Predominance of Multidrug-Resistant Bacteria with High Resistance to Empiric Antibiotics in Diabetic Foot Ulcers: A Cross-Sectional Study
Summary: Published March 11, 2026 in Scientific Reports (Nature), this cross-sectional study from IMU University (Kuala Lumpur, Malaysia) and Universiti Putra Malaysia characterizes the bacterial profile and antibiotic resistance landscape in 153 patients with diabetic foot ulcers (DFUs). Gram-positive bacteria predominated (62% of isolates), led by Staphylococcus aureus and coagulase-negative staphylococci (CoNS), with Gram-negative pathogens Pseudomonas aeruginosa and Klebsiella pneumoniae also prominent. Multidrug resistance (MDR) was observed in approximately 95% of Gram-negative isolates and 60–87% of Gram-positive isolates, with a median resistance profile spanning 9–11 different antibiotics per isolate — the majority of which are included in current empirical DFU treatment regimens. This means standard first-line therapy is likely to be ineffective in the majority of cases without prior culture-guided selection. The authors applied the WHO AWaRe (Access, Watch, Reserve) antibiotic classification framework to identify agents that can be prioritised for DFU treatment while protecting Reserve-category antibiotics (such as carbapenems and last-resort agents) for confirmed MDR cases only. The findings urgently underscore the need for microbiological profiling of DFU infections before initiating antibiotics, periodic updates to institutional empirical treatment protocols, and strengthened antimicrobial stewardship programs. Malaysia has one of Southeast Asia’s highest diabetes prevalence rates, and MDR in diabetic foot infections significantly increases the risk of amputation, prolonged hospitalisation, and mortality. The study was funded by IMU University’s internal research grant and conducted in accordance with national ethics registration requirements (NMRR KKM/NIHSEC/P18-2188).
Key Highlights:
- 153 DFU patients; 62% Gram-positive isolates (dominated by S. aureus and CoNS), 38% Gram-negative (P. aeruginosa, K. pneumoniae) — consistent with the polymicrobial DFI profile observed globally
- MDR prevalence: ~95% of Gram-negative and 60–87% of Gram-positive isolates met MDR criteria; median resistance to 9–11 antibiotics per isolate — most of which appear in standard empirical regimens
- WHO AWaRe framework applied: Access-category antibiotics prioritised where effective; Watch-category used with culture guidance; Reserve-category antibiotics strictly protected for confirmed MDR cases
- Clinical implication: routine wound culture and sensitivity testing is essential before or alongside empirical antibiotic initiation; institutional treatment protocols require periodic evidence-based updates
- Malaysia context: DFU affects approximately 20–25% of people with diabetes at some point; MDR in diabetic foot infections increases amputation risk, hospitalisation duration, and mortality
- Antibiotic stewardship: study supports integration of DFU microbiology profiling into standard wound care protocols as a patient safety and antimicrobial conservation priority
Keywords: multidrug resistant diabetic foot infection, DFU antibiotic resistance, diabetic foot infection microbiology, antibiotic stewardship wound care, Staphylococcus aureus diabetic foot, AWaRe antibiotic classification
Natasha Nabila Mohammed Shoaib Ebenezer Chitra Jing Rou Ong Willem B. Jay Tan Vasantha Kumari Neela Ashraf Hakim Ab Halim Fabian Davamani