Invest Clin 62(3): 276 - 289, 2021 https://doi.org/10.22209/IC.v62n3a07

Corresponding author: Karla Alejandra Vizcarra Zevallos. Escuela Profesional de Medicina Humana, Universidad

Privada San Juan Bautista, Chorrillos, Lima, Perú. Telephone: 051926546720. Email: karla.vizcarra@upsjb.edu.pe

The landscape of diabetic foot in Peru.

Ericka Saravia-Hernández

, José Salvador-Carrillo

2,3

, Alejandra Zevallos

and Jorge Calderón-Ticona

4,5

Escuela Profesional de Medicina Humana, Universidad Privada San Juan Bautista,

Chorrillos, Lima, Perú.

Escuela Profesional de Medicina Humana, Universidad Privada San Juan Bautista,

Chincha Alta, Ica Perú.

Universidad Privada San Juan Bautista, Av. José Antonio Lavalle, Chorrillos, Lima,

Perú.

Hospital Nacional Arzobispo Loayza, Lima, Perú.

Facultad de Medicina “San Fernando”, Universidad Nacional Mayor de San Marcos,

Cercado de Lima, Lima, Perú.

Key words: diabetic foot; diabetes mellitus; Peru; Public Health.

Abstract. Diabetic foot (DF) is one of the main complications responsible

for the significant deterioration of the quality of life in diabetic patients, par-

ticularly, in developing countries. In Peru, 18.9% of diabetic inpatients present

DF and 61% develop a foot sepsis. Therefore, the burden of DF is considerable

in the country. In this work, we summarize the current scientific evidence of DF

in the Peruvian population describing its epidemiology, risk factors, increase

of time of hospitalization, bacterial resistance, rate of amputations, and the

theoretical medical costs for disease management. According to the reviewed

literature, we suggest that more local research should be conducted to better

understand the impact of the DF on the Peruvian population.

Diabetic foot in Peru 277

Vol. 62(3): 276 - 289, 2021

El panorama del pie diabético en el Perú.

Invest Clin 2021; 62 (3): 276-289

Palabras clave: pie diabético; diabetes mellitus; Perú; Salud Pública.

Resumen. El pie diabético (PD) es una de las principales complicaciones

responsables del deterioro de la calidad de vida de los pacientes diabéticos, par-

ticularmente en países en vías de desarrollo. En Perú, el 18,9% de los pacientes

diabéticos hospitalizados presentan PD y el 61% desarrolla una sepsis del pie.

Por lo tanto, la carga de PD es considerable en el país. En el presente trabajo, se

ha resumido la actual evidencia científica sobre el PD en la población peruana

de esta manera, describiendo su epidemiología, factores de riesgo, incremento

en el tiempo de hospitalización, resistencia bacteriana, tasa de amputación y el

costo médico teórico del manejo de esta patología. De acuerdo con nuestra re-

visión de la literatura, se considera que más estudios locales deben ser conduci-

dos para mejorar el entendimiento del impacto del PD en la población peruana.

Received: 28-12-2020 Accepted: 04-05-2021

INTRODUCTION

Diabetes mellitus (DM) burden repre-

sents a serious problem for public health in

Latin America. In fact, it is expected that it

will affect up to 49.1 million people by 2045

(1). Diabetic Foot (DF) disease is considered

as one of the principal complications of DM

and it usually has a multifactorial origin.

Among its principal contributors are periph-

eral neuropathy and vascular disease, which

can be found in 10% of diabetic type 2 pa-

tients and can lead to foot ulceration (2,3).

The lifetime risk of developing at least one

diabetic foot ulcer is between 15 to 25% (4).

In general, this pathology is character-

ized by ulceration, infection or destruction

of foot tissue (5). More than half of diabetic

foot infections lead to foot ulcers, which

usually ends in lower extremity amputation

(6). Other complications that are often pres-

ent coupled with DF are nephropathy, reti-

nopathy, ischemic heart disease and cere-

brovascular disease (7,8). DF is attributed

for increasing hospitalization time, amputa-

tion rates, costs for the health system and

deterioration of the patient’s quality of life

(4,9–11).

