Journal of Health and Nutrition Research

• The healing process of Diabetic Foot Ulcers (DFU) is greatly influenced by infection control during wound care. Pineapple stems in the form of hand sanitizer can be an alternative antibacterial agent during wound care procedures

Diabetes Mellitus (DM) is a chronic disease that is a public health problem in the world with a very high (1). Indonesia are ranked 7th in Southeast Asia with the largest number of sufferers and the percentage of deaths due to diabetes in Indonesia is the second highest (2). One type of complication experienced by DM sufferers is Diabetic Foot Ulcer (DFU ) (3). The risk of DFU in DM patients is stated to be 85.7% (4). Sufferer DM with neuropathy own risk tall For become DFU and among them experience amputation (5). Diabetes experts estimate 50% to 75% Amputation incidents can be avoided with good foot care (6). The key to treating DFU is recognizing and treating diabetes before complications occur (7). More than a Half of all leg ulcers will become infected and require hospitalization and 20% from infection extremities lower will end with amputation (5) . DFU treatment will have a significant impact on preventing the occurrence of complications chronicle foot diabetic like ulcer or even gangrene (8). The importance of comprehensive diabetic foot care that is effort overcome, remove or reduce infection until wound healed total (9). Nurses provided by health workers in hospitals are expected to fulfill various aspects, one of which is patient safety, including preventing patients from infections that occur in hospitals (10)(11)(12).

Good hand hygiene is a very important infection control measure resulting from person-to-person contact (13)(14). Hand hygiene is essential to prevent the spread of infectious diseases and is an infection control measure (15)(16). Long-term side effects of use of alcohol on the skin is considered can cause skin irritation skin, dry skin so need necessitating a more gentle and natural alternative (17). The utilization of pineapple fruit is generally limited to the flesh of the fruit only and other parts such as the crown, skin, and pineapple stem have not been optimally utilized and are even thrown away even though these parts contain the enzyme compound bromelain which has an effect on healing cuts (18). However, the use of pineapple stems as a hand sanitizer in DFU wound care to reduce the risk of infection has never been studied before.

Previous research using pineapple skin as a disinfectant spray to reduce the number of germs on the dining table with the result of a decrease in the number of germs on the dining table after using a disinfectant spray from pineapple skin extract (19). In addition, another study that utilizes pineapple skin extract made into nano spray gel against the growth of Staphylococcus epidermidis bacteria in Ulcers with the results of antibacterial activity against Staphylococcus epidermidis at a concentration of 75% (20). Therefore, this study aimed to develop and evaluate the antimicrobial effectiveness of a hand sanitizer derived from Pineapple Core and to assess its preliminary utility in preventing infections during the care of diabetic foot ulcers.

The research design using true experiment with a quantitative descriptive approach. This study was conducted at the Hospital of Muhammadiyah Palembang from 1st February to 25th April 2025 with a population of all DM patients in the internal medicine surgery room with the total 588 patients. The study was conducted in two phases: first, a microbiological assessment of hand swabs from 16 nurses with and without the use of the pineapple stump sanitizer. The second, a single-arm observational cohort assessment of infection incidence in 43 patients with DFU following wound care where the sanitizer was used. The inclusion criteria DFU Patients’ were : (1) DM patients with a duration of DM ≤ 10 years; (2) Having Diabetic Foot Ulcers; and (3) Willing to be respondents. While the exclusion criteria were DM patients with severe complications such as heart disease and stroke. The sampling technique uses purposive sampling by selecting intentionally to adjust the research objectives (21).

