For clinical characterization, demographic and clinical data were collected from medical records. The analysed parameters included age, sex, type and duration of DM, last hemoglobin A1c (HbA1c) (accepted if collected within the last 3 months), current antidiabetic drugs, presence of microvascular (diabetic peripheral neuropathy, diabetic kidney disease, and diabetic retinopathy) and macrovascular disease (ischemic heart disease, cerebrovascular disease), heart failure, tobacco abuse, and risk factors for multidrug-resistant microorganisms (MDROs). The definitions of microvascular and macrovascular complications were based on the guidelines outlined in the S tandards of Care in Diabetes-2024 [ 7 – 9 ]. The risk factors for MDROs included a history of previous antibiotic therapy or hospitalization within the last three months and undergoing hemodialysis [ 10 ]. DFU was defined as a full-thickness lesion that was present distal to the malleolus [ 4 ]. The severity of the NDFI was assessed using the International Working Group of the Diabetic Foot PEDIS system, which categorizes DFUs into four grades based on perfusion, extension/size, depth/tissue loss, infection, and sensation [ 11 ]. Additionally, for NDFI characterization, we recorded the wound location, analytic parameters (C-reactive protein (CPR) and erythrocyte sedimentation rate (ESR) at admission), and magnetic resonance imaging (MRI) scan findings (including osteomyelitis, abscess, and other relevant observations). Specimens for culture were collected using four methods: blood culture, biopsy from the base of the ulcer, aspiration of purulent exudate, and intraoperative biopsy (proximal and distal bone samples). These procedures were performed under strict aseptic techniques. For biopsy from the base of the ulcer and for aspiration of the purulent exudate, the nursing team performed necrotic tissue debridement, followed by cleaning of the area with a simple saline solution before sampling [ 12 ]. During intraoperative biopsies, tissues were washed with diluted hydrogen peroxide between sample collection, and surgical equipment and materials were replaced [ 4 , 13 ]. In cases where aseptic collection was not possible or when the patient was at risk (due to insupportable pain induction or the risk of ulcer enlargement), we did not collect samples. Minor amputation was defined as being distal to the tarsometatarsal joint (i.e., transphalangeal or transmetatarsal amputation of single or multiple digits), whereas major amputation was defined as being proximal to this joint [ 14 ]. The described surgical procedure represents the most radical intervention carried out (i.e., if a patient underwent a toe amputation and an above-knee amputation, the surgery type considered was major amputation). All microbiological isolates were considered, and their susceptibility test results were analysed. Pathogens isolated from more than one sample were counted only once. If a bacterium was isolated multiple times with different susceptibility profiles, the less favourable profile was considered due to the likelihood of antibiotic resistance development. Considering the frequent use of β-lactams for the treatment of diabetic foot infections, we also attempted to identify which microorganisms exhibit resistance mechanisms to β-lactams, particularly the expression of carbapenemases and AmpC-type and ESBL (extended spectrum β-lactamases) β-lactamases. Succinctly, carbapenemases are members of the molecular class A, B, and D β-lactamases of the Ambler classification and are capable of inactivating most of the β-lactams, including carbapenems. AmpC β-lactamases and ESBL belong to the class C and A of the Ambler classification, respectively, and can inactivate a broad spectrum of β-lactam antibiotics, including penicillins, cephalosporins, and monobactams; however, ESBLs are especially effective against extended-spectrum cephalosporins, such as cefepime [ 15 ]. The clinical microbiology laboratory at our hospital center employs the Matrix-Assisted Laser Desorption/Ionization Time-Of-Flight Mass Spectrometry (MALDI-TOF MS) method for bacterial susceptibility profiling. Based on this profile, agents displaying phenotypic behavior characteristic of carbapenemase or ESBL production are identified. The identification of potentially AmpC-producing strains was performed through a subsequent analysis of susceptibility profiles by the authors. 2.3. Statistical analysis The data analysis was performed from the perspective of admissions and using SPSS Statistics 27® software. Continuous variables with a normal distribution were presented as the mean ± standard deviation (SD), while continuous variables with a nonnormal distribution were expressed as the median and interquartile range (IQR). The normality of the data distribution was examined using skewness and kurtosis, except for the variable 'pack-year', for which we performed the Kolmogorov‒Smirnov test of normality. Categorical variables were displayed as frequencies and percentages. All procedures performed in this study were in accordance with the ethical standards of the institution. 3. Results 3.1. Participants This study enrolled a total of 60 admissions for the NDFI. The mean age of the participants was 59.1 ± 11.5 years, and 37 (61.7%) were males. Most inpatients were diagnosed with type 2 DM (n = 46, 76.7%). The average time since DM diagnosis was 22.5 ± 11.9 years, and the mean HbA1c was 77.0 ± 1.00 mmol/mol. Among them, 40 (66.7%) were receiving insulin treatment, with a median total daily insulin dosage of 0.47 (0.00–0.92) UI/Kg. Diabetic retinopathy (n = 38, 64.4%) and diabetic kidney disease (n = 36, 60.0%) were the most common complications. In 41 (68.3%) patients, at least one risk factor for MDROs was identified. The remaining clinical characteristics are provided in Table 1 . Table 1 – Demographics and clinical characteristics of NDFIs hospitalization (n = 60) in total of 48 patients. Age (years) 59.1 ± 11.5 Gender - n (%) Male 37 (61.7) Female 23 (38.3) Diabetes mellitus – n (%) Type 1 9 (15.0) Type 2 46 (76.7) Others (Post-transplant diabetes mellitus, MODY, steroid-induced diabetes) 5 (8.30) Time since diabetes diagnosis (years) a 22.5 ± 11.9 HbA1c (mmol/mol) b 77.0 ± 1.00 On insulin treatment – n (%) 40 (66.7) TDI (UI/Kg) b 0.47 (0.00–0.92) On oral or injectable antidiabetics – n (%) Metformin 28 (46.7) SGLT2i 21 (35.0) DDP4 inhibitors 15 (25.0) GLP-1 agonist 12 (20.0) Sulphonylureas 6 (10.0) Thiazolidinediones 1 (1.70) Diabetic kidney disease – n (%) 36 (60.0) End-stage kidney disease – n (%) 7 (19.4) Diabetic retinopathy – n (%) c 38 (64.4) Diabetic peripheral neuropathy – n (%) 60 (100) Ischemic heart disease – n (%) 6 (10.0) Cerebrovascular disease – n (%) 10 (16.7) Heart failure – n (%) 9 (15.0) Active or past tobacco abuse – n (%) d 33 (68.9) Pack-year f 25.0 (-18–68) Risk factors for MDROs – n (%) 41 (68.3) Previous antibiotic therapy and/or hospitalization in last three months 38 (63.3) Haemodialysis 3 (5.00) MODY: Maturity−Onset Diabetes of the Young. HbA1c: Hemoglobin A1C. TDI: total daily insulin. SGLT−2i: Sodium− glucose transport protein 2 inhibitors. GLP−1: Glucagon−like peptide−1 receptor. DPP−4: Dipeptidyl Peptidase. MDROs: multidrug−resistant microorganisms. a missing: 3 (5.00%); b missing: 1 (2.50%); c missing: 1 (1.67%); d missing: 12 (20.0%); f missing: 6 (18.2%). 3.2. Diabetic foot ulcers Of the diabetic foot ulcers (DFUs), 37 (61.7%) were categorized as PEDIS 3, while 23 (38.3%) were classified as PEDIS 4. Upon admission, inpatients displayed elevated inflammatory parameters, with a mean CPR of 122.7 ± 88.4 mg/L and a mean ESR of 79.0 ± 29.4 mm/hr. Osteomyelitis was diagnosed in 54 (90.0%) of the inpatients. Abscesses were present in 27 (45.0%) patients, and septic arthritis was diagnosed in 6 (10.0%) patients based on MRI scans. Surgical debridement was performed in 49 (81.7%) inpatients, and the overall amputation rate was 50.0%, with 43.3% of patients having minor amputations and 6.67% having major amputations. Further details can be found in Table 2 . Table 2 – Clinical characterization of ulcers in NDFIs and surgical management. PEDIS classification – n (%) PEDIS 3 37 (61.7) PEDIS 4 23 (38.3) Location of ulcer – n (%) a Toe or interdigital space 33 (55.0) Plantar surface 17 (25.8) Dorsal surface 3 (4.50) Borders of foot 4 (6.10) Hindfoot 7 (10.6) Ankle 1 (1.50) Extension to the leg or thigh 1 (1.50) C-protein reactive (mg/L) 122.7 ± 88.4 Erythrocyte sedimentation rate (mm/hr) b 79.0 ± 29.4 MRI scan findings – n (%) Osteomyelitis 54 (90.0) Abscess 27 (45.0) Brodi abscess 1 (1.70) Septic arthritis 6 (10.0) Chronic Charcot foot 4 (6.67) Surgery – n (%) Non-surgical debridement 11 (18.3) Surgical debridement 14 (23.3) Surgical debridement and ostectomy 5 (8.30) Minor amputation 26 (43.3) Major amputation 4 (6.67) Time until surgery (days) 10.0 (1.00–19.00) Surgical reintervention – n (%) c 17 (34.7) Postoperative complication or repeat surgical site infection control– n (%) 8 (47.1) According to the PEDIS system, in Grade 3, ulcers have an area of more than 1 to 3 cm2, involving deeper tissues such as muscle, fascia, or tendon, without the presence of systemic inflammatory response syndrome (SIRS). Patients with grade 4 disease exhibit SIRS [11]. MRI: Magnetic resonance imaging. a In six (10.0%) patients, there was more than one location of ulcer. b missing: 7 (11.7%). c Other reasons for surgical reintervention included two−stage procedures and vascular or plastic surgery. Four (8.89%) patients underwent more than 2 procedures. 3.2. Microbiology Tissue specimens for microbial analysis were collected from 90.0% of the individuals. An absence of microbial growth was observed in 7 patients (11.7%). Table 3 provides further details on the etiological characteristics of the positive cultures. Biopsies from the base of the ulcer were the most successful at isolating at least one pathogen, achieving a success rate of 96%. However, most pathogens (n = 64, 62.7%) were isolated from intraoperative biopsies, followed by biopsies from the base of the ulcer (n = 40, 39.2%) and aspiration of purulent exudate (n = 15, 14.7%). Bacteraemia was found in one patient (1.67%). Table 3 Characteristics of positive cultures (n = 80). Percentage of patients who had a positive culture out of the total number of patients from whom sample could be collected– n (%) Blood Biopsy from the ulcer base Aspiration of purulent exudate 1 24 10 (1.70) (96.0) (90.9) Intraoperative biopsy – distal bone samples a Intraoperative biopsy – proximal bone samples 38 6 (79.2) (60.0) Number of pathogens isolated in each sample – n (%) b Biopsy from the ulcer base 40 (39.2) Aspiration of purulent exudate 15 (14.7) Intraoperative biopsy – distal samples to amputation 1 64 (62.7) Intraoperative biopsy – proximal samples to amputation 7 (6.86) Polymicrobial infection – n (%) c 32 (53.3) Of the total number of individuals, tissue samples could not be collected in 6 patients (10.0%), and blood cultures were not collected in 8 patients (13.3%). Additionally, in 7 individuals (11.7%), no pathogens were isolated. a Includes samples collected intraoperatively when no amputation was performed. b One hundred and five distinct pathogens were isolated, among which 21 were found in more than one sample, and three bacteria appeared to have developed resistance in response to antibiotic pressure. c missing: 13 (21.7%). A total of 102 pathogens were isolated, resulting in an average of 1.91 ± 1.25 organisms per admission when tissue specimens were collected for microbiology culture. Polymicrobial infection was detected in 32 (53.3%) individuals. The prevalence of the isolated pathogens and their susceptibility profiles are described in Tables 4 and 5 , respectively. Among the total isolates, four (3.92%) were fungi, specifically Candida spp. Gram-positive bacteria accounted for 62 (60.8%) of the isolates, gram-negative bacilli were identified in 32 (31.4%) of the isolates, and anaerobic bacteria were identified in four (3.92%). Staphylococcus aureus (n = 19, 18.6%) was the most frequently identified pathogen, followed by Enterococcus faecalis (n = 17, 16.7%) and coagulase-negative Staphylococci (n = 14, 13.7%). Among the gram-negative bacteria, Pseudomonas aeruginosa was the most prevalent, with eight (7.84%) isolates. Twenty-four (23.5%) bacteria were isolated from the Enterobacterales family, with Enterobacter cloacae (n = 7, 6.86%) being the most frequently isolated agent. Table 4 Pathogens isolated from inpatients with NDFIs (n = 102). Pathogen Frequency – n (%) Gram-positive aerobic bacteria 62 (60.8) Staphylococcus aureus a 19 (18.6) Enterococcus faecalis 17 (16.7) Coagulase-Negative Staphylococcus b 14 (13.7) β hemolytic Streptococcus c 8 (7.84) Corynebacterium spp. d 2 (1.96) Enterococcus faecium 2 (1.96) Gram-negative aerobic bacteria 32 (31.4) Pseudomonas aeruginosa 8 (7.84) Enterobacterales 24 (23.5) Enterobacter cloacae 7 (6.86) Klebsiella pneumoniae 6 (5.88) Proteus mirabilis 5 (4.90) Morganella morganii 2 (1.96) Escherichia coli 2 (1.96) Providencia rettgeri 1 (0.98) Serratia marcescens 1 (0.98) Anaerobic bacteria e 4 (3.92) Fungi 4 (3.92) Candida parapsilosis 3 (2.94) Candida albicans 1 (0.98) a In the case of bacteremia, a single strain of Staphylococcus aureus was isolated. b Included Staphylococcus capitis, Staphylococcus epidermidis, Staphylococcus haemolyticus, Staphylococcus lentus, and Staphylococcus hominis. c Including Streptococcus agalactiae, Streptococcus anginosus¸ and Streptococcus constellatus. d Including Corynebacterium tuberculostearicum and Corynebacterium jeikeium. e Included Fusobacterium varium, Bacteroides fragilis, Gardanella vaginallis, and Actinobaculum schaalii. MDROs: multidrug-resistant microorganisms. 