Diabetes is a chronic disease that affects a large percentage of patients while being considered a public health problem. Diabetes and foot problems "are often simultaneous [1-2]. This overlap has often been found to result in neuropathy, changes in blood consciousness and subsequent injury, expressed by diabetic foot syndrome [3-19]. The complications of the injury give the pathological picture of foot diabetes, which plays a "key" role in the development of wet gangrene [2]. Pseudomonas spp., Enterobacter spp., and Proteus spp. They have an important role to play as they are responsible for the breakdown and contamination of the tissue and, consequently, for the weakness of the blood supply to the foot tissue [4,3]. 

In addition, there is the involvement of anaerobic bacteria and complications in the injury. Obviously, with the development of the injury, the tissue becomes resistant to antibiotic treatment [1]. Therefore, it became necessary to treat the bacterial injury responsible for those lesions in order to avoid "the occurrence of such complications and to stop foot diabetes. Early diagnosis of microbial injuries contributes to the direction and success of antibiotic therapy. From this view, a microbial study had to be carried out in the city of Al-Muthanna province for foot diabetes damage. Patients with diabetes mellitus frequently experience foot issues, which contribute to their morbidity. Patients with type 1 or type 2 diabetes may have a 34 percent lifetime risk of developing a foot ulcer [6-7]. These findings highlight the value of routine foot examinations in diabetes patients to identify those at risk for foot ulceration and other symptoms [8]. 

For antimicrobial therapy and to guide the development of novel therapeutics, a deeper understanding of the microbiology of diabetic foot infections is essential [9,20]. The microbiological analysis of diabetic foot infections and their patterns of susceptibility to antibiotic therapy have been extensively studied in the literature and are available in a number of articles from all over the world. The province of Al-Muthanna in Iraq, however, lacks such information. A diagnostic investigation was conducted to determine the relative frequency of aerobic and anaerobic bacterial isolates cultured from community acquired diabetic foot injuries and to assess their pattern of antibiotic susceptibility to the commonly used antibiotics.

During this study, 51 people with foot diabetes were studied and monitored throughout Al-Muthanna province (from Feb. 2019 to Oct. 2020). Most of these injured were reviewed at Samawah general hospital and private hospitals, some of whom were clinically diagnosed with "the presence of foot lesions and dependent on" the presence of these lesions. They were divided according to the degree of injury, where we were given the symbol 0, a reference to the absence of ulcers with the occurrence of thickness in the tissue and the appearance or abnormalities of bone. Grade 1 indicates the presence of surface ulceration of the toe, while grade 2 indicates deep blistering without reaching the bone. The grade 3 is the appearance of revised abscesses which include the bone, the grade 4 to include topical gangrene, and grade 5 to include full gangrene of the foot [10]. Ulcer swabs were used to examine abscesses surrounding the blisters if any. Moreover, damaged substances were also collected from dead tissue for aerobic and anaerobic culture [3].

A Gram stain test was conducted directly on the samples while they were cultured on the blood agar, MacConkey agar, and Thioglycolate broth with Robertson cooked meat agar. The culture included samples of cell and gangrene death. It was also performed on the lysed blood agar supplement with vitamin K, Neomycin blood media, and egg yolk media for anaerobic culture purposes [4].

The bacterial isolates were diagnosed with biochemical tests, as was the application of the Nagler reaction test to diagnose Clostridium perfringes [18], which is based on the use of the anti-gangrene serum. the study also examined the Antibiotic susceptibility for diagnosed bacterial isolates using the antibodies (Ciprofloxacin, Cloxacillin, Pefloxacin, Amikacin, Gentamicin, Cefotaxime) as recommended method of kirby-Baurt [3].

The majority of people with diabetic feet were males 33 males and 18 females, aged 36-62. The infected subjects were divided according to the "degree of injury," where the number of infected people was in division 0,1,2,3,4,4,5 and 22,14,6,4,3,2, respectively, in Table 1.

The bacterial cultures showed 60 aerobic growth isolates while the number of anaerobic isolates was only four for two patients, one had gangrene and the other had cell death, Table 2. Bacterial isolates of various degrees of injury, whether ulcers, cell death or gangrene, varied from one isolation (single) to two isolations, and sometimes more than three isolations for each bacterial culture. Isolation was present in 13 out of 36 infected people suffering from ulcers and cell death, while co-isolates of bacterial culture (more than two) were in 26, and on the other hand, some bacterial cultures showed negative findings for 12 infected people with ulcers. gangrene's wet feet included 5 of the total patients, of whom Clostridium perfringes and Bcteriodes fragilis were isolated as mixed aerobic bacteria.

