Journal of Diabetes Mellitus, 2022, 12, 18-27

https://www.scirp.org/journal/jdm
ISSN Online: 2160-5858
ISSN Print: 2160-5831

Diabetic Foot: Epidemiological, Therapeutic

and Evolutionary Aspects in the Department of
Medicine and Endocrinology of the Hospital in
Mali, Mali

Nanko Doumbia1,2*, Adams Alexis Diarra3, Seydou Mariko2,4, Drissa Sangare2,5, Danfaga Bakary3,
Nouhoum Ouologuem1,2, Samaké Magara2,6, Sekou Mamadou Cisse5, Mamady Coulibaly2,7,
Mahamadou Saliou2,8, Bakary Dembele2, Yacouba L. Diallo1,2, Amadou Kone1, Modibo Mariko1,
Bah Traore1, Massama Konate1,9, Djenebou Traore9,10, Djeneba Sylla1,9, Kaya Assetou Soucko9,10,
Assa Traore9
1
Department of Medicine of the Mali Hospital, Bamako, Mali
2
National Center for Scientific and Technological Research (CNRST), Bamako, Mali
3
Kati Reference Center, Kati, Mali
4
Gynaecology Department of the Mali Hospital, Bamako, Mali
5
Department of Medicine and Medical Specialty of the Fousseyni Daou Hospital, Kayes, Mali
6
Nephrology Unit of the Fousseyni DAOU Hospital, Kayes, Mali
7
Health and Social Affairs Department of the National Police, Bamako, Mali
8
Internal Medicine Department of the Gabriel Toure University Hospital, Bamako, Mali
9
Faculty of Medicine, Bamako, Mali
10
Internal Medicine Service of the Point G University Hospital, Bamako, Mali

How to cite this paper: Doumbia, N., Abstract

Diarra, A.A., Mariko, S., Sangare, D., Ba-
kary, D., Ouologuem, N., Magara, S., Cisse, Introduction: The diabetic foot remains a public health problem due to its
S.M., Coulibaly, M., Saliou, M., Dembele, high frequency, difficult and costly management. The aim of this study was to
B., Diallo, Y.L., Kone, A., Mariko, M., determine the epidemiological, therapeutic and evolutionary aspects of the
Traore, B., Konate, M., Traore, D., Sylla, D.,
diabetic foot in a hospital setting in Bamako. Methodology: This is a retros-
Soucko, K.A. and Traore, A. (2022) Di-
abetic Foot: Epidemiological, Therapeutic pective, descriptive, cross-sectional and monocentric study conducted be-
and Evolutionary Aspects in the Depart- tween September 1, 2011 and December 31, 2015 on diabetic patients aged 14
ment of Medicine and Endocrinology of the years and older arriving in our department with a foot infection. Results: We
Hospital in Mali, Mali. Journal of Diabetes identified 94 cases of diabetic foot infection out of a total of 828 hospitalized
Mellitus, 12, 18-27.
https://doi.org/10.4236/jdm.2022.121003
patients, a prevalence of 11.35%. The age range 41 - 60 years represented 57
cases (60.6%), the extreme ages were 14 and 81 years. Men (38.3%), women
Received: October 10, 2021 (61.7%) with a sex ratio of 0.62%. Housewives 50%, illiterate 51 cases (54.3%),
Accepted: December 14, 2021 low economic standard of living 40 cases (42.6%), presence of osteitis 40 cases
Published: December 17, 2021
(42.6%), foot at stage D Grade3 28 cases (29.8%). Management was medical
in 48 cases (51.1%), treatment with insulin 58 cases (61.7%), Amoxicillin +

DOI: 10.4236/jdm.2022.121003 Dec. 17, 2021 18 Journal of Diabetes Mellitus

 N. Doumbia et al.

Copyright © 2022 by author(s) and

Scientific Research Publishing Inc. Metronidazole used 36 cases (38.29%). Amputation was performed in 35 cas-
This work is licensed under the Creative es (37.2%). Deaths concerned 5 patients (9.6%) with hypoglycemia as the
Commons Attribution International
main cause in 4 cases. Conclusion: Diabetic foot is a frequent complication
License (CC BY 4.0).
http://creativecommons.org/licenses/by/4.0/ of diabetes. The establishment of a multidisciplinary team should contribute
Open Access to the improvement of the prognosis of the diabetic foot in a management
center.

