Symposium

Burden of Diabetic Foot in the Western Pacific Region

Shigeo Kono
WHO-Collaborating Centre for Diabetes,
National Hospital Organization, Kyoto Medical Center
Kyoto – Japan

The number of diabetic foot lesions and amputations is increasing in the Western Pacific region
(WPR). However, there are quite a few foot care specialists such as podiatrists or chiropodists in WPR and
there is much ignorance amongst medical staff as to how to identify and educate those at risk and treat
those who develop problems. Furthermore, the regional characteristics of diabetic foot, especially the risk
factors for amputation and the methods of cost-effective interventions, remain unknown. In order to combat
against this devastating problem, we launched Kyoto Foot Meeting in 2006, International Diabetes
Federation (IDF)-Western Pacific Region (WPR) Diabetic Foot Care Project (IDF-WPR DFC) meeting in
2011 which was succeeded to Asian Association for the Study of Diabetes (AASD) Diabetic Foot Care
Project in 2016. Through these regional projects, we have held the training course of collected the clinical
data of diabetic foot from those countries in order to develop regional clinical guidelines directly applicable
to the regional lifestyle. We announced “Recommendation of Management of Diabetic Foot Ulcer from
AASD” at the annual meeting of AASD (Nagoya, Japan) in 2017. Besides the meetings, we held the
practical training course of diabetic foot care for doctors and nurses in Kyoto and Osaka, Japan. Since
2000, we have invited the doctors and nurses from various countries in WPR including Indonesia to our
hospital and visited many countries to share the knowledge and expertise in the management of diabetic
foot problems. In my presentation, I would like to introduce the regional diabetic foot problems, future
international medical collaboration, and strategy to save the limbs in WPR.

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Diabetic Foot in Indonesia

Sarwono Waspadji
Division of Endocrinology and Metabolism, Department of Medicine,
Dr.Cipto Mangunkusumo General Hospital / Faculty of Medicine Universitas Indonesia
Jakarta - Indonesia

The prevalence of diabetes mellitus is increasing tremendously toward global epidemic

throughout the globe, especially in African region, roaring to nearly 100% from the year 2013−2035.
Indonesia is estimated to have the seventh biggest diabetic population among top 10 countries, after
China, India USA, Brazil, Russia and Mexico. The DM prevalence in Indonesia is also increasing in line
with lifestyle changes, as especially seen in bigger cities in Indonesia. Latest Indonesia National Health
Survey 2018 showed that Jakarta has the highest prevalence rate (3.4%) as well as increasing rate (2013
to 2018) among other Indonesian regions. Leave untreated DM will cause huge problems as for its
macrovascular and microvascular complications, including diabetic foot problems. Diabetic foot is the
most devastating and dreaded complication of DM. Foot problems in diabetic patients account for higher
and longer hospital admission, high mortality, higher amputation rate leading to higher cost than any long-
term complications of DM. However, interest to deal with foot problems in Indonesia are still insuffcient
and there is currently no specific education / training to cope with diabetic foot problems (podiatrist-
chiropodist). More over patient’s ignorance and financial problems−insufficient financial support− make
the situation even worse.
In Cipto Mangunkusumo General Hospital Jakarta (2007−2009), 10−40% of the admission for
diabetics was due to diabetic ulcer/gangrene. Most of the patients were in their fourth−fifth decade of their
life. They came to the hospital mostly in very late state, even after the wound duration of more than 4
weeks. The precipitating factors were mostly mechanical, chemical and thermal although some wound
occured spontaneously. Many of them have some risk factors for the development of foot ulcer, including
foot deformities. Diabetic neuropathy were very prominent among them. (73% with monofilament test).
Impaired vascular was also prominent, only 50% of them had normal limb vascular profile. The duration of
suffering DM varied from 1−2 years to more than 18 years. The site of wound were mostly at the digital
and foreplantar sites. For the hospitalized-patients, 71% had very large wound and deep wound
(subdermis,fascia, muscle and tendon-78%) and even up to bone or joint (14%). Osteomyelitis was found
in 41% (inpatients) and 54% of the outpatients. The length of stay were mostly very long (41% for 30-45
days), even up to more than 60 days in 5% of them. The hospitalized-patients, were mostly presented with
uncontroled hyperglycemia (75.9%), anemia (54,8%) and hypoalbuminemia (51.7%). Many of them had
chronic diabetic complications both macrovascular and microvascular complications. Twenty four percent
of them had renal failure, 3% were on chronic hemodyalisis. As much as 40% had proliferative retinopathy
and some 9% were on laser therapy.
As for the outcome results, in 2009−2010, 62.5% improved, 20.8% underwent minor amputation
and 18.7% major amputation. These outcomes were much better as compared to the 2003 and 2007
results which were 16.1% and 14.3% patients died respectively. During the 2011−2012 observation we
had more or less similar characteristics, with much better and varied outcome (38.3% healed, 34% healed

