pa hogens
Case Repo
Me hicillin-Resis an S aphylococcus au eus Diabe ic
Foo C ossed In ec ion: A Case Repo
Ma ía Reina-Bueno * , Inmaculada C. Palomo-Toucedo , Au o a Cas o-Méndez,
Gab iel Domínguez-Maldonado and Ma ía del Ca men Vázquez-Bau is a
Depa men o Podia y, Uni e si y o Se ille, 41009 Se ille, Spain; [email p o ec ed] (I.C.P.-T.);
au o acas [email p o ec ed] (A.C.-M.); [email p o ec ed] (G.D.-M.); [email p o ec ed] (M.d.C.V.-B.)
*Co espondence: [email p o ec ed]; Tel.: +34-954-486-544
Recei ed: 1 June 2020; Accep ed: 6 July 2020; Published: 8 July 2020


Abs ac :
This wo k p esen s a p o ocol o p e en he ansmission o mul id ug- esis an in ec ions.
We ocus on he Diabe ic Foo Uni Podia y Clinic A ea a ached o he Uni e si y o Se ille in
pa icula . The mos common complica ion o pa ien s wi h diabe es is leg ulce s. Toge he wi h
neu opa hy, asculopa hy, and immunological esponse diso de , hese indi iduals ha e a high
p edisposi ion o de eloping in ec ions. S aphylococcus au eus is a highly p e alen mic oo ganism
in humans which, a imes, may ac as a pa hogen. Due mainly o indisc imina e abuse o an ibio ics,
he me hicillin- esis an s ain known by i s ini ials as MRSA is he mos ex ended nosocomial in ec ion
globally and is a se e e communi y and hospi al heal hca e p oblem. This pape desc ibes compliance
wi h new gene al ecommenda ions on cleaning, hygiene, and decon amina ion, in addi ion o
implemen a ion o his speci ic p o ocol, a e de ec ion o c oss in ec ion (heal hca e- ela ed in ec ion)
in he s udied uni in wo pa ien s wi h MRSA-in ec ed ulce s. A e an in-dep h bibliog aphical
e iew, s ic hand hygiene measu es and use o non-s e ile glo es we e used when ea ing all
pa ien s wi h a diabe ic oo . Finally, we e lec on he need o educa e heal hca e pe sonnel o
gua an ee co ec p esc ip ion o selec ed an ibio ics. The ole o he podia is in he mul idisciplina y
eam is highligh ed no only in e ms o managemen and ea men o lesions in diabe ic pa ien s,
bu also as a heal hca e agen o he de ec ion and p e en ion o MRSA oge he wi h o he
mul id ug- esis an in ec ions.
Keywo ds:
diabe ic oo ; diabe ic oo in ec ion; oo ulce ; me hicillin- esis an S aphylococcus au eus;
heal hca e-associa ed in ec ion; mul id ug- esis an in ec ions
1. In oduc ion
Diabe es melli us (DM) is a combina ion o me abolic diso de s cha ac e ized by hype glycemia
whe e insulin is incapable o unc ioning and/o he amoun o seg ega ed insulin is insu icien o
ob ain he necessa y hypoglycemic e ec . In 2019, 463 million people we e diagnosed wi h DM
globally. Howe e , he p e alence o his disease is on he ise. I is es ima ed ha in 2045 he e will be
app oxima ely 700.2 million people wi h DM [1].
Diabe ic oo synd ome is de ined by he Wo ld Heal h O ganiza ion (WHO) as “ulce a ion,
in ec ion, and/o gang ene o he oo associa ed wi h pe iphe al neu opa hy in di e en deg ees o
pe iphe al a e ial disease and he esul o he complex in e ac ion o di e en ac o s” [2].
These ulce s a e he consequence o a complex in e ac ion o se e al pa hophysiological ac o s,
mainly neu opa hic, asculopa hic, and immunopa hic. App oxima ely 15% o 25% o pa ien s wi h
DM de elop diabe ic oo ulce s (DFUs) o e he cou se o hei li e ime [
3
]. This leads o a majo
socioeconomic impac and loss o he pa ien ’s quali y o li e. This condi ion is mo e common in men
han in women [4].