Keywords
Diabetic Foot, Epidemiology, Therapeutics, Evolution, Mali Hospital

1. Introduction
According to the WHO, the number of people with diabetes worldwide has in-
creased from 108 to 422 million over the past 30 years [1]. In Belgium, this
number increased from around 300,000 to over 500,000 individuals between
2001 and 2011 [2]. Projections for 2030 are over one million [3]. In Africa, the
number of diabetics was estimated at 14.2 million people in 2015 and 34.2 mil-
lion are expected in 2040 [4].
The diabetic foot is defined according to the international consensus on the
diabetic foot (developed by IWGDF: International Working Group on Diabetic
Foot) of 2007 as any Infection, ulceration or destruction of the deep tissues of
the foot associated with neuropathy and/or peripheral arterial disease of the
lower limbs in diabetics [5].
These lesions in ill-balanced patients, difficult and expensive to treat most of-
ten lead to amputation, which makes this pathology a major public health prob-
lem, especially noting that every 30 seconds, a lower limb will be lost due to the
diabetes [6].
Diabetic foot is a frequent and serious complication of diabetes with a very
high rate of amputations of the lower limbs and often dramatic socio-economic
and psychological consequences [7].
In Africa, foot injuries in diabetics are unfortunately very common. Poverty,
poor hygiene and barefoot walking interact to aggravate the impact of foot inju-
ries caused by diabetes [8]. In Mali there are few studies on diabetic foot [9] and
there is an increase in the number of cases in the department. The objective of
this study was to describe the epidemiological, therapeutic and evolutionary pro-
file of the diabetic foot in a hospital setting in Mali.

2. Methodology
We conducted a retrospective, descriptive, cross-sectional study between Sep-
tember 1, 2011 and December 31, 2015 among diabetic patients aged 14 and over
who arrived in the endocrinology/medicine department of the hospital in Mali.
Inclusion criteria:
- Study: retrospective, descriptive, transversal.

DOI: 10.4236/jdm.2022.121003 19 Journal of Diabetes Mellitus

N. Doumbia et al.

- Duration: 4 years and 3 months.

- Be 14 years old and over.
- All diabetic patients who arrive in the endocrinology department of the hos-
pital in Mali with a foot infection.
- We collected clinical, paraclinical and therapeutic data from these patients.
- Voluntary and informed consent was given in writing before being enrolled
in the study.
Non-inclusion criteria:
We excluded from our series the incomplete files as well as the other causes
apart from the diabetic foot.
Information was collected from patient charts using survey forms on which
diabetic foot lesions were described according to the Texas classification (see
Table 1). The questionnaires were entered and analyzed on Excel 2007 and SPSS
version 20.0 software after data verification.

3. Results
We identified 94 cases of diabetic foot out of a total of 828 hospitalized patients,
i.e. a prevalence of 11.35%. The age range 41 - 60 years represented (60.6%), the
extreme ages were 14 and 81 years (Cf. Table 2). Men 36 cases (38.3%), women
57 cases (60.6%) with a sex ratio of 0.62%. Housewives 47 cases 50% (see Figure
1). Non-educated people 51 cases (54.3%) (see Figure 2). The economic stan-
dard of living was considered low in 40 cases (42.6%) and sufficient in 54 (57.4%).
The presence of osteitis was observed in 40 cases (42.6%). Doppler ultrasound
was abnormal in 48 patients (51%) (see Figure 3). Cytobacteriological examina-
tion of the pus was positive in 56 cases (59.6%). Staphylococcus aureus was
found in 21 samples (22.4%) (see Table 3). The wounds were classified as stage
D Grade 3 in 28 cases (29.8%) (see Table 4). Fifty-nine (61.7%) and 25.5% of the

Table 1. University of Texas classification (UT).

Grade 0 Grade 1 Grade 2 Grade 3

Lesion Wound Tendon Damage to the
epithelialized superficial involvement bone or joint

Stage A
No infection 0A 1A 2A 3A
No ischemia

Stage B
Infection, but 0B 1AB 2B 3B
No ischemia

Stage C
No infection 0C 1C 2C 3C
But ischemia

Stage D
0D 1D 2D 3D
Infection and ischemia

DOI: 10.4236/jdm.2022.121003 20 Journal of Diabetes Mellitus

 N. Doumbia et al.

Table 2. Age distribution of patients.

