Diabetes is an expensive health issue for both patients with diabetes and the healthcare systems globally. The number of individuals with diabetes has almost doubled over the previous 40 years [1] . As reported by the International Diabetes Federation, approximately 463 million adults worldwide are impacted by diabetes, and this number is projected to rise by at least 1.5 times by 2045 [2] [3] . The worldwide incidence of diabetes among adults over 18 years of age has also grown from 4.7% in 1980 to 8.5% in 2014 [4] . Diabetes mellitus is a common chronic disease characterized by persistent hyperglycemia. One of the most serious complications of this disease is diabetic wound infections [5] . According to Hurlow [6] , diabetic wound infections contribute substantially to morbidity, prolonged hospital stays, and costs of healthcare globally for diabetes mellitus patients. Approximately up to 25% of diabetics develop diabetic wound infections in their lifetime. A recent meta-analysis has shown a greater mortality rate in diabetics with diabetic wound infections (99.9 per 1000 person-year) compared to those without diabetic wound infections (41.6 per 1000 person-year) [6] .

Diabetic wound infections can contain single or multiple microbes that complicate treatment [7] . Staphylococcus aureus is the predominant organism responsible for acute diabetic wound infections [8] . S. aureus has emerged as a leading causative agent due to its adaptability and multiple virulence factors, such as adhesins, that facilitate host infection [9] . Formation of biofilms, and the formation of a polysaccharide capsule and several lytic enzymes that protect it from the host immune system and antibiotics [10] - [12] . This array of virulence factors, therefore, makes the presence of S. aureus in diabetic wounds a big challenge in the treatment and management of diabetes. The clinical significance of the pathogen has been exacerbated by the emergence and rapid spread of multidrug resistance among its strains, which complicates treatment for people with diabetes [13] . According to Anafo [14] The rise of antibiotic-resistant strains such as methicillin-resistant S. aureus (MRSA) has especially exacerbated the burden of diabetic wound infections, slowing down their healing rates and commonly resulting in amputations. These resistant strains often lead to treatment failures, necessitating the use of more expensive or toxic antibiotics, thereby increasing the economic and clinical burden on healthcare systems [14] .

In Kenya, the presence of S. aureus in diabetic wounds has previously been reported [15] - [17] . The studies have shown that S. aureus is a predominant pathogen in diabetic wound infections, contributing to delayed healing and increased complications. Although some reports have indicated the emergence of antibiotic resistance among these isolates, the scope of existing studies remains limited, with an insufficient focus on comprehensive antibiotic susceptibility testing and a larger patient population, in particular within the local context of Moi Teaching and Referral Hospital (MTRH). This research fills this void by offering current, site-specific insights into resistance patterns related to diabetic wound infections at MTRH. Thus, understanding the prevalence and antibiotic susceptibility patterns of S. aureus is crucial for tailoring effective treatment strategies and guiding antibiotic stewardship administration. The present study sought to determine the prevalence and antibiotic susceptibility patterns of S. aureus in samples from diabetic wounds from patients attending the MTRH. The findings of this study can be instrumental in guiding clinical treatment protocols concerning the most effective antibiotics for managing diabetic wound infections. Furthermore, the results can offer critical insights into local antibiotic resistance patterns of S. aureus, thereby assisting public health authorities in refining antibiotic stewardship strategies. Ultimately, the results of this study can contribute to improving patient treatment outcomes by reducing the burden of antibiotic-resistant infections and shaping the overall management of diabetic wounds in Kenya and beyond.

A total of 156 samples were obtained from wounds of diabetic patients attending the outpatient diabetic clinic at the MTRH during the study period. 31 samples were positive, while 125 samples tested negative. This translates to a prevalence of 19.87%. The prevalence result of this study is lower when compared to similar studies conducted at Vihiga County Referral Hospital [15] . That study established an overall 60.3% prevalence of S. aureus infection among diabetes mellitus patients. Similar studies in Ethiopia also recorded higher prevalence of 31.1% [20] and 25.19% [21] . Mutonga [16] recorded 98% prevalence while Amini [22] reported 87% prevalence. The difference can not only be attributed to the differences in periods and settings in which the studies were conducted, but also to the fact that these studies focused on foot ulcers. According to Mutonga [16] , it is estimated that 10 - 15% of diabetic patients will develop DFUs at some point in their lives. Tuvei [15] also documents that foot ulcers are more prone to infections than other wounds. These high prevalences can be attributed to the fact that most often, S. aureus colonizes skin or mucosal surfaces. However, it has been documented that children, HIV or diabetic patients are more prone to S. aureus colonization if they have wounds [23] . They also have the potential to cause serious infections if not treated early. Even when the virulence and invasive capability of S. aureus strains recovered from diabetes patients’ wounds are lower than those of strains typically seen in infections, they nevertheless retain the ability to cause and sustain invasive and deep tissue infections [24] .