Pa hogens 2020,9, 549; doi:10.3390/pa hogens9070549 www.mdpi.com/jou nal/pa hogens
Pa hogens 2020,9, 549 2 o 9
O e 50% o hese ulce a ions will become in ec ed, esul ing in high a es o hospi aliza ion,
inc eased mo bidi y, and po en ial lowe limb ampu a ion. P edisposing ac o s o he de elopmen o
diabe ic oo in ec ion (DFI) in diabe ic pa ien s include neu opa hy, asculopa hy, and immunopa hy [
5
].
DFI ea men equi es wound ca e, an imic obial he apy, and o en su gical p ocedu es. As a
esul , DFIs a e he mos common diabe ic complica ion equi ing hospi aliza ion and he wo ld’s
leading cause o non auma ic lowe limb ampu a ion [3].
Se e al s udies ha e e ealed ha DFIs a e polymic obial, including bac e ial lo a (S aphylococcus
au eus,S ep ococcus epide midis, Pep ococcus, and Bac e oides agilis) [
6
,
7
]. S aphylococcus au eus is he
mos commonly isola ed mic oo ganism [6–9], bu he ex ended spec um be a-lac amases Klebsiella
and Pseudomonas ae uginosa can also be de ec ed in small concen a ions, inc easing he isk o limb
ampu a ion [6–8].
As wi h o he ansien lo a bac e ia, S aphylococcus au eus is bo h a commensal bac e ium and a
human pa hogen [
3
,
9
]. App oxima ely 15–30% o he human popula ion is colonized wi h S aphylococcus
au eus [
9
]. Ne e heless, acco ding o he me a-analysis by S acey e al. pa ien s wi h diabe es ha e
a 4.75% highe coloniza ion a e han non-diabe ic people [
10
]. Impo an ly, his bac e ium causes a
wide ange o clinical in ec ions (e.g., bac e emia, endoca di is, skin and so issue, os eoa icula ,
pulmona y, and de ice- ela ed in ec ions). The p e alence o me hicillin- esis an S aphylococcus au eus
(MRSA) in DFI is 16.78% [
10
]. Howe e , subsequen s udies ha e epo ed highe a es in acco dance
wi h geog aphic a iables [6,7,9].
The mos impo an mechanism o he p opaga ion o MRSA and he o he mic oo ganisms ci ed
below is con ac be ween people. The mos common ans e is om one pe son o ano he by means
o con amina ed hands o heal hca e/auxilia y pe sonnel who do no wash hem co ec ly be ween one
pa ien and he nex [
8
]. T ansmission because o con amina ion o heal hca e ma e ial and/o su aces
has also been epo ed and is known as heal hca e-associa ed in ec ion (HAI). Hygiene and disin ec ion
guidelines a e essen ial o p e en ion in he hospi al and heal hca e cen e se ings. To a oid hese
in ec ions, a se ies o s anda d p ecau ions is necessa y o all pa ien s, and some speci ic egula ed
p ocedu es mus be added in hose pa ien s diagnosed wi h MRSA in gene al as well as hose wi h
DFI [11–13].
The Diabe ic Foo Uni o he Podia y Clinic A ea a ached o he Uni e si y o Se ille has a
ca e, esea ch, and eaching pu pose, because i sees pa ien s, pe o ms a ious esea ch lines, and is a
loca ion o wo k expe ience o s uden s comple ing a g adua e deg ee in podia y. This uni p o ides
diabe es melli us pa ien s wi h ull p e en i e ca e and ea men . Se en y pe cen o consul a ions a e
o ulce managemen . In June 2018, unde clinical suspicion o wound in ec ion, ulce sampling was
conduc ed in se e al cases. Mic obiological cul u es con i med o wo pa ien s p esen ed MRSA in
DFI. C oss in ec ion had occu ed, so HRI was diagnosed. In hese cases, in addi ion o he s anda d
p ecau ions ca ied ou , a speci ic p o ocol is se ou below wi h he pu pose o s opping ansmission
as a pa o a mul imodal s a egy. This s udy was au ho ized by he Resea ch E hical Commi ee o
he Uni e si y Hospi als Vi gen Maca ena and Vi gen del Roc
í
o. W i en consen was ob ained om
he pa icipan s.
