Susceptibility to infections in diabetes--effects on metabolism

Diabetic patients suffer from recurrent episodes of infections. The cellular and the humoral elements of the defense system against germ invasion are disturbed by the diabetic metabolism. Neuropathy and vascular damage promote the development of wounds and inhibit their healing. Altered motility of the gastrointestinal and the urinary tract lead to increased penetration of bacteria even there. Rare bacteria, atypical courses and frequent complications of infections result in delayed diagnosis and therapy. Dehydration, electrolyte disturbances, malnutrition, and reduced general conditions even increase susceptibility to an infection. On the other hand, an infection deteriorates the metabolic situation in diabetes, resulting in the need for higher insulin doses, or insulin injections in patients normally on oral medication. Altered every-day-life with modified food intake and reduced physical activity complicate diabetes therapy. Neuropathy, angiopathy, retinopathy, nephropathy and other diabetic complications can be triggered and aggravated during the course of an infection. To disrupt this vitious circle of hyperglycemia enforcing infections, which then raise blood glucose, it is necessary to know about the characteristic features of the interactions of diabetes and infection.     

Hand infections in patients with diabetes mellitus

In a study of diabetic patients with hand infections reviewed at Jackson Memorial Hospital, University of Miami School of Medicine, 20 such diabetic patients with hand infections were found. The most outstanding result was that seven of the 20 had amputation either to control infection or because the function of the extremity was impaired by the remaining ravaged part. Pathologic examination of tissue removed showed the same changes commonly seen in diabetic gangrene of the lower extremity. Electromyographic studies, when done, have been confirmatory of a peripheral neuropathy with delayed nerve conduction studies. The bacterial organisms of the infections were variable, but a predominance of Gram-negative organisms were cultured in twelve of the 20 patients. Early aggressive management, including surgical debridement and intravenous antibiotics, is recommended to prevent unnecessary amputations and improve residual function.     

The reconstruction of mechanical properties of layered viscoelastic media based on impedance measurements

Twenty-eight patients with upper extremity infections and positive for the human immunodeficiency virus (HIV) were identified. The risk factor for HIV infection was intravenous drug injection in 24 patients, homosexual contact in 3, and heterosexual contact in 1. Eight of the patients had the acquired immunodeficiency syndrome. Two of the cases were prolonged herpetic infections of more than 6 months' duration that did not respond to oral acyclovir. The other 26 cases were bacterial in origin. Twenty-six of 28 cases responded to therapy with resolution of the infection. One patient refused surgical treatment and one died of systemic illness before resolution of the hand infection.     

Evaluation and treatment of the infected foot in a community teaching hospital

More inpatient hospital days are used for the care of diabetic foot infection than for any other diabetic sequela. Both the number of lower extremity amputations and the overall treatment cost of treating diabetic infections may be reduced by using a team approach in the care of the infected diabetic pedal wound. The authors propose an evaluation and treatment protocol of infected pedal ulcerations in an urban, community teaching institution when admitted to an established, multidisciplinary diabetic foot care team. The hospital course of 111 patients admitted with a primary diagnosis of infected pedal ulceration are retrospectively reviewed. Results revealed an average-length hospital stay of 7.4 days with a 96% limb-salvage rate. The authors suggest that in the treatment of the infected pedal wound, a diabetic foot care team with a well developed treatment protocol may yield a consistently favorable outcome and a cost-effective hospital course.     

Randomised placebo-controlled trial of granulocyte-colony stimulating factor in diabetic foot infection