To date, DF prevalence in DM patients

who were hospitalized is 18.9%, represent-

ing an important disease burden in Perú (12).

Therefore, this work aims to present a review of

the scientific data published about DF in order

to improve the understanding of the epidemiol-

ogy, clinical characteristics and the economic

impact of this pathology in the country.

In order to limit our research, we

looked for papers in SCOPUS, PubMed, Sci-

ELO, LILACS and Google Scholar databases

from January 1 to October 30, 2020. The

keywords used for the search were “diabetic

foot” AND “diabetic foot ulcer” AND “dia-

betes” AND “Peru” AND “epidemiology”. For

the Spanish database, equivalents keywords

were used according to the Health Sciences

Descriptors (DECS). Reference lists of all

the included papers were reviewed to iden-

tify potential papers.

Papers written in Spanish, Portuguese

or English were considered and studies in-

volving the Peruvian population were includ-

ed. We did not restrict the study´s design

278 Saravia-Hernández et al.

Investigación Clínica 62(3): 2021

(population-based, medical records review,

clinical-based, others) or the level (national

or regional) of the studies. Two investigators

reviewed the titles and abstracts of papers

independently. Relevant articles were select-

ed, and disagreements were discussed and

solved by the senior investigator.

DIABETIC FOOT EPIDEMIOLOGY

IN PERU

According to the World Health Orga-

nization (WHO) DF is an infectious process

which leads to the destruction of deep tis-

sue of the feet, associated with neurological

abnormalities, such as loss of sensitivity to

pain, and peripheral vascular disease of vary-

ing severity in the lower limbs (13).

In Latin America, a cross-sectional and

multicentric study (from nine countries, in-

cluding Peru) found that the rate of DF in

11,357 inpatients (mean age 61.7 years)

was 14.8% (CI 95%; 14.1-15.4) (14). In Perú,

Yovera-Aldana et al. (12) reported that the

prevalence of DF inpatients was 2.8% (95%

CI: 2.4-3.1) and the prevalence among DM

inpatients was 18.9% (CI 95% 16.7–21.1).

In this study, 8,346 patients from 39 health

centers were included (age 62 ± 12 years).

On the other hand, Ramos et al. (15) de-

scribed that the rate of DF was 6% in DM

patients (including inpatients and outpa-

tients), leading as the second most frequent

complication in this population. This study

included 2,959 diabetic patients (57.2 ±

15.7 years) from 18 hospitals that belonged

to the diabetes surveillance system of Peru

during 2012.

Additionally, Lazo-Porras et al. (16)

showed an 18-month incidence in diabetic

patients at risk of foot ulcers (risk groups

2 or 3 according to the International Work-

ing Group on the Diabetic Foot (IWGDF)).

DF ulcers cumulative incidence was 17.7%

(28/158) in the total sample (mean age 61

years); however, it was higher among pa-

tients with a history of previous ulceration

(27.8%, 25/90).

In literature, these papers were the only

ones that described the prevalence and in-

cidence of DF among Peruvian diabetic pa-

tients; nevertheless, more studies should be

conducted to improve the understanding of

the epidemiological situation of DF in vul-

nerable populations (17,18).

DF represents one of the main causes of

hospitalization due to infections in diabetic

patients, especially in elderly patients with

long standing illness (19). It is estimated

that DF is the cause of approximately 50%

of diabetes-related hospital admissions (20).

In a study made in Peru, from an analysis

of 1,230 admissions of diabetic patients in

a tertiary care public hospital, it was found

that DF was the most common cause of hos-

pitalization, which accounted for up to 20.5%

of the total analyzed samples (21). Similarly,

Gonzales-Grández et al (22) found that DF

infection was the second leading cause of

hospitalization (20.8%) in 424 diabetic pa-

tients (40.6% over 65 years). These results

are lower than those reported in other coun-

tries (20,23,24), but similar to other studies

carried out in South America such as Brazil,

where complications related to DF were the

cause of 18.2% of all hospital admissions in

diabetic patients (25).