The results of this study indicate that antibiotic resistance is not widespread among diabetic patients, which has also been reported by other authors before [15] [16] [20] - [22] . These findings differ from those of Amini [22] Reported 63.9% resistance by S. aureus isolates to Clindamycin. Atlaw [21] Also documented a high level of resistance of S. aureus to erythromycin and trimethoprim, unlike in the current study. The authors, however, reported that the S. aureus isolates were sensitive to clindamycin, just like in the current study. These also concur with the findings of Fawad. [25] who documented that the S. aureus they isolated showed high sensitivity to Cefoxitin and Clindamycin. Bhat [26] Also documented that S. aureus presented better susceptibility to commonly used antibiotics like Erythromycin, ceftriaxone, and clindamycin. S. aureus isolates showed high rates of resistance to oxacillin (95.2%), clindamycin (68.7%), and erythromycin (65.6%) according to Owais [27] the spread of antibiotic-resistant S. aureus complicates therapy, underscoring the need for robust infection control measures, such as enhanced hygiene, and the development of novel therapeutic approaches. Given the variability in antibiotic resistance patterns, personalized treatment plans based on susceptibility testing are essential for effective management.

The findings of this study regarding the influence of age group on the prevalence of S. aureus concur with those of earlier studies. Tuvei [15] reported an even higher prevalence rate among those in the 60 years and older age group at 63.8%. Amini [22] also documented that more than half (51/90) were more than 60 years old. This was similar to Rashid. [28] , who established a higher prevalence for those aged over 50 years. This observation could be attributed to this group of patients having other pre-existing medical conditions like hypertension, reduced mobility, and rare visits to the diabetic clinic. The danger of T2D is at its peak with an increase in age, especially after 45 years, due to less exercise, and thus gaining weight [29] . Therefore, aging may augment T2DM risk through pathophysiological mechanisms independent of obesity. As has been reported by other authors before, as people age, their immune systems become less effective at fighting off infections. Older individuals often have reduced neutrophil function and other immune impairments, making them more susceptible to infections like S. aureus. [30] .

The sex of a diabetic patient significantly (p = 0.025) influenced infection with S. aureus in this study cohort. The sex of diabetic patients, particularly those attending the outpatient diabetic clinic at MTRH, can be linked to the existence and subsequent isolation of S. aureus in their wounds. This is evident from the results of this study, whereby female diabetic patients returned a significantly higher positivity rate (11.54%) when compared to male diabetic patients. The highest prevalence of S. aureus infections in diabetic wounds in females could be attributed to the kind of chores traditionally female-dominated. Most studies have not explored the influence of sex in the occurrence of diabetes. That is despite an estimated 17.7 million more men than women worldwide suffering from diabetes mellitus. However, when type 2 diabetes is diagnosed, women seem to have a higher load of risk factors. Most studies have also not explored the influence of sex in the occurrence of diabetes. Women experience greater hormonal fluctuations throughout their lives, particularly during pregnancy and menopause, which can affect glucose metabolism and increase the risk of developing diabetes [31] . The influence of sex is therefore inconclusive, as some studies demonstrated male gender as a risk factor, some female gender as a risk factor, while other studies have shown no difference. Amini [22] reported equal proportions of infections in both sexes. Tuvei [15] reported that females had a higher prevalence of 57.4% as compared to their male counterparts at 42.6% just as was in this study also shared the same view [28] [32] [33] . However, this study’s results contradicted those of other studies reporting a higher prevalence in males than in females [21] [34] - [37] .

More than half (56.41%) of the diabetic patients attending the outpatient diabetic clinic at MTRH during the duration of this study had underlying conditions. The most frequent was hypertension, followed by heart disease and kidney disease. Just like other studies before, this study found that underlying conditions raise diabetes risk by altering metabolic health, causing insulin resistance, and complicating the care of modifiable risk factors. The higher positivity rate can be attributed to the already low immune systems among most diabetic patients. Underlying conditions weaken the patient’s immune system, rendering them highly susceptible to other infections. Reveles [35] they are of the same opinion, with their findings comparable to those from this study. According to the authors, hypertension (76%), dyslipidaemia (52%), obesity (49%), peripheral vascular disease (37%), and kidney disease (12%) significantly predispose diabetic patients to S. aureus infection.

A majority of the diabetic patients, 133 (85.26%) in this study, had previously been hospitalized for various reasons, out of which 26 (16.67%) of them returned a positive result. This is slightly lower than the findings of Reveles [35] . The authors documented a prevalence of 19% among patients with a history of recent hospitalization. This suggests that it is possible that S. aureus infection among diabetic patients in this and other studies could be due to nosocomial risk. The use of improperly sterilized equipment as well as contaminated fomites in hospitals could be the main reason.

The present study identified previous hospitalization as an independent risk factor for S. aureus infection. Hospital-acquired infection is one of the most common causes of microbial infections [38] . According to Liu [39] the occurrence of hospital-acquired infections is mainly due to the poor ward environment and the inadequate implementation of isolation measures for patients.