2. Case P esen a ion
2.1. Case 1 (Possible Impo ed Hospi al Case)
A 68-yea -old e i ed diabe ic woman.
Family his o y: Un ema kable.
Pe sonal his o y: No known alle gies, insulin-dependen ype 2 diabe es melli us, aged 25 wi h
well-con olled clinical symp oms. The pa ien was on me o min (500 mg) wo daily be o e b eak as
and a e dinne . P e-p andial glucose was 160 mg/dL and HbA1c was 8%. Well-con olled hype ension
unde ea men wi h a enolol; high choles e ol unde ea men wi h lu as a in; o me smoke ;
Pa hogens 2020,9, 549 3 o 9
being ea ed wi h pla ele an i-agg egan . Ampu a ion o p oximal phalanx o he i s le oe 2 yea s
ago. Discha ged om hospi al 3 weeks ago a e p esen ing wi h acu e pyeloneph i is and bac e emia.
P esen ed a neu o-ischemic ulce wi h a 2-week clinical cou se unde he heads o he second and
hi d me a a sals o he le leg wi h a oul smell and abundan exuda e. This in ec ion was classi ied
as g ade 2 [14]. Bio ilm was no de ec ed.
Examina ion: This e ealed pale colo ing o he skin wi h coldness. Neu ological examina ion
e ealed no sensi i i y wi h he Semmes–Weins ein mono ilamen and Rydel–Sei e uning o k.
The ankle–b achial index e ealed a e ial calci ica ion and igidi y in he join s. A p obe o bone (-)
was done.
Addi ional es s: Do soplan a X- ay did no de ec any signs o os eoa h i is. A sample was
aken by swab o mic obiological cul u e and me hicillin- esis an S aphylococcus au eus was isola ed.
T ea men : Ce u oxime (500 mg/12 h) was p esc ibed acco ding o an an ibiog am, and he ulce
was ea ed wice pe week acco ding o he TIME algo i hm: [15–17].
-
The wound was cleaned and decon amina ed wi h a solu ion ha is also e ec i e o MRSA
(pu i ied wa e , 0.1% undecylamidop opyl be aine, and 0.1% polyhexamide);
- Deb idemen o de i alized issue and slough;
- P o ec ion o pe i-lesional issue wi h a non-i i an skin p o ec o ;
- Ca bon and sil e d essing;
- Algina e d essing;
- Polyu e hane oam d essing.
This ea men ecommenda ion was main ained o 4 mon hs and hese d essings we e
subsequen ly eplaced by me allop o einase modula o ma ix o 25 days un il ull healing. A e ull
healing, p e-p andial glucose was 90 mg/dL and HbA1c was 6.8%.
Du ing his ime, due o ha ing a no i iable disease, he pa ien con inued o be e iewed in he
Depa men s o In ec ion and Endoc inology in hei e e ence hospi al un il in ec ion was e adica ed.
2.2. Case 2
A 48-yea -old e i ed man wi h o al pe manen incapaci y.
Family his o y: Fa he wi h ype 2 diabe es melli us, Alzheime ’s disease, and a mo he wi h
Alzheime ’s disease.
Pe sonal his o y: No known alle gies, poo ly con olled ype 1 diabe es melli us wi h a clinical
cou se o 20 yea s. The o al daily insulin dose was 24 UI (b eak as 8 UI; lunch 6 UI;
dinne 8 UI
).
P e-p andial glucose was 180 mg/dL and HbA1c was 9%. Well-con olled hype ension unde
ea men wi h losa an; high choles e ol unde ea men wi h sim as a in; smokes 15 ciga e es a day.
T ansme a a sal ampu a ion o he le oo 8 yea s ago.
P esen ed wi h a neu oischemic ulce o wi h a clinical cou se o 3 mon hs ha appea ed a e a
blis e -like lesion in he do sal a ea o he i h oe o he igh oo . This was classi ied as a g ade 3
in ec ion [
14
] and ea ed wi h Be adine. Bio ilm was no de ec ed. Gi en ha he clinical cou se o he
pa ien was incomple e, hei podia is e e ed him o ou cen e o ollow-up.
