Diabetic foot ulcers (DFUs) represent one of the most debilitating, costly, and severe chronic complications of diabetes mellitus [1]. Globally, it is estimated that up to 25% of all patients diagnosed with diabetes will develop a foot ulcer during their lifespan [2]. In the Indian subcontinent—often cited as one of the epicenters of the global diabetes epidemic—the burden of DFUs is disproportionately high due to unique socio-cultural factors, such as barefoot walking, rural geography, constrained healthcare literacy, and delayed clinical presentation [3].

The pathophysiology of a DFU is dictated by a dangerous clinical triad: peripheral sensory-motor neuropathy, peripheral arterial disease (PAD), and localized infection [4]. Peripheral neuropathy causes a structural loss of protective sensation (LOPS), leaving minor mechanical or thermal trauma entirely unnoticed by the patient until advanced ulcerative breakdown occurs [5]. Concurrently, macro- and microvascular ischemia impairs cellular nutrient delivery, stalling the typical wound healing phases and rendering the localized tissue highly susceptible to aggressive microbial invasion [6].

In Southern Odisha, Maharaja Krishna Chandra Gajapati (MKCG) Medical College and Hospital serves as the premier tertiary referral hub, managing a vast demographic of both rural and semi-urban patients. Many patients presenting to this center exhibit advanced chronicity, extensive tissue necrosis, and prior empirical treatment failures. Understanding the precise clinico-microbiological and demographic architecture within this specific region is imperative for tailoring localized healthcare strategies and empirical antibiotic guidelines.

This study outlines the specific clinical presentations, pathophysiological traits, microbiological profiles, and surgical outcomes of 120 DFU cases treated within this regional institution between 2020 and 2022.

2.1 Study Design and Setting This prospective, hospital-based cross-sectional study was executed within the Department of General Surgery, in coordination with the Departments of Medicine and Microbiology, at MKCG Medical College and Hospital, Berhampur, Odisha. The investigation spanned a fixed two-year timeline from October 2020 to October 2022. 2.2 Patient Selection Criteria A total sample size of 120 consecutive patients (N=120) presenting to the outpatient clinic or emergency surgical wards was selected based on targeted criteria. Inclusion Criteria: Patients aged ≥18 years with verified Type 2 Diabetes Mellitus presenting with a localized cutaneous break or ulceration on the foot (below the malleoli) lasting more than two weeks. Exclusion Criteria: Patients presenting with foot ulcers purely secondary to non-diabetic etiologies (e.g., Hansen’s disease, pure traumatic lacerations without metabolic disease, deep venous thrombosis ulcers), or those with concurrent severe terminal malignant comorbidities. 2.3 Clinical and Pathophysiological Assessment Detailed medical histories were obtained, noting the known duration of diabetes, systemic comorbidities, smoking habits, and footwear preferences. Neurological Screening: Performed using the standard 10-g Semmes-Weinstein monofilament test across 10 designated plantar anatomical sites. Loss of sensation in ≥3 sites was diagnosed as Loss of Protective Sensation (LOPS). Vascular Screening: Handheld Doppler ultrasound assessments were used to evaluate the Ankle-Brachial Index (ABI). An ABI score <0.9 confirmed peripheral arterial disease (PAD), whereas values >1.3 indicated medial arterial calcification, requiring supplementary Toe-Brachial Index (TBI) validation. Ulcer Grading: Staged using the traditional Wagner-Meggitt Classification system (Grades 0 through 5 based on wound depth, osteomyelitis presence, and localized gangrene extent). 2.4 Microbiological Investigation To accurately identify bacterial profiles and bypass superficial colonization, the wound beds were thoroughly cleansed with sterile normal saline, followed by the harvesting of deep tissue aspirates or deep swab scrapings from the ulcer base. Samples were instantly transferred into transport media to the Department of Microbiology for Gram staining, aerobic culturing on MacConkey and Blood agar plates, and subsequent antibiotic susceptibility testing using the Kirby-Bauer disk diffusion technique. 2.5 Statistical Analysis Collected data were entered into Microsoft Excel and analyzed using SPSS Version 24.0. Continuous variables were expressed as mean ± standard deviation (SD), while categorical variables were structured into frequencies and percentages.

