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American Association for Hand Surgery
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Theme: Inclusion and Collaboration Theme: Inclusion and Collaboration

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Determining Predictability of Hemoglobin A1c and Glucose on Admission on Culture Results and Ultimate Antibiotic Choice for Hand Infections Among Diabetic Patients
Andrew J. Hayden, MD1; Steven A. Burekhovich, BS1; Neil V. Shah, MD, MS11; Sarah G. Stroud, AB1; Aadit T. Shah, BS2; Steven M. Koehler, MD1; Bassel G. Diebo, MD1
1State University of New York, Downstate Medical Center, Brooklyn, NY; 2Albert Einstein College of Medicine, Bronx, NY

Introduction: Hand infections can lead to significant morbidity including stiffness, chronic pain, amputation and sepsis without prompt and aggressive treatment. Diabetic patients are particularly at risk if improper antibiotic selection delays treatment. Hand infections among non-diabetic patients predominately grow gram positive organisms, yet pathogens found in diabetics' hand infections are frequently gram negative, polymicrobial, or fungal. Appropriate empiric selection and early aggressive debridement may improve outcomes and reduce cost and length of stay of diabetic patients with hand infections. The goal of this study is to determine whether HbA1c or admitting glucose level is predictive of culture and ultimate antibiotic or antifungal regimen.

Materials/Methods: 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 then stratified into groups by presence or absence of comorbid systemic diseases. Patients with recent history of surgery, comorbid infection proximal to the distal wrist crease, history of osteomyelitis, or human or animal bite mechanisms were excluded. Independent t-tests and chi-square analysis were employed to compare hemoglobin A1c, lengths of stay, admitting blood glucose level, and infection parameters between diabetic and non-diabetic patient groups.

Results: 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 (diabetics: 54.0 years; non-diabetics: 40.9 years). Both groups were 45% female.
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 diabetic and non-diabetic groups, Staphylococcus aureus was the most commonly identified pathogen (diabetics: 12/22 [54.5%] cultures S. aureus-positive; non-diabetics: 14/23 [60.9%] cultures S. aureus-positive). S. aureus culture identification rates between these groups were similar (p=0.610). Rates of methicillin-resistant S. aureus (18% vs. 30%, p=0.340) and gram-negative bacteria (22.7% vs 14.3%, p=0.412) identification did not vary significantly between diabetics and non-diabetics. ESR was significantly different between populations of diabetics and non-diabetics (p=0.015), while WBC, CRP, and length of stays did not significantly differ between diabetic and non-diabetic patients (all p>0.05).

Conclusion: Hemoglobin A1c and admitting glucose level were not predictive of rates of positive MRSA, gram negative, or fungal cultures. Diabetics with hand infections should be started on antibiotics with coverage for both gram-positive and gram-negative bacteria and empiric anti-fungal coverage should be considered at the provider's discretion.

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