Examina ion: Inspec ion e ealed good colo ing on bo h sides o he leg and no hai . Neu ological
examina ion did no e eal any sensi i i y o he Semmes–Weins ein mono ilamen and Rydel–Sei e
uning o k. The ankle–b achial index was 0.9, and join igidi y was shown. A posi i e p obe o bone
in he head o he middle phalanx o he 5 h oe o he igh oo was ound.
Addi ional es s: Do soplan a X- ay e ealed signs o os eomyeli is. A swab sample o mic obiological
cul u e ga e a posi i e esul o me hicillin- esis an S aphylococcus au eus.
T ea men : O al ancomycin (1000 mg/12 h) was p esc ibed acco ding o an an ibiog am and he
ulce was ea ed wice a week acco ding o he TIME algo i hm: [15–17].
-
The wound was cleaned and decon amina ed wi h a solu ion ha is e ec i e o MRSA (pu i ied
wa e , 0.1% undecylamidop opyl be aine, and 0.1% polyhexamide);
Pa hogens 2020,9, 549 4 o 9
- Deb idemen o de i alized issue and slough;
- P o ec ion o pe i-lesional issue wi h non-i i an skin p o ec o ;
- Applica ion o hyd ogel o he wound bed;
- Nanoc ys alline sil e d essing;
- Polyu e hane oam d essing.
This ea men was main ained o 1.5 mon hs and hese d essings we e subsequen ly eplaced
wi h a me allop o einase modula o ma ix o 2 weeks up un il ully healed. A e ull healing,
p e-p andial glucose was 110 mg/dL and HbA1c was 7.5%.
Du ing his ime, due o ha ing a no i iable disease, he pa ien con inued o be e iewed in he
Depa men s o In ec ion and Endoc inology in hei e e ence hospi al un il in ec ion was e adica ed.
3. P oposed P o ocol
Acco ding o he ecommenda ions o he Spanish Ne wo k o Epidemiological Moni o ing [
13
],
all pa ien s seen in he same consul a ion oom o who sha ed he same he apeu ic in e en ion we e
loca ed. They we e in es iga ed, and no o he pa ien was ound o be in ec ed by MRSA because o
non-compliance wi h he wo necessa y equi emen s, which a e a posi i e mic obiological cul u e o
his pa hogen and signs o in ec ion [11–13].
S anda d p ecau ions we e ollowed wi h he aim o s op ansmission be ween pa ien s and o
p e en c oss-in ec ions, e en by means o omi es du ing he p o ision o podia y ca e.
-
The pa ien mus be scheduled in he las imeslo o he day, whe e e possible. I should be
eco ded ha his is a pa ien in con ac isola ion.
- T ea men oom ca s should emain emp y.
-
Be o e he pa ien en e s he oom, all he u ni u e in he oom should be co e ed wi h disposable
clo hs, which a e exclusi ely used o pa ien s in con ac isola ion.
-
I is essen ial o wash hands wi h an isep ic soap and unning wa e be o e and a e seeing he
pa ien . Be o e in e en ion, alcohol-based hand ub (ABHR) may be used o p e en skin damage.
- D y hands using disposable owels.
- The podia is mus p epa e he ma e ial necessa y o ea men in ad ance.
-
The pa ien mus en e unaccompanied and lea e hei pe sonal e ec s behind (jewel y, coa s,
jacke s, c u ches, pushchai s, e c.).
-
Pu he disposable ma e ial gene a ed du ing he ea men in o a con aine wi h a bag so ha i
does no emain on he loo and has no con ac wi h he en i onmen . Gauzes and emaining
disposable ma e ial used should go di ec ly in o he usual con aine s which a e p ocessed no mally.
Su gical ma e ial ha equi es s e iliza ion is p ocessed no mally.
-
All pe sonnel who ake pa in he p ocess in some way mus wea a disposable gown, o e shoe
co e s, a cap, glo es, and a mask. Once he ea men is inished, all o his ma e ial should be
emo ed and placed in he a o emen ioned con aine .