Table 1: Distribution of Positive Bacterial Isolates by Degree of Lesion

Table 2: Frequency of Bacterial Isolates Related to Lesion Type

Table 3: Percent of Antibiotic Susceptibility Testing Related to Bacteria Type

Antibiotic susceptibility for those isolates was conducted where some isolators showed the effect of antibiotics ( Ciprofloxacin, Cloxacillin, Pefloxacin ) with 62.5% Proteus spp. 80% Pseudomonas spp. 83% Klebsiella spp. 80% Enterobacter spp. 80% for Staphylococcus spp, 90% for E. coli, noting that all aerobic bacteria were sensitive to anti-Amikacin and Gentamicin except for two Pseudomonas spp. Also, the aerobic and anaerobic bacteria showed the effect to anti-Cefotaxime (Table 3).

The present study showed the results that there were thirty-six infected subjects with preliminary ulcers, 10 with cell death, and 5 with gangrene, varied in isolation ratios. The type and severity of isolation varied, resulting from delays in diagnosis of injuries associated with diabetes or inadequate treatment after the microbial diagnosis, causing injury to deteriorate at the stage of ulcers to cell death and gangrene. So the impact factor in this injury occurs when crossing the blistering phase in which the injured tissue becomes a symptom of another pathogen or the tissue may develop three or more pathogens [10]. These results showed that the majority of patients had uncontrolled hyperglycemia and had a higher propensity for ulceration and cellular death, this agreed with studies carried out in India, Germany, and the USA [22, 27, 21], among other countries. This suggests that glycemic control should be taken as being important. Therefore, patients with diabetic foot ulcers will experience a lower risk of injury when their glucose is under optimal control. The results of this study showed that ulcers and cellular death symptoms were more common in diabetic foot patients than other symptoms associated with gangrene (Table 1), This study was in line with the research done by Fahrun Nur Rosyid [23]. Another study found that mono- and poly-microbial infections accounted for 44.4% of all infections. A South Indian study found that mono-microbial infections had a prevalence rate of 56%, which was higher than that of poly-microbial infections (44%). [24, 25]

Gram-negative bacteria predominated over gram-positive bacteria (Staphlococcus spp. 36%) in this study's microbiological evaluation of diabetic foot infections (Proteus spp. 13.3%, Pseudomonas spp. 16.7%, E. coli, 16.7%, Enterobacter spp. 8.3%, Klebsiella spp. 6.7%). which agreed with earlier studies.[5,11]. Gram-negative organisms were more common than gram-positive aerobes (63.8%, 65/102), according to a previous study (36.1%, 37/102). [11].

Gram-positive bacteria were more prevalent in Grades 0, 1, and 2 while Gram-negative bacteria and mixed infections were more noticeable in Grades 3, 4, and 5. This finding suggests that Gram-negative infections are more severe [26]. The same results were obtained by other studies. [12, 13]. In contrast, a different study conducted by AkoNai et al. [14] revealed that E. coli is the most common bacteria whereas Osariemen et al. [15] claimed that P. aeruginosa was the most prevalent pathogen. In anaerobic culture, Bacteroides fragilis and Cl. perfringes, both isolated from diabetic feet in grade 5, accounted for 25% and 27%, respectively, of the obligate anaerobes. Both aerobes and anaerobes were frequently involved in polymicrobial infections, according to this study and others [16, 17].

The results of the antibiotic susceptibility examination also indicate that all aerobic isolates have shown the effect of the antibodies under consideration, so they have given antibodies (Cefotaxime, Amikacin, and Gentamicin) the results of an effective antibiotic susceptibility (100%), While the results of the antibiotic susceptibility examination of antibiotics (Ciprofloxacin, Cloxacillin, and Pefloxacin) showed equal and lesser sensitivity, it was recommended that these antibodies be administered to those with ulcers due to their lower side symptoms [3]. 

Therefore, Ciprofloxacin and Cloxacillin were used to dose their sufferers for 10 to 15 days, and those with Cefotaxime were injected for 10 days as the growth of Proteus spp. was observed to decrease. Although it is worth noting here that anaerobic bacteria do not appear during the phase of ulcers, and this corresponds to Bailey [4].

From this study, we conclude that an abscess culture and conducting continuous antibiotic susceptibility screening for diabetes feet play an important role in the treatment of injury in patients with cell death and gangrene. Another important observation here is that bacterial culture helped 36 sufferers prevent injury deterioration and complications such as cellular death and gangrene.

1. Frykberg, R.G. “Diabetic foot ulcers: Current concepts.” Journal of Foot and Ankle Surgery, vol. 37, no. 5, 1998, pp. 440–446.

2. Shea, K.W. “Antimicrobial therapy for diabetic foot infections: A practical approach.” Postgraduate Medicine, vol. 106, no. 1, 1999, pp. 85–94.

3. Smith, J.M.B. et al. “Diabetic foot lesions of skin and soft tissue infections of surgical importance.” The Surgeon’s Guide to Antimicrobial Chemotherapy, 2002, pp. 218–221.