The DF patient’s quality of life is deeply

affected across familial, economic, and social

levels (25,26). Amputation by DF not only

causes disability, functional impairment or

consequential dependence on relatives (27),

but it also leads the patient to develop emo-

tional disorders such as depression (28).

RISK FACTORS ASSOCIATED

WITH DIABETIC FOOT

Risk factors play an important role in

the pathology of DF since they are related to

its evolution and complications. In Peru, risk

factors has been described in some studies

such as peripheral neuropathy (PN), periph-

eral vascular disease (PVD), disease time,

inadequate glucose control, comorbidities,

among others (26,27). The most frequent

Diabetic foot in Peru 279

Vol. 62(3): 276 - 289, 2021

factors associated with DF in the Peruvian

population are described below:

Peripheral Neuropathy

This pathology is one of the main com-

plications of DM and is one of the most com-

mon risk factors for the development of DF.

It can be found in up to 69% of diabetic pa-

tients and it is directly associated with the

long-standing DM (28). In Perú, the fre-

quency of PN among patients with DF can

depend on some factors, such as time of dis-

ease and type of patient care (outpatient vs

inpatient). Torres-Aparcana et al. (27) found

that PN was present in 95% of all the hos-

pitalized diabetic patients in a tertiary care

public hospital (n=166; 59.4 ± 12.0 years).

The average time of disease was 12.5±8.1.

On the other hand, Damas-Casani et al (29)

found that just 35% of total ambulatory pa-

tients (n=370; 60.3 ± 11.1 years) presented

PN. In this study, 60% of patients had more

than 5 years since the diagnosis of the dis-

ease. Additionally, PN was defined differently

in both studies.

A case-control study carried out by Ar-

ribasplata and Lena-Muñoz (26) showed a

significant association between DF with PN

(OR: 2.88, 95% CI: 1,45 – 5,72) in univariate

analysis. However, this association was not

observed in multivariate analysis (p>0.05).

The sample (n=165) comprised patients

treated at the Endocrinology Service in a

tertiary care public hospital. PN was present

in 69% of them. Furthermore, 70.3% of pa-

tients were older than 60 years and 70.9% of

the subjects had a diabetes diagnosis of over

10 years. The criteria to identify peripheral

neuropathy was not disclosed by the authors.

Peripheral vascular disease

Patients with DM have a high risk of de-

veloping PVD. This complication alone can

rarely cause ulceration, but when PVD is pres-

ent with NP and a minor trauma, this can lead

to tissue breakdown (30) and critical compli-

cations such lower limb amputation (31,32).

Torres-Aparcana et al (27) also described the

frequency of PVD in their retrospective cross-

sectional study. This pathology was present in

51.2% of all the patients (n=166; 59.4 ± 12.0

years). In addition, PN was the most frequent

co-morbidity in patients with PVD (88.2%).

Damas-Casani et al (29) found that PVD was

present in 38% of the total patients (n=370;

60.3 ± 11.1 years) who were treated at the

Diabetic Foot Unit of a tertiary care public

hospital. These different outcomes may be ex-

plained through patient´s characteristics as

well previously commented in the PN section

(time of disease and type of patient care).

These differences were consistent with anoth-

er study that evaluated 301 diabetic patients

attended in a tertiary care public hospital in

the city of Trujillo, a northern Peruvian city.

PVD was present in 18.6% of all the patients,

but it was present in 89% of the patients who

were over 50 years old, and 61.5%, with a time

from diagnosis higher than 5 years (33).

In the study of Arribasplata and Lena-

Muñoz (26), PVD was reported in 56.4% of

DF patients and a significant association

was found between those two variables (OR

= 2.54; 95% CI = 1.31 - 4.94) in univariate

analysis. Nevertheless, similarly to PN, this

association was not observed in multivari-

ate analysis. For a more detailed information

about population baseline characteristics,

the PN section summarized this data.