-
Disposable ma e ial ha co e s he chai and emaining u ni u e should go in he con aine wi h
he emaining con amina ed issues.
- The con aine ’s bag mus be sealed a he end.
Once he in e en ion is o e , he oom, including mobile objec s, side ables, and clinical
u ni u e (chai s, lamps, and s ools), should be cleaned exhaus i ely wi h 1% sodium hypochlo i e o
concen a ed disin ec an de e gen (TP18). The ma e ials necessa y o pe o m his cleaning should
be exclusi ely used o his kind o ea men and should unde go con ac isola ion so ha hey a e
only used in he ea men oom. This mus be pe o med om he cleanes a eas o he a eas wi h he
mos was e.
Pa hogens 2020,9, 549 5 o 9
The loo should be cleaned by means o mopping wi h a damp mop in a zigzag di ec ion.
I should subsequen ly be cleaned wi h a mop and bleach in a 1:10 p opo ion (30 mL o common
bleach pe li e o wa e ).
In pa allel, some ules need o be implemen ed in he diabe ic oo uni o manage all pa ien s.
-
The podia is mus wash his hands a he s a and end o his wo king day as well as be o e and
a e seeing each pa ien .
-
Rings and b acele s mus be emo ed o a oid he adhe ence o any subs ance o mic oo ganism.
-
The podia is mus wea glo es when ea ing pa ien s. These mus be changed o each pa ien
o i hey b eak.
- The pa ien mus en e unaccompanied.
-
The podia is and s uden s mus use g ee ing wo ds and e ain om shaking hands.
A e inishing he in e en ion, a a ewell wi hou di ec con ac is necessa y.
-
Comple e disin ec ion o oo and ankle wi h an isep ic should be done, eaching he dis al hi d
o he leg o disin ec he skin close o he ulce .
- Pa ien s mus ecei e hygiene educa ion and p omo ion.
- T ea men ca s mus only ha e ma e ial ha is essen ial o pe o ming he ea men s.
-
A he end o each shi , he loo and su aces should be cleaned and disin ec ed by he same
p ocedu e as ou lined abo e.
In addi ion, The Podia y Clinic A ea implemen ed a mul imodal s a egy o imp o e he hand
hygiene compliance in pa allel. This in e en ion included ou componen s ecommended by he
WHO wi h adap a ions o his con ex : sys em change (numbe o sinks nea o he poin o ca e,
access o ABHR dispense s), educa ion (speci ic aining sessions o all he s a , including cleaning
pe sonnel and s uden s), eminde s in he wo kplace (“how o handwash” and “my i e momen s o
hand hygiene” pos e s), and sa e y clima e (pa ien pa icipa ion, DFI an ibio ic ea men manual) [
18
].
4. Discussion
We ha e epo ed wo MRSA case s udies in pa ien s om he Diabe ic Foo Uni in he Uni e si y
o Se ille. As e lec ed in he li e a u e, diabe ic oo in ec ion is a complica ion ha can a ec 50% o
diabe ic pa ien s and is ela ed o high a es o mo bidi y and mo ali y [3].
Acco ding o he Eu opean Commission, HRI a e in ec ions ha a pe son can ge when ecei ing
heal hca e o du ing hei s ay in a ea men cen e (heal h cen e , hospi al, day ca e cen e , ge ia ic
cen e , e c.) and a e no p esen in he incuba ion pe iod a he ime o ecei ing his ea men .
These in ec ions a e a o ed when he e a e abno mali ies in de ense mechanisms, when he pa ien s
ha e a ch onic disease such as DM, and also when he e a e in e up ions in he con inui y o
skin, such as ulce s [
11
,
19
,
20
]. Diabe ic pa ien s ha e mul iple isk ac o s o coloniza ion wi h
me hicillin- esis an S aphylococcus au eus (MRSA), a nosocomial pa hogen associa ed wi h signi ican
mo bidi y and mo ali y a es [7,10].
In ec ions caused by mul id ug- esis an mic oo ganisms a e a majo challenge o ea men by
he usual me hods, mainly due o he bio ilms o med by bac e ia and he di icul managemen wi h
an ibio he apy. I is o his eason ha p e en ion is a undamen al pilla [3].
