Bacterial Profile and Antimicrobial Resistance Patterns in Infected Diabetic Foot Ulcers in Gulf Cooperation Council Countries (2005–2025): A Systematic Review and Meta-Analysis of Observational Studies

When the body's sugar regulation system fails, a condition known as diabetes, the consequences can reach far beyond blood tests and insulin injections. One of the most serious complications is a wound on the foot that refuses to heal. In a healthy person, a small cut might scab over and disappear in days, but for someone with diabetes, poor blood flow and nerve damage can turn a minor injury into a deep, open sore. These wounds are not just empty spaces in the skin; they are complex environments teeming with microscopic life. Bacteria, invisible to the naked eye, move in and colonize the tissue. Sometimes, these microbes are harmless visitors, but often they multiply into an infection that can eat away at the foot, leading to severe pain, long hospital stays, and in the worst cases, the loss of a limb. The challenge for doctors is that these bacteria are not all the same. They change from place to place, and they can become tough to kill with standard medicines. Understanding exactly which bugs are causing trouble in a specific region, and which medicines still work against them, is the key to saving feet and lives.

In the Gulf Cooperation Council region, a group of six nations in the Arabian Peninsula, the number of people living with diabetes is rising rapidly. As the population of people with diabetes grows, so does the number of these difficult foot infections. For years, doctors in this area have treated these wounds based on general knowledge or data from other parts of the world, but the specific mix of bacteria and their resistance patterns in the Gulf had never been fully mapped out in a single, comprehensive study. To fill this gap, a team of researchers from universities and hospitals across the region, including Saudi Arabia, Kuwait, and the United Arab Emirates, set out to gather every available piece of evidence. They did not conduct new experiments on patients themselves. Instead, they acted as archivists and synthesizers, hunting down sixteen existing scientific studies published between 2005 and 2025. These studies had already examined thousands of patients, collected samples from their infected wounds, and identified the bacteria living inside them. The researchers carefully checked the quality of each study to ensure the data was reliable, then combined the results to create a clear picture of the microbial landscape across the entire Gulf region.

What they found was a world of diverse and stubborn microscopic invaders. The analysis covered 3,260 patients, and the data revealed that these foot infections are rarely caused by a single type of bacteria. Instead, they are almost always a mix of different species living together. The most common culprit identified across the region was a bacterium called Staphylococcus aureus, which appeared in nearly 90 percent of the studies reviewed. This organism is responsible for about 29 percent of all the bacterial isolates found in these wounds. Following closely behind were two other major players: Pseudomonas aeruginosa and Escherichia coli. These bacteria, along with others like Klebsiella pneumoniae, formed a complex community that made treating the infections difficult. The researchers noted that the specific mix of bacteria varied from one hospital to another and from one country to another, suggesting that a treatment plan that works in one city might not be the best choice in the next.

The most critical finding of this work, however, concerned the weapons used to fight these infections: antibiotics. The researchers looked at how well different medicines were able to stop the bacteria from growing. They discovered that many of the older, commonly used antibiotics had lost their power. Resistance to ampicillin was extremely high, affecting two-thirds of the bacteria tested. Tetracycline, gentamicin, and ciprofloxacin also failed to work on more than half of the bacteria they were supposed to kill. This means that if a doctor were to prescribe one of these older drugs without first testing the specific bacteria in a patient's wound, the treatment would likely fail, allowing the infection to spread. In contrast, the data showed that newer, more powerful classes of antibiotics, such as carbapenems and vancomycin, remained effective against the vast majority of the bacteria found in these Gulf region wounds. The resistance to these stronger drugs was very low, with vancomycin showing almost no resistance at all.

Despite the clear success of these newer medicines, the researchers warned that relying on them without caution is dangerous. The study highlighted that multidrug-resistant bacteria, which are immune to multiple types of antibiotics, are already present in the region. These superbugs were found in nearly 40 percent of the studies that reported on them. The presence of these tough organisms, combined with the high rate of resistance to common drugs, suggests that the region is facing a serious challenge. The researchers pointed out that the data was not perfect; the studies they reviewed varied in how they collected samples and how they reported their findings, which made it hard to calculate exact numbers for every single type of bacteria. Some countries in the Gulf, like Bahrain and Qatar, had no eligible studies included in the review, leaving gaps in the regional map. Furthermore, the studies often did not distinguish between bacteria that were just living on the skin and those actually causing the deep infection, a distinction that is vital for deciding whether to use strong antibiotics at all.

The authors concluded that the current situation requires a shift in how these infections are managed. They argued that doctors in the Gulf should not rely on guesswork or old habits when choosing antibiotics. Instead, they need to test the specific bacteria in each patient's wound to see which medicines will actually work. This approach, known as antimicrobial stewardship, helps ensure that the powerful drugs that still work are saved for when they are truly needed, preventing the bacteria from becoming resistant to them as well. The study serves as a call to action for the region to invest in better surveillance and to develop treatment guidelines that are specific to the local bacteria. By understanding the true nature of the enemies in these wounds, healthcare providers can make better choices, reduce the risk of amputation, and improve the lives of the millions of people living with diabetes in the Gulf. The work does not solve the problem of antibiotic resistance, but it provides the essential map needed to navigate it.