3.4. Susceptibility pattern Three (15.8%) Staphylococcus aureus and eight (66.7%) coagulase-negative Staphylococci isolates were methicillin resistant (MRSA). The susceptibility of these agents to methicillin was inferred by their susceptibility to oxacillin. Among the patients from whom methicillin-resistant Staphylococcus spp. were isolated, two (18.2%) had no risk factors for MDROs (such as a history of previous antibiotic therapy or hospitalization within the last three months and who were undergoing hemodialysis). Resistance to clindamycin was identified in seven (36.8%) Staphylococcus aureus isolates and 2 (16.7%) coagulase-negative Staphylococci isolates. Furthermore, two (10.5%) Enterococcus spp. were ampicillin resistant, both of which were sensitive to vancomycin. Additionally, both patients exhibited risk factors for MDROs. None of the isolated strains of Pseudomonas aeruginosa were resistant to piperacillin-tazobactam, ceftazidime or cefepime. Among the Pseudomonas aeruginosa isolates, one (12.5%) was resistant to carbapenems. Among the Enterobacterales isolates, 17 (85.0%) were resistant to amoxicillin/clavulanic acid, eight (34.8%) were resistant to ceftazidime, eight (34.8%) were resistant to piperacillin-tazobactam, four (17.4%) were resistant to cefepime, and three (13.0%) were resistant to carbapenems. Extended-spectrum β-lactamases (ESBL), Klebsiella pneumoniae carbapenemases (KPC), and AmpC β-lactamases were found in one (4.17%), four (16.7%), and four (17.4%) of the isolated Enterobacterales , respectively. These bacteria were isolated from patients who displayed risk factors for MDROs. Table 5 Pathogen resistance profile. A. Gram-positive aerobic bacteria Resistance – n (%) Staphylococcus spp. Enterococcus spp. Staphylococus aureus Coagulase-Negative Staphylococus a Ampicillin - - 2 (10.5) Oxacillin 3 (15.8) 8 (66.7) - Clindamycin 7 (36.8) 2 (16.7) - Tetracycline 3 (15.8) 4 (33.3) - Co-trimoxazole 1 (5.26) 4 (33.3) - Vancomycin - - - 0 (0.00) B. Gram-negative aerobic bacteria Resistance – n (%) Pseudomonas aeruginosa b Enterobacterales c Amoxicillin clavulanic acid - 17 (85.0) Ceftazidime 0 (0.00) 8 (34.8) Cefepime 0 (0.00) 4 (17.4) Aztreonam 0 (0.00) - Imipenem / meropenem 1 (12.5) 3 (13.0) Piperacillin tazobactam 0 (0.00) 8 (34.8) Quinolones 1 (14.3) 5 (20.8) Co-trimoxazole - 7 (30.4) ESBL 0 (0.00) 1 (4.17) KPC 0 (0.00) 4 (16.7) AmpC β-lactamases - 4 (17.4) ESBL: extended−spectrum β−lactamases; KPC: Klebsiella pneumoniae carbapenemases. a missing: oxacillin, clindamycin, tetracycline, co−trimoxazole – 2 (14.3%). b missing: cefepime, imipenem/meropenem – 4 (50.0%), quinolones – 1 (12.5%). c missing: amoxicillin clavulanic acid − 4 (16.7%), ceftazidime, cefepime, imipenem/meropenem, piperacillin tazobactam, co−trimoxazole, ESBL, AmpC β−lactamases – 1 (4.20%). 4. Discussion This study investigated the microbiology of NDFI and detailed and essential data pertaining to the etiological pathogens responsible for NDFI and their corresponding susceptibility profiles in our population. This pivotal prevalence study contributes to the understanding of local epidemiology and provides guidance for empirical antibiotic therapy in NDFI patients. The sociodemographic and clinical data related to DM in our population overlapped with previous national and international studies [ 5 , 16 – 19 ], showing that NDFI is more prevalent in men and tends to affect professionally active individuals. In our cohort, the prevalence of ischemic heart disease [ 5 , 16 , 19 ] was lower, as expected given our focus on the NDFI. The high prevalence of both microvascular and macrovascular diseases reflects poor diabetes control and prolonged disease duration [ 20 , 21 ], contributing to increased immunosuppression and compromised wound healing [ 3 , 4 ]. Our findings underscore the severity of NDFI within our patient population, with 38.3% of cases displaying systemic repercussions according to the PEDIS classification. Furthermore, elevated inflammatory parameters, namely, osteomyelitis, abscess, and septic arthritis, were present in 90.0%, 46.7%, and 10.0% of the patients, respectively, underscoring the strength of the situation. These findings highlight a greater prevalence of bone involvement in this study than in other studies (50–65%) [ 3 , 5 , 17 , 22 , 23 ]. MRI, the most sensitive modality (95.6%) and more specific than plain radiography used in other reports (80.7% vs. 68.0%) [ 3 ], was employed for osteomyelitis diagnosis in our study. In contrast to previous studies [ 5 , 16 , 17 , 24 – 26 ], this research exclusively relied on deep tissue and bone sampling techniques for microbiological diagnosis. Tissue specimens are considered the gold standard [ 4 ], offering greater sensitivity and specificity in causative pathogen identification while excluding colonizers or contaminants [ 4 , 27 ]. Although most pathogens were isolated from intraoperative biopsies, the proportion of positive cultures was lower than that of preoperative samples. This difference may be attributed to the initiation of empirical antibiotic therapy prior to surgery in some patients, owing to the severity of the NDFI and the extended period until surgery. This approach could hinder pathogen identification. Importantly, among the collected proximal bone samples, 60% yielded positive cultures, indicating persistent bone infection after amputation. Although findings on this matter remain controversial, this persistence might correlate with poorer outcomes, including postoperative complications and readmissions [ 4 , 28 ]. It is crucial to acknowledge that not every identified agent may have an active role as a potential pathogen, especially for coagulase-negative Staphylococcus , β-hemolytic Streptococcus , and Corynebacterium spp ., which are known skin commensals [ 14 ]. Furthermore, Gardenerella vaginalis was identified as a contamination case. Nevertheless, the collection of all specimens from deep tissues under aseptic conditions reinforced our confidence that the isolates were true pathogens. Aerobic gram-positive cocci usually lead to monomicrobial infections in acute, untreated cases, while polymicrobial infections commonly involve gram-positive cocci , Enterobacterales , Pseudomonas , and anaerobes, especially in chronic or deep wounds [ 16 , 17 , 27 , 28 ]. Enterococcus spp. are considered commensal but assume pathogenic roles in patients with diabetes, especially chronic ulcers [ 5 ]. Although a correlation between prior antibiotic exposure and isolated microorganisms could not be established due to differences in the number of participants, our clinical practice suggests the predominant isolation of gram-negative bacilli in MDRO-risk patients. Similarly, with other studies, the prevalence of anaerobes might be underestimated due to challenges in isolation by routine clinical microbiology laboratories [ 26 ]. Our findings are in line with previously reported results [ 5 , 16 – 19 , 24 – 26 ], where gram-positive bacteria prevailed. A recent review analysed the global epidemiology of diabetic foot infection, and Staphylococcus aureus remained the most common pathogen (11–46%), particularly in Western countries [ 22 ]. The incidence of gram-negative bacteria has surged, especially in Asia, and gram-negative bacteria are becoming the most frequently isolated pathogen. The worldwide prevalence of Pseudomonas aeruginosa ranges from 10 to 26.6% [ 22 ]. Two additional bacterial surveys were conducted in Portugal, where Staphylococcus aureus prevailed (19.7–21.8%) [ 5 , 16 ]. In the most recent study, a significant proportion of the isolates were gram-negative bacteria (48.9%), particularly from the Enterobacterales family (30.6%) [ 16 ]. Our study contrasts with these reports, which revealed a greater prevalence of coagulase-negative Staphylococcus (4.37%), whereas certain gram-negative bacteria, such as Pseudomonas aeruginosa (13.7%), were more common [ 16 ]. The incidences of Enterococcus spp. (8.84%), β-hemolytic Streptococcus (4.08%), and Enterobacterales (10.9%) were lower, while the incidence of Corynebacterium spp. (8.16%) was higher in another survey [ 5 ]. Compared with both international and national data, our observed MRSA prevalence was lower (15.8%). National surveys reported MRSA proportions ranging from 41.7 to 53.1% [ 5 , 16 ], while recent European surveys reported MRSA proportions ranging from 24.7–27.1% [ 17 , 29 ]. Globally, the incidence of MRSA has been steadily increasing and ranges from 16–44% [ 18 ]. Limited information exists on coagulase-negative Staphylococci methicillin resistance, but our survey indicated a significant rate (66.7%). This rate remained below that of a middle-income country (91.8%) [ 18 ], exceeding that of another high-income country (55.4%) [ 30 ], and that of a national survey (27.2%) [ 5 ]. Enterococcus spp . displayed notable susceptibility to ampicillin (10.5%), which is consistent with other international reports (2.00–17.4%) [ 18 , 30 , 31 ] and is attributed to the minority of Enterococcus faecium isolates [ 18 ]. A Portuguese study reported increased ampicillin resistance (33.3%) [ 32 ]. Notably, no vancomycin-resistant Enterococcus (VRE) strains were detected. The prevalence of VRE among Enterococcus spp . ranges from 0.00–7.69% [ 5 , 16 , 17 , 29 – 33 ] in previous reports. These disparities can be attributed to several factors: in several studies, peripheral arterial disease was identified as a risk factor for MDROs [ 22 ]. This study analysed the microbiology of NDFI. Additionally, other national studies occurred in reference centres where most complex cases are transferred, likely presenting identified risk factors for MDROs, such as previous hospitalization, amputation, and antibiotic exposure [ 22 , 34 ]. National data predate 2018; in recent years, the incidence of MRSA has been declining due to the implementation of hospital infection control measures [ 34 ]. In our centre, we only used empirical broad-spectrum antibiotics in patients with risk factors for MDROs. This approach to antibiotic use may contribute to a lower prevalence of resistance [ 5 , 16 ]. Regarding gram-negative bacterial susceptibility, our study revealed a favourable profile, particularly concerning fluoroquinolone resistance. This rate was lower than that reported in most international and national studies ( Pseudomonas aeruginosa : 14.3% vs. 18.2–57.3% [ 16 – 18 , 22 , 29 , 33 ]; Enterobacterales : 20.8% vs. 40.0–50.0% [ 18 , 22 , 29 ]). This divergence might stem from global fluoroquinolone overuse in recent decades, despite declining prescriptions in last years [ 35 ]. Our centre avoids fluoroquinolones for empirical therapy in both outpatient and inpatient settings. The imipenem or meropenem resistance rates ( Pseudomonas aeruginosa : 25.0%; Enterobacterales : 20.8%) were concerning. The prevalence of Pseudomonas was similar to that in other southern European countries (9.1–23.5%) [ 29 , 33 ] but greater than that in northern European countries (5.4%) [ 15 ]. In Asia, resistance rates are as high as 55% [ 20 , 35 ]. Enterobacterales rates approach those reported in Asia (13.4–16.5%) [ 20 , 27 , 36 , 37 ]. In other Western countries, the resistance rate was substantially lower (1.73–7.5%) [ 29 , 30 , 33 ]. Our ESBL prevalence matches that of national studies (4.17% vs. 2.40-6,25% [ 5 , 16 ]); however, it was lower than that of other European reports (20.0-29.8% [ 29 , 36 ]). Conversely, our lower KPC incidence aligns with the findings of national and European studies (16.7% vs. 1.79-5.00% [ 16 , 29 ]). Additionally, the prevalence of ESBL, KPC and AmpC β-lactamases in our study was considerably lower than that in Asiatic series, reaching 50.0% [ 22 , 37 ]. Our study has limitations that must be acknowledged. First, due to its retrospective nature, some crucial data, including the duration and regimen of antibiotic therapy before admission, were missing from medical records. Information about previous instances of NDFI, hospitalizations for NDFI, amputations, the healthcare setting before admission (community or hospital), adverse events during hospitalization, and outcomes after discharge was not available. MRI