A la ge numbe o hese in ec ions occu in heal hca e cen e s, so i is necessa y o inc ease
p e en ion and hygiene measu es o a oid hem [
21
–
26
]. Pa ien s wi h his ype o in ec ion equi e
wo ypes o ac ion, gene al and speci ic [13,19].
Acco ding o mic obiological sampling, bo h in ec ions desc ibed in his s udy we e ela ed,
and we can s a e ha c oss in ec ion occu ed in ou cen e as i was de ec ed wi hin a pe iod o less
han one mon h [
3
,
8
]. One o he mos impo an p ocedu es implemen ed in ou uni is hand hygiene
a he s a and end o he wo king day and be o e and a e seeing e e y pa ien .
Hand washing is eplaced by hand hygiene, which in ol es de ailed and sys ema ic washing
o achie e e ec i e decon amina ion o he skin [
11
,
18
,
20
,
21
,
24
,
27
]. We need o cla i y he gene al

Pa hogens 2020,9, 549 6 o 9
measu es se ou by he WHO and colla ed in a ious guidelines which ecommend he use o
hyd oalcohols [
11
,
18
,
27
] o chlo hexidine a e managing MRSA pa ien s when di iness is no
obse ed [
11
,
18
,
24
]. This is due o h ee easons. Fi s , ega ding he pa hogen, S aphylococcus au eus is
a bac e ium ha does no p oduce spo es. Second, such compounds ha e been p o en o be mo e
e ec i e as an isep ics [
20
,
21
,
24
], and hi d, as a wo k- ela ed p e en i e measu e because soaps a e
mo e likely o lead o skin abno mali ies such as xe osis o de ma i is in heal hca e wo ke s and ca e s
han ABHR [11,18,20,24,27,28].
ABHR should be used wi h a co ec echnique ollowing WHO ecommenda ions o op imal
esul s [
18
]. The olume, ex ension, and ime equi ed o applica ion a e being s udied. As a gene al
ule, a su icien amoun o solu ion depending o he size o he hand, abou 2–3 mL, is enough.
Rubbing o 30 s o co e all su aces on he palm, do sum, all inge s, humbs, and be ween hem
is equi ed.
Gi en ha exposu e o exuda es, blood, o sec e ions o en occu s in ou diabe ic oo depa men ,
i is p e e able o pe o m his hygiene me hod wi h soap and wa e ; al hough i he e a e no emnan s
o di , his could be pe o med wi h ABHR [
27
,
29
,
30
]. Solu ions ha con ain 60% o 95% alcohol
a e he mos e ec i e [
3
]. This is he simples , mos e ec i e, and mos e icien me hod o p e en
ansmission du ing heal hca e [11,31].
Because o his same ci cums ance, ano he ule implemen ed in ou depa men is he obliga ion
o ea all pa ien s wi h non-s e ile glo es. This ule is in esponse o he ac ha in ou uni he e
is di ec con ac wi h non-in ac skin [
29
,
30
]. Wea ing glo es mus be a gene al equi emen when
ea ing all pa ien s, because due o sensi i i y p oblems, DM pa ien s may p esen oo wounds ha
go unno iced [2].
The use o glo es mus no e e eplace co ec hand washing [
24
,
31
]. Wea ing he same
pai o glo es o mo e han one pa ien is an unaccep able echnique, as washing glo es is no
ecommended. [
20
,
27
] They mus be co ec ly disposed o a e con ac wi h any con amina ed
pa ien o su ace [
29
,
30
]. On he con a y, inco ec use o glo es may po en ially be esponsible o
in ec ion [
31
], as epo ed by McB ide e al. who eco ded 17% ansmission om pa ien s colonized
wi h MRSA om heal h wo ke s’ glo es [2,32].
In he case o pa ien s colonized o in ec ed wi h MRSA, s ic p e en ion measu es a e
needed, so a p o ocol o ea hese pa ien s was es ablished ollowing ecommenda ions by di e en
guidelines [12,19,29] and pape s [22,23,26,27].