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after Split Thickness Skin Grafting, 6.4 minor amputation. 2.1% major amputation and 4.3% died. There
were 14.9% of them had forced discharge.
The effort to save the limb is very costly; moreover if we take into account the indirect impact of
the diabetic foot problem. Therefore an attempt to prevent the occurrence of diabetic foot problems should
be the first priority of any diabetes management program. The miserable foot complications could be
prevented through a good diabetic education and other well-organized preventive measures. Neuropathy,
vascular insufficiency and infections are predisposing factors, which are very important for the
development of diabetic foot ulcer. In addition, trivial precipitating factors such as physical, thermal or
chemical trauma might cause diabetic wound. In the management of diabetic foot we follow the pathways
advocated by International Working Group on the Diabetic Foot 2007, namely metabolic control, infection
control, wound control, vascular control, pressure control and education control should be practiced
accordingly in multi-interdisciplinary teamwork. We have been able to follow the recommendation
accordingly as seen by better results achieved if we make a comparison between former outcomes
(2003−2007) and the latest (2009−2010 and also 2011−2012) as seen above.
Education on foot care, and establishment of foot clinics are activities which have been done in
several parts of Indonesia. Training for doctors, nurses and dieticians as the core group of diabetes
mellitus management personnel are organized routinely in our diabetes center as well as in other diabetes
centers in Indonesia. So far the results are promising, although we have not had hard data on the results
of the diabetes management program. Most of the available reports are on the activities itself; none of
them try to evaluate the long-term outcome of diabetes management program, nonetheless the diabetic
foot program.
As the ulcer developed, without proper management, the mortality and amputation rates will be
higher. The attitude of the attending physician is not sufficiently positive toward the effort to save the limb.
The wound debridement was not done thoroughly, yielding spreading of the infections and rendering the
amputation as the grave outcome. Moreover most of the patients came in the very late stages, and having
financial problems to give a full backup for the limb salvage attempt. The availability of appropriate
antibiotics to combat the infection which is mostly very severe was most of time insufficient. The general
condition as well as the nutritional status of the patients is not optimal for the wound healing. The attitude
of the surgeon most of the time were also less agreeable to the limb salvage. This complex condition
resulted in higher amputation rate and less often done advance surgical procedures to save the limb as
seen in the former periods. However, the status quo has been changing lately. Advanced wound treatment
such as negative pressure−vacuum assisted wound management, skin thickness skin grafting, and
advanced vascular−endovascular procedures have been implemented more often to save the limb. At the
latest surveys, more feet can be salvaged and healed spontaneously or with Split Thickness Skin Grafting.
Less major amputation and also less fatalities were achieved although there were many of the patients,
due to certain reasons (mostly financial), discharged on their own will.
Regular case discussion and meeting among the diabetes foot team care are of paramount
important to improve the promising results of the diabetes foot salvage program. The improvement of the
patient’s general condition could be enhanced. The provision of more appropriate measures can be given
to the patients. Financial help can be looked for through the charity foundations. The availability of
talented surgeon having the skill and the strong empathy to save the limb will have a lot of influence on the
overall results of the diabetes limb salvage program. Surgical techniques from simple to advance

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procedures, which has been able to be implemented in our center, might give a better outcome. Many
factors should be done toward the achievement of these promising results.
The availability of active rehabilitation team included the orthotic division further enhanced the
promising results to save the limb, especially the prevention program. Foundations to support the unable
diabetic foot victims are strongly needed to solve the diabetic foot problems. Brighter future seems to be
imminent with the efforts, which has been done in our region to save the limb.

