MRSA: Where Do We Go From Here?

By David G. Armstrong, DPM, MSc, PhD

   Foot ulcers are a major predictor of future lower limb amputations. Fourteen to 24 percent of patients with diabetes with foot ulcers eventually require an amputation and more than 60 percent of nontraumatic lower extremity amputations occur in those with diabetes.1,2 Although risk factors may vary, the majority of diabetes-related amputations result from peripheral arterial disease, peripheral neuropathy or infection.3    The healthcare costs associated with diabetic foot infections are staggering. In an analysis of medical and pharmacy insurance claims filed by more than 7 million people during a two-year period, Holzer, et. al., reported that the direct medical expenditures associated with lower extremity ulcers in patients with diabetes exceeded $16 million and 80.7 percent of those costs were hospital-related.4    Overall, 6 percent of diabetic patients with foot ulcers require hospitalization.3 According to data from the 1983-1990 National Hospital Discharge Surveys (NHDS), chronic ulcers were present in 2.7 percent of all hospitalized patients with diabetes.5 The average hospital length of stay for patients with an extremity ulcer was 59 percent longer than for those without an ulcer. Patients without ulcers remained in the hospital about 10 days whereas those with ulcers stayed approximately 15 days.    Although up to 90 percent of ulcers will heal when they are treated aggressively with a comprehensive approach, recovery can be slow.6 Ulcers may take weeks or months to heal, and patients remain at high risk for ulcer recurrences.7 Ramsey, et. al., reported that diabetic foot ulcers are predictive of increased mortality.8 Among 8,905 patients with either type 1 or type 2 diabetes, the cumulative three-year survival rate was 72 percent for patients with a foot ulcer versus 87 percent for those without ulcers.    While not all diabetic foot ulcers become infected, delayed or inadequate treatment can result in an infection that may lead to gangrene, osteomyelitis or even limb amputation. The risk of infection remains high in these cases even when lesions are treated quickly and appropriately.

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