Time of disease from diagnosis

The time of disease is a critical factor

associated with DF degree of severity. Torres-

Aparcana et al (27) found that the average

time from the diagnosis of diabetes to the

appearance of the first lesion in the foot was

12.5 ± 8.1 years in hospitalized patients

(n=166; 59.4 ± 12.0 years). Studies carried

out in developing countries reported simi-

lar data (24,34,35); however, in developed

countries, the time to the first lesion is high-

er (19,36,37). As a matter of fact, DF time

to disease is delayed in developed countries

due to higher education levels and broader

access to adequate treatment and health

care services (38).

280 Saravia-Hernández et al.

Investigación Clínica 62(3): 2021

In Latin America, a multicenter study

executed in 1,677 hospitalized patients

who had DF (14), reported a median time

of disease of 10 years. Furthermore, it found

that patients with lesions 0 and 1, accord-

ing to the Wagner scale, had shorter time

from diagnosis when compared to patients

with Wagner lesions ≥2 (p<0.001). Seven

Peruvian public hospitals of 135 Latin Amer-

ica health centers contributed towards this

study (14). The population average age was

61.7 years.

Additionally, in the work by Arribaspla-

ta-Espinoza and Luna-Muñoz (26), multi-

variable analysis evidenced that people with

a time of disease greater than 10 years had

a higher risk for developing DF in this study

(OR: 12.77, 95% CI: 4.12 - 39.60).

Inadequate glucose control

Poor long-term glucose control is criti-

cal for the development of diabetic foot ul-

ceration and other complications (35,36).

Although this fact is important for the man-

agement and prevention of DF in diabetic

patients, developing countries do not usu-

ally have a health care system that ensures

adequate glucose control in their popula-

tion (38).

In Peru, a study carried out in 18 Pe-

ruvians hospitals with 2,959 patients evalu-

ated glycated hemoglobin (HbA1c) and fast-

ing glycemia levels at two time points: at the

time of enrollment and the last follow-up vis-

it. The outcomes showed that 73.4% of all pa-

tients had levels ≥ 7.0% HbA1c while 63.5%

had values ≥ 130 mg/dL of glycemia. The av-

erage time from diagnosis in this population

was 5.6 years, and the average age was 57.2

± 15.7 years old (15). Furthermore, this

work showed the rate of treatment abandon-

ment in Peruvian diabetic patients (65.3%)

and the high frequency of inadequate glu-

cose control within them.

Inadequate glucose control in diabetic

patients has also been associated with DF. In

the study of Arribasplata and Lena-Muñoz

(26) it was found that patients with poor

HbA1c management presented a risk of 6.2

times higher for DF development (95% CI =

1.79-21.41) in multivariate analysis.

Comorbidities

The presence of other comorbidities

leads to an increased risk for the develop-

ment of DF. Nevertheless, only one work

considered them in its analysis in Peruvi-

an medical literature. In this case-control

study, chronic kidney disease, obesity, ar-

terial hypertension, dyslipidemia, and ony-

chomycosis were present in 36.4%, 85.5%,

67.3%, 49.1% and 94.5% of total samples

(case group: 55 DF patients), respectively.

However, only chronic kidney disease (OR:

3.023, CI 95%: 1.014- 9.013) and ony-

chomycosis (OR: 7.1; CI 95%: 1.5-34.1)

increased the risk for DF in logistic re-

gression analysis. Obesity and arterial hy-

pertension were significant in univariate

analysis but not in multivariate analysis.

On the other hand, dyslipidemia behaved

as a protective factor (OR: 0.24; CI 95%

0.11 – 0.48)(26). The apparent contradic-

tion of these outcomes with the interna-

tional literature (35,36,39) may probably

be explained by the size of the samples. In

accordance with this, some variables had a

wide CI 95%. In this study, more than 70%

of total patients were older than 60 years

old and had a diabetes diagnosis of over

10 years.