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Peripheral Arterial Disease in Diabetic Foot

Yu-Yao Huang
Director of Department of Medical Nutrition Therapy, Chang Gung Memorial Hospital
Associated Professor, College of Medicine, Chang Gung University,
Chairperson, Taiwan working group on diabetic foot
Taoyuan City – Taiwan

Diabetic foot complications (DFCs) are major sequelae of diabetes and contribute to most causes of
non-traumatic lower-extremity amputations (LEAs) worldwide. In addition, patients with DFCs have been
known to have higher recurrence rate of ulcers and worse survival than that of many common cancers.
The medical expense of patients with these complications is even higher than the most costly cancers;
moreover, patients who received LEAs usually had worsened consequences including lower self-esteem,
shortened life span, and the burden of social care. Peripheral arterial disease stands for a sign of systemic
atherosclerosis and is commonly found in a poor healing wound. The PAD and foot infection are the
leading causes of LEAs in patients with DFCs. Therefore, the diagnosis of PAD is essential for every
patient with a foot complication.
The International Working Group on the Diabetic Foot (IWGDF) guidelines released in The Hague this
year will provide evidence-based approaches for diagnosis, treatment, and prognosis. In our study for
patients with severe grade of diabetic foot infections, the PAD is the independent factor for poor treatment
outcomes. I will also report our recent study using more aggressive management to improve DFU healing
in patients with concomitant PAD. A large, national, 8-year study has conducted to better understand the
prevalence and time trends of patients with diabetic foot complications, including demographics of
patients, affected foot, and major procedures introduced to treat these patients, including LEAs. The
nationwide long-term data in Taiwan suggest DFCs remain a sustained medical and public health issue.
This study reveals trends toward older people with greater comorbidities such as peripheral arterial
diseases and renal diseases. Nevertheless, increasing medical attention including early intervention for
ulcers to avoid gangrene, and proper vascular intervention could provide a decrease in LEAs over time.
The utility of hospitalization and the medical expense for DFCs, however, were not increased. This report
demonstrates the impact of continued vigilance and rapid, coordinated interdisciplinary diabetic foot care
on LEA outcomes in a country level.

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Rehabilitative Aspects of Diabetic Foot Care

Gulapar Srisawasdi
Foot Clinic, Department of Rehabilitation Medicine,
Siriraj Hospital, Faculty of Medicine Mahidol University
Bangkok – Thailand

For long term diabetes especially the poor control ones, late complications which include peripheral
polyneuropathy and/or peripheral arterial occlusive diseases develop. The feet become dry, cold,

insensate, and deform which usually result in unrecognized chronic foot ulcer and commonly end up with
amputation. Plantar pressure distribution and gait pattern will be changed after minor/major amputations

which make it easy to develop recurrent ulcers and finally end up with higher level of amputations. The

long process of chronic ulcer management and amputation deteriorate patients’ physical and mental
health and limit patients from social activities. The major goals of rehabilitation medicine are to maintain,
restore, and improve quality of life. Rehabilitative aspects of diabetic foot care include offloading footwear
and exercise. Off-loading concept is recommended as one of key therapy for diabetic foot ulcer prevention

and management. Off-loading modalities include foot orthosis, shoe modification, and custom-molded

shoes. Patients with limitation of movement will develop immobilization syndrome which is a major cause

of functional decline. It is also a major obstacle for using orthosis and prosthesis. Rehabilitation exercise

program to prevent and improve this condition is another key therapy to improve quality of patients’ lives.

Last but not least, in order to make the diabetic foot care system success, national policy and
interdisciplinary care teams along with national and international networks are important.

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Early Detection and Management of Diabetic Foot

Tri Juli Edi Tarigan

Division of Endocrinology and Metabolism, Department of Internal Medicine
Dr.Cipto Mangunkusumo General Hospital / Faculty of Medicine Universitas Indonesia
Jakarta – Indonesia

Diabetic foot disease is among the most serious and costly complications of diabetes. It also
1,2
represents major causes of morbidity and mortality in people with diabetes. Diabetic foot disease arises
from chronic pathologic processes such as neuropathy, peripheral artery disease (PAD), biomechanical
3
problems, and impaired wound healing. The lifetime risk of a person with diabetes developing foot ulcer
could be as high as 25%. Every 30 seconds, a lower limb or part of a lower limb, is lost due to amputation
somewhere in the world as a consequence of diabetes. The incidence of diabetic foot is increasing due to
4
the increased prevalence of diabetes and the prolonged life expectancy of diabetic patients.

The identification of diabetic foot disease begins with a complete history and thorough physical
examination. This examination should be focused on the manifestations of diabetic neuropathy, peripheral
3
arterial disease, and, particularly any evidence of diabetic foot ulcers or infection. Foot examination is
important to detect the disease early and should be done regularly. Following examination of the foot,
stratifying each patient using the IWGDF risk category system to guide subsequent preventative screening
frequencies and management is needed. There are comprehensive diabetic foot screenings including
assessment of the following sensation, vascularity, deformity, areas of pressure, footwear (all types), skin
.5
breakdown, and infection.

