Diabetic Foot Ulcers in Africa: A Systematic Review of Microbial Profiles and Clinical Outcomes in the Context of Multidrug Resistance

Diabetic foot ulcers (DFUs) are among the most severe complications of  diabetes mellitus, contributing to infection, limb loss, and premature mortality. In Africa, the rising prevalence of diabetes, combined with limited laboratory capacity and frequent empirical antibiotic use, has intensified the problem of multidrug-resistant (MDR) infections. Understanding the microbial spectrum and associated outcomes is critical for guiding evidence-based management. This review systematically synthesizes data on microbial etiologies, antimicrobial-resistance patterns, and clinical outcomes of DFUs in African populations. Methods: Following PRISMA 2020 guidelines, PubMed, Scopus, Embase, Web of Science, African Journals Online, and Google Scholar were searched for studies published between 2000 and 2025. Eligible studies included adults with DFUs in African settings that reported bacterial isolates, resistance profiles, or clinical outcomes. Two reviewers independently screened and extracted data, and study quality was appraised using the Joanna Briggs Institute checklist. Data were synthesized narratively and summarized using descriptive statistics. Sixteen verified studies from ten African countries, encompassing approximately 2,700 participants, were included. Staphylococcus aureus and Pseudomonas aeruginosa were the predominant isolates, followed by Escherichia coli, Klebsiella pneumoniae, and Proteus mirabilis. MDR prevalence was high, with methicillin-resistant S. aureus (MRSA) detected in 25–45% of isolates and extended-spectrum β-lactamase (ESBL)–producing Enterobacterales in 30–50%. Among studies reporting outcomes, amputation rates ranged from 15% to 38% and mortality from 7% to 16%, with poorer outcomes in MDR infections. Considerable heterogeneity existed in sampling and testing methods across studies. Saureus remains the dominant pathogen in African DFUs, but AMR is pervasive across bacterial species. Strengthening diagnostic laboratory systems, infection-control practices, and antimicrobial stewardship (alongside integrated diabetic foot care) is essential to reduce preventable amputations, mortality, and the continent’s growing burden of drug-resistant infections.<br /> <b>Keywords: </b>Diabetic