Age of patients

The age of patients is also an important

factor in the development of DF. A cross-

sectional study that reviewed the medical re-

cords of 166 patients hospitalized due to DF

in a tertiary care public hospital found that

60.8% of the individuals were aged between

50 and 69 years old (27). Moreover, Arribas-

plata and Lena Muñoz (26) found that 70.3%

of DM patients (n=165) with DF were older

than 60 years. However, an age over 60 years

was not significantly associated with the de-

velopment of DF (p = 0.22).

Diabetic foot in Peru 281

Vol. 62(3): 276 - 289, 2021

PROLONGED LENGTH OF STAY

IN HOSPITAL

DF is usually the main reason for the

admission of diabetic patients in hospitals

and it has a significant socioeconomical im-

pact in the health care system budget (40).

Hospital length-of-stay tends to be longer in

diabetic patients with DF. According to the

National Diabetes Foot Care Audit (NDFA)

Hospital Admissions Report 2014-2017 (41),

more than 95,000 hospital bed-days were oc-

cupied by DF patients, and median hospital

length-of-stay for major amputation was 25

days. Another report showed that the length-

of-stay for inpatients with DF is longer than

those without diabetes (median stay: 8

nights vs 5 nights, respectively) and it repre-

sented 5,912,837 bed-days per year (4).

In Latin America, a multicenter study

made with 11,357 DF patients from 135

health centers (seven health centers from

Peru reported that the median length of hos-

pital stay was 10 days (14). In Peru, a lon-

gitudinal observational study found that DF

patients (n=424) spend longer periods of

time hospitalized among the diabetic inpa-

tients (average of 21.2 days and a maximum

stay of 90 days). In this population, the me-

dian age and time from diagnosis was 64 and

9.5 years, respectively. Furthermore, more

than half of the patients had some diabetes

complication. These risk factors were prob-

ably the reason for the higher length of hos-

pitalization in this study (22).

Similar outcomes were found in a

retrospective study in three tertiary care

public hospitals in Cusco, a southern re-

gion of Peru. The median of hospital days

of diabetic patients with DF (20 days, in-

terquartile range (IQR): 14 - 31 days) was

higher in comparison to those without DF

diagnosis (9 days, IQR: 5 - 14 days). An

increase in the number of hospitalization

days (17 days more, 95% CI = 5.7-28.3

days, p = 0.003) was attributed to DF. The

median age and time from diagnosis of

this population (n=153) were 61 and 13

years, respectively (42).

On the other hand, Torres-Aparcana

et al (27) found different hospital length-

of-stays among 166 patients with DF at-

tended in other public hospitals. Patients

who received only medical treatment pre-

sented an average hospital length-of-stay

of 13.32 ± 12.0 days, which was consider-

ably lower than those who underwent some

type of surgical treatment [32 ± 13.4 days

(p <0.001)]. In this population, the aver-

age age and time of disease was 59.4 ± 12

years and 12.5 ± 8.1 years, respectively.

The increase of hospital length-of-stay in

an operatively treated DF patient in com-

parison with a non-operatively treated DF

patient was consistent with other studies

(43,44).

BACTERIAL RESISTANCE IN PATIENTS

WITH DIABETIC FOOT

Infections are one of the main causes

of hospitalizations, amputations, and death

in patients with DM in Peru, and DF is one

of the most frequent types of infections

(22,45–47). When a patient with infected

DF is attended, they are first empirically

treated a then sampled in order to provide

a personalized treatment based on culture

and antibiogram results. However, the deci-

sion-making process might become complex

according to bacterial resistance and the

population-based clinical evidence available,

as well as the severity of the infection, previ-

ously prescribed antibiotics, and stock avail-

ability in the hospital (48).