Empowering the patient and family is mandatory in prevention and early detection of diabetic foot.
Patient must be educated for what they should or should not do at home. Community health care should
be involved in this program to prevent the delay in referring patient to hospital. The goal of management is
to protect diabetic foot from breakdown, prevent foot ulceration, and avoid amputation of lower extremities
6
as an ultimate focus. Comprehensive diabetic foot risk assessments and foot care based on prevention,
education and a multi-disciplinary team approach will reduce foot complications and amputations by up to
4
85%. Moreover, multidisciplinary teams must recognize that their goals relate not only to management of
the acute and chronic wound, but also to the correction of the factors that have led or may lead to
ulceration through the appropriate management. By achieving these targets, it is hoped that the team can
5
be succeed in breaking the cycle of diabetic foot problem.

References
1. Guidelines P, Development GC. IWGDF Guidelines on the prevention and management of diabetic foot
disease IWGDF Guidelines. 2019; Available from: www.iwgdfguidelines.org
2. American Diabetes. Standart of Medical Care in Diabetes 2019. Diabetes Res Clin Pract. 2019;42:1–
193.
3. Del Core MA, Ahn J, Lewis RB, Raspovic KM, Lalli TAJ, Wukich DK. The Evaluation and Treatment of

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Diabetic Foot Ulcers and Diabetic Foot Infections. Foot Ankle Orthop. 2018;3(3):247301141878886.
4. International Diabetes Federation. Eighth edition 2017. IDF Diabetes Atlas, 8th edition. 2017.1–150 p.
5. Turns M. Prevention and management of diabetic foot ulcers. Br J Community Nurs. 2015;20:S30–7.
6. Ibrahim A. IDF Clinical Practice Recommendation on the Diabetic Foot: A guide for healthcare
professionals. Vol. 127, Diabetes Research and Clinical Practice. 2017. 285–287 p.

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Patient Education to Prevent Diabetic Foot

Ida Ayu Kshanti

Division of Endocrinology, Metabolic and Diabetes, Department of Internal Medicine
Fatmawati General Hospital
Jakarta – Indonesia

Diabetes and its complications are rapidly becoming the world’s most significant cause of morbidity
1
and mortality. One of the most expensive and debilitating complications of diabetes is diabetic foot
2
disease. Diabetic foot is defined by WHO as foot in diabetics with neurologic disorders, some degree of
vascular involvement with or without metabolic complications of diabetes in lower extremity and prone to
3,4
infection, scarring, with or without deep tissue damage. In diabetics, the lifetime risk of having this
5
complication is as high as 25%. Diabetic foot ulcers can lead to infection, gangrene, amputation and even
death if the necessary care is not provided. The rate of lower limb amputation in diabetics is 10–30 times
6,7
higher than non-diabetics. The studies showed that every 30 seconds one leg is amputated due to
1,8
diabetes in the world. The most important point is that with comprehensive diabetic foot assessments
and foot care, based on prevention, education and a multi-disciplinary team approach, may reduce foot
2
complications and amputations by up to 85%.
9
Inadequate health literacy has been identified as a major barrier to self-care in people with diabetes.
Healthcare professionals (HCPs) in every level of health care facility are encouraged to pay far more
attention to the diabetic foot. With respect to foot care, the need for education is not only to focus in
preventing ulcers but also as a primary prevention. Education as secondary prevention to prevent
recurrence of ulcers and re-amputation must not be forgotten. Studies showed in the first two years after
10
amputation, there is a 50%risk of re-amputation and three years after lower limb amputation, 50% of
11
patients may be dead.
According to the International Working Group on the Diabetic Foot (IWGDF) Guidance 2015, there are
five key elements that underpin prevention of foot problems: identification of the at-risk foot; regular
inspection and examination of the at-risk foot; education of patient, family and healthcare providers; routine
12
wearing of appropriate footwear; and treatment of pre-ulcerative signs. Identification of the at-risk foot is
needed to protect the diabetic foot from breakdown, preventing foot ulceration and lower limb amputations,
by taking preventative measures early in the disease process and treating the foot in the early Risk
2
Categories of 1, and 2 and before they become the very high Risk Category 3. It is necessary for all
diabetic patients, especially patients at risk for foot ulcers, to be familiar with the basics of foot care. It is
much needed to facilitate active participation of patients and family members in care. Several studies
13-15
suggest that patient education about foot care is effective in prevention of diabetic foot ulcers.
2,16,17
Many diabetic foot care education programs have been proposed, considering the consequence
of continuing educational programs. The basic principles of foot care include: foot examination daily for
discoloration, swelling, skin cracks, pain or numbness; the use the self-help methods to help foot
examination by using mirrors; foot hygiene (daily washing, followed by drying feet carefully, especially
between the fingers); controlling water temperature before foot washing, avoidance of going barefoot or