Tools and materials used is pineapple stump, 0.1 M phosphate buffer pH 7, gram staining, microscope, oil immersion, blender, and centrifuge. Procedure Work making hand sanitizer from pineapple stem, namely: a pineapple stump that has cleaned up cut small pieces, adding 0.1 M phosphate buffer pH 7, ground with using a blender , the blender results are squeezed, the results squeeze saved at temperature room for 24 hours so that settle , take results sediment Then centrifuged with speed 3500 rpm for 15 minutes obtained filtrate containing extract pineapple stump (22) . Procedure Work gram staining is made stock review above the object glass then fixed above bunsen, then dripped with crystal violet then left alone for 1-2 minutes. the rest substance color thrown away, then rinsed with running water. All preparation dripped with solution lugol and let for 30 seconds. Throw away solution lugol and rinse with running water. Preparation dispelled with alcohol 96% to all substance color fade, and soon wash with running water. Dripping with substance safranin color, let it for 2 minutes Then rinse with running water Then left alone dry (23). Procedure Work inspection bacteria in a way microscopic namely: observing below microscope with enlargement lens objective 100x use emersion. Staphylococcus aureus is gram-positive bacteria and cocci form clusters (24). The data of Characteristics of Patients using the Medical record data and to assess infection of wound characteristics’ using the Diabetic observation sheet Foot Ulcer Assessment Scale (DFUAS) Concurrent, construct, and predictive validity tests have been conducted on DFUAS. The reliability test of DFUAS is stated to be reliable with an Alpha value Cronbach 0.654

Data processed in a way analysis descriptive based on results positive found bacteria. Inspection results done analysis in a way descriptive based on results microscopic found bacteria (25). For infection incidence, data analysis using univariate analysis in the form of frequency distribution and percentage produced the distribution of wound characteristics and severity of DFU (26).

Table 1. The presentation results in a way microscopic on hand swab, the nurse who uses Pineapple Core hand sanitizer is positive (18.75%) and negative (81.25%), while without hand sanitizer is positive (68.75%) and negative (31.25%).

Table 1. Microbiological Results of Nurses' Hand Swabs with and without use of Pineapple Core Hand Sanitizer (n=16 samples per group).

Table 2. Characteristics of Patients with DFU (43)

The demographic and clinical data presented in Tables 2 and 3 indicate a study population predominantly composed of elderly individuals (55.9% >60 years old) and females (62.8%), the majority of whom have managed diabetes for 5 to 10 years. Despite the severity of the participants' conditions—with 58.14% of wounds penetrating the subcutaneous or dermal layers and 88.37% of ulcers classified as significantly wide—the clinical outcomes following the application of the pineapple core extract were remarkably positive. Specifically, 76.74% of patients showed no signs of infection, 55.81% exhibited high levels of tissue granulation (76–100%), and 48.84% presented with healthy, pink wound edges. These results suggest that the antimicrobial and anti-inflammatory properties of the pineapple extract, likely driven by the enzyme bromelain, effectively stabilized the wound environment by preventing secondary infections and promoting tissue regeneration, even in high-risk elderly patients with deep diabetic ulcers.

Table 3. Characteristics of Wound on Respondents after wound care (n=43)

The results of this study indicate that hand sanitizer from pineapple stem extract as an antibacterial has a negative result of 81.25%, while for the control group, the negative result was only 31.25%. The difference with previous studies, hand sanitizers were made using aloe vera extract and betel leaves with the addition of 70% alcohol and there were also those who used betel leaves and lime, using a filtration process (27)(28). Pineapple Cores contain very beneficial compounds, namely the enzyme bromelain which has been proven in various studies to have an effect on healing cuts (20). Studies have also been done on the effectiveness of antimicrobial hand sanitizers made from natural Piper battle L and Aloe vera (29). Natural hand sanitizers are more in demand by the public and have added value because they are considered safer than chemical hand sanitizers in general and are easily obtained in the wider community environment (30).

In this study, inflammation showed no infection (76.74%). It is a condition in which there are pathogenic microorganisms that grow in wounds which cause the wound to change color to reddish, swollen, painful, and purulent (31). The previous studies about DFU stated that the presence of infection can increases the risk of lower limb amputation by up to 50% compared to DFU without infection (32). Moreover, again on wound which due to by 2 or more pathogen (combined infection) can own risk which increasing. Matter this in accordance with study previously Which shows that the wound with combined infection 11.39 time higher risk of amputation (33). Depth wound on study This show that most of respondents have wound characteristics with subcutaneous/dermis depth (58.14%). The study explains that the risk of major amputation is 7.5 times higher when the wound penetrates or reaches the depth of the bone (6)(32). This is because the more in wound prevalence of pathogens anaerob will increase. Diabetic foot infection often time happen on wound with depth reach tendon and capsule on joints (34). The severity of the wound is also influenced by the size of the wound (35). The results showed that more respondents had wound characteristics with a size of 1 cm2 < x ≤ 4 cm2 than other sizes. The size of the wound will affective on long healing and risk amputation (36). Similarity to the characteristics of wound size, wound assessment is used to predict the length of wound healing. In addition, the wider the wound, the more Wounds are at greater risk of becoming a place for microorganisms to grow which can cause infection (32).