A retrospective and descriptive work

carried out at a third-level public hospital

evaluated the infection of DF in 95 patients

(average age 61.7 ± 11.6 years and time

from diagnosis 10.75 ± 7.9 years). In this

work, 109 infection events were identified,

and 132 bacteria strains were isolated. Gram

(+) bacteria were isolated in 73 cases (55%),

in which Staphylococcus aureus was the

282 Saravia-Hernández et al.

Investigación Clínica 62(3): 2021

most frequent (48%). Among the remaining

cases, the most frequent Gram (-) bacteria

were Escherichia coli (49%). When suscepti-

bility to antibiotics was analyzed, S. aureus

was sensitive to clindamycin, oxacillin, and

vancomycin in 25%, 32%, and 100% of the

cases, respectively. Imipenem was 100% ef-

fective against bacteria from the genus En-

terobacteriaceae and Pseudomonas aerugi-

nosa. On the other hand, 0% sensitivity was

found for some antibiotics in the case of P.

aeruginosa against ceftriaxone and aztreo-

nam, and Enterococcus spp. for clindamycin

and oxacillin. Patients with DF who belong

to risk groups 1 to 3, according to the Wag-

ner scale, had an increased risk of being in-

fected with Gram (+) bacteria rather than

with Gram (-) (OR = 3.11, 95% CI: 1.2-7.8).

In addition, patients with DF which presents

neuropathy or vascular diseases concomi-

tantly, had a higher risk of infection by Gram

(+) germs with resistance to oxacillin (OR

= 8.2, 95% CI = 1.5-43.5 and OR = 6.3, 95%

CI = 1.2-32.4, respectively) (49).

Another cross-sectional study evaluated

bacterial resistance and associated factors in

88 patients with infected DF with no major

amputation outcomes, attended at a third-

level public hospital. The average age of the

patients was 60.6 ± 12 years with a medi-

an time from diagnosis of 15 years. Among

them, patients classified as grades 3 and 4

in the Wagner scale were the most frequent

(39.8% and 40%, respectively). Polymicrobial

cultures represented 42% of the total and the

most frequently isolated bacteria were Esch-

erichia coli (23.4%), Enterococcus faecalis

(14.1%) and Staphylococcus aureus (13.3%).

In terms of antibiotic resistance, 33% of En-

terobacteriaceae were beta-lactam resistant

and Extended-Spectrum Beta-lactamases

(ESBL) producers. On the other hand, Gram

(-) bacteria such as P. aeruginosa and A. bau-

manii were highly resistant to carbapenem

agents (83% and 100%, respectively). Inter-

estingly, no cases of vancomycin resistance

in S. aureus or E. faecalis were reported. The

presence of ESBL positive bacteria was as-

sociated with a previous DF infection, high

levels of C-reactive protein (PCR) and scores

in the Laboratory Risk Indicator Necrotizing

fasciitis (LRINEC) higher than 6, when com-

pared to patients carrying ESBL negative

bacteria (p < 0.05). The presence of positive

methicillin-resistant S. aureus (MRSA) was

only associated with high CRP values in dia-

betic patients (p < 0.05) (46).

Another third cross-sectional study re-

viewed the medical records of 5007 patients

with infected DF, and the aerobic cultures

data was treated in the Diabetic Foot Pro-

gram of a Peruvian public hospital (average

age 60.7 ± 12.2 years, but time from diag-

nosis was not detailed). A total of 652 mi-

croorganisms were isolated: 407 Gram (-)

and 245 Gram (+) bacteria were identified.

There were reported microorganisms with

more than 90% of antibiotic sensitivity to

vancomycin, teicoplanin, meropenem, and

ertapenem. On the other hand, microorgan-

isms were also found with more than 80%

of antibiotic resistance to cotrimoxazole,

amoxicillin, dicloxacillin, oxacillin, penicil-

lin, cephalexin, and amoxicillin/clavulanic

acid. Unlike the two aforementioned studies

(46,49), this work did not conduct addition-

al analysis (50).