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wearing shoes without socks; the usage of customed-fit shoes (the best time for buying shoes is in the
afternoon); appropriate fingernails cutting; the use of mousturizer on the dry surfaces of foot except
between the fingers; as well as the importance of medical visit when necessary. These can be demanding,
18
especially for individuals with poor health literacy. HCPs can evaluate patient requirements and design
personalized educational program for each of patients and their families, using simple language,
2,19
appropriate for all segments of diabetics and their families.

References

1. International Diabetes Federation. IDF Diabetes Atlas, 7th ed. Brussels, Belgium: International
Diabetes Federation, 2015. http:// www.diabetesatlas.org

2. IDF Clinical Practice Recommendations on the Diabetic Foot 2017

3. Frykberg Rg, Zgonis T, Armstrong Dg, Driver Vr, Giurini Msjm, Kravitz Sr, Et Al. Surgery Diabetic Foot
Disorders: A Clinical Practice Guideline (2006 Revision ) Diabetic Foot Disorders : The Journal of Foot and
Ankle Surgery. 2006;45(5):1–66.
4. International Working Group on the Diabetic Foot (2015) In: International consensus on the diabetic foot.
International Working Group on the Diabetic Foot, The Netherlands, pp 20–96
http://iwgdf.org/guidelines/definitions- criteria-2015/
5. Singh N, Armstrong DG, Lipsky BA. Preventing foot ulcers in patients with diabetes. JAMA
2005;293:217–28.
6. Siitonen OL, Niskanen LK, Laakso M, Siitonen JT, Pyorala K: Lower-extremity amputations in diabetic
and on diabetic patients: a population-based study in eastern Finland. Diabetes Care 1993, 16:16–20.
7. Trautner C, Haastert B, Giani G, Berger M: Incidence of lower limb amputations and diabetes.
Diabetes Care 1996, 19:1006–1009.
8. Every thirty seconds a limb is lost somewhere in the world as a consequence of diabetes. Lancet
2005, 366 (9498):1719–1724.
9. Schillinger D, Grumbach K, Piette J, et al. Association of health literacy with diabetes outcomes.
JAMA 2002;288:475–82.
10. Goldner MG: The rate of the second leg in the diabetic amputee. Diabetes 1960, 9:100–103.
11. Boulton AJM, Vileikyte L, RagnarsonTenvall G, Apelquist J: The Global Burden of Diabtic Foot
Disease. Lancet 2005, 366:1719–1724.
12. Schaper NC, van Netten JJ, Apelqvist J, et al. Bakker K on behalf of the International Working Group
on the Diabetic Foot (IWGDF) (2016). Prevention and management of foot problems in diabetes: a
Summary Guidance for Daily Practice 2015, based on the IWGDF Guidance. Diabetes Metab Res
Rev. 2016;32 (1):7‒15.
13. Spollett GR: Preventing amputations in the diabetic population. Nurs Clin North Am 1998, 33(4):629–
641
14. Culleton JL: Preventing Diabetic Foot Complication: Tight Glucose Control and patient education are
keys. Postgrad Med 1999, 106(1):74–78.
15. Viswanathan V, Madhavan S, Rajasekar S, Chamukuttan S, Ambady R: Amputation prevention
initiative in South India: positive impact of foot care education. Diabetes Care 2005, 28(5):1019–
1021.

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16. Microvascular Complications and Foot Care: Standards of Medical Care in Diabetes 2019 Diabetes Care
2019;42(Suppl. 1):S124–S138 | https://doi.org/10.2337/dc19-S01
17. Clarke EAM, Tsubane M: The role of the podiatrist in managing the diabetic foot ulcer. Wound Healing
Southern Africa 2008, 1(1):40–42.
18. Williams MV, Baker DW, Parker RM, et al. Relationship of functional health literacy to patients'
knowledge of their chronic disease. A study of patients with hypertension and diabetes. Arch Intern
Med 1998;158:166–72.
19. Seaman S: The role of nurse specialist in the care of patients with diabetic foot ulcers. Foot Ankle Int
2005, 26(1):19–26.