BACKGROUND: Diabetic foot infections cause substantial morbidity and mortality. Neutrophil superoxide generation, a crucial part of neutrophil bactericidal activity, is impaired in diabetes. Granulocyte-colony stimulating factor (G-CSF) increases the release of neutrophils from the bone marrow and improves neutrophil function. We assessed G-CSF as adjuvant therapy for the treatment of severe foot infections in diabetic patients. METHODS: 40 diabetic patients with foot infections were enrolled in a double-blind placebo-controlled study. On admission, patients were randomly assigned G-CSF (filgrastim) therapy (n = 20) or placebo (n = 20) for 7 days. Both groups received similar antibiotic and insulin treatment. Neutrophils from the peripheral blood of these participants and from healthy controls were stimulated with opsonised zymosan, and superoxide production was measured by a spectrophotometric assay (reduction of ferricytochrome C). FINDINGS: G-CSF therapy was associated with earlier eradication of pathogens from the infected ulcer (median 4 [range 2-10] vs 8 [2-79] days in the placebo group; p = 0.02), quicker resolution of cellulitis (7 [5-20] vs 12 [5-93] days; p = 0.03), shorter hospital stay (10 [7-31] vs 17.5 [9-100] days; p = 0.02), and a shorter duration of intravenous antibiotic treatment (8.5 [5-30] vs 14.5 [8-63] days; p = 0.02). No G-CSF-treated patient needed surgery, whereas two placebo recipients underwent to amputation and two had extensive debridement under anaesthesia. After 7 days' treatment, neutrophil superoxide production was significantly higher in the G-CSF group than in the placebo group (16.1 [4.2-24.2] vs 7.3 [2.1-11.5] nmol per 10(6) neutrophils in 30 min; p < 0.0001). G-CSF therapy was generally well tolerated. INTERPRETATION: G-CSF treatment was associated with improved clinical outcome of foot infection in diabetic patients. This improvement may be related to an increase in neutrophil superoxide production.     

Withholding thrombolysis in patients with diabetes mellitus and acute myocardial infarction

The benefits of thrombolytic therapy in a patient with diabetes having a myocardial infarction are now well accepted but this treatment may be withheld inappropriately because of concerns about retinal haemorrhage. We therefore examined whether junior doctors alter their use of thrombolysis for the treatment of acute myocardial infarctions according to the type of diabetic retinopathy present. A questionnaire asking whether thrombolysis would be given to a 50-year-old male smoker with insulin-treated diabetes and an acute anterior MI was shown, with four unlabelled retinal photographs, to all doctors prescribing thrombolytic therapy in a south London teaching hospital and an affiliated district general hospital. In all, 24 medical SHOs, 16 medical registrars/specialist registrars, 3 medical senior registrars, and 23 casualty SHOs were interviewed. Of these 89% would thrombolyse such a patient with normal fundi, 55% with background diabetic retinopathy, 54 % if this also involved the macula, and 26% if they saw proliferative retinopathy. The more senior grades were more aggressive in their approach. As we believe that all patients with an acute anterior myocardial infarction and diabetes should be considered for thrombolysis irrespective of their retinal appearance these results suggest thrombolytic therapy is being withheld inappropriately.     

Endangering hospital patients to infection by therapeutic measures (author's transl)

About 5% of all patients fall ill with anosocomial infection, i.e. one acquired in hospital. Among the principal causes of this are therapeutic measures which lead to an increased exposure of patients to organisms (soiled artificial respiration equipment, venous catheters, urinary catheters etc.) and to a raised disposition in the patients due to reduction of endogenous defense (cytostatic therapy, corticoids irradiation, operations etc.). Cross infections are largely transmitted on the hands of doctors and nursing personnel. The detection, prevention and control of hospial infections by specially trained personnel (hospital infection officers, specialist hygiene nurses, hospital hygiene committees) is absolutely necessary and justified for economic reasons alone.     

Ectopic pregnancy diagnosis in very high risk patients

SETTING: Hepatosplenic abscesses in neutropenic patients, especially during the recovery phase, are almost always attributed to fungal infections. We report similar lesions due to Mycobacterium tuberculosis in neutropenic patients in a tertiary care centre in India. OBJECTIVE: To characterize the features of hepatosplenic tuberculosis in neutropenic patients. DESIGN: Retrospective comparison of disease pattern and response to treatment of hepatosplenic tuberculosis in febrile neutropenia patients (four of 30 with severe prolonged neutropenia) and in non neutropenic patients diagnosed during the same 12-month period (n = 4, control group). RESULTS: The disease in the neutropenic patients typically presented during the recovery phase of neutropenia, with ultrasonic abnormalities similar to those seen in hepatosplenic fungal infections. In contrast to the marked organomegaly and typical granulomatous response found in the control group, the disease in the neutropenic patients was characterised by an absence of organomegaly, non-involvement of other sites, poor inflammatory response and a high bacillary load. The initial response to therapy was satisfactory in both groups. CONCLUSION: Tuberculosis needs to be considered in the diagnostic work-up of hepatosplenic abscesses that occur during the recovery phase of neutropenia.     