is valuable for detecting osteomyelitis, yet histological and microbiological methods are the gold standard. Even though our samples were collected from deep tissues, it is important to note that the assumption that all isolated pathogens were causative agents of NDFI might not be entirely accurate, as previously mentioned. Specimen collection before empirical antibiotic therapy is ideal. Our study's strength lies in the comprehensive description of resistance profiles among NDFI pathogens. To our knowledge, this is the most detailed study conducted in Portugal, offering important insights. All cultures were obtained through purulent aspiration and deep tissue or bone biopsies under aseptic techniques, reducing contamination risk and clarifying the causative pathogens of NDFI. Given the variations in epidemiology among different centers, understanding the local epidemiology and resistance pattern is crucial for tailored empirical antibiotic therapy protocols. Our findings suggest considering a higher dose of amoxicillin-clavulanic acid for empirical antibiotic therapy in patients without risk factors for MDROs. This selection, which offers effective bone penetration [ 38 ] and coverage against gram-positive aerobes and anaerobes, could be crucial. However, it may fail to cover gram-negative bacteria. For patients with risk factors for MDROs, we suggest vancomycin along with piperacillin tazobactam or ceftazidime. This combination would provide coverage against MRSA, coagulase-negative methicillin-resistant Staphylococcus , and gram-negative bacteria. Nonetheless, it is important to note that approximately 34.8% of the Enterobacterales were not covered, underscoring the necessity of obtaining specimens as early as possible for guiding antibiotic therapy decisions. In conclusion, local microbiology analysis proves invaluable in establishing antimicrobial stewardship practices and selecting empiric antibiotic therapy critical for managing severe infections with the potential for amputation and disability, particularly among working individuals. Timely and appropriate interventions have the potential to enhance quality of life and reduce morbidity and mortality in affected individuals. Hence, continued vigilance in this domain is imperative for improving outcomes in managing NDFI. Abbreviations DM Diabetes mellitu s DFU diabetic foot ulcer NDFI neuropathic diabetic foot infection HbA1c hemoglobin A1c MDROs multidrug-resistant microorganisms SIRS Systemic inflammatory response syndrome CPR C-reactive protein ESR erythrocyte sedimentation rate MRI Magnetic resonance imaging ESBL Extended-spectrum β-lactamases MALDI-TOF MS Matrix-assisted Laser Desorption/Ionization Time-of-Flight Mass Spectrometry SD standard deviation IQR interquartile range MRSA Methicillin-resistant Staphylococcus aureus KPC Klebsiella pneumoniae carbapenemases VRE Vancomycin-resistant Enterococcus Declarations Ethics approval and consent to participate : This study was performed in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the ethics committee of Unidade Local de Saúde de São João (CES 330/23). For this type of study (retrospective and observational), formal consent was not needed. Consent for publication: Not applicable. Availability of data and materials: The dataset for this study is available from the corresponding author upon reasonable request and ethical approval. Competing interests: The authors declare that they have no competing interests. Funding: No funds, grants, or other support was received. Authors’ contributions: Conceptualization, J.G. and A.G.; methodology, J.G. and A.G.; software, J.G. and A.G.; validation, J.P. N.N., R.S.S. L.S. and J.Q.; formal analysis, J.G. and A.G.; investigation, J.G., A.G., H.U.F., S.R., T.M., M.B.C., I.M., P.F., N.F., R.S.S.; data curation, J.G. and A.G.; writing original draft preparation, J.G. and A.G.; writing, review and editing, M.B.C., F.S., J.P., N.N., R.S.S., L.S. and J.Q.; visualization, all authors; supervision, J.P., N.N., L.S. and J.Q. All authors have read and agreed to the published version of the manuscript. J.G. and A.G. are considered co-first authors and contributed equally to this work. Acknowledgements: Not applicable References Sun H, et al. Diabetes Atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diabetes Res Clin Pract. 2022;183:109119. Ibrahim A. IDF Clinical Practice Recommendation on the Diabetic Foot: A guide for healthcare professionals. Diabetes Res Clin Pract. 2017;127:285–7. Mponponsuo K, Sibbald RG, Somayaji R. A Comprehensive Review of the Pathogenesis, Diagnosis, and Management of Diabetic Foot Infections. Adv Skin Wound Care. 2021;34(11):574–81. Schaper NC, et al. Practical Guidelines on the prevention and management of diabetic foot disease (IWGDF 2019 update). Diabetes Metab Res Rev. 2020;36(Suppl 1):e3266. Mendes JJ, et al. Clinical and bacteriological survey of diabetic foot infections in Lisbon. Diabetes Res Clin Pract. 2012;95(1):153–61. Diabetes OONd. Diabetes: Factos e Números – O Ano de 2019, 2020 e 2021 – Relatório Anual do Observatório Nacional da Diabetes 03/2023 . 2023. ElSayed NA, et al. 12. Retinopathy, Neuropathy, and Foot Care: Standards of Care in Diabetes-2023. Diabetes Care. 2023;46(Suppl 1):S203–15. ElSayed NA, et al. 11. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes-2023. Diabetes Care. 2023;46(Suppl 1):S191–202. ElSayed NA, et al. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2023. Diabetes Care. 2023;46(Suppl 1):S158–90. Lipsky BA et al. 2012 Infectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections. Clin Infect Dis, 2012. 54(12): pp. e132-73. Chuan F, et al. Reliability and validity of the perfusion, extent, depth, infection and sensation (PEDIS) classification system and score in patients with diabetic foot ulcer. PLoS ONE. 2015;10(4):e0124739. Alavi A, Niakosari F, Sibbald RG. When and how to perform a biopsy on a chronic wound. Adv Skin Wound Care, 2010. 23(3): p. 132 – 40; quiz 141-2. Senneville E, et al. Surgical techniques for Bone Biopsy in Diabetic Foot Infection, and association between results and treatment duration. J Bone Jt Infect. 2020;5(4):198–204. Birmpili P, et al. Outcomes after minor lower limb amputation for peripheral arterial disease and diabetes: population-based cohort study. Br J Surg. 2023;110(8):958–65. Hall BG, Barlow M. Revised Ambler classification of {beta}-lactamases. J Antimicrob Chemother. 2005;55(6):1050–1. Machado C, et al. Evolutionary trends in bacteria isolated from moderate and severe diabetic foot infections in a Portuguese tertiary center. Diabetes Metab Syndr. 2020;14(3):205–9. Arias M, Hassan-Reshat S, Newsholme W. Retrospective analysis of diabetic foot osteomyelitis management and outcome at a tertiary care hospital in the UK. PLoS ONE. 2019;14(5):e0216701. Palomo AT et al. Microbiology of Diabetic Foot Infections in a Tertiary Care Hospital in São Paulo, Brazil. Antibiot (Basel), 2022. 11(8). Aragón-Sánchez J, Lipsky BA, Lázaro-Martínez JL. Gram-negative diabetic foot osteomyelitis: risk factors and clinical presentation. Int J Low Extrem Wounds. 2013;12(1):63–8. Nathan DM, et al. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329(14):977–86. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet, 1998. 352(9131): pp. 837 – 53. Hawkins BK, et al. Diabetic foot infections: A microbiologic review. Foot (Edinb). 2022;51:101877. Lipsky BA. Bone of contention: diagnosing diabetic foot osteomyelitis. Clin Infect Dis. 2008;47(4):528–30. Richard JL, et al. Management of patients hospitalized for diabetic foot infection: results of the French OPIDIA study. Diabetes Metab. 2011;37(3):208–15. Veve MP, et al. Prevalence and Predictors of Pseudomonas aeruginosa Among Hospitalized Patients With Diabetic Foot Infections. Open Forum Infect Dis. 2022;9(7):ofac297. Dorr S, et al. Bacterial diversity and inflammatory response at first-time visit in younger and older individuals with diabetic foot infection (DFI). Acta Diabetol. 2021;58(2):181–9. Nelson A, et al. CODIFI (Concordance in Diabetic Foot Ulcer Infection): a cross-sectional study of wound swab versus tissue sampling in infected diabetic foot ulcers in England. BMJ Open. 2018;8(1):e019437. Schmidt BM, et al. Prospective Analysis of Surgical Bone Margins After Partial Foot Amputation in Diabetic Patients Admitted With Moderate to Severe Foot Infections. Foot Ankle Spec. 2019;12(2):131–7. Boschetti G et al. Antimicrobial Resistance Patterns in Diabetic Foot Infections, an Epidemiological Study in Northeastern Italy. Antibiot (Basel), 2021. 10(10). Kim JJ, et al. Diabetic Foot Infections: Local Prevalence of and Case-Control Study of Risk Factors for Methicillin-Resistant Staphylococcus aureus and Pseudomonas aeruginosa. Open Forum Infect Dis. 2020;7(10):ofaa412. Perzon O, et al. Enterococci in Diabetic Foot Infections: Prevalence, Clinical Characteristics, and Outcomes. Open Forum Infect Dis. 2023;10(5):ofad238. Semedo-Lemsaddek T, et al. Characterization of multidrug-resistant diabetic foot ulcer enterococci. Enferm Infecc Microbiol Clin. 2016;34(2):114–6. Demetriou M, et al. Antibiotic Resistance in Diabetic Foot Soft Tissue Infections: A Series From Greece. Int J Low Extrem Wounds. 2017;16(4):255–9. Kwon KT, Armstrong DG. Microbiology and Antimicrobial Therapy for Diabetic Foot Infections. Infect Chemother. 2018;50(1):11–20. Control EC. f.D.P.a. Antimicrobial consumption in the EU/EEA (ESAC-Net) - Annual Epidemiological Report 2021 . 2022; https://qap.ecdc.europa.eu/public/extensions/AMC2_Dashboard/AMC2_Dashboard.html#country-comparison-tab . Uivaraseanu B et al. Clinical, Pathological and Microbiological Evaluation of Diabetic Foot Syndrome. Med (Kaunas), 2020. 56(8). Datta P, et al. Evaluation of various risk factors associated with multidrug-resistant organisms isolated from diabetic foot ulcer patients. J Lab Physicians. 2019;11(1):58–62. Thabit AK, et al. Antibiotic penetration into bone and joints: An updated review. Int J Infect Dis. 2019;81:128–36. Additional Declarations No competing interests reported. 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João","correspondingAuthor":false,"prefix":"","firstName":"Joana","middleName":"","lastName":"Queirós","suffix":""},{"id":313359436,"identity":"3460a5da-32df-4c10-a060-bea00c187121","order_by":14,"name":"Consulta de Grupo Pé Diabético","email":"","orcid":"","institution":"Unidade Local de Saúde de São João","correspondingAuthor":false,"prefix":"","firstName":"Consulta","middleName":"de Grupo Pé","lastName":"Diabético","suffix":""}],"badges":[],"createdAt":"2024-06-02 11:08:19","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4516742/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4516742/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12879-024-09677-3","type":"published","date":"2024-08-06T15:57:44+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":62298425,"identity":"a14220a3-0c39-444b-92b0-a50dfadafe18","added_by":"auto","created_at":"2024-08-12 16:13:10","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":863234,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4516742/v1/dbf0ec86-b1ae-4beb-a0d7-a7eb445fd8a5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Microbiological Characterization of Neuropathic Diabetic Foot Infection: a Retrospective Study at a Portuguese Tertiary Hospital","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eDiabetes mellitus (DM) is a significant global health issue that affects approximately 10.5% of the adult population worldwide [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Diabetic foot disease is recognized as one of the most serious complications of DM. The estimated lifetime incidence of diabetic foot ulcers (DFUs) ranges from 15\u0026ndash;34% [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. DFUs arise from a complex interplay of risk factors, including diabetic neuropathy and peripheral artery disease. The combination of loss of protective sensitivity, foot deformities, and limited joint mobility leads to abnormal foot loading, thereby increasing the likelihood of ulceration [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Bacterial colonization occurs due to skin breakdown and can lead to infection, facilitated by immunosuppression related to DM [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDFUs are the most frequent cause of disability among individuals with DM and are the main cause of nontraumatic lower limb amputations. In Portugal, in 2021, 2,445 lower limb amputations were performed in patients with DM [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], resulting in substantial burdens on healthcare systems in terms of hospitalizations and costs. Additionally, DFUs are associated with a 5-year mortality rate of approximately 50% [\u003cspan additionalcitationids=\"CR3\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe management of neuropathic diabetic foot infection (NDFI) requires crucial interventions, including offloading, appropriate antibiotic therapy, debridement surgery, and optimal glycemic control [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Current guidelines recommend collecting specimens for microbiological culture before initiating empiric antibiotic therapy [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The selected antibiotics should effectively target all potential pathogens while minimizing the risk of antibiotic resistance [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Therefore, knowledge of local microbiological epidemiology is crucial for adjusting empirical antibiotic therapy and improving patient outcomes.