Khyber Pakhtunkhwa study maps resistance in diabetic foot infections

Diabetic foot infections at four centres in Khyber Pakhtunkhwa, Pakistan, were predominantly caused by Gram-negative bacteria and frequently exhibited clinically important antimicrobial-resistance phenotypes, according to a multicentre cross-sectional study of 170 adults with culture-positive infections. Gram-negative organisms accounted for 101 of 170 primary isolates, or 59.4%, with Escherichia coli, Klebsiella pneumoniae and Pseudomonas aeruginosa the most common. Severe ulceration was independently associated with ischaemia and higher HbA1c, two findings from the regional sample that require cautious interpretation because the study did not establish causation.

Researchers enrolled consecutive adults with clinically diagnosed, culture-positive diabetic foot infections between October 2025 and June 2026 at four centres in three districts of Khyber Pakhtunkhwa. The cross-sectional design characterized pathogens, susceptibility patterns and resistance phenotypes at the time of sampling while assessing factors statistically associated with ulcer severity. IWGDF/IDSA infection-severity criteria were unavailable, so the investigators defined severe ulceration as a Wagner grade of at least 3. Of 190 patients screened, 170 were included. The analysis concerned the enrolled regional population and did not test treatment strategies or determine whether particular management regimens improved clinical outcomes.

Resistance was widespread among the Enterobacterales. A presumptive extended-spectrum beta-lactamase, or ESBL, surrogate phenotype was present in 59 of 76 isolates, representing 77.6%. Carbapenem resistance was organism-restricted in 18 of 99 isolates, or 18.2%, while any recorded resistant carbapenem result occurred in 25 of 110 records, or 22.7%. Among 54 Staphylococcus aureus isolates, 17, or 31.5%, were methicillin-resistant S. aureus, or MRSA. These denominators differed by organism and susceptibility test, reflecting the isolates available for each analysis rather than a single uniform sample of all infections.

Laboratory susceptibility results varied markedly among antimicrobial groups. Meropenem was the most active agent against the 101 Gram-negative primary isolates, with activity against 86 isolates, or 85.1%. Amikacin was active against 66 of 97 tested isolates, or 68.0%, while piperacillin/tazobactam was active against 65 of 101 isolates, or 64.4%. Linezolid and vancomycin were the most active agents against Gram-positive isolates. These figures describe in-vitro susceptibility rather than clinical cure, and the reported denominators reflect the isolates tested for each agent. The investigators supported empirical therapy informed by local microbiology, followed by rapid culture-guided de-escalation and strengthened antimicrobial stewardship, but the cross-sectional study did not compare the effectiveness of management regimens.

Multivariable logistic regression identified two factors associated with severe ulceration. Ischaemia was associated with an adjusted odds ratio of 3.05, with a 95% confidence interval of 1.49–6.23. Each 1-percentage-point increase in HbA1c was associated with an adjusted odds ratio of 1.50 for severe ulceration, with a 95% confidence interval of 1.08–2.09. The ischaemia association remained after ulcers with gangrene were excluded. These estimates represent adjusted associations within the study population, not evidence that impaired perfusion or higher HbA1c caused ulcers to become severe. The culture-positive inclusion criterion also means the sample may not represent all diabetic foot ulcers, particularly infections or ulcers that could not be sampled, and the unavailable IWGDF/IDSA classification limits comparison with studies using that severity framework. Overall, the findings provide a contemporary regional profile of microbiology and resistance in diabetic foot infections, alongside the vascular and glycaemic measures associated with ulcer severity in the four-centre cohort.

Subject of Research: Microbiology, antimicrobial resistance and ulcer severity in diabetic foot infections in Khyber Pakhtunkhwa

Article Title: Microbiological profile, antimicrobial resistance, and factors associated with ulcer severity in diabetic foot infections: a multicentre cross-sectional study from Khyber Pakhtunkhwa, Pakistan

Article References: Atif, E., Ahmad, A., Ullah, R., Ahmad, D., Haq, Y. U., Khan, M. S., Shah, S. I., Farooq, H., Bin Shakoor, M. T., Haidar, Y., Haq, M., & Qazi, S. (2026). Microbiological profile, antimicrobial resistance, and factors associated with ulcer severity in diabetic foot infections: a multicentre cross-sectional study from Khyber Pakhtunkhwa, Pakistan. BMC Infectious Diseases. https://doi.org/10.1186/s12879-026-14396-y

Image Credits: AI Generated

DOI: 10.1186/s12879-026-14396-y

Keywords: diabetic foot infections, antimicrobial resistance, Gram-negative bacteria, ESBL, carbapenem resistance, MRSA, ulcer severity, ischaemia, HbA1c, Khyber Pakhtunkhwa, Microbiological, profile