These three studies (46,49,50) were

the only papers found in Medical Litera-

ture that describe bacterial resistance in

the Peruvian population with DF. The bac-

terial resistance was different among pop-

ulation studies, possibly due to unequal

patients’ conditions, the severity of DF,

previous infections, and presence of co-

morbidities. We grouped the microorgan-

isms with total bacterial resistance to at

least one antibiotic found in these works

in a heat map (Fig. 1).

AMPUTATION OF THE DIABETIC FOOT

Amputation patients represent pro-

longed hospital length-of-stay, increased by

high dependency/Intensive Care Unit, mul-

tiple readmissions and a critical cost of pa-

Diabetic foot in Peru 283

Vol. 62(3): 276 - 289, 2021

tients for public health (43). The lower-limb

amputation in diabetic patients is eight

times higher than in nondiabetic individuals

(51) and approximately 85% of all amputa-

tions are preceded by DF ulceration (52). In

addition, it is reported that every 30 seconds

one leg is amputated due to DF ulceration

worldwide (20).

In Perú, most of the limb amputations

occurred in lower-limb amputation (78.1%)

and it is caused mainly by diabetic angiopa-

thy (53). During the period 1989-1997, the

frequency of amputation among DF patients

was 61% (n= 206 DF inpatients, mean age

was 61.4 years (range 27.-86)) (47). Inter-

estingly, another study conducted at the

Fig. 1. Microorganisms with total bacterial resistance to at least one antibiotic found in patients with diabetic

foot, attended at three hospitals of Peru. Microorganisms with 100% bacterial resistance to at least

one antibiotic found in Peruvian patients with infected DF attended at three hospitals (46,49,50) were

considered for this heatmap. Green to red gradient depicting resistance to antibiotics (0 to 100%).

No data for microorganisms/antibiotic matches is represented by grey background. Pip/Taz: pipera-

cilin/tazobactam; Tic/Cla: ticarcilin/ clavulanic acid; PV: Proteus vulgaris; KP: Klebsiella pneumo-

niae; MM: Morganella morganii; CF: Citrobacter freundii; ECI: Enterobacter cloacae; PA: Pseudomonas

aeruginosa; AB: Acinetobacter baumannii; EF: Enterococcus faecalis; SA: Staphylococcus aereus; Ent:

Enterococo spp.

284 Saravia-Hernández et al.

Investigación Clínica 62(3): 2021

same institution reported an increase of

overall rate amputation to 64% in the period

of 2006-2008 (n=166 DF inpatients, mean

age was 59.4±12.0 years) (27). Despite that,

the major amputation rate decreased be-

tween both periods (from 69.05% to 59.2%).

The reduction of the major amputation rate

is probably due to an improvement in the

early approach to DF patients, as well as the

effect of multidisciplinary actions; however,

more studies are necessary to confirm this

hypothesis.

The cornerstone of DF patient care to

reduce the amputation rate is the early iden-

tification of the risk factors associated with

this endpoint in the population. Local knowl-

edge of these factors and their influence on

this outcome is critical for multidisciplinary

teams to develop adequate management and

treatment plans for their population (54);

however, in Peru, few studies have been con-

ducted to study these factors. Risks factors

to amputation in Peruvian DF patients were

summarized in Table I; however, these stud-

ies showed some limitations such as sample

size (55,56).

COST OF DISEASE IN PATIENTS

WITH DIABETIC FOOT

As previously commented, DF-related

complications represent a high human

TABLE I

RISK FACTORS ASSOCIATED WITH DIABETIC FOOT AMPUTATION IN THE PERUVIAN POPULATION.