Pineapple peel has the potential to be used for wound healing because it contains compounds such as the enzyme bromelain, flavonoids, tannins, and saponins, which have anti-inflammatory and antimicrobial effects and support the formation of new skin tissue. Research shows that pineapple peel extract can accelerate wound healing, including burns and cuts, and is often formulated as a gel for easy absorption (21). Other studies using pineapple peel eco-enzyme solution have shown it contains secondary metabolites in the form of tannins and saponins. Tannins function as astringents that can deposit proteins on cell surfaces with low permeability. This causes skin pores to shrink and can stop leakage and bleeding, thus accelerating the wound healing process. The saponins contained in the eco-enzyme solution are growth factors that can accelerate the re-epithelialization of epidermal tissue and the infiltration of inflammatory cells in the wound area (19)(21)

Based on the study results, it can be concluded that some DFU patients do not experience infection when using an alternative antiseptic hand sanitizer, pineapple stump, and active maintenance of the DFU wound. The presence of signs of infection, such as exudative fluid, can affect the occurrence of maceration. Maceration is damage to the skin around wounds caused by continuous exposure to moisture/exudate (36). However, the study found that respondents' own characteristics were more strongly associated with maceration than those of other categories. Maceration can be prevented by proper wound care, such as using a dressing that absorbs exudate. If maceration occurs, it will result in damage to skin integrity and prolong the healing period of wounds (33).

This study demonstrates that pineapple stem extract exhibits significant antibacterial activity when formulated into a hand sanitizer. Microscopic analysis showed that the pineapple-based sanitizer effectively reduced bacterial presence on nurses' hands (81.25% negative for bacteria), comparable to standard hygiene outcomes. Furthermore, its application in diabetic foot ulcer (DFU) care demonstrated promising safety, with most patients maintaining infection-free wounds. Instead of relying solely on alcohol-based agents, this natural formulation offers a viable, eco-friendly, and cost-effective alternative for infection control, particularly in resource-limited settings. Future research should focus on conducting randomized controlled trials (RCTs) with larger sample sizes and specific bacterial cultures to further establish its clinical efficacy and stability.

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The funding in this study was supported by the Research Center of Muhammadiyah Foundation Batch VIII.

The author thanked the participants in this study and the nurse managers who supported the data collection process.

The authors declare no conflict of interest.

1. Moschiar Almeida B, Evans R, Kayssi A. Fundamentals of wound care for amputation prevention. Semin Vasc Surg [Internet]. 2025;38(1):54–63. Available from: https://doi.org/10.1053/j.semvascsurg.2025.01.001

2. Ahmed MM, Ibrahim RM, Younis NM. Diabetic Distress among Patients with Type II: A Descriptive Study. Adv Biomed Res. 2025;14(1):1–4.

3. Fritz M, Grimm M, Thi H, Hanh M, Koot JAR, Nguyen GH, et al. Effectiveness of community- ­ based diabetes and hypertension prevention and management programmes in Indonesia and Viet Nam : a quasi- ­ experimental study. 2024;

4. Wellmann IA, Ayala LF, Rodríguez JJ, Guetterman TC. Implementing integrated hypertension and diabetes management using the World Health Organization ’ s HEARTS model : protocol for a pilot study in the Guatemalan national primary care system. Implement Sci Commun [Internet]. 2024;1–15. Available from: https://doi.org/10.1186/s43058-023-00539-8

5. Fejfarová V, Koliba M, Piťhová P, Flekač M, Prýmková V, Venerová J, et al. Economic burden of podiatric care for diabetic foot ulcers in the Czech Republic: A prospective multicenter study. Diabetes Res Clin Pract. 2025;223(March).