\u003c/p\u003e \u003cp\u003eThe aim of our study was to characterize the microbiological profile and susceptibility pattern of NDFI in patients requiring hospitalization at our centre.\u003c/p\u003e"},{"header":"2. Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1. Study design and participants\u003c/h2\u003e \u003cp\u003eWe performed a retrospective observational study evaluating all patients with moderate to severe NDFI who were hospitalized in the Endocrinology Department of a tertiary hospital in Portugal between January 2020 and June 2023. All patients were treated by the same multidisciplinary team, including Endocrinology, Infectious Diseases and Orthopedics, all of whom had expertise in the treatment of NDFI, following national and international guidelines and recommendations. Peripheral arterial disease was excluded by the Vascular Surgery team.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Data collection and definitions\u003c/h2\u003e \u003cp\u003eFor clinical characterization, demographic and clinical data were collected from medical records. The analysed parameters included age, sex, type and duration of DM, last hemoglobin A1c (HbA1c) (accepted if collected within the last 3 months), current antidiabetic drugs, presence of microvascular (diabetic peripheral neuropathy, diabetic kidney disease, and diabetic retinopathy) and macrovascular disease (ischemic heart disease, cerebrovascular disease), heart failure, tobacco abuse, and risk factors for multidrug-resistant microorganisms (MDROs). The definitions of microvascular and macrovascular complications were based on the guidelines outlined in the S\u003cem\u003etandards of Care in Diabetes-2024\u003c/em\u003e [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The risk factors for MDROs included a history of previous antibiotic therapy or hospitalization within the last three months and undergoing hemodialysis [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDFU was defined as a full-thickness lesion that was present distal to the malleolus [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. The severity of the NDFI was assessed using the International Working Group of the Diabetic Foot PEDIS system, which categorizes DFUs into four grades based on perfusion, extension/size, depth/tissue loss, infection, and sensation [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Additionally, for NDFI characterization, we recorded the wound location, analytic parameters (C-reactive protein (CPR) and erythrocyte sedimentation rate (ESR) at admission), and magnetic resonance imaging (MRI) scan findings (including osteomyelitis, abscess, and other relevant observations).\u003c/p\u003e \u003cp\u003eSpecimens for culture were collected using four methods: blood culture, biopsy from the base of the ulcer, aspiration of purulent exudate, and intraoperative biopsy (proximal and distal bone samples). These procedures were performed under strict aseptic techniques. For biopsy from the base of the ulcer and for aspiration of the purulent exudate, the nursing team performed necrotic tissue debridement, followed by cleaning of the area with a simple saline solution before sampling [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. During intraoperative biopsies, tissues were washed with diluted hydrogen peroxide between sample collection, and surgical equipment and materials were replaced [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. In cases where aseptic collection was not possible or when the patient was at risk (due to insupportable pain induction or the risk of ulcer enlargement), we did not collect samples.\u003c/p\u003e \u003cp\u003eMinor amputation was defined as being distal to the tarsometatarsal joint (i.e., transphalangeal or transmetatarsal amputation of single or multiple digits), whereas major amputation was defined as being proximal to this joint [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The described surgical procedure represents the most radical intervention carried out (i.e., if a patient underwent a toe amputation and an above-knee amputation, the surgery type considered was major amputation).\u003c/p\u003e \u003cp\u003eAll microbiological isolates were considered, and their susceptibility test results were analysed. Pathogens isolated from more than one sample were counted only once. If a bacterium was isolated multiple times with different susceptibility profiles, the less favourable profile was considered due to the likelihood of antibiotic resistance development.\u003c/p\u003e \u003cp\u003eConsidering the frequent use of β-lactams for the treatment of diabetic foot infections, we also attempted to identify which microorganisms exhibit resistance mechanisms to β-lactams, particularly the expression of carbapenemases and AmpC-type and ESBL (extended spectrum β-lactamases) β-lactamases.\u003c/p\u003e \u003cp\u003eSuccinctly, carbapenemases are members of the molecular class A, B, and D β-lactamases of the Ambler classification and are capable of inactivating most of the β-lactams, including carbapenems. AmpC β-lactamases and ESBL belong to the class C and A of the Ambler classification, respectively, and can inactivate a broad spectrum of β-lactam antibiotics, including penicillins, cephalosporins, and monobactams; however, ESBLs are especially effective against extended-spectrum cephalosporins, such as cefepime [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe clinical microbiology laboratory at our hospital center employs the Matrix-Assisted Laser Desorption/Ionization Time-Of-Flight Mass Spectrometry (MALDI-TOF MS) method for bacterial susceptibility profiling. Based on this profile, agents displaying phenotypic behavior characteristic of carbapenemase or ESBL production are identified. The identification of potentially AmpC-producing strains was performed through a subsequent analysis of susceptibility profiles by the authors.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e2.3. Statistical analysis\u003c/h2\u003e \u003cp\u003eThe data analysis was performed from the perspective of admissions and using SPSS Statistics 27\u0026reg; software. Continuous variables with a normal distribution were presented as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD), while continuous variables with a nonnormal distribution were expressed as the median and interquartile range (IQR). The normality of the data distribution was examined using skewness and kurtosis, except for the variable 'pack-year', for which we performed the Kolmogorov‒Smirnov test of normality. Categorical variables were displayed as frequencies and percentages. All procedures performed in this study were in accordance with the ethical standards of the institution.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003e3.1. Participants\u003c/h2\u003e \u003cp\u003eThis study enrolled a total of 60 admissions for the NDFI. The mean age of the participants was 59.1\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5 years, and 37 (61.7%) were males. Most inpatients were diagnosed with type 2 DM (n\u0026thinsp;=\u0026thinsp;46, 76.7%). The average time since DM diagnosis was 22.5\u0026thinsp;\u0026plusmn;\u0026thinsp;11.9 years, and the mean HbA1c was 77.0\u0026thinsp;\u0026plusmn;\u0026thinsp;1.00 mmol/mol. Among them, 40 (66.7%) were receiving insulin treatment, with a median total daily insulin dosage of 0.47 (0.00\u0026ndash;0.92) UI/Kg. Diabetic retinopathy (n\u0026thinsp;=\u0026thinsp;38, 64.4%) and diabetic kidney disease (n\u0026thinsp;=\u0026thinsp;36, 60.0%) were the most common complications. In 41 (68.3%) patients, at least one risk factor for MDROs was identified. The remaining clinical characteristics are provided in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Demographics and clinical characteristics of NDFIs hospitalization (n\u0026thinsp;=\u0026thinsp;60) in total of 48 patients.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e59.1\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;11.5\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender - n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(61.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(38.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetes mellitus \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType 1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(15.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eType 2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(76.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOthers (Post-transplant diabetes mellitus, MODY, steroid-induced diabetes)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(8.30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime since diabetes diagnosis (years)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;11.9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHbA1c (mmol/mol)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;1.00\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOn insulin treatment \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(66.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTDI (UI/Kg)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.00\u0026ndash;0.92)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOn oral or injectable antidiabetics \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMetformin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(46.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSGLT2i\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(35.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDDP4 inhibitors\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(25.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGLP-1 agonist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(20.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSulphonylureas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(10.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThiazolidinediones\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1.70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetic kidney disease \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(60.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEnd-stage kidney disease \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(19.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetic retinopathy \u0026ndash; n (%)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(64.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiabetic peripheral neuropathy \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e60\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(100)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIschemic heart disease \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(10.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCerebrovascular disease \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeart failure \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(15.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eActive or past tobacco abuse \u0026ndash; n (%)\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(68.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePack-year\u003csup\u003ef\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(-18\u0026ndash;68)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRisk factors for MDROs \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(68.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrevious antibiotic therapy and/or hospitalization in last three months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(63.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHaemodialysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(5.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eMODY: Maturity\u0026minus;Onset Diabetes of the Young. HbA1c: Hemoglobin A1C. TDI: total daily insulin. SGLT\u0026minus;2i: Sodium\u0026minus; glucose transport protein 2 inhibitors. GLP\u0026minus;1: Glucagon\u0026minus;like peptide\u0026minus;1 receptor. DPP\u0026minus;4: Dipeptidyl Peptidase. MDROs: multidrug\u0026minus;resistant microorganisms. \u003csup\u003ea\u003c/sup\u003emissing: 3 (5.00%); \u003csup\u003eb\u003c/sup\u003emissing: 1 (2.50%); \u003csup\u003ec\u003c/sup\u003emissing: 1 (1.67%); \u003csup\u003ed\u003c/sup\u003emissing: 12 (20.0%); \u003csup\u003ef\u003c/sup\u003emissing: 6 (18.2%).