The impact of nosocomial infections on patient outcomes following cardiac surgery

STUDY OBJECTIVE: To evaluate the relationship between nosocomial infections and clinical outcomes following cardiac surgery, and to identify risk factors for the development of nosocomial infections in this patient population. DESIGN: Prospective cohort study. SETTING: Barnes-Jewish Hospital, St. Louis, a university-affiliated teaching hospital. PATIENTS: Six hundred five consecutive patients undergoing cardiac surgery. INTERVENTIONS: Prospective patient surveillance and data collection. MAIN OUTCOME MEASURES: Occurrence of nosocomial infections, multiorgan dysfunction, hospital mortality, and risk factors for the acquisition of nosocomial infections. RESULTS: One hundred thirty-one (21.7%) patients acquired at least one nosocomial infection following cardiac surgery. Four independent risk factors for the development of a nosocomial infection were identified: the duration of mechanical ventilation, postoperative empiric antibiotic administration, the duration of urinary tract catheterization, and female gender. Thirty (5.0%) patients died during their hospitalization. The mortality rate of patients acquiring a nosocomial infection (11.5%) was significantly greater than the mortality rate of patients without a nosocomial infection (3.2%) (odds ratio [OR]=4.0; 95% confidence interval [CI]=2.7 to 5.8; p<0.001). Multiorgan dysfunction was found to be the most important independent determinant of hospital mortality (adjusted OR=23.8; 95% CI=13.5 to 42.1; p<0.001) along with the aortic cross-clamp time (adjusted OR=2.3; 95% CI=1.7 to 3.0; p=0.002) and severity of illness as measured by APACHE II (acute physiology and chronic health evaluation) (adjusted OR=1.1; 95% CI=1.1 to 1.2; p=0.019). Ventilator-associated pneumonia, clinical sepsis, female gender, the cardiopulmonary bypass time, and severity of illness were identified as independent risk factors for the development of multiorgan dysfunction. Among hospital survivors, patients acquiring a nosocomial infection had longer hospital lengths of stay compared to patients without a nosocomial infection (20.1+/-13.0 days vs 9.7+/-4.5 days; p<0.001). CONCLUSIONS: Nosocomial infections, which are common following cardiac surgery, are associated with prolonged lengths of hospitalization, the development of multiorgan dysfunction, and increased hospital mortality. These data suggest potential interventions for the prevention of nosocomial infections following cardiac surgery that could substantially improve patient outcomes and decrease medical care costs.     

Intravenous-to-oral antibiotic switch therapy. A cost-effective approach

Every attempt should be made to switch hospitalized infectious-disease patients from intravenous to oral antibiotic therapy as soon as clinical improvement makes it possible. In addition to tremendous cost savings, the advantages of oral therapy are impressive and include a decrease in the number of nosocomial infections, shorter length of hospital stay, and lower incidence of intravenous-line infections. The main barrier to the acceptance of switch therapy is a lack of understanding of its efficacy, safety, and cost advantages. The wide-scale institution of managed care has resulted in the dawning of the era of oral antimicrobial therapy. Everything from infective endocarditis in intravenous drug abusers to neuroborreliosis may be treated effectively by the oral route.     

Bone densitometry: patients receiving prolonged steroid therapy

Bone mass loss and osteoporosis are associated with various conditions, such as asymptomatic primary hyperparathyroidism, and treatments, such as prolonged steroid therapy. Bone densitometry is used to measure bone mass density to determine the degree of osteoporosis and to estimate fracture risk. Bone densitometers measure the radiation absorption by the skeleton to determine bone mass of the peripheral, axial, and total skeleton. Common techniques include single-photon absorptiometry (SPA) of the forearm and heel, dual-photon (DPA) and dual-energy x-ray absorptiometry (DXA) of the spine and hip, quantitative computed tomography (QCT) of the spine or forearm, and radiographic absorptiometry (RA) of the hand. Part I of this report addresses important technical considerations of bone densitometers, including radiation dose, site selection, and accuracy and precision, as well as cost and charges. Part II evaluates the clinical utility of bone densitometry in the management of patients receiving prolonged steroid therapy. Steroids have broad effects on both immune and inflammatory processes and have been used to treat a wide variety of immunologically mediated diseases. Osteoporosis and vertebral compression fractures have been considered major complications of prolonged steroid therapy. Bone loss is also a direct result of many of the diseases treated with steroids. Issues addressed are the type and extent of bone loss associated with steroid therapy, risk for fracture, whether steroid dose reduction or alternative therapy is an option, and whether osteoporosis associated with prolonged steroid use can be prevented or treated. The other assessments in this series address the clinical utility of bone densitometry for patients with: asymptomatic primary hyperparathyroidism, end-stage renal disease, vertebral abnormalities, and estrogen-deficient women.     