3.1 Demographic and Baseline Characteristics

Of the 120 enrolled patients, 71.67% () were male and 28.33% () were female, maintaining a male-to-female ratio of 2.5:1. The cohort’s mean age was  years, with the majority falling between 51 and 70 years. The average known duration of Type 2 Diabetes was  years. Notably, 15.83% () of patients were completely unaware of their diabetic status prior to DFU development. Chronic poor glycemic control was endemic, reflected by a mean glycated hemoglobin () level of .

Table 1: Demographic and Pathophysiological Distribution ()

3.2 Severity of Presentation (Wagner-Meggitt Grade)

A vast majority of patients presented late to the tertiary care center, resulting in high baseline ulcer grades. More than 55% of the cohort presented with Wagner Grade 3 or worse.

Table 2: Distribution according to Wagner-Meggitt Grading

3.3 Microbiological Profile

Out of 120 collected tissue/pus specimens, 110 (91.67%) yielded positive microbial growth. Monomicrobial growth was seen in 68.18% () of the positive cultures, while polymicrobial growth was recorded in 31.82% (). Gram-negative bacilli comprised the majority of the total bacterial isolates.

• Pseudomonas aeruginosa: (28.18%)
• Klebsiella pneumoniae: (21.82%)
• Escherichia coli: (16.36%)
• Staphylococcus aureus: (13.64%) — Note: 40% () of these were confirmed as Methicillin-Resistant S. aureus (MRSA).
• Proteus mirabilis: (10.91%)
• Enterococcus species: (9.09%)

Antibiotic susceptibility data showed that the dominant Gram-negative isolates displayed high sensitivity to Carbapenems (Imipenem/Meropenem, 84%) and Piperacillin-Tazobactam (76%), but extensive resistance to conventional fluoroquinolones and third-generation cephalosporins.

3.4 Therapeutic Interventions and Outcomes

Management required a strict multimodal medical and surgical protocol. All patients underwent instant mechanical offloading and systematic systemic optimization (intensive insulin infusions).

Table 3: Distribution of Primary Surgical Interventions Performed

The overall limb salvage rate stood at 87.50%. Total mortality recorded during the inpatient or immediate follow-up period was 3.33% (), primarily secondary to advanced diabetic ketoacidosis, systemic sepsis, or concurrent cardiovascular events.

This two-year clinical review involving 120 patients at MKCG MCH Berhampur highlights the challenging realities of managing diabetic foot complications in Southern Odisha. The prominent male skew (71.67%) aligns closely with previous studies across India, likely driven by higher outdoor occupational exposure, suboptimal adherence to protective footwear, and increased smoking or tobacco use among males [7, 8]. The average HbA1c of 9.2% in our study highlights poor long-term metabolic control as a primary culprit behind accelerated nerve and vessel damage. Peripheral neuropathy was the leading predisposing factor, present in 82.5% of our patients. This confirms the well-established understanding that the loss of protective sensation is the primary trigger for ulceration [9]. A regional finding of note is the overwhelming dominance of Gram-negative pathogens, led by Pseudomonas aeruginosa (28.18%) and Klebsiella pneumoniae (21.82%). This stands in contrast to Western literature, where Gram-positive Staphylococcus aureus is typically the primary DFU pathogen [10]. However, it matches emerging patterns reported across other tropical and developing regions [11]. The prevalence of Gram-negative bacteria is exacerbated by local habits, such as barefoot walking on moist, contaminated soils, and washing wounds with stagnant water, which introduces opportunistic environmental pathogens into deep tissue spaces [12]. The high proportion of patients presenting with Wagner Grade 3 or worse (over 55%) underscores a critical gap in early diagnosis and referral. Many patients first seek care from local alternative practitioners or self-treat minor trauma, presenting to a tertiary center only after developing deep abscesses, foul-smelling discharge, or localized gangrene [13]. Despite these late presentations, our institution achieved a limb salvage rate of 87.5% through a coordinated multi-departmental protocol. This strategy focused on early surgical debridement, targeted empirical antibiotic coverage against Gram-negative organisms, strict non-weight-bearing offloading, and close metabolic regulation [14, 15].

Diabetic foot ulcers remain a major public health challenge in Southern Odisha. Patients frequently present with advanced, neuro-ischemic wounds complicated by multi-drug resistant, Gram-negative infections. Improving limb salvage and reducing lower-limb amputations will require shifting focus toward primary prevention. This includes structured foot-care education at the primary health center level, early screening for loss of protective sensation, and establishing standardized, region-specific empiric antibiotic protocols.

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