Correction of hyperglycemia after surgery for diabetic foot infection and its association with clinical outcomes

Abstract

Objective Constantly high glycemia levels might influence outcomes in the management of patients undergoing surgery for diabetic foot infections (DFI). In our center for DFI, we performed a case–control study using a multivariate Cox regression model. Patients developing a new DFI could participate in the study several times. Results Among 1013 different DFI episodes in 586 individual adult patients (type I diabetes 148 episodes [15%], 882 [87%] with osteomyelitis; median antibiotic therapy of 21 days), professional diabetes counselling was provided by a specialized diabetes nurse in 195 episodes (19%). At admission, blood glucose levels were elevated in 110 episodes (11%). Treatments normalized glycemia on postoperative day 3 in 353 episodes (35%) and on day 7 for 321 (32%) episodes. Glycemia levels entirely normalized for 367 episodes (36%) until the end of hospitalization. Overall, treatment of DFI episodes failed in 255 of 1013 cases (25%), requiring surgical revision. By multivariate analysis, neither the provision of diabetes counseling, nor attaining normalizations of daily glycemic levels at day 3, day 7, or overall, influenced the ultimate incidence of clinical failures. Thus, the rapidity or success of achieving normoglycemia do not appear to influence the risk of treatment failure for operated DFI episodes.

Initial antibiotic therapy for postoperative moderate or severe diabetic foot infections: Broad versus narrow spectrum, empirical versus targeted

“…3 In the literature, few if any antibiotic-related variables have been found to influence key treatment outcomes. 1,4,6,7,[9][10][11][12][13][14][15][16][17][18][19] We agree with the International Working Group on the Diabetic Foot/IDSA infection guidelines position that an initial, empirical broad-spectrum antibiotic regimen should be reserved for severe (septic) DFI cases, unless it is administered as targeted or empirical treatment for known or suspected multidrug-resistant pathogens. 1,18 Unfortunately, many clinicians also select broad-spectrum antibiotic coverage in locally complicated DFI cases marked by ischaemia, destructive osteomyelitis or multiple co-morbidities.…”

“…The selection of an antibiotic regimen is only one part of the multifaceted management of DFIs, which requires concomitant attention to appropriate wound care, pressure off‐loading, optimized glycaemic control and assessment for possible need for revascularization or other surgery 3 . In the literature, few if any antibiotic‐related variables have been found to influence key treatment outcomes 1,4,6,7,9–19 …”

“…Secondly, our clinic employs infectious diseases physicians who are highly specialized in orthopaedic and diabetic infections, 1,12–14 which might theoretically reduce the likelihood of an inadequate choice. Thirdly, by concentrating on our study question, we chose not to analyse the impact of other variables that have been separately investigated, such as the antibiotic‐related costs, adverse events of broad‐spectrum therapies, 12,13,28 quality of wound debridement, 14 total duration of postoperative antibiotic treatment, 4,12,13 glycaemic control, 2,15 malnutrition, 16 or other immune suppressed states beyond that of diabetes 17 . Fourthly, because we live in a resource‐rich, small city with a low endemicity of multiresistant pathogens, our outcomes could be different from those in settings with a high endemicity of community‐acquired resistances.…”

Risk Factors for Surgical Site Infections in Elective Orthopedic Foot and Ankle Surgery: The Role of Diabetes Mellitus

“…We recognize that some special groups can have a higher risk, such as diabetic or immunosuppressed patients [ 2 , 6 ]. These elements, such as non-glycemic control in the preoperative time of surgery or host immunosuppression, could be added as important risk factors for SSI [ 1 , 7 ]. Indeed, diabetes mellitus is described as an independent risk factor for SSI, or community-acquired infections, in the entire orthopedic field [ 8 ].…”

“…The microbiological characteristics of orthopedic foot surgery SSIs are well described, but not specifically for the subgroup of patients with diabetic foot surgery. Usually, the most common isolated pathogens are coagulase-negative Staphylococcus and S. aureus , and similar studies have observed proliferation in difficult-to-treat bacterial isolates of methicillin-resistant S. aureus and S. epidermidis , and vancomycin-resistant S. aureus and Enterococcus in clean elective surgery [ 7 , 14 , 19 , 20 ]. The question regarding a better gram-negative perioperative antibiotic prophylaxis in diabetic foot surgeries is not resolved.…”