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Adjuvant Therapy for Diabetic Foot:

Stem Cell, Platelet Rich Plasma and Growth Factors Therapy

Pradana Soewondo1, Cindy Astrella2

1
Division of Endocrinology and Metabolism, Department of Internal Medicine,
Dr. Cipto Mangunkusumo General Hospital / Faculty of Medicine Universitas Indonesia
Jakarta – Indonesia
2
Faculty of Medicine Universitas Indonesia

Diabetes foot ulcer (DFU) is a common complication of diabetes and the main etiology of amputation
among diabetic patient. Recent data showed that approximately 15% of diabetic patient had DFU during
their lifetime and had 40 times higher chance of amputation compared to non-diabetic patient. Given the
high burden of DFU, optimal management of DFU is needed.
The gold standard therapy of DFU includes the following steps: debridement of the wound,
management of any infection, revascularization procedures when indicated, and off-loading of the ulcer.
Nevertheless, in some cases where the degree of wound is too severe which severe peripheral arterial
disease until critical limb ischemia, revascularization might not be possible to be done. Hence, other
therapeutic modalities such as adjuvant therapy of stem cell therapy, platelet rich plasma (PRP) and
growth factors might give an alternative. However, the efficacy and safety of these adjuvant therapies still
needs to be studied. This paper will focused more on the stem cell, PRP and growth factor therapy for
DFU.
Stem cell therapy is an emerging regenerative medicine field that has been proposed as a hope for
the management of degenerative disease. The main characteristic of stem cell is its ability of self-renewal
and totipotency. Previous study by Qin H et al. showed the use of adjuvant therapy of local injection and
endovascular injection of umbilical cord mesenchymal stem cell (UCMSC) after angioplasty resulted in
greater improvement of ABI, transcutaneous oxygen pressure (TcPO2) and also complete or gradual ulcer
healing.
Platelet rich plasma contains various growth factors, protein and cytokines that play role in the tissue
healing process that is derived from blood centrifugation. Platelet rich plasma is considered low-cost and
minimally invasive technique to deliver high concentrations of autologous GFs and cytokines in
physiological proportion. A systematic review of the effect of PRP for DFU found that PRP increased the
likelihood of chronic wound healing (RR = 1.32; 95% CI: 1.11, 1.57, I2 = 15%) and also decrease time to
complete wound healing (MD = −11.18 days; 95% CI: −20.69, −1.68; I2 = 53%). However, lack of studies
reported the safety aspect of PRP.
In addition, single growth factor may also be used as therapy for DFU. The most common growth
factors used in studies of DFU are epidermal growth factor (EGF) and platelet-derived growth factor
(PDGF). Previous RCT by Afshari et al. which recruited 30 patients with DFU revealed that after 4 weeks
follow up, participants with topical EFG and standard wound therapy had greater wound closure compared

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to control group (71.2 vs. 48.9%, p = 0.03).

In summary, stem cell, PRP and growth factors might give benefit for DFU adjuvant therapy. However,
current evidence of these adjuvant therapies is usually conducted in small sample size with short term of
follow up. Further studies are needed to study the efficacy and safety of stem cell, PRP and growth factor
for DFU.

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How to Manage Hyperglycemia in Diabetic Foot

Imam Subekti
Division of Endocrinology and Metabolism, Department of Internal Medicine,
Dr. Cipto Mangunkusumo General Hospital / Faculty of Medicine Universitas Indonesia
Jakarta – Indonesia

Introduction
Diabetic foot is a major medical, social and economic problem worldwide. High level of glycaemia
increases the risk of microvascular and macrovascular complications in diabetes. An average lifetime risk
of a person with diabetes with foot ulcer is 25% and an ulcer precedes 85% of all lower extremity
amputations in diabetes patients. Amputation is 10 - 20 times more common in people with diabetes
compared to non-diabetic individuals.

Development of Diabetic Foot

High blood glucose can damage the entire nerves in our body. Nerve damage can be quite significant,
causing wounds to go untreated, leading to ulceration, extreme infections and amputations in some cases.
The most important metabolic factor, however, is the glucose regulation determined by the level of
glycated hemoglobin (HbA1c). Intensive management of blood glucose (HbA1c<7%) may lead to a 35%
reduction in the risk of amputation compared to less intensive management. UKPDS reported, a 1% mean
reduction in HbA1c was specifically shown to be associated with a 43% reduction in amputation or fatal
peripheral blood vessel disease.

