Hand Infection and Antibiotic Choice in the Diabetic Patients of an Underserved Population
Andrew J. Hayden, MD1; Steven A. Burekhovich, BS1; Sarah G. Stroud, AB1; Neil V. Shah, MD, MS1; Aadit T. Shah, BS2; Steven M. Koehler, MD1; Bassel G. Diebo, MD1; (1)State University of New York, Downstate Medical Center, Brooklyn, NY, (2)Albert Einstein College of Medicine, Bronx, NY
Diabetic patients who acquire infections of the hand face devastating consequences without prompt and aggressive treatment. However, vancomycin resistance constitutes a growing challenge for the treatment of infections in both diabetics and non-diabetics. This study sought to establish whether diabetic status influences the antibiotics that providers choose to treat hand infections.
This was a retrospective review of a prospectively collected, single-center database. Patients who presented from 2014-2016 with any hand infection were identified and stratified into groups by presence or absence of diabetes mellitus. Patients with recent history of surgery, comorbid infection proximal to the hand, history of osteomyelitis, or human or animal bite mechanisms were excluded. Analysis of variance (ANOVA) was employed to compare antibiotic regimens between and within disease groups.
Of the fifty-three patients who met inclusion criteria (diabetics: n=24 [45.3%]; non-diabetics: n=24 [45.3%]; unknown status: n=5 [9.4%]). Mean overall patient age was 46 years, with diabetics being significantly older (diabetics: 54.0 years; non-diabetics: 40.9 years; p=0.009). Hypertension was the second most common systemic comorbidity (17.0% affected).
Mean hemoglobin A1C was significantly higher among diabetics compared to non-diabetics (12.16 vs. 6.07, p=0.003), as was glucose on admission (302.8 vs. 99.9, p<0.0001) and highest random glucose reported (316 vs. 116, p<0.0001). In both the diabetic and non-diabetic groups, In both groups, Staphylococcus aureus was the most commonly identified pathogen (diabetics: 12/22 [54.5%]; non-diabetics: 14/23 [60.9%]. S. aureus, methicillin-resistant S. aureus, and gram negative culture identification rates between these groups were similar (p>0.05).
Antibiotic regimens differed between diabetics and non-diabetics. Diabetics received a combination vancomycin/piperacillin/tazobactam regimen significantly more often than non-diabetics (52% vs. 8%, p<0.001). Providers were significantly more likely to treat diabetics with vancomycin/piperacillin/tazobactam than with any clindamycin-containing regimen (p<0.01), any ampicillin/sulbactam-containing regimen (p<0.05), or any sulfamethoxazole/trimethoprim-containing regimen (p<0.01).
Appropriate operative intervention combined with antibiotic treatment is crucial to preserving hand function and limiting the spread of infection. This study found that in an underserved population, diabetics were significantly more likely to be prescribed a combination vancomycin/piperacillin/tazobactam regimen compared to non-diabetics, despite no difference in rates of identification of MRSA or non-resistant S. aureus. This suggests that antibiotic selection in underserved diabetics is overly-aggressive, potentially contributing to development of vancomycin-resistance. Future studies should focus on the outcomes of hand infections by diabetic status and antibiotic regimen in order to establish guidelines on drug selection to maximize outcomes and minimize resistance.
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