\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Diabetic foot ulcers\u003c/h2\u003e \u003cp\u003eOf the diabetic foot ulcers (DFUs), 37 (61.7%) were categorized as PEDIS 3, while 23 (38.3%) were classified as PEDIS 4. Upon admission, inpatients displayed elevated inflammatory parameters, with a mean CPR of 122.7\u0026thinsp;\u0026plusmn;\u0026thinsp;88.4 mg/L and a mean ESR of 79.0\u0026thinsp;\u0026plusmn;\u0026thinsp;29.4 mm/hr. Osteomyelitis was diagnosed in 54 (90.0%) of the inpatients. Abscesses were present in 27 (45.0%) patients, and septic arthritis was diagnosed in 6 (10.0%) patients based on MRI scans. Surgical debridement was performed in 49 (81.7%) inpatients, and the overall amputation rate was 50.0%, with 43.3% of patients having minor amputations and 6.67% having major amputations. Further details can be found in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Clinical characterization of ulcers in NDFIs and surgical management.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePEDIS classification \u0026ndash; n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePEDIS 3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(61.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePEDIS 4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(38.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocation of ulcer \u0026ndash; n (%)\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eToe or interdigital space\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(55.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePlantar surface\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(25.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDorsal surface\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(4.50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBorders of foot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(6.10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHindfoot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(10.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnkle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(1.50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExtension to the leg or thigh\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(1.50)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eC-protein reactive (mg/L)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e122.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;88.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eErythrocyte sedimentation rate (mm/hr)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e79.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u0026plusmn;\u0026thinsp;29.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMRI scan findings \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOsteomyelitis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(90.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbscess\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(45.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBrodi abscess\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(1.70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSeptic arthritis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(10.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChronic Charcot foot\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(6.67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery \u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNon-surgical debridement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(18.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical debridement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(23.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical debridement and ostectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(8.30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinor amputation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(43.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMajor amputation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(6.67)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTime until surgery (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(1.00\u0026ndash;19.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgical reintervention \u0026ndash; n (%)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(34.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative complication or repeat surgical site infection control\u0026ndash; n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(47.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAccording to the PEDIS system, in Grade 3, ulcers have an area of more than 1 to 3 cm2, involving deeper tissues such as muscle, fascia, or tendon, without the presence of systemic inflammatory response syndrome (SIRS). Patients with grade 4 disease exhibit SIRS [11]. MRI: Magnetic resonance imaging. \u003csup\u003ea\u003c/sup\u003eIn six (10.0%) patients, there was more than one location of ulcer. \u003csup\u003eb\u003c/sup\u003emissing: 7 (11.7%). \u003csup\u003ec\u003c/sup\u003eOther reasons for surgical reintervention included two\u0026minus;stage procedures and vascular or plastic surgery. Four (8.89%) patients underwent more than 2 procedures.\u003c/p\u003e\u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e3.2. Microbiology\u003c/h2\u003e \u003cp\u003eTissue specimens for microbial analysis were collected from 90.0% of the individuals. An absence of microbial growth was observed in 7 patients (11.7%). Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e provides further details on the etiological characteristics of the positive cultures. Biopsies from the base of the ulcer were the most successful at isolating at least one pathogen, achieving a success rate of 96%. However, most pathogens (n\u0026thinsp;=\u0026thinsp;64, 62.7%) were isolated from intraoperative biopsies, followed by biopsies from the base of the ulcer (n\u0026thinsp;=\u0026thinsp;40, 39.2%) and aspiration of purulent exudate (n\u0026thinsp;=\u0026thinsp;15, 14.7%). Bacteraemia was found in one patient (1.67%).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCharacteristics of positive cultures (n\u0026thinsp;=\u0026thinsp;80).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePercentage of patients who had a positive culture out of the total number of patients from whom sample could be collected\u0026ndash; n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood\u003c/p\u003e \u003cp\u003eBiopsy from the ulcer base\u003c/p\u003e \u003cp\u003eAspiration of purulent exudate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e24\u003c/p\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(1.70)\u003c/p\u003e \u003cp\u003e(96.0)\u003c/p\u003e \u003cp\u003e(90.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative biopsy \u0026ndash; distal bone samples\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIntraoperative biopsy \u0026ndash; proximal bone samples\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e38\u003c/p\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(79.2)\u003c/p\u003e \u003cp\u003e(60.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of pathogens isolated in each sample \u0026ndash; n (%)\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBiopsy from the ulcer base\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(39.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAspiration of purulent exudate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(14.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative biopsy \u0026ndash; distal samples to amputation\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e64\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(62.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIntraoperative biopsy \u0026ndash; proximal samples to amputation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(6.86)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePolymicrobial infection \u0026ndash; n (%)\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(53.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eOf the total number of individuals, tissue samples could not be collected in 6 patients (10.0%), and blood cultures were not collected in 8 patients (13.3%). Additionally, in 7 individuals (11.7%), no pathogens were isolated. \u003csup\u003ea\u003c/sup\u003eIncludes samples collected intraoperatively when no amputation was performed. \u003csup\u003eb\u003c/sup\u003eOne hundred and five distinct pathogens were isolated, among which 21 were found in more than one sample, and three bacteria appeared to have developed resistance in response to antibiotic pressure. \u003csup\u003ec\u003c/sup\u003emissing: 13 (21.7%).\u003c/p\u003e \u003cp\u003eA total of 102 pathogens were isolated, resulting in an average of 1.91\u0026thinsp;\u0026plusmn;\u0026thinsp;1.25 organisms per admission when tissue specimens were collected for microbiology culture. Polymicrobial infection was detected in 32 (53.3%) individuals. The prevalence of the isolated pathogens and their susceptibility profiles are described in Tables\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e, respectively. Among the total isolates, four (3.92%) were fungi, specifically \u003cem\u003eCandida\u003c/em\u003e spp. Gram-positive bacteria accounted for 62 (60.8%) of the isolates, gram-negative bacilli were identified in 32 (31.4%) of the isolates, and anaerobic bacteria were identified in four (3.92%). \u003cem\u003eStaphylococcus aureus\u003c/em\u003e (n\u0026thinsp;=\u0026thinsp;19, 18.6%) was the most frequently identified pathogen, followed by \u003cem\u003eEnterococcus faecalis\u003c/em\u003e (n\u0026thinsp;=\u0026thinsp;17, 16.7%) and coagulase-negative \u003cem\u003eStaphylococci\u003c/em\u003e (n\u0026thinsp;=\u0026thinsp;14, 13.7%). Among the gram-negative bacteria, \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e was the most prevalent, with eight (7.84%) isolates. Twenty-four (23.5%) bacteria were isolated from the \u003cem\u003eEnterobacterales\u003c/em\u003e family, with \u003cem\u003eEnterobacter cloacae\u003c/em\u003e (n\u0026thinsp;=\u0026thinsp;7, 6.86%) being the most frequently isolated agent.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePathogens isolated from inpatients with NDFIs (n\u0026thinsp;=\u0026thinsp;102).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePathogen\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003eFrequency \u0026ndash; n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGram-positive aerobic bacteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(60.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStaphylococcus aureus\u003c/em\u003e\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(18.6)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEnterococcus faecalis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCoagulase-Negative \u003cem\u003eStaphylococcus\u003c/em\u003e\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(13.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eβ hemolytic \u003cem\u003eStreptococcus\u003c/em\u003e\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(7.84)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCorynebacterium\u003c/em\u003e spp.\u003csup\u003ed\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(1.96)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEnterococcus faecium\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(1.96)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGram-negative aerobic bacteria\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(31.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(7.84)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEnterobacterales\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003e24\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e(23.5)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEnterobacter cloacae\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(6.86)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(5.88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eProteus mirabilis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(4.90)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eMorganella morganii\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(1.96)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEscherichia coli\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(1.96)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eProvidencia rettgeri\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(0.98)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eSerratia marcescens\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(0.98)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnaerobic bacteria\u003csup\u003ee\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(3.92)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFungi\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(3.92)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCandida parapsilosis\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(2.94)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCandida albicans\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e(0.98)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e\u003csup\u003ea\u003c/sup\u003eIn the case of bacteremia, a single strain of Staphylococcus aureus was isolated. \u003csup\u003eb\u003c/sup\u003eIncluded Staphylococcus capitis, Staphylococcus epidermidis, Staphylococcus haemolyticus, Staphylococcus lentus, and Staphylococcus hominis. \u003csup\u003ec\u003c/sup\u003eIncluding Streptococcus agalactiae, Streptococcus anginosus\u0026cedil; and Streptococcus constellatus. \u003csup\u003ed\u003c/sup\u003eIncluding Corynebacterium tuberculostearicum and Corynebacterium jeikeium. \u003csup\u003ee\u003c/sup\u003eIncluded Fusobacterium varium, Bacteroides fragilis, Gardanella vaginallis, and Actinobaculum schaalii. MDROs: multidrug-resistant microorganisms.