Conside ing he high a e o gene al popula ion MRSA coloniza ion a he Diabe ic Foo Uni
Podia y Clinic A ea o he Uni e si y o Se ille, which is e en highe in pa ien s wi h diabe es
melli us [
10
,
21
,
27
,
30
], pa ien s a e ca ed o unaccompanied, excep hose ha a e dependen o unde
18 yea s o age. E en hough we ha e no ound any speci ic ecommenda ions in he guidelines,
i emains clea ha colonized pa ien s can be ec o s o he in ec ion o o he s o can sel -con amina e
hei own wound. The pa ien may ha e an ac i e ole in he ansmission o hese diseases [
23
].
The e o e, as a p e en i e measu e, we ecommend he a oidance o shaking hands. Is enes e al.
epo ed ha 39% o pa ien s s udied showed con amina ion om a leas one pa hogen on hei
hands and speci ically 14% p esen ed a posi i e MRSA cul u e, 48 h a e hospi al admission [
26
].
Fo his eason, p omo ing hand hygiene p og ams and good p ac ices among pa ien s, in gene al,
can con ibu e o educing HAI.
Di e en aining sessions on hand hygiene a e also held o p e en he sp ead o mul i esis an
o ganisms, as ecommended by he WHO [
18
] and he p e en ion guidelines. All o ou si e’s pe sonnel
a end hese ac i i ies [12,13,23,25,27].
These in ec ions mus be decla ed, and he pa ien s mus be ollowed up and moni o ed join ly wi h
he depa men o in ec ious diseases and mic obiology o Vi gen Maca ena Uni e si y Hospi al [
12
,
13
].
The podia is ’s unc ion wi hin his mul idisciplina y eam no only lies in p e en ion, ollow-up,
and ea men o he diabe ic oo , bu hey a e also essen ial o he ea ly de ec ion o in ec ious
p ocesses. Acco ding o he li e a u e, he iden i ica ion o clinical signs o ulce in ec ion is he i s
Pa hogens 2020,9, 549 7 o 9
s ep o he cul u e o wounds. Subsequen mic obiological con i ma ion is wha enables e i ica ion
o suspicions [6,12,13].
Despi e he ac ha MRSA is usually sensi i e o opical an ibio ics, such as mupi ocin o
usidic acid, i is p e e able no o use hem in pa ien s wi h ch onic ulce s such as FPI, because he
pa hogen easily becomes esis an o hem. [
8
]. Thus, in ou guidelines o managing diabe ic ulce s,
local an ibio ic he apy is no p esen ed.
De ailed inspec ion and e alua ion o lesions enables a dis inc ion o be made be ween a
con amina ed and an in ec ed ulce [
12
,
13
,
33
]. Diagnosis mus se ou he c i e ia o co ec ea men
and an ibio ics should only be used in case o in ec ion and no as gene alized p ophylaxis. Selec i e
an ibio ic ea men , in addi ion o he pa ien ’s adhe ence o his, is undamen al o ea and p e en
his p ocess and o a oid p opaga ion o MRSA in ec ion because p olonged and indisc imina e use o
an imic obials is ela ed o inc eased mul i esis an in ec ions [
6
,
12
,
13
,
34
], which en ails a h ea o he
global heal h sys em. [12,13,33,35]
Heal hca e pe sonnel mus upda e hei knowledge o iden i y esis ance pa e ns in he diabe ic
oo and imp o e hei aining based on guidelines on he co ec use o an ibio ics [6,12,13,33,35].
Au ho Con ibu ions:
Concep ualiza ion, M.R.-B. and I.C.P.-T.; esou ces, M.d.C.V.-B. and A.C.-M.; me hodology,
I.C.P.-T.; in es iga ion, M.R.-B. and I.C.P.-T.; o mal analysis, I.C.P.-T. and G.D.-M.; w i ing—o iginal D a , M.R.-B.
and M.d.C.V.-B.; w i ing— e iew and edi ing, A.C.-M. and G.D.-M.; supe ision, M.R.-B. and I.C.P.-T. All au ho s
ha e ead and ag eed o he published e sion o he manusc ip .
Funding: This esea ch ecei ed no ex e nal unding.
Con lic s o In e es : The au ho s decla e no con lic o in e es .
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