Diabetic hand infections

Compared with the limited experience reported in the literature to date, analysis of the authors' clinical series of hand infections demonstrates that more than one third of the patients are diabetic. This can be attributed to the population of African-Americans in Washington, DC, the high incidence of diabetes in this particular race, and the inherent susceptibility of diabetics to develop an infection of the hand. The most severe infections occur in insulin-dependent diabetic patients or those with chronic renal failure because of protein depletion, poor wound healing, neuropathy, and ischemia. Although a similar spectrum of infections is encountered in diabetic and nondiabetic patients, some characteristic presentations are somewhat unique to the diabetic population. Gram-negative and mixed organism infections are particularly common in diabetic patients. Despite the poor prognosis of diabetic hand infections in general and the unsatisfactory outcome in patients on renal dialysis, most diabetic patients successfully heal following early and appropriate intervention. Early diagnosis and aggressive and adequate surgical drainage and tissue excision or amputation (if indicated) are key principles. The authors have learned that the surgical incision must extend along the entire area of erythema and induration because the infection often is more extensive than suspected both before and during the initial surgery. Observation, local wound care, and the administration of antibiotic agents are not acceptable substitutes for surgical decompression in the diabetic patient with a hand infection. In the subgroup of diabetic patients most prone to develop hand infections (i.e., associated renal dialysis), the surgeon must recognize that ongoing tissue loss is commonplace, repeat wound debridements are required, and an eventual amputation is highly likely.