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e3.4. Susceptibility pattern\u003c/h2\u003e \u003cp\u003eThree (15.8%) \u003cem\u003eStaphylococcus aureus\u003c/em\u003e and eight (66.7%) coagulase-negative \u003cem\u003eStaphylococci\u003c/em\u003e isolates were methicillin resistant (MRSA). The susceptibility of these agents to methicillin was inferred by their susceptibility to oxacillin. Among the patients from whom methicillin-resistant \u003cem\u003eStaphylococcus\u003c/em\u003e spp. were isolated, two (18.2%) had no risk factors for MDROs (such as a history of previous antibiotic therapy or hospitalization within the last three months and who were undergoing hemodialysis). Resistance to clindamycin was identified in seven (36.8%) \u003cem\u003eStaphylococcus aureus\u003c/em\u003e isolates and 2 (16.7%) coagulase-negative \u003cem\u003eStaphylococci\u003c/em\u003e isolates. Furthermore, two (10.5%) \u003cem\u003eEnterococcus\u003c/em\u003e spp. were ampicillin resistant, both of which were sensitive to vancomycin. Additionally, both patients exhibited risk factors for MDROs. None of the isolated strains of \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e were resistant to piperacillin-tazobactam, ceftazidime or cefepime. Among the \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e isolates, one (12.5%) was resistant to carbapenems. Among the \u003cem\u003eEnterobacterales\u003c/em\u003e isolates, 17 (85.0%) were resistant to amoxicillin/clavulanic acid, eight (34.8%) were resistant to ceftazidime, eight (34.8%) were resistant to piperacillin-tazobactam, four (17.4%) were resistant to cefepime, and three (13.0%) were resistant to carbapenems. Extended-spectrum β-lactamases (ESBL), \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e carbapenemases (KPC), and AmpC β-lactamases were found in one (4.17%), four (16.7%), and four (17.4%) of the isolated \u003cem\u003eEnterobacterales\u003c/em\u003e, respectively. These bacteria were isolated from patients who displayed risk factors for MDROs.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePathogen resistance profile. A. Gram-positive aerobic bacteria\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResistance \u0026ndash; n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eStaphylococcus spp.\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e\u003cem\u003eEnterococcus spp.\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003eStaphylococus aureus\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003eCoagulase-Negative Staphylococus\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmpicillin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(10.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOxacillin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(15.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(66.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClindamycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(36.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(16.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTetracycline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(15.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCo-trimoxazole\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(5.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(33.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVancomycin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e(0.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003cp\u003eB. Gram-negative aerobic bacteria\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResistance \u0026ndash; n (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e\u003csup\u003e\u003cem\u003eb\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cem\u003eEnterobacterales\u003c/em\u003e\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmoxicillin clavulanic acid\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(85.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCeftazidime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(34.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCefepime\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(17.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAztreonam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImipenem / meropenem\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(12.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(13.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePiperacillin tazobactam\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(34.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eQuinolones\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(14.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(20.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCo-trimoxazole\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(30.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eESBL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(4.17)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKPC\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e(0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(16.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmpC β-lactamases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e(17.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eESBL: extended\u0026minus;spectrum \u0026beta;\u0026minus;lactamases; KPC: Klebsiella pneumoniae carbapenemases. \u003csup\u003ea\u003c/sup\u003emissing: oxacillin, clindamycin, tetracycline, co\u0026minus;trimoxazole \u0026ndash; 2 (14.3%). \u003csup\u003eb\u003c/sup\u003emissing: cefepime, imipenem/meropenem \u0026ndash; 4 (50.0%), quinolones \u0026ndash; 1 (12.5%). \u003csup\u003ec\u003c/sup\u003emissing: amoxicillin clavulanic acid \u0026minus; 4 (16.7%), ceftazidime, cefepime, imipenem/meropenem, piperacillin tazobactam, co\u0026minus;trimoxazole, ESBL, AmpC \u0026beta;\u0026minus;lactamases \u0026ndash; 1 (4.20%).\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThis study investigated the microbiology of NDFI and detailed and essential data pertaining to the etiological pathogens responsible for NDFI and their corresponding susceptibility profiles in our population. This pivotal prevalence study contributes to the understanding of local epidemiology and provides guidance for empirical antibiotic therapy in NDFI patients.\u003c/p\u003e \u003cp\u003eThe sociodemographic and clinical data related to DM in our population overlapped with previous national and international studies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], showing that NDFI is more prevalent in men and tends to affect professionally active individuals. In our cohort, the prevalence of ischemic heart disease [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] was lower, as expected given our focus on the NDFI. The high prevalence of both microvascular and macrovascular diseases reflects poor diabetes control and prolonged disease duration [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], contributing to increased immunosuppression and compromised wound healing [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur findings underscore the severity of NDFI within our patient population, with 38.3% of cases displaying systemic repercussions according to the PEDIS classification. Furthermore, elevated inflammatory parameters, namely, osteomyelitis, abscess, and septic arthritis, were present in 90.0%, 46.7%, and 10.0% of the patients, respectively, underscoring the strength of the situation. These findings highlight a greater prevalence of bone involvement in this study than in other studies (50\u0026ndash;65%) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. MRI, the most sensitive modality (95.6%) and more specific than plain radiography used in other reports (80.7% vs. 68.0%) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], was employed for osteomyelitis diagnosis in our study.\u003c/p\u003e \u003cp\u003eIn contrast to previous studies [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], this research exclusively relied on deep tissue and bone sampling techniques for microbiological diagnosis. Tissue specimens are considered the gold standard [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e], offering greater sensitivity and specificity in causative pathogen identification while excluding colonizers or contaminants [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Although most pathogens were isolated from intraoperative biopsies, the proportion of positive cultures was lower than that of preoperative samples. This difference may be attributed to the initiation of empirical antibiotic therapy prior to surgery in some patients, owing to the severity of the NDFI and the extended period until surgery. This approach could hinder pathogen identification. Importantly, among the collected proximal bone samples, 60% yielded positive cultures, indicating persistent bone infection after amputation. Although findings on this matter remain controversial, this persistence might correlate with poorer outcomes, including postoperative complications and readmissions [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIt is crucial to acknowledge that not every identified agent may have an active role as a potential pathogen, especially for coagulase-negative \u003cem\u003eStaphylococcus\u003c/em\u003e, \u003cem\u003eβ-hemolytic Streptococcus\u003c/em\u003e, and \u003cem\u003eCorynebacterium spp\u003c/em\u003e., which are known skin commensals [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Furthermore, \u003cem\u003eGardenerella vaginalis\u003c/em\u003e was identified as a contamination case. Nevertheless, the collection of all specimens from deep tissues under aseptic conditions reinforced our confidence that the isolates were true pathogens. Aerobic gram-positive cocci usually lead to monomicrobial infections in acute, untreated cases, while polymicrobial infections commonly involve gram-positive \u003cem\u003ecocci\u003c/em\u003e, \u003cem\u003eEnterobacterales\u003c/em\u003e, \u003cem\u003ePseudomonas\u003c/em\u003e, and anaerobes, especially in chronic or deep wounds [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Enterococcus spp. are considered commensal but assume pathogenic roles in patients with diabetes, especially chronic ulcers [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Although a correlation between prior antibiotic exposure and isolated microorganisms could not be established due to differences in the number of participants, our clinical practice suggests the predominant isolation of gram-negative bacilli in MDRO-risk patients. Similarly, with other studies, the prevalence of anaerobes might be underestimated due to challenges in isolation by routine clinical microbiology laboratories [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur findings are in line with previously reported results [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan additionalcitationids=\"CR17 CR18\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan additionalcitationids=\"CR25\" citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e], where gram-positive bacteria prevailed. A recent review analysed the global epidemiology of diabetic foot infection, and \u003cem\u003eStaphylococcus aureus\u003c/em\u003e remained the most common pathogen (11\u0026ndash;46%), particularly in Western countries [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. The incidence of gram-negative bacteria has surged, especially in Asia, and gram-negative bacteria are becoming the most frequently isolated pathogen. The worldwide prevalence of \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e ranges from 10 to 26.6% [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTwo additional bacterial surveys were conducted in Portugal, where \u003cem\u003eStaphylococcus aureus\u003c/em\u003e prevailed (19.7\u0026ndash;21.8%) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In the most recent study, a significant proportion of the isolates were gram-negative bacteria (48.9%), particularly from the \u003cem\u003eEnterobacterales\u003c/em\u003e family (30.6%) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Our study contrasts with these reports, which revealed a greater prevalence of coagulase-negative \u003cem\u003eStaphylococcus\u003c/em\u003e (4.37%), whereas certain gram-negative bacteria, such as \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e (13.7%), were more common [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The incidences of \u003cem\u003eEnterococcus spp.