Global gram-negative diabetic foot infection prevalence and its associations with climate: a systematic review and meta-analysis
9 affiliations
- 1Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine
- 2Department of Epidemiology, Rollins School of Public Health
- 3Gangarosa Department of Environmental Health, Rollins School of Public Health
- 4Woodruff Health Sciences Center Library, Emory University
- 5Department of Medicine, Medical College of Georgia
- 6Grady Health System
- 7Emory Global Diabetes Research Center, Woodruff Health Sciences Center and Emory University
- 8Department of Infectious Diseases, Gustave Dron Hospital of Tourcoing
- 9Hubert Department of Global Health, Rollins School of Public Health
Abstract
Background The International Working Group on the Diabetic Foot guidelines state that Pseudomonas aeruginosa and overall gram-negative diabetic foot infections (psaDFI and gnDFI) are more common in tropical and subtropical zones vs. temperate zones, and in North Africa/Asia vs. Western Europe/North America based on non-systematic comparisons of cohort studies. Methods We performed a systematic review and meta-analysis of studies of any design and language published between January 1, 2010, and December 15, 2020, that reported the proportion of participants with DFIs and microbiological tests that were positive or negative for Pseudomonas aeruginosa and/or gram-negatives of any species. We calculated the pooled prevalence of psaDFIs and gnDFIs using random effects models. Results We identified 246 studies (36,788 participants) reporting on psaDFI prevalence and 55 studies (6,079 participants) reporting on gnDFI prevalence. The psaDFI pooled prevalence in tropical, subtropical, and temperate zones was 19% (95%CI 17–22%), 14% (95%CI 12–17%), and 14% (95%CI 11–17%), respectively. The gnDFI pooled prevalence in tropical, subtropical, and temperate zones was 68% (95%CI 61–74%), 54% (95%CI 45–63%), and 43% (95%CI 35–52%), respectively. The pooled prevalence of psaDFIs and gnDFIs was higher in studies conducted in Asia/North Africa [psaDFI 18% (95%CI 16–20%) and gnDFI 57% (95%CI 51–64%)] compared to studies conducted in North America/Western Europe [psaDFI 12% (95%CI 9–16%) and gnDFI 42% (95%CI 32–52%)]. However, the pooled prevalences of these infections were similar in temperate zones of these regions. Few studies reported data on key risk factors for psaDFIs and gnDFIs, including DFI severity (53%) and prior antibiotic exposure (91%), and there was substantial between-study heterogeneity within climate zones and regions. Conclusions This meta-analysis indicates psaDFIs and gnDFIs may be more prevalent in tropical zones compared to temperate zones and suggests solar climate zones provide additional nuance compared to the guideline-proposed broad regional groupings. However, available studies lack necessary data to separate the effects of climate and location from other risk factors for psaDFIs and gnDFIs. Our findings cannot establish causality between solar climates, regions, and DFI microbiology. Registration PROSPERO CRD42022279019.
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BibTeX
@article{schechter2026global,
title = {{Global gram-negative diabetic foot infection prevalence and its associations with climate: a systematic review and meta-analysis}},
author = {Marcos C. Schechter and Ben Rabin and Ellen Martinson and Mia S. White and Baffour Otchere and J. Raymond and Jillian Dunbar and Meg McAloon and Priyanka A. Bhanushali and Kyra L. Urquhart-Foster and Maya Fayfman and Mohammed K. Ali and Eric Senneville and Rodrigo M. Carrillo-Larco and Sophie Lockwood},
journal = {BMC Infectious Diseases},
year = {2026},
month = jul,
doi = {10.1186/s12879-026-13916-0},
url = {https://doi.org/10.1186/s12879-026-13916-0},
note = {CC BY},
}
RIS
TY - JOUR
TI - Global gram-negative diabetic foot infection prevalence and its associations with climate: a systematic review and meta-analysis
AU - Marcos C. Schechter
AU - Ben Rabin
AU - Ellen Martinson
AU - Mia S. White
AU - Baffour Otchere
AU - J. Raymond
AU - Jillian Dunbar
AU - Meg McAloon
AU - Priyanka A. Bhanushali
AU - Kyra L. Urquhart-Foster
AU - Maya Fayfman
AU - Mohammed K. Ali
AU - Eric Senneville
AU - Rodrigo M. Carrillo-Larco
AU - Sophie Lockwood
PY - 2026
DA - 2026/07/01
JO - BMC Infectious Diseases
DO - 10.1186/s12879-026-13916-0
UR - https://doi.org/10.1186/s12879-026-13916-0
AB - Background The International Working Group on the Diabetic Foot guidelines state that Pseudomonas aeruginosa and overall gram-negative diabetic foot infections (psaDFI and gnDFI) are more common in tropical and subtropical zones vs. temperate zones, and in North Africa/Asia vs. Western Europe/North America based on non-systematic comparisons of cohort studies. Methods We performed a systematic review and meta-analysis of studies of any design and language published between January 1, 2010, and December 15, 2020, that reported the proportion of participants with DFIs and microbiological tests that were positive or negative for Pseudomonas aeruginosa and/or gram-negatives of any species. We calculated the pooled prevalence of psaDFIs and gnDFIs using random effects models. Results We identified 246 studies (36,788 participants) reporting on psaDFI prevalence and 55 studies (6,079 participants) reporting on gnDFI prevalence. The psaDFI pooled prevalence in tropical, subtropical, and temperate zones was 19% (95%CI 17–22%), 14% (95%CI 12–17%), and 14% (95%CI 11–17%), respectively. The gnDFI pooled prevalence in tropical, subtropical, and temperate zones was 68% (95%CI 61–74%), 54% (95%CI 45–63%), and 43% (95%CI 35–52%), respectively. The pooled prevalence of psaDFIs and gnDFIs was higher in studies conducted in Asia/North Africa [psaDFI 18% (95%CI 16–20%) and gnDFI 57% (95%CI 51–64%)] compared to studies conducted in North America/Western Europe [psaDFI 12% (95%CI 9–16%) and gnDFI 42% (95%CI 32–52%)]. However, the pooled prevalences of these infections were similar in temperate zones of these regions. Few studies reported data on key risk factors for psaDFIs and gnDFIs, including DFI severity (53%) and prior antibiotic exposure (91%), and there was substantial between-study heterogeneity within climate zones and regions. Conclusions This meta-analysis indicates psaDFIs and gnDFIs may be more prevalent in tropical zones compared to temperate zones and suggests solar climate zones provide additional nuance compared to the guideline-proposed broad regional groupings. However, available studies lack necessary data to separate the effects of climate and location from other risk factors for psaDFIs and gnDFIs. Our findings cannot establish causality between solar climates, regions, and DFI microbiology. Registration PROSPERO CRD42022279019.
SN - 1471-2334
ER -