differences in microbiomes between intact diabetic skin, diabetic foot … springer apma...
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Differences in Microbiomes Between Intact Diabetic Skin, Diabetic Foot
Ulcers, and Non-Diabetic Skin Katie Springer, BS
Dr. William M. Scholl College of Podiatric Medicine
July 13, 2019
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Disclosure
• Grant support – NIH grant T35DK074390 from the National Institute
of Diabetes and Digestive and Kidney Diseases. – American Podiatric Medical Students’ Association.
• The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIDDK, NIH or APMSA.
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Introduction • Individuals with diabetes are more prone to infection. • Shifts in the bioburden can increase a person’s risk of
infection. • 3 Dimensions of bioburden
– Microbial load – Microbial diversity – Microbial shift toward pathogenicity
• The purpose of this study was to evaluate differences in the microbiome between DFU, DS, and NDS.
1. Dewilde, S., Harris, T., Hosking, F. J., & Cook, D. G. (2018). Risk of Infection in Type 1 and Type 2 Diabetes Compared With the General Population: A Matched Cohort Study. Diabetes Care, 41(3), 513–521.
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Methods • 40 subjects participated in this
study • 20 with diabetes and a single
UTSA Grade 1A plantar ulcer • 20 age (+/-4 years) and
gender match controls
• Wound/skin cultures via Levine technique • Subjects with diabetes
• Wound • Equivalent ulcer location contralateral
foot • Controls
• Plantar aspect of bilateral feet
• Quantitative cultures • 16S ribosomal RNA (rRNA) gene amplicon sequencing
• Statistical Analysis
• Analysis of Similarity (ANOSIM) • Alpha-diversity measurements
• Richness, evenness, diversity, and variation in taxonomic distinctness
1. Copeland-Halperin, L. R., Kaminsky, A. J., Bluefeld, N., & Miraliakbari, R. (2016). Sample procurement for cultures of infected wounds: a systematic review. Journal of Wound Care, 25(Sup4), S4–S10.
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Results: Characteristics Controls Subjects with Diabetes p-value
Mean HbA1c 5.53+/- 0.9 7.38 +/- 1.5 <0.001
Mean Glucose 103.3 +/- 16.4 162.4 +/- 74.4 0.0013
Mean BMI 30.0 +/- 6.8 31.1 +/- 6.2 0.604
Mean Age 59.4 +/- 12.9 58.6 +/- 12.4
Gender ratio (M:F)
14:6 14:6
Wound duration (months)
N/A 11.5 +/- 18.5
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Microbial Load
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Alpha Diversity Indices • Number of genera detected (S),
richness (d), evenness (J’), Shannon Index (H’) and Simpson Index (1-Lambda’).
• Kruskal-Wallis used to determine if populations of microbiome are significantly different.
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Microbial Community Ordination Non-metric MDS
Standardise Samples by TotalTransform: Square rootResemblance: S17 Bray-Curtis similarity
ConditionDFUDSNDS
2D Stress: 0.15
• Analysis of similarity o The difference in microbial community
structure between the three groups o Diabetic skin and diabetic foot ulcer
microbiomes were most similar to each other (low R) and ANOSIM results were not significant t p<0.05.
o Both diabetic skin and diabetic skin ulcer microbiomes were significantly different from non-diabetic skin
Analysis of Similarity (ANOSIM)
Comparison R value p-value
DFU, DS 0.07 0.074
DFU, NDS 0.424 0.001
DS, NDS 0.152 0.006
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Dominant Taxa
Klebsiella
Enhydrobacter
Stenotrophomonas
Micrococcus
Staphylococcus
Corynebacterium 1
Finegoldia
Peptoniphilus
Anaerococcus
Ezakiella
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100
200
T _ u l
c e r
R F _
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R F C
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Discussion • Diversity is commonly used as an indicator of ecosystem health • Decreased microbiome diversity in individuals with diabetes
– Potentiate microbiome shift towards pathogenicity infection
• Decreased diversity in the skin microbiome in DS vs. NDS – Skin barrier compromised – Microbiome migration and shift towards pathogenicity
• Potential changes in individuals with diabetes leading to decreased diversity: – Increased skin pH – Advanced glycation end (AGE) products in the skin matrix – Increased levels of skin inflammation – Inadequate immunological response
1. Gardiner, M., Vicaretti, M., Sparks, J., Bansal, S., Bush, S., Liu, M., … Burke, C. M. (2017). A longitudinal study of the diabetic skin and wound microbiome, 2035, 1–23. 2. Yosipovitch G, Tur E, Cohen O, Rusecki Y. 1993. Skin surface pH in intertriginous areas in NIDDM patients. Possible correlation to candidal intertrigo. Diabetes Care 16:560–563 3. Gkogkolou P, Bohm M. 2012. Advanced glycation end products: key players in skin aging? Dermato-Endocrinology 4:259-270 4. Tellechea A, Kafanas A, Leal EC, Tecilazich F, Kuchibhotla S, Auster ME, Kontoes I, Paolino J, Carvalho E, Nabzdyk LP, Veves A. 2013. Increased skin inflammation and blood vessel density in human and experimental diabetes. International Journal of Lower Extremity Wounds 12:4–11 5. Mor A, Berencsi K, Nielsen JS, Rungby J, Friborg S, Brandslund I, Christiansen JS, Vaag A, Beck-Nielsen H, Sorensen HT, Thomsen RW. 2016. Rates of communitybased antibiotic prescriptions and hospital-treated infections in individuals with and without type 2 diabetes: a Danish nationwide
cohort study, 2004–2012. Clinical Infectious Diseases 63:501–511
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Discussion cont. • Current focus on treatment of diabetic foot infections
– Better culture techniques, antibiotics
• Shift in research focus – Explore factors that drive microbial colonization in people
with diabetes – Gut-skin axis – Develop new promicrobia and antimicrobial therapeutics
• Shifting the microbiome of the DS towards the NDS as a preventative treatment of the diabetic foot
Kurečič, M., Rijavec, T., Hribernik, S., Lapanje, A., Kleinschek, K. S., & Maver, U. (2018). Novel electrospun fibers with incorporated commensal bacteria for potential preventive treatment of the diabetic foot. Nanomedicine, 13(13), 1583–1594. https://doi.org/10.2217/nnm-2018-0014
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Limitations and Future Studies
• Limitations: – Pilot study – Small sample size
• Future Studies: – Association/stratification
with other patient parameters
• HbA1c • Glucose levels
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Conclusion
• Diabetes doesn’t appear to affect microbial load of intact skin
• Dysbiosis in the DS is marked by significantly reduced microbial diversity – Potential instigator of diabetic foot infection
• Targeting research to focus on the pathogenic shift – Microbiomes role in diabetic foot infection
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Acknowledgments • Stephanie Wu, DPM, MS, FACFAS • Stefan Green, PhD • Sasha Shafikhani, PhD • Chalen Yang, MS • Jacqueline Ortiz, CCRP