6. Caruso P, Scappaticcio L, Gicchino M, Castaldo F, Barrasso M, Carbone C, et al. Short-term glucose variability as a determinant of the healing rate of diabetic foot ulcer: A retrospective study. Diabetes Metab Syndr Clin Res Rev [Internet]. 2024;18(3):102990. Available from: https://doi.org/10.1016/j.dsx.2024.102990

7. Huong AKC, Sukki JM, Ngu XTK. Mobiledfu: Classification of Diabetic Foot Ulcer Infection on the Edge. J Eng Sci Technol. 2025;20(2):577–89.

8. Sun H, Heng H, Liu X, Geng H, Liang J. Evaluation of the healing potential of short-term ozone therapy for the treatment of diabetic foot ulcers. Front Endocrinol (Lausanne). 2023;14(January):1–9.

9. Banerjee D, Paul S, Selvan C, Pai S, Nandakumar BS, Mukherjee S, et al. Uncovering the Role of Tertiary Lymphoid Organs in the Inflammatory Landscape: A Novel Immunophenotype of Diabetic Foot Ulcers. J Cell Mol Med. 2025;29(7):1–12.

10. Najm AMA, Yasir AA. Nurses’ Practices Concerning Infection Control Measures in Intensive Care Units. Iran J War Public Heal. 2024;16(2):175–80.

11. Jarelnape AA, Ali ZT, Fadlala AA, Sagiron EI, Osman AM, Abdelazeem E, et al. The Influence of Nursing Interventions on Patient Outcomes: A Systematic Review. Saudi J Heal Syst Res. 2023;1–7.

12. Suarmayasa IN. Pola Kuman Pada Manset Sphygmomanometer : Studi Deskriptif Di Rsd Mangusada. J Ris Kesehat Nas. 2023;7(2):163–8.

13. R MMM. Assessment of Staff Knowledge and Practices for Nosocomial Infection Control and Prevention. 2024;12(1):159–64.

14. Li J. Awareness of Nosocomial Infection Prevention and Practices Among Undergraduate Nursing Students. 2024;1(1):33–41.

15. Wang Y, Wang L, Ma W, Zhao H, Han X, Zhao X. Development of a novel dynamic nosocomial infection risk management method for COVID-19 in outpatient settings. BMC Infect Dis [Internet]. 2024;24(1):1–11. Available from: https://doi.org/10.1186/s12879-024-09058-w

16. Kahusadi OA, Tumurang MN, Punuh MI. Pengaruh Penyuluhan Kebersihan Tangan terhadap ( Hand Hygiene) Perilaku Siswa SD GMIM 76 Maliambao Kecamatan Likupang Barat Kabupaten Minahasa Utara. J KESMAS. 2018;7(5):1–9.

17. Hanina, Humaryanto, Gading PW, Aurora WID, Harahap H. Nurul Iman Tentang Infeksi Staphylococcus Aureus Di Kulit Dengan Metode Penyuluhan. Medic. 2022;5(2):426–30.

18. Bahri S, Ginting Z, Vanesa S, ZA N. Formulasi Sediaan Gel Minyak Atsiri Tanaman Nilam (Pogostemon Cablin Benth) Sebagai Antiseptik Tangan (Hand Sanitizer). J Teknol Kim Unimal. 2021;8(1):87.

19. Mosayan GA, Hukma S S, Walidah P H H. Pinaplast: Plester Luka dari Ekstrak Bonggol Nanas (Ananas Comosus (L.) Merr.) sebagai Pengobatan Alami Luka Sayat. J Edukasi dan Sains Biol. 2022;4(1):26–33.

20. Handayani H, Haryanti S, Amri C. Efektivitas Penggunaan Ekstrak Kulit Nanas Madu sebagai Disinfektan Spray terhadap Penurunan Angka Kuman Meja Makan. J Kesehat Lingkung Mandiri. 2024;2(2):19–30.

21. Muaratan J, Natalia A, Ginting B, Meutia R, Pranita NJ. Aktivitas Nano Spray Gel Ekstrak Kulit Nanas ( Ananas comosus L . ) terhadap Pertumbuhan Bakteri Staphylococcus epidermidis pada Ulkus Diabetes Melitus Secara In Vitro Program Studi Farmasi Klinis , Universitas Prima Indonesia , Medan , Sumatera Utara , I. 2025;3.