\u003c/em\u003e (8.84%), β-hemolytic \u003cem\u003eStreptococcus\u003c/em\u003e (4.08%), and \u003cem\u003eEnterobacterales\u003c/em\u003e (10.9%) were lower, while the incidence of \u003cem\u003eCorynebacterium spp.\u003c/em\u003e (8.16%) was higher in another survey [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eCompared with both international and national data, our observed MRSA prevalence was lower (15.8%). National surveys reported MRSA proportions ranging from 41.7 to 53.1% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e], while recent European surveys reported MRSA proportions ranging from 24.7\u0026ndash;27.1% [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Globally, the incidence of MRSA has been steadily increasing and ranges from 16\u0026ndash;44% [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. Limited information exists on coagulase-negative \u003cem\u003eStaphylococci\u003c/em\u003e methicillin resistance, but our survey indicated a significant rate (66.7%). This rate remained below that of a middle-income country (91.8%) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e], exceeding that of another high-income country (55.4%) [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], and that of a national survey (27.2%) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. \u003cem\u003eEnterococcus spp\u003c/em\u003e. displayed notable susceptibility to ampicillin (10.5%), which is consistent with other international reports (2.00\u0026ndash;17.4%) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] and is attributed to the minority of \u003cem\u003eEnterococcus faecium\u003c/em\u003e isolates [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. A Portuguese study reported increased ampicillin resistance (33.3%) [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. Notably, no vancomycin-resistant \u003cem\u003eEnterococcus\u003c/em\u003e (VRE) strains were detected. The prevalence of VRE among \u003cem\u003eEnterococcus spp\u003c/em\u003e. ranges from 0.00\u0026ndash;7.69% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan additionalcitationids=\"CR30 CR31 CR32\" citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] in previous reports.\u003c/p\u003e \u003cp\u003eThese disparities can be attributed to several factors: in several studies, peripheral arterial disease was identified as a risk factor for MDROs [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. This study analysed the microbiology of NDFI. Additionally, other national studies occurred in reference centres where most complex cases are transferred, likely presenting identified risk factors for MDROs, such as previous hospitalization, amputation, and antibiotic exposure [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. National data predate 2018; in recent years, the incidence of MRSA has been declining due to the implementation of hospital infection control measures [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In our centre, we only used empirical broad-spectrum antibiotics in patients with risk factors for MDROs. This approach to antibiotic use may contribute to a lower prevalence of resistance [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eRegarding gram-negative bacterial susceptibility, our study revealed a favourable profile, particularly concerning fluoroquinolone resistance. This rate was lower than that reported in most international and national studies (\u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e: 14.3% vs. 18.2\u0026ndash;57.3% [\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]; \u003cem\u003eEnterobacterales\u003c/em\u003e: 20.8% vs. 40.0\u0026ndash;50.0% [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]). This divergence might stem from global fluoroquinolone overuse in recent decades, despite declining prescriptions in last years [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. Our centre avoids fluoroquinolones for empirical therapy in both outpatient and inpatient settings. The imipenem or meropenem resistance rates (\u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e: 25.0%; \u003cem\u003eEnterobacterales\u003c/em\u003e: 20.8%) were concerning. The prevalence of \u003cem\u003ePseudomonas\u003c/em\u003e was similar to that in other southern European countries (9.1\u0026ndash;23.5%) [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] but greater than that in northern European countries (5.4%) [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In Asia, resistance rates are as high as 55% [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. \u003cem\u003eEnterobacterales\u003c/em\u003e rates approach those reported in Asia (13.4\u0026ndash;16.5%) [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. In other Western countries, the resistance rate was substantially lower (1.73\u0026ndash;7.5%) [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Our ESBL prevalence matches that of national studies (4.17% vs. 2.40-6,25% [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]); however, it was lower than that of other European reports (20.0-29.8% [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]). Conversely, our lower KPC incidence aligns with the findings of national and European studies (16.7% vs. 1.79-5.00% [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]). Additionally, the prevalence of ESBL, KPC and AmpC β-lactamases in our study was considerably lower than that in Asiatic series, reaching 50.0% [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOur study has limitations that must be acknowledged. First, due to its retrospective nature, some crucial data, including the duration and regimen of antibiotic therapy before admission, were missing from medical records. Information about previous instances of NDFI, hospitalizations for NDFI, amputations, the healthcare setting before admission (community or hospital), adverse events during hospitalization, and outcomes after discharge was not available. MRI is valuable for detecting osteomyelitis, yet histological and microbiological methods are the gold standard. Even though our samples were collected from deep tissues, it is important to note that the assumption that all isolated pathogens were causative agents of NDFI might not be entirely accurate, as previously mentioned. Specimen collection before empirical antibiotic therapy is ideal.\u003c/p\u003e \u003cp\u003eOur study's strength lies in the comprehensive description of resistance profiles among NDFI pathogens. To our knowledge, this is the most detailed study conducted in Portugal, offering important insights. All cultures were obtained through purulent aspiration and deep tissue or bone biopsies under aseptic techniques, reducing contamination risk and clarifying the causative pathogens of NDFI. Given the variations in epidemiology among different centers, understanding the local epidemiology and resistance pattern is crucial for tailored empirical antibiotic therapy protocols. Our findings suggest considering a higher dose of amoxicillin-clavulanic acid for empirical antibiotic therapy in patients without risk factors for MDROs. This selection, which offers effective bone penetration [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e] and coverage against gram-positive aerobes and anaerobes, could be crucial. However, it may fail to cover gram-negative bacteria. For patients with risk factors for MDROs, we suggest vancomycin along with piperacillin tazobactam or ceftazidime. This combination would provide coverage against MRSA, coagulase-negative methicillin-resistant \u003cem\u003eStaphylococcus\u003c/em\u003e, and gram-negative bacteria. Nonetheless, it is important to note that approximately 34.8% of the \u003cem\u003eEnterobacterales\u003c/em\u003e were not covered, underscoring the necessity of obtaining specimens as early as possible for guiding antibiotic therapy decisions.\u003c/p\u003e \u003cp\u003eIn conclusion, local microbiology analysis proves invaluable in establishing antimicrobial stewardship practices and selecting empiric antibiotic therapy critical for managing severe infections with the potential for amputation and disability, particularly among working individuals. Timely and appropriate interventions have the potential to enhance quality of life and reduce morbidity and mortality in affected individuals. Hence, continued vigilance in this domain is imperative for improving outcomes in managing NDFI.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDiabetes mellitu\u003cem\u003es\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDFU\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ediabetic foot ulcer\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eNDFI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eneuropathic diabetic foot infection\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHbA1c\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ehemoglobin A1c\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMDROs\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003emultidrug-resistant microorganisms\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSIRS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eSystemic inflammatory response syndrome\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCPR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eC-reactive protein\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eESR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eerythrocyte sedimentation rate\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMagnetic resonance imaging\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eESBL\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eExtended-spectrum β-lactamases\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMALDI-TOF MS\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMatrix-assisted Laser Desorption/Ionization Time-of-Flight Mass Spectrometry\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eSD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003estandard deviation\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eIQR\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003einterquartile range\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eMRSA\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eMethicillin-resistant \u003cem\u003eStaphylococcus aureus\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eKPC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e carbapenemases\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eVRE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eVancomycin-resistant \u003cem\u003eEnterococcus\u003c/em\u003e\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e:\u0026nbsp;\u003c/em\u003e\u003c/strong\u003eThis study was performed in accordance with the principles of the Declaration of Helsinki. Ethical approval was obtained from the ethics committee of Unidade Local de Sa\u0026uacute;de de S\u0026atilde;o Jo\u0026atilde;o (CES 330/23). For this type of study (retrospective and observational), formal consent was not needed.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials:\u003c/strong\u003e The dataset for this study is available from the corresponding author upon reasonable request and ethical approval.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u003c/strong\u003e The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e No funds, grants, or other support was received.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions:\u003c/strong\u003e Conceptualization, J.G. and A.G.; methodology, J.G. and A.G.; software, J.G. and A.G.; validation, J.P. N.N., R.S.S. L.S. and J.Q.; formal analysis, J.G. and A.G.; investigation, J.G., A.G., H.U.F., S.R., T.M., M.B.C., I.M., P.F., N.F., R.S.S.; data curation, J.G. and A.G.; writing original draft preparation, J.G. and A.G.; writing, review and editing, M.B.C., F.S., J.P., N.N., R.S.S., L.S. and J.Q.; visualization, all authors; supervision, J.P., N.N., L.S. and J.Q. All authors have read and agreed to the published version of the manuscript. J.G. and A.G. are considered co-first authors and contributed equally to this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u0026nbsp;\u003c/strong\u003eNot applicable\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSun H, et al. Diabetes Atlas: Global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diabetes Res Clin Pract. 