Management of Hyperglycemia in Diabetic Foot

Proper management of diabetic foot issues starts with a patient’s comprehensive medical assessment
accompanied by early treatment with a focus on preventive strategies. The best preventive strategy is
focused on training, close monitoring and clear communication between a multidisciplinary team. There
are some characteristics of diabetic patient and resources should be observed to determine treatment
target. Individualization is the key of the target of treatment in diabetes. Due to their long period of diabetes
and coexisting chronic complications and other co-morbidities, especially diabetic foot with infection,
insulin therapy is the cornerstone in the treatment of hyperglycemia with or without another oral anti
hyperglycemia. Education, medical nutrition therapy and physical activity should be part of the holistic
management in type 2 diabetes.

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How to Manage Infection and Biofilm Problem

Anis Kurniawati
Clinical Microbiologist, Department of Microbiology,
Dr.Cipto Mangunkusumo General Hospital / Faculty of Medicine Universitas Indonesia
Jakarta – Indonesia

Diabetic foot infection is the leading cause of hospitalization and the most common cause of non-
traumatic lower-limb amputation. Diabetic patients may suffer from sensory neuropathy, which will reduce
the awareness of pain due to foot injury or infection. Other problem like impairment of peripheral vascular
disease, neutrophil function and immune response to infection will prolong the healing of ulcers and
infections. Determining the presence and severity of an infection in foot diabetic, as well as defining the
risk of osteitis or osteomyelitis are crucial in the management of patients.
Wound cultures should be obtained prior to initiating antibiotics, however empirical antibiotics should
not be delayed for foot ulceration with systemic infection. The specimens for culture are aspiration of an
abscess or tissue curettage from the ulcer base following debridement of necrotic tissue. The culture result
of infected ulcers is useful in determining the definitive antimicrobial therapy, especially when multi-
resistant organisms is detected and there is poor response to empiric therapy.
Antibiotics should not be used for uninfected wounds as there is no evidence that antibiotics quicken
healing of the wound, besides that the unnecessary use of antibiotics causes the emergence of antibiotic
resistance. The choice of empiric antibiotic therapy should be based on the severity of wound infection and
the suspected pathogens involved or local data. Most diabetic foot infections are polymicrobial, acute
infection without history of antibiotic treatment is usually caused by aerobic Gram-positive cocci, whereas
deeper or chronic wounds are commonly polymicrobial including aerobic and anaerobic pathogens.
Biofilms are accumulation and organization of microbes’ consortia at surfaces within an extracellular
polymer, or glycocalyx, with interspersed water channels. The formation of bacterial biofilm starts when a
planktonic bacterium finds its way to an exposed, conditioning, film-coated surface through Brownian or
flagellar motion and makes initial attachment to that surface. Although biofilm communities can be
beneficial to many aspects of human life (for example provision of colonization resistance to the large
intestine), it may cause problems both in industrial and clinical setting as well. Biofilm interfere or
complicate the elimination by antimicrobial agents and the host’s immune response. Biofilms producing
bacteria are generally reported to be far less susceptible to antimicrobial treatments than their planktonic
counterparts, with more than 100-1000 decreases in susceptibility.
Biofilm-related infections are very difficult to eradicate, examples of biofilm-associated infections
include the colonization of implanted medical devices such as central venous catheters, urinary catheters,
dental caries; and chronic wounds. The majority of human infections (60%–80%) are biofilm associated,
include burns, pressure ulcers, surgical site infections, and diabetic foot ulcers. Many available antibiotics

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are used to treat acute infections and planktonic bacteria typically respond to antibiotics and are easily
eradicated by immune system. Chronic wounds are normally characterized by a tenacious and excessive
inflammatory response when compared with acute wounds and are less susceptible to antibiotics. A
clinical study found that biofilm could be removed by surgical debridement of chronic wound, but 2 days
after the debridement, biofilm started to re-emerge. The use of suitable antimicrobial agents to treat such
infections is critical.