AGE (year) Workforce Percentage

14 - 20 1 1.06
21 - 40 7 7.98
41 - 60 57 60.6
61 - 81 28 29.79
Total 94 100

Table 3. Distribution according to the germs found in the culture.

Isolated germs Workforce Percentage

Staphylococcus aureus 21 22.34
Klebseilla Pneumonieux 9 9.57
E. coli 11 11.70
Morganela morga 6 6.38
Protus mirabilis 5 5.31
Pseudomonas aeruginosa 4 4.25
Sterile 37 39.36
Not done 1 1.06
Total 94 100

Table 4. Distribution of patients by Texas classification.

Wound stage
Grade
Stage A Stage B Stage C Stage D
Grade 0 5 2 0 0
Grade 1 8 19 0 0
Grade 2 0 16 5 4
Grade 3 0 4 3 28
Total 13 41 8 32

16

50 Others
60 0
pupil / student
0
40 16 driver
0
Trader
20 Official
household
0
Percentage

household Official Trader driver pupil / student Others

Figure 1. Distribution of patients by occupation.

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N. Doumbia et al.

54.3

12.8 Illiterate
60
12.8 Superior
40
19.6
Secondary
20
Primary
0
Percentage

Primary Secondary Superior Illiterate

Figure 2. Distribution of patients by education level.

50
45
40 45.7
35
30
25
20
22.3
15 20.2
10
5 8.5 3.2
0
Percentage

Normal Stenosing arterial disease Non-stenosing arterial disease Vein thrombosis Not done

Figure 3. Distribution of patients by Doppler ultrasound findings.

patients were on insulin and oral anti-diabetic drugs respectively, while 12.8%
had no anti-diabetic treatment. Medical treatment was mainly Amoxicillin +
Metronidazole used in 36 cases (38.29%) and amputation was performed in 35
cases (37.2%) (Cf. Table 5, Table 6). The evolution was favorable in 85 cases
(90.4%), 9.6% (5 patients) died of which the main causes were hypoglycemia in 4
cases and sepsis in 3 cases.

4. Discussion
The study included 94 cases out of a total of 828 hospitalized patients, for a pre-
valence of 11.35%. This hospital prevalence is close to those reported by Djim. F
et al. [9] and Koffi D [10] respectively 16.37% and 15.29%. In Africa, it is esti-
mated overall at 5.5% [11] and in France (ENTRED), the prevalence is 6% [12].
The 41 - 60 age group was the most represented, 60.6%, Djim. F et al. [9]
found 59.6%. The average age was 42.66 years, other African studies: SANI.R et
al. [13], Nghario L et al. [14], Gueye D.D et al. [15], Dr Merad M S et al. [16],
Mohaman Djibril et al. [17] found respectively 53 years, 54 years, 57 years, 60.5
years, 60.74 years. That reported in European literature varies between 67 years

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 N. Doumbia et al.

Table 5. Distribution of patients according to the type of antibiotics used.

Antibiotics Workforce Percentage

Ciprofloxacin + Metronidazole 36 38.29
Amoxicillin + acid Clavilanique + Gentamicine 19 20.21
Ceftriaxone + Gentamicine 14 14.89
Fusidic acid 11 11.70
Cefotaxime 6 6.38
Imipenème 8 8.51
Total 94 100

Table 6. Distribution of patients according to surgical management.

Therapeutic gestures Workforce Percentage

Disarticulation of the toes 9 9.6
Transmetatarsal amputation 4 4.3
Trans-femoral amputation 2 2.1
Amputation of the lower 1/3 of the leg 9 9.6
Amputation of the middle 1/3 of the leg 5 5.3
Amputation of the upper 1/3 of the leg 6 6.4
Revascularization 1 1.1
Disarticulation of the knee 1 1.1
Not applicable 57 60.6
Total 94 100