AUTHORS POPULATION RISK

FACTORS FOR

AMPUTATION

TYPE

OF STUDY

FREQUENCY OR

(95% CI)

Nicho L.

et al (57)

218 Time from

diagnosis

(> 10 years)

Case-control 88.10% 3.21 (1.58 – 6.51)

Male gender 87.20% 2.46 (1.22 – 4.97)

Inadequate

glucose control

(≥100 mg/dL)

52.30% 3.68 (2.06 – 6.60)

Wagner score of

lesion severity

(grade 4)

79.80% 5.62 (3.08 – 10.28)

Torres H.

et al (26)

166 Peripheral

vascular disease

Cross-sectional 84.70% 6.59 (3.03 – 14.33)

Vidal-

Domínguez

(56)

91 Time from

diagnosis

(> 10 years)

Case-control 77.80% –

Wagner score of

lesion severity

(grade 4)

77.80% 7.79 (3.12 – 20.53)

Absence of pulse

only in pedial and

posterior tibial

arteries

73.3% 7.79 (3.07-19.80)

Diabetic foot in Peru 285

Vol. 62(3): 276 - 289, 2021

and financial cost for health systems and

society. In England, the cost of health

care for ulceration and amputation in dia-

betes during 2014-2015 was estimated at

between £837 million and £962 million;

and it represented 0.8% to 0.9% of the Na-

tional Health Service (NHS) budget (57).

In Brazil, the direct medical costs related

to DF ulceration was estimated at US$180

million in 2014 (58). On the other hand,

in Peru, the direct annual cost of preven-

tion and management attributable to DF

patients at high-risk ulceration was calcu-

lated at $ 74.5 million in the sub-optimal

care system in 2012 (59); however, the

comparison of cost for this pathology be-

tween developing and developed countries

is difficult to perform.

Also, the authors calculated the di-

rect annual cost of prevention and man-

agement of DF patients in two different

care systems: a standard care system ac-

cording to the International Diabetes Fed-

eration (IDF), and an intensive strategy

based on standard care plus temperature

monitoring. Both were compared with the

sub-optimal care system. The implementa-

tion of the first system in Peru decreases

the cost-of-illness by $ 71.8 million dollars

with the prevention of 791 deaths. On the

other hand, with the implementation of

the second care system, the cost increases

to $ 96.8 million dollars, but 1,385 deaths

can be halted.

These results show that the current

sub-optimal care system is not cost-effec-

tive and death by diabetic foot can be pre-

ventable; however, this study has various

limitations due to the lack of reliable in-

formation to estimate some costs as mo-

bilization costs and waiting time, among

others. In the light of the theoretical esti-

mates, we suggest these results should be

verified.

LIMITATIONS OF PERUVIAN

LITERATURE

While the present review shows impor-

tant studies to understand the impact of the

DF on the Peruvian population and health

system, certain limitations should be ac-

knowledged regarding Peruvian literature in

DF: a) poorly labelled studies may have been

unintentionally omitted in the synthesis of

the Peruvian literature, since some papers

are not published in indexed journals in elec-

tronic databases. Greater investment in the

appropriate indexing of Peruvian research

in electronic databases is urgently required

(18,60). b) The majority of works are sin-

gle-center studies and focus on population

attended at hospitals of Lima (the capital

city). This fact makes the extrapolation of

the outcomes at national level difficult. c)

Finally, most of the studies analyzed clinical

charts of DF patients, provided data at only

one point of time and, in some cases, worked

with a small sample. Longitudinal and pro-

spective studies are required to improve the

level of evidence about this problem in Perú.

In general, the literature available in

Latin America about DF is scarce and pres-

ents similar limitations to those present in

the Peruvian studies (14,17,61).

CONCLUSIONS

Although early identification of risk fac-

tors for DF is crucial for its epidemiological

control, we have to face great challenges to

improve diagnosis, management and treat-

ment of these patients in Perú, to reduce

the medical and economic burdens of this

disease as it mainly becomes detrimental to

patients from low-socioeconomic status. In

addition, more national research should be

conducted to better understand the real im-

pact of DF on the Peruvian population.

286 Saravia-Hernández et al.

Investigación Clínica 62(3): 2021

ACKNOWLEDGEMENT

The authors would like to thank the

Universidad Privada San Juan Bautista for

the economic funding (N° 032-2019-VRI-UP-

SJB) to carry out this work.

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