A multicentre study from Khyber Pakhtunkhwa has found that most diabetic foot infections in the province are caused by Gram-negative bacteria, many of them resistant to commonly used antibiotics. The study was published in BMC Infectious Diseases on 14 September by researchers from Peshawar Medical College, Alfaisal University in Riyadh and hospitals in Peshawar and Swabi.
What the study did
The researchers enrolled 170 adults with culture-positive diabetic foot infections, out of 190 screened, at four centres in three districts of Khyber Pakhtunkhwa between October 2025 and June 2026. They analysed the organisms isolated, their antibiotic susceptibility and the factors associated with ulcer severity.
Key findings
- Gram-negative bacteria made up 59.4% of primary isolates, led by E. coli, K. pneumoniae and P. aeruginosa.
- A presumptive ESBL (extended-spectrum beta-lactamase) phenotype was found in 59 of 76 Enterobacterales isolates (77.6%).
- Carbapenem resistance was 18.2% to 22.7%, depending on how it was measured.
- 17 of 54 S. aureus isolates (31.5%) were MRSA.
- Meropenem was the most active agent against Gram-negative isolates (85.1%), followed by amikacin (68.0%) and piperacillin/tazobactam (64.4%). Linezolid and vancomycin were the most active against Gram-positive isolates.
Severe ulcers (Wagner grade 3 or above) were associated with ischaemia (adjusted odds ratio 3.05) and higher HbA1c (adjusted odds ratio 1.50 per percentage point). The authors note these are associations, not proof of cause, and the study did not test treatments or measure clinical outcomes.
What the authors recommend
The authors call for locally informed empirical antibiotic choices, rapid culture-guided narrowing of therapy, vascular assessment, better glycaemic control, timely source control and stronger antimicrobial stewardship.
The wider picture in Pakistan
Pakistan has one of the world’s largest diabetes populations, and diabetic foot disease is a leading cause of amputation. Recent initiatives include a 24-hour diabetic foot helpline and footcare services in 171 rural health centres, but infections that do not respond to first-line antibiotics remain a major obstacle to limb salvage.
IMEA POD Perspective
International guidance on diabetic foot infection is largely built on data from settings with lower resistance, and this study shows why local antibiograms matter. Where nearly four in five Enterobacterales carry an ESBL pattern, standard empirical regimens may fail, yet growing reliance on carbapenems carries its own risk. Foot care teams can help by taking tissue samples after debridement rather than superficial swabs, so that therapy can be narrowed quickly. The link between ischaemia and severe ulcers is equally important: routine vascular screening, such as ankle-brachial index and toe pressures, should be part of every diabetic foot assessment, with prompt referral when perfusion is poor. Podiatrists, wound care nurses, microbiologists and vascular surgeons all have a part to play.
Sources and further reading
- Atif E et al. 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, 2026
- Bioengineer: Khyber Pakhtunkhwa study maps resistance in diabetic foot infections
- IWGDF/IDSA guidelines on diabetes-related foot infections