and 73 years [18]. This age difference can be explained by the young age of onset
of diabetes in African populations, but above all by poor treatment compliance by
our patients. The reasons for this poor compliance are multiple: the non-acceptance
of diabetes, traditional therapy, beliefs and especially poverty [19].
Women were in the majority (61.7%) against 38.3% for men with a sex ratio
of 0.62%. This female predominance has been noted by some authors such as
Samaké D [20]. On the other hand, the male predominance which has been stu-
died by Dr Merad M S et al. [16] (sex ratio M/F 2.33) is a phenomenon con-
firmed by several authors. Sani et al. [13] found a sex ratio of 2.46; it is 2.5 for
Amoussou-Guenou [21]. The generally recognized poor adherence to therapy in
men explained this male predominance [22].
Housewives were the most represented in our study (50%). This same predo-
minance was observed by Djim F et al. [9] 53.3%.
The majority of our patients were not educated with 54.3%. This same result
was observed by Traoré D.Y [23] 55.5% and Nghario L et al. [14] 47%. In fact,
ignorance of the diabetic status due to illiteracy has also been reported in a vari-
able proportion in the African literature: 13.1% in Niger [24]; 27.9% in Tanzania
[25].

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N. Doumbia et al.

The socio-economic level was low in 42.6%, Nghario L et al. [14] found a low
level in 66.10% of patients. The Doppler ultrasound was abnormal in 51% of our
patients. Djim F C. et al. [9] had 48.6% arteriopathy of the lower limbs and 20%
obliteration.
The presence of germs was noted in 59.6% of samples taken from wounds.
Nghario L et al. [14] had reported in 50% of his samples.
Among the germs isolated, staphylococcus aureus was found more in 22.4%,
the same germ was the most isolated in 16.13% in Djim F C. et al. [9]. On the
other hand, in the Aouam study [26], the most frequently found germ was
Pseudomonas aeruginosa. A study done in India and published in 2017 found
poly-microbial infections in 54% with other mono-microbial in 43%. [27]. In
Morocco the bacteriological sample carried out had objectified the multisensitive
Staphylococcus aureus in 28.23% [28].
According to the University of Texas classification, the foot was classified as
stage D Grade 3 in (29.8%), Guèye D.D et al. [15] found grade 1b lesions which
represented 34.0%, followed by 26.4% by grade 2d lesions and 24.5% by grade 3d
lesions. Also, Dr Merad M S et al. [16], had found osteitis at Stage 3D in 46% of
patients.
During hospitalization, insulin therapy alone was started in 61.7% of cases.
This result was with Djim F et al. [9] in Mali with 95.7% insulin therapy and Dr
L. Elazizi et al. [29] had performed insulin therapy in 77.20% of patients. The
most widely used antibiotic therapy was the combination Ciprofloxacin + Me-
tronidazole in 38.29% of cases, the same combination found in Djim F et al. [9]
at 37.8%. Similarly, this antibiotic therapy was generally introduced by Dr L.
Elazizi et al. [29] in 89.20%.
Amputation was performed in 37.2% of our patients including 24.3% in the
lower 1/3 of the leg, 16.3% in the upper 1/3 of the leg and a disarticulation of the
big toe in 24, 3% of cases. SANI.R et al. [13] found amputation in 37 cases
(41.1%), of which the amputation site was the foot in 23 cases (62.2%) followed
by the leg in 11 cases (29, 7%) and the thigh in 3 cases. Case (8.1%), as well as
authors such as Sidibé AT et al. [30] and Merad M S et al. [16] reported respec-
tively 41.36% and 34% of amputations in their studies.
The outcome was favorable in 90.4% of cases, other favorable results have
been reported by authors such as Koffi D [10] which reported 91.70% and 71%
of cases in Assia EL Ouarradi [31].
We recorded a mortality rate of 9.6% during the study period. This rate was
reported at Djim. F et al. [9], Sidibé AT et al. [30], Gueye D.D et al. [15], SANI.R
et al. [13], Djibril et al. [17] respectively 10.6%; 5.75%; 16.9%; 16.7%; 6.45%.
Hypoglycemia in 4.3% of cases was the leading cause of death. Djim. F et al. [9]
found that sepsis was the cause of death (60%) and for Nghario L et al. [14] sep-
sis and hyperglycemia were the main causes of death in 50% of cases.

5. Conclusion
Foot lesions are relatively frequent in our diabetic patients, and are responsible

DOI: 10.4236/jdm.2022.121003 24 Journal of Diabetes Mellitus

 N. Doumbia et al.

for high mortality and morbidity. A delay in management with lesions received
at advanced stages is always noted. The management of the diabetic foot must be
multidisciplinary.

Conflicts of Interest
The authors declare no conflicts of interest regarding the publication of this pa-
per.

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