22. Saputra R. Buku Ajar Statistik. Vol. 8, Forum Statistika dan Komputasi. 2016. 1–7 p.

23. Lubis AW, Maulina J. Pemanfaatan Ekstrak Kulit Nanas (Ananas comosus L.) Dalam Pembuatan Hand Wash Sebagai Antibakteri. BEST J (Biology Educ Sains Technol. 2020;3(1):70–5.

24. Hayati LN, Tyasningsih W, Praja RN, Chusniati S, Yunita MN, Wibawati PA. Isolation and Identification of Staphylococcus aureus in Dairy Milk of The Etawah Crossbred Goat with Subclinical Mastitis in Kalipuro Village, Banyuwangi. J Med Vet. 2019;2(2):76–82.

25. Asman, Salnus S, Suswani A, Hasanuddin ARP. Gambaran Telur Cacing Balita Stunting Menggunakan Pewarnaan Antosianin Dari Ekstrak Ubi Ungu Metode Flotasi Di Kabupaten Bulukumba. J TLM Blood Smear. 2020;1(1):6–13.

26. Rosnawaty R, Suryati Y, Sriati A, Inayah I, Imelisa R. Penurunan Beban Keluarga Dalam Merawat Klien Skizofrenia Melalui Triangle Terapy Di Masa Pandemik Covid-19. J keperawatan jiwa. 2022;10(3):535–44.

27. Kusumaningrum NSD, Saputri AD, Kusuma H, Erawati M. Karakteristik Diabetic Foot Ulcer (DFU) pada Individu dengan Diabetes Mellitus (DM): Studi Deskripsi – Cross Sectional. J Holist Nurs Sci. 2020;7(2):88–98.

28. Saputri D, Pratama AA, Iza L, Rohmawati L. Pembuatan Handsanitizer Bahan Alam dari Ekstrak Lidah Buaya dan Daun Sirih. Semin Nas Fis. 2021;174–7.

29. Listari N, Isviyanti I, Triandini IGAAH. Pembuatan Hand Sanitizer Alami di tengah Upaya Mengatasi Kelangkaan pada Masa Pandemi COVID-19 di SMK Bhakti Kencana Mataram. Lumbung Inov J Pengabdi Kpd Masy. 2020;5(2):34.

30. Kusdiyah E, Darmawan A, Indah Dewi Aurora W, Irbah ah, Ilmu Kesehatan dan Kedokteran Keluarga Fakultas Kedokteran dan Ilmu Kesehatan Universitas Jambi D. Nomor 3, Halaman 48-52. J Kesehat Masy Indones. 2022;17(September):48.

31. Lee SH, Kim SH, Kim KB, Kim HS, Lee YK. Factors Influencing Wound Healing in Diabetic Foot Patients. Med. 2024;60(5):1–12.

32. Fan Z, Huang J, Liu Y, Xie H, Yang Q, Liang Y, et al. Multifactorial analysis of risk factors for foot ulcers in patients with neurovascular complications of diabetes. Front Endocrinol (Lausanne). 2024;15(October):1–9.

33. Parveen K, Hussain MA, Anwar S, Elagib HM, Kausar MA. Comprehensive review on diabetic foot ulcers and neuropathy: Treatment, prevention and management. World J Diabetes [Internet]. 2025;16(3):100329. Available from: http://www.ncbi.nlm.nih.gov/pubmed/40093290%0Ahttp://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=PMC11885961

34. Nur D, Muslim A, Said FM, Nambiar N, Intan N, Husnul H. Comparison Of Wound Healing Process Between Hepar Sulph With Aloe Vera Wound Care Dressing Treatment Among Diabetic Foot Ulcers : A Pilot Study. 2025;3(1):1–7.

35. Lazzarini PA, van Netten JJ. Best practice offloading treatments for diabetic foot ulcer healing, remission, and better plans for the healing-remission transition. Semin Vasc Surg [Internet]. 2025;38(1):110–20. Available from: https://doi.org/10.1053/j.semvascsurg.2025.01.012

36. Da Ros R, Assaloni R, Michelli A, Brunato B, Barro E, Meloni M, et al. Burden of Infected Diabetic Foot Ulcers on Hospital Admissions and Costs in a Third-Level Center. Diabetology. 2024;5(2):141–50.