2022;183:109119.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eIbrahim A. IDF Clinical Practice Recommendation on the Diabetic Foot: A guide for healthcare professionals. Diabetes Res Clin Pract. 2017;127:285\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMponponsuo K, Sibbald RG, Somayaji R. A Comprehensive Review of the Pathogenesis, Diagnosis, and Management of Diabetic Foot Infections. Adv Skin Wound Care. 2021;34(11):574\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchaper NC, et al. Practical Guidelines on the prevention and management of diabetic foot disease (IWGDF 2019 update). Diabetes Metab Res Rev. 2020;36(Suppl 1):e3266.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMendes JJ, et al. Clinical and bacteriological survey of diabetic foot infections in Lisbon. Diabetes Res Clin Pract. 2012;95(1):153\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDiabetes OONd. \u003cem\u003eDiabetes: Factos e N\u0026uacute;meros \u0026ndash; O Ano de 2019, 2020 e 2021\u0026thinsp;\u0026ndash;\u0026thinsp;Relat\u0026oacute;rio Anual do Observat\u0026oacute;rio Nacional da Diabetes 03/2023\u003c/em\u003e. 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElSayed NA, et al. 12. Retinopathy, Neuropathy, and Foot Care: Standards of Care in Diabetes-2023. Diabetes Care. 2023;46(Suppl 1):S203\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElSayed NA, et al. 11. Chronic Kidney Disease and Risk Management: Standards of Care in Diabetes-2023. Diabetes Care. 2023;46(Suppl 1):S191\u0026ndash;202.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eElSayed NA, et al. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2023. Diabetes Care. 2023;46(Suppl 1):S158\u0026ndash;90.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLipsky BA et al. 2012 \u003cem\u003eInfectious Diseases Society of America clinical practice guideline for the diagnosis and treatment of diabetic foot infections.\u003c/em\u003e Clin Infect Dis, 2012. 54(12): pp. e132-73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChuan F, et al. Reliability and validity of the perfusion, extent, depth, infection and sensation (PEDIS) classification system and score in patients with diabetic foot ulcer. PLoS ONE. 2015;10(4):e0124739.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlavi A, Niakosari F, Sibbald RG. When and how to perform a biopsy on a chronic wound. Adv Skin Wound Care, 2010. 23(3): p. 132\u0026thinsp;\u0026ndash;\u0026thinsp;40; quiz 141-2.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSenneville E, et al. Surgical techniques for Bone Biopsy in Diabetic Foot Infection, and association between results and treatment duration. J Bone Jt Infect. 2020;5(4):198\u0026ndash;204.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBirmpili P, et al. Outcomes after minor lower limb amputation for peripheral arterial disease and diabetes: population-based cohort study. Br J Surg. 2023;110(8):958\u0026ndash;65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHall BG, Barlow M. Revised Ambler classification of {beta}-lactamases. J Antimicrob Chemother. 2005;55(6):1050\u0026ndash;1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMachado C, et al. Evolutionary trends in bacteria isolated from moderate and severe diabetic foot infections in a Portuguese tertiary center. Diabetes Metab Syndr. 2020;14(3):205\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArias M, Hassan-Reshat S, Newsholme W. Retrospective analysis of diabetic foot osteomyelitis management and outcome at a tertiary care hospital in the UK. PLoS ONE. 2019;14(5):e0216701.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePalomo AT et al. Microbiology of Diabetic Foot Infections in a Tertiary Care Hospital in S\u0026atilde;o Paulo, Brazil. Antibiot (Basel), 2022. 11(8).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eArag\u0026oacute;n-S\u0026aacute;nchez J, Lipsky BA, L\u0026aacute;zaro-Mart\u0026iacute;nez JL. Gram-negative diabetic foot osteomyelitis: risk factors and clinical presentation. Int J Low Extrem Wounds. 2013;12(1):63\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNathan DM, et al. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993;329(14):977\u0026ndash;86.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e\u003cem\u003eIntensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group.\u003c/em\u003e Lancet, 1998. 352(9131): pp. 837\u0026thinsp;\u0026ndash;\u0026thinsp;53.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHawkins BK, et al. Diabetic foot infections: A microbiologic review. Foot (Edinb). 2022;51:101877.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLipsky BA. Bone of contention: diagnosing diabetic foot osteomyelitis. Clin Infect Dis. 2008;47(4):528\u0026ndash;30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eRichard JL, et al. Management of patients hospitalized for diabetic foot infection: results of the French OPIDIA study. Diabetes Metab. 2011;37(3):208\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eVeve MP, et al. Prevalence and Predictors of Pseudomonas aeruginosa Among Hospitalized Patients With Diabetic Foot Infections. Open Forum Infect Dis. 2022;9(7):ofac297.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDorr S, et al. Bacterial diversity and inflammatory response at first-time visit in younger and older individuals with diabetic foot infection (DFI). Acta Diabetol. 2021;58(2):181\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNelson A, et al. CODIFI (Concordance in Diabetic Foot Ulcer Infection): a cross-sectional study of wound swab versus tissue sampling in infected diabetic foot ulcers in England. BMJ Open. 2018;8(1):e019437.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSchmidt BM, et al. Prospective Analysis of Surgical Bone Margins After Partial Foot Amputation in Diabetic Patients Admitted With Moderate to Severe Foot Infections. Foot Ankle Spec. 2019;12(2):131\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBoschetti G et al. Antimicrobial Resistance Patterns in Diabetic Foot Infections, an Epidemiological Study in Northeastern Italy. Antibiot (Basel), 2021. 10(10).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKim JJ, et al. Diabetic Foot Infections: Local Prevalence of and Case-Control Study of Risk Factors for Methicillin-Resistant Staphylococcus aureus and Pseudomonas aeruginosa. Open Forum Infect Dis. 2020;7(10):ofaa412.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePerzon O, et al. Enterococci in Diabetic Foot Infections: Prevalence, Clinical Characteristics, and Outcomes. Open Forum Infect Dis. 2023;10(5):ofad238.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSemedo-Lemsaddek T, et al. Characterization of multidrug-resistant diabetic foot ulcer enterococci. Enferm Infecc Microbiol Clin. 2016;34(2):114\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDemetriou M, et al. Antibiotic Resistance in Diabetic Foot Soft Tissue Infections: A Series From Greece. Int J Low Extrem Wounds. 2017;16(4):255\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKwon KT, Armstrong DG. Microbiology and Antimicrobial Therapy for Diabetic Foot Infections. Infect Chemother. 2018;50(1):11\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eControl EC. f.D.P.a. \u003cem\u003eAntimicrobial consumption in the EU/EEA (ESAC-Net) - Annual Epidemiological Report 2021\u003c/em\u003e. 2022; \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://qap.ecdc.europa.eu/public/extensions/AMC2_Dashboard/AMC2_Dashboard.html#country-comparison-tab\u003c/span\u003e\u003cspan address=\"https://qap.ecdc.europa.eu/public/extensions/AMC2_Dashboard/AMC2_Dashboard.html#country-comparison-tab\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eUivaraseanu B et al. Clinical, Pathological and Microbiological Evaluation of Diabetic Foot Syndrome. Med (Kaunas), 2020. 56(8).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDatta P, et al. Evaluation of various risk factors associated with multidrug-resistant organisms isolated from diabetic foot ulcer patients. J Lab Physicians. 2019;11(1):58\u0026ndash;62.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eThabit AK, et al. Antibiotic penetration into bone and joints: An updated review. Int J Infect Dis. 2019;81:128\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Diabetic foot infection, Diabetic foot ulcer, Microbiology, Epidemiology, Antibiotics","lastPublishedDoi":"10.21203/rs.3.rs-4516742/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4516742/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eDiabetic foot infection imposes a significant burden and is the major cause of nontraumatic limb amputation. Adequate patient management with effective antibiotic therapy is crucial.\u003c/p\u003e \u003cp\u003eThis retrospective cohort study aimed to characterize the microbiology and resistance patterns of moderate to severe neuropathic diabetic foot infection in patients hospitalized at a tertiary referral hospital between January 2020 and June 2023. Deep tissue specimens from ulcers were collected for culture.\u003c/p\u003e \u003cp\u003eSixty inpatients were included (62% male, mean age 59.1\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5 years). Osteomyelitis was present in 90% of the patients. Among 102 microorganisms (average of 1.91\u0026thinsp;\u0026plusmn;\u0026thinsp;1.25 pathogens per patient), 60.8% were gram-positive bacteria, 31.4% were gram-negative, 3.92% were anaerobic bacteria, and 3.92% were fungi. \u003cem\u003eStaphylococcus aureus\u003c/em\u003e (19%) and \u003cem\u003eEnterococcus faecium\u003c/em\u003e (17%) were the most common. \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e (8%) and bacteria of the \u003cem\u003eEnterobacterales\u003c/em\u003e family (24%) accounted for all the isolated gram-negative bacteria. Sixteen percent of \u003cem\u003eStaphylococcus aureus\u003c/em\u003e and 67% of coagulase-negative \u003cem\u003eStaphylococci\u003c/em\u003e were resistant to methicillin. Resistance to ampicillin was found in 11% of \u003cem\u003eEnterococci\u003c/em\u003e. All \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e isolates were sensitive to piperacillin-tazobactam, ceftazidime, or cefepime. Among the \u003cem\u003eEnterobacterales\u003c/em\u003e, resistance rates were 35% for piperacillin-tazobactam, 35% for ceftazidime, 17% for cefepime, and 13% for carbapenems.\u003c/p\u003e \u003cp\u003eAlthough the prevalence of methicillin-resistant staphylococci was lower than that in other studies, carbapenem resistance among gram-negative bacteria warrants attention. This study highlights the importance of understanding local epidemiology for effective diabetic foot infection management and resistance mitigation.\u003c/p\u003e","manuscriptTitle":"Microbiological Characterization of Neuropathic Diabetic Foot Infection: a Retrospective Study at a Portuguese Tertiary Hospital","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-06-17 10:13:56","doi":"10.21203/rs.3.rs-4516742/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-07-02T05:00:07+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-30T15:29:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"262979670467495415476099424618171782535","date":"2024-06-27T21:23:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-24T12:54:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"39932126193316550549235671798691278996","date":"2024-06-24T06:15:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"46577391597184691208683883610247183894","date":"2024-06-21T18:50:50+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-06-12T01:55:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"40593735657225028169071197026210235498","date":"2024-06-07T14:34:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-06-06T16:21:47+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-06-04T09:58:25+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-06-04T07:25:29+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-06-04T03:27:22+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2024-06-02T10:55:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7e93f6b9-7006-484b-8525-40e18120647b","owner":[],"postedDate":"June 17th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-08-12T16:03:59+00:00","versionOfRecord":{"articleIdentity":"rs-4516742","link":"https://doi.org/10.1186/s12879-024-09677-3","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2024-08-06 15:57:44","publishedOnDateReadable":"August 6th, 2024"},"versionCreatedAt":"2024-06-17 10:13:56","video":"","vorDoi":"10.1186/s12879-024-09677-3","vorDoiUrl":"https://doi.org/10.1186/s12879-024-09677-3","workflowStages":[]},"version":"v1","identity":"rs-4516742","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4516742","identity":"rs-4516742","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}