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Role of Dressing in Diabetic Foot Ulcer

Em Yunir1, Angela Sarumpaet2

1
Division of Endocrinology and Metabolism, Department of Internal Medicine,
Dr. Cipto Mangunkusumo General Hospital / Faculty of Medicine Universitas Indonesia
Jakarta – Indonesia
2
Research Assistant, Faculty of Medicine Universitas Indonesia

Diabetic foot ulcer (DFU) is one of diabetes complications that accounts for significant morbidity,
mortality, and healthcare expenditures. It is reported from the International Diabetes Federation (IDF) that
9.1 – 26.1 million people will develop DFUs annually. Treatment of DFU accounts for approximately one-
third of the total cost of diabetic care. Diabetic foot problem needs more frequent emergency visit and
hospital admission and longer length period of stay. In Cipto Mangunkusumo General Hospital, the budget
was spent mostly on modern dressing at 41% compared to the total costs on medicine in managing DFU.
Many dressings have been introduced during the past decade. The fundamental aim of DFU
management is wound closure. The quality of foot care should be a partnership between patients and
healthcare professionals. Multidiscipline approach is essential in decision making of the therapy as well as
supporting good self-care from the patients. The European Wound Management Association emphasizes
that DFUs should have repeated debridement, frequent inspection and bacterial control and balance
moisture to prevent maceration. Most dressings are signed to create a moist wound environment. The
various types of dressing materials and class of dressing depend on the type of wound characteristics.
According to Food and Drug Administrations (FDA) 1994, there are four main classes of dressings that are
suggested: non-resorbable gauze/sponge, hydrophilic/absorptive, occlusive, and hydrogel. A different type
of dressing may be needed as the status of the wound changes, because DFUs can change very quickly,
especially if infection is not appropriately addressed. Guidance of the appropriate dressing should be used
in conjunction with clinical judgement and local protocols.
International Working Group on Diabetes Foot (IDGWF) guideline does not provide specific type
of dressing for a diabetic foot infection. Dressings should be changed daily, both to apply a clean wound
covering and careful examination of the wound for infection. Wound dressing should be used in
combination with appropriate wound bed preparation, systemic antibiotic therapy, pressure offloading and
diabetic control.

References
1. Gottrup F, Apelqvist J: Present and new techniques and devices in the treatment of DFU: a critical
review of evidence. Diabetes Metab Res Rev 28 Suppl 1:64-71, 2012.

Jakarta Diabetic Foot Meeting 2019

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2. International Working Group on the Diabetic Foot. International consen- sus on the diabetic foot and
practical guidelines on the management and the prevention of the diabetic foot. Amsterdam, the
Netherlands, 2015.
3. European Wound Management Association (EWMA). Position document: wound bed preparation in
practice. London: MEP ltd, 2013. Available at: http://woundsinternational.com Accessed October
2019.

Treatment of Peripheral Neuropathy in Diabetic Foot

Manfaluthy Hakim
Clinical Neurophysiology and Neuromuscular / Peripheral Disorder Division,
Department of Neurology, Dr. Cipto Mangunkusumo General Hospital,
Faculty of Medicine Universitas Indonesia
Jakarta – Indonesia

Neuropathy is the most common symptomatic complication of diabetes mellitus (DM) and accounts for
a large share of morbidity and hospitalization associated with the disease. The symptoms of neuropathy in
diabetes may present with autonomic, motor or sensory symptoms. Symmetric distal sensory
polyneuropathy is the most common form, affecting the distal lower extremities and hands in a “glove and
stocking” pattern. It is estimated that about 90% of patients with diabetes for more than 20 years will
develop diabetic neuropathy. What is worrying is that in approximately 40% of these patients, the diabetic
neuropathy may be asymptomatic. Neuropathy whether sensory, motor, or autonomic may lead to the
formation of fissures or calluses which lead to ulceration. Treatment of diabetic neuropathy consists of
three components such as glycaemic control, pain control and foot care. Early treatment of diabetic
neuropathy should, therefore, include tight glycaemic control. Tight glycaemic control is the only strategy
which has demonstrated to show prevention and progress of diabetic peripheral neuropathy and
autonomic neuropathy. All patients should be screened for diabetic neuropathy starting at diagnosis of
type 2 DM and 5 years after diagnosis of type 1 DM and at least annually thereafter. An annual
comprehensive foot examination is a must for all patients with diabetes and consists of examination of foot
and footwear, neuropathy screening, vascular assessment, and musculoskeletal assessment of feet. This
would help in identification of risk factor predictive of ulcers and amputation.

Keywords: diabetes mellitus, diabetic neuropathy, peripheral neuropathy, foot care.

Jakarta Diabetic Foot Meeting 2019