Outcome of trigger finger treatment in diabetes

Trigger finger is an underdiagnosed hand disorder causing disability in longstanding diabetic patients. Sixty diabetic patients [39 insulin-dependent diabetes mellitus (IDDM) and 21 non-insulin-dependent diabetes mellitus (NIDDM)] and 60 nondiabetic patients were examined. All were initially treated by steroid injections: failure to alleviate symptoms was the indication for surgery. The incidence of multiple digit involvement was higher in IDDM patients as compared with the control group (p < 0.001). The diffuse type was 1.45 times more frequent in IDDM and NIDDM than in nondiabetic patients (p < 0.008). The diabetic patients had a relatively longer duration of symptoms (p < 0.003). Significantly, a higher recovery rate upon steroid injection was achieved in control patients as compared with the diabetic ones (p < 0.001). IDDM patients required more surgery compared with NIDDMs and, in 13.3% of diabetic patients, the surgical outcome was not successful. Diabetic patients should be diagnosed early for multiple and diffuse types of trigger digits. Steroid injection as the first mode of therapy is highly recommended although not always successful. Surgery is the definitive treatment but requires a long course of physiotherapy and may be associated with some complications.     

Toe amputation in the diabetic patient

BACKGROUND: We considered whether it is more practical to amputate the toe of a diabetic patient with osteomyelitis and good circulation or to treat the patient with antibiotics for a prolonged period. METHODS: We undertook a retrospective study of 141 diabetic patients who had undergone a toe-ray amputation for proven or documented osteomyelitis. RESULTS: The mean ankle/brachial index of all patients was 0.81 (range, 0.68 to 1.14); the mean functional days lost on antibiotic therapy was 39 (range, 7 to 84 days). The cost of 6 to 8 weeks of preoperative antibiotic therapy was $900 to $2240 (mean, $1440). CONCLUSIONS: Diabetic patients with good circulation and osteomyelitis of the toe may benefit from prompt toe amputation.     

The diagnosis and medical management of pulmonary parenchymal mycobacterial diseases

Pulmonary mycobacterial infections are an increasing clinical problem. The complex task of isolation and identification of the specific mycobacteria requires special stains, cultures, biochemical testing, and nucleic acid probes. Once the organism has been identified, the therapy with multiple drugs will be dictated by the type of organism and its drug susceptibility. An increasing number of patients presenting with drug-resistant tuberculosis or nontuberculous pulmonary mycobacterial infections require individualized, prolonged multi-drug regimens. The thoracic surgeon must be aware of the subtleties of mycobacterial pulmonary infections because diagnosis and failed medical treatment may require surgical intervention.     

Corticosteroid responsive tenosynovitis is a common pathway for limited joint mobility in the diabetic hand

OBJECTIVE: To test the hypothesis that diabetic tenosynovitis participates in the contractures of the syndrome of limited joint mobility (SLJM). METHODS: Adults with diabetes mellitus were referred for the evaluation of diabetic hand conditions. Patients with SLJM or diabetic trigger finger were studied after Dupuytren's contracture, hand neuropathy, carpal tunnel syndrome, and arthritis were excluded. A time series design was employed in which patients were observed for 3 mo to obtain a baseline, then the planar flexor tendon sheaths were injected with 10 mg of methylprednisolone acetate or 10 mg triamcinolone acetonide and were reassessed at 1, 3, and 12 mo. RESULTS: Response rates, defined by complete resolution of digital contractures and triggering after corticosteroid injection, were 94% (31/33), 76% 28/33), and 61% (17/29) at 1, 3, and 12 mo, respectively, which were all significantly different from preinjection (p < 0.001). Individual response rates for SLJM and trigger finger were similar. No appreciable differences between methylprednisolone acetate and triamcinolone acetonide were observed, although there was a trend for earlier recurrence with methylprednisolone. CONCLUSION: Corticosteroid injection is a safe and effective therapy that should be considered in patients with SLJM or diabetic trigger finger. The excellent response to injection indicates that diabetic tenosynovitis is a common pathway in diabetic hand conditions.     

