Health system gaps and missed opportunities in diabetic foot sepsis care in South Africa: a retrospective cohort study

Background Diabetic foot sepsis (DFS) is a major cause of lower extremity amputation (LEA) in Sub-Saharan Africa, contributing significantly to morbidity and mortality. Beyond disease severity, this burden is compounded by health system gaps in the continuum of care including weak referral systems, delayed presentation, limited post-operative follow-up, and delayed rehabilitation. This study evaluated these healthcare system gaps in DFS care. Methods A single-centre retrospective cohort study was conducted at Edenvale Regional Hospital (ERH) in Johannesburg, South Africa, including 101 type 2 diabetes patients who underwent major and minor LEA for DFS between July 2018 and June 2021. Demographics, referral pathways, comorbidities, infection severity, amputation level, and survival time were examined. Vital status and cause-of-death were determined via facility documentation or unverified telephonic interviews with next-of-kin for home deaths. Kaplan–Meier analysis estimated post-LEA survival, and Cox proportional hazards regression investigated predictors of all-cause mortality. Findings Only 17.8% (18/101) of DFS patients arrived via the nationally recommended Primary Health Care (PHC) referral pathways, while 51/101 (50.5%) presented directly from home. The three-year mortality rate was 24.8% (25/101), with 64.0% (16/25) of deaths occurring within six months post-amputation. 48.0% (12/25) of deaths were associated with defaulting diabetic medical treatment post-operatively. Increasing age and low serum albumin were significant predictors of mortality. Interpretation The high rate of early post-operative mortality reflects an association with suboptimal disease control, treatment default, and a lack of multi-disciplinary care. Urgent priorities include strengthening primary care referral systems, establishing transitional post-operative surveillance, and expanding access to multidisciplinary diabetic foot services. Funding No funding was obtained for this study.