4. Bailey, T.S. et al. “Patterns of foot examination in a diabetes clinic.” American Journal of Medicine, vol. 78, no. 3, 1985, pp. 371–374.

5. Anandi, C. et al. “Bacteriology of diabetic foot lesions.” Indian Journal of Medical Microbiology, vol. 22, no. 3, 2004, pp. 175–178.

6. Armstrong, D.G. et al. “Diabetic foot ulcers and their recurrence.” New England Journal of Medicine, vol. 376, no. 24, 2017, pp. 2367–2375.

7. Walsh, J.W. et al. “Association of diabetic foot ulcer and death in a population-based cohort from the United Kingdom.” Diabetic Medicine, vol. 33, no. 11, 2016, pp. 1493–1498.

8. Singh, N. et al. “Preventing foot ulcers in patients with diabetes.” JAMA, vol. 293, no. 2, 2005, pp. 217–228.

9. Sloan, G. et al. “Pathogenesis, diagnosis and clinical management of diabetic sensorimotor peripheral neuropathy.” Nature Reviews Endocrinology, vol. 17, no. 7, 2021, pp. 400–420.

10. Balzer, K. and M. Heidrich. “Diabetische gangrän am fuß.” Der Chirurg, vol. 70, no. 7, 1999, pp. 831–844.

11. LoGerfo, F.W. and J.D. Coffman. “Vascular and microvascular disease of the foot in diabetes: Implications for foot care.” New England Journal of Medicine, vol. 311, no. 25, 1984, pp. 1615–1619.

12. El-Tahawy, A.T. “Bacteriology of diabetic foot.” Saudi Medical Journal, vol. 21, no. 4, 2000, pp. 344–347.

13. Goh, T.C. et al. “Clinical and bacteriological profile of diabetic foot infections in a tertiary care.” Journal of Foot and Ankle Research, vol. 13, no. 1, 2020, pp. 1–8.

14. Ako Nai, A.K. et al. “Characterization of bacterial isolates from diabetic foot infections in Ile-Ife, Southwestern Nigeria.” The Foot, vol. 16, no. 3, 2006, pp. 158–164.

15. Osariemen, I.J. et al. “Aerobic bacteria associated with diabetic wounds in patients attending clinic in a rural community in Nigeria.” Global Research Journal of Microbiology, vol. 3, no. 1, 2013, pp. 8–12.

16. Colayco, C.A.S. et al. “Microbiologic and clinical profile of anaerobic diabetic foot infections.” Philippine Journal of Microbiology and Infectious Diseases, vol. 31, 2002, pp. 151–160.

17. Banoo, S. et al. “Bacterial and clinical profile of diabetic foot patients.” Annals of Tropical Medicine and Public Health, vol. 5, no. 2, 2012.

18. Zubair, M. et al. “Clinico-bacteriology and risk factors for the diabetic foot infection with multidrug resistant microorganisms in North India.” Biology and Medicine, vol. 2, no. 4, 2010, pp. 22–34.

19. Andersen, C.A., and T.S. Roukis. “The diabetic foot.” Surgical Clinics of North America, vol. 87, no. 5, 2007, pp. 1149–1177.

20. Cancienne, J.M. et al. “The association of perioperative glycemic control with deep postoperative infection after anterior cervical discectomy and fusion in patients with diabetes.” World Neurosurgery, vol. 102, 2017, pp. 13–17.

21. Pscherer, S. et al. “Amputation rate and risk factors in type 2 patients with diabetic foot syndrome under real-life conditions in Germany.” Primary Care Diabetes, vol. 6, no. 3, 2012, pp. 241–246.

22. Nelson, R.G. et al. “Lower-extremity amputations in NIDDM: 12-year follow-up study in Pima Indians.” Diabetes Care, vol. 11, no. 1, 1988, pp. 8–16.

23. Rosyid, F.N. “Etiology, pathophysiology, diagnosis and management of diabetics’ foot ulcer.” International Journal of Research in Medical Sciences, vol. 5, no. 10, 2017, pp. 4206–4213.

24. Sekhar, S.M. et al. “Antimicrobial susceptibility pattern in diabetic foot ulcer: A pilot study.” Annals of Medical and Health Sciences Research, vol. 4, no. 5, 2014, pp. 742–745.

25. Sugandhi, P. and D.A. Prasanth. “Bacteriological profile of diabetic foot infections.” International Journal of Innovative Research in Science, Engineering and Technology, vol. 3, 2014, pp. 14688–14692.

26. Chahine, E.B. et al. “Diabetic foot infections: An update on treatment.” U.S. Pharmacist, vol. 38, no. 4, 2013, pp. 23–26.

27. Jain, S.K. and R. Barman. “Bacteriological profile of diabetic foot ulcer with special reference to drug-resistant strains in a tertiary care center in North-East India.” Indian Journal of Endocrinology and Metabolism, vol. 21, no. 5, 2017, pp. 688.

28.