Bacterial urinary tract infections in diabetes

Diabetes mellitus has a number of long-term effects on the genitourinary system. These effects predispose to bacterial urinary tract infections in the patient with diabetes mellitus. Bacteriuria is more common in diabetic women than in nondiabetic women because of a combination of host and local risk factors. Upper tract infection complications are also more common in this group. Diabetic patients are at higher risk for intrarenal abscess, with a spectrum of disease ranging from acute focal bacterial pyelonephritis to renal corticomedullary abscess, to the renal carbuncle. A number of uncommon complicated urinary tract infection complications occur more frequently in diabetics, such as emphysematous pyelonephritis and emphysematous pyelitis. Because of the frequency and severity of urinary tract infection in diabetic patients, prompt diagnosis and early therapy is warranted. A plain abdominal radiograph is recommended as a minimum radiographic screening tool in the patient with diabetes presenting with systemic signs of urinary tract infection. Ultrasonography or further radiographic studies such as CT scanning may also be warranted, depending on the clinical picture, to identify upper urinary tract complications early for appropriate intervention.     

Necrotizing fasciitis and gangrene of the upper extremity

Necrotizing fasciitis is a severe, fulminant infection most commonly encountered in patients with diabetes mellitus, alcohol abuse, and intravenous drug abuse. The infection can spread-unrecognized along fascial planes beneath seemingly normal skin. The relatively benign appearance of the extremity is misleading and often results in delay in diagnosis and increased morbidity or death. Immediate aggressive surgical debridement through extensile incisions in combination with antibiotic therapy is necessary for control of these limb- and life-threatening, soft-tissue infections. Gas gangrene, or clostridial myonecrosis, is encountered commonly in those extremity wounds that involve devitalized or necrotic soft tissues. Clostridial microorganisms are anaerobes that produce local and systemic toxins. Delay in treatment can lead to hemolysis, renal failure, and death. Treatment consists of immediate wound debridement, intravenous antibiotics, and hyperbaric oxygen therapy. Diabetic gangrene typically occurs in those diabetic patients with severe peripheral vascular or renal disease. The infections are usually polymicrobial. Treatment involves broad-spectrum antibiotics and multiple surgical debridements or amputation.     

Bacteremia with granulocytopenia--microbiology and empiric antibiotic treatment

This article sums up a retrospective analysis of 84 episodes of bacteraemia in acute leukaemia patients with severe neutropenia in a Norwegian teaching hospital during the period 1990-95. Gram negative bacteria represented 54% of the blood culture isolates, all of which were susceptible to aminoglycosides, and nearly all to ceftazidime and imipenem. Penicillin/aminoglycoside was used as initial therapy in 43% of the episodes. Initial empiric therapy was modified in 52% of the events. Only 15% of patients receiving the penicillin/aminoglycoside combination actually had infections with organisms susceptible to penicillin. Only 2% of patients with gram negative infections received initial synergistic treatment with two effective drugs. Mortality from infections was 8% in acute leukaemia patients with documented bacteraemia. Deaths mainly occurred in patients with terminal leukaemia disease. Late breakthrough bacteraemias with Stenotrophomonas maltophilia and Pseudomonas aeruginosa caused 50% of all fatal infections. The analysis suggests that no patients died during initial bacteraemia with penicillin-resistant organisms treated with penicillin/aminoglycoside. The antibiotic susceptibility of the isolated bacteria was favourable compared to what has been found in other countries. For the time being, we believe that the ecological advantages of using penicillin/aminoglycoside as initial empiric treatment of febrile neutropenia are greater than the disadvantages.     

Maternal malignant melanoma metastatic to the products of conception. Report of a case

Beclomethasone dipropionate aerosol at a dose of 100 mug four times a day was administered to 32 patients suffering from chronic perennial asthma. Twenty-three of these patients had previously received prolonged treatment with corticosteroids, causing various degrees of adrenal suppression in some patients. Almost complete recovery of adrenal function was observed within a period of six months in most patients. Treatment with beclomethasone dipropionate did not affect the hypothalamic-pituitary-adrenal axis in the other nine asthmatic patients who had not received prolonged corticosteroid therapy previously and who served as a control group.