Another 50 (32.05%) diabetic patients attending the outpatient diabetic clinic at MTRH in this study had used antibiotics before enrolment. Of the 31 (19.87%) positive cases, 9 (5.77%) diabetic patients had used antibiotics. The statistically insignificant chi-square test p-value of 0.6874 at a 95% confidence level indicates that there was no relation between prior antibiotic use and the presence of S. aureus in the wounds of diabetic patients. This means that the S. aureus isolates could not be directly labelled as resistant to the antibiotics used by the patients before this study. That means they may have been contracted after completion of the prescribed dosage. However, that contradicts the findings from Amini. [22] who reported that 55.4% of the positive cases had a history of recent antibiotic therapy in the last few days. Reveles [35] also holds the same view with a 43% positivity rate documented by the authors. According to Yuan [40] antibiotics can raise the risk of diabetes by altering the gut microbiota and impacting metabolic health. Additionally, the risk may be confounded by underlying diseases that require the use of antibiotics.

A majority (122) of the diabetic patients attending the outpatient diabetic clinic at MTRH during this study period were married. 14.1% (22) of them returned positive results for S. aureus infections in their wounds. 1.92% (3) of the positive cases were from those who were single, while 3.85% (6) of the positive cases were from others (widows/widowers). Similar findings have also been documented by earlier studies. Tuvei [15] noted that those married had a higher prevalence of 84.0%. Aedh [34] also documented similar findings. According to Karimi [41] , divorced people are less likely to have T2DM, widowed people are less likely to have T2DM, and single people are more likely to have it. It has also been documented that single men may have a higher risk of diabetes compared to married men, while the impact on women can be different depending on the specific marital status. Social support, which is frequently provided by marriage, has a favourable impact on health-related behaviours, including diet, exercise, and treatment compliance. Regarding the effect of marital status on S. aureus infection rates, the majority of studies have produced conflicting findings, with the majority suggesting that married participants had higher rates [42] . This can be attributed to increased exposure and transmission opportunities within households.

Out of the 31 (19.87%) positive cases for the presence of S. aureus in wounds of diabetic patients, the majority, 16 (10.26%) out of 69, had a primary school education. Those with tertiary school education were 33, with 9 (5.77%) returning positive results of S. aureus infections. Diabetic patients who attended the outpatient diabetic clinic at MTRH during the duration of this study and had no school experience or had with secondary school education returned 3 (1.92%) positive cases each, from a total of 18 and 36, respectively. Tuvei [15] Conducted an education level analysis from their data and noted that those with primary level education had the highest prevalence rate at 51.1% just like in the current study. Aedh [34] also reported similar findings. Reduced socioeconomic status is frequently associated with lower education levels, which can result in more exposure to cramped living arrangements, unsanitary environments, and restricted access to medical treatment. Low levels of education may also contribute to poor dressing of their wounds, as most do not acquire sanitary techniques. Highly educated people may have easier access to early detection and treatment, which lowers the risk of severe infections [43] . These factors can increase the risk of diabetes and/or S. aureus infections.

The study reports an S. aureus prevalence of 19.87% from diabetic wounds of patients attending MTRH. The majority of the S. aureus isolates were susceptible to Cefoxitin, Erythromycin, and Clindamycin, with lesser susceptibility to Ampicillin. With other antibiotics having at least instances of intermediate sensitivity and/or antibiotic resistance by the isolates. Sex influences the occurrence of S. aureus in diabetic wounds of patients attending the diabetic clinic at MTRH. Age, underlying conditions, previous hospitalization, previous antibiotic use, marital status, and level of education do not significantly predispose the occurrence of S. aureus in diabetic wound patients. The study recommends Surveillance and early screening to detect any presence of S. aureus in diabetic wounds at MTRH to track the development of resistance trends and guide empirical treatment recommendations, as well as to inform early management measures. Considering the detected patterns of antimicrobial susceptibility, the study suggests that MTRH’s local empirical treatment protocols for infections related to diabetic wounds should favor Cefoxitin and Clindamycin, while reevaluating the standard use of Ampicillin due to elevated resistance levels. Female diabetic patients should be more cautious to prevent any traumatic injury, which could lead to diabetic wound infections.

All data generated or analyzed during this study are included in this published article.

Written informed consent was obtained from all participants before the commencement of the study.

The study was carried out with approval obtained from NACOSTI (license no: NACOSTI/P/24/34462) as well as the Institutional Research and Ethics Committee (IREC) of Moi MTRH and Moi University School of Medicine, and permission to conduct the study from MTRH management (Approval No: 0004852).

The authors contributed equally to the development of the research concept. DOO researched while RS and ABN supervised the work. DOO analysed the data and developed the draft manuscript. RS and ABN reviewed the manuscript and data analysis.

The authors would like to thank the staff at Moi Teaching and Referral Hospital’s diabetic clinic and Laboratory Directorate, as well as the entire management, for the opportunity to conduct our research within the facility, along with their kind cooperation and encouragement.