Characterizing Hand Infections in an Underserved Population: The Role of Diabetic Status and Location of Infection
Andrew J. Hayden, MD; Steven A. Burekhovich, BS; Sarah G. Stroud, AB; Neil V. Shah, MD, MS; Aadit T. Shah, BS; Steven M. Koehler, MD; Bassel G. Diebo, MD
State University of New York, Downstate Medical Center, Brooklyn, NY
Whether inflammatory markers like erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) vary predictably among zones of the hand in hand infections (HIs) is under debate. A high index of clinical suspicion enables providers to identify severe HIs early and maximize preservation of structure/function. This study aims to examine how common bacterial agents, infection location, and patients' laboratory findings differ based on diabetic status to determine which characteristics could raise clinical suspicions for closed-space HIs.
This was a retrospective review of a prospectively-collected, single-center database. Patients presenting with any HI from 2014-2016 were identified and stratified by diabetic status and site of infection (proximal to digit [Proximal] or within digit [Distal]). Patients with recent history of surgery, comorbid proximal infection, history of osteomyelitis, or human or animal bite mechanisms were excluded. Diabetes status, hemoglobin A1c (HbA1c), blood glucose, white blood cell count (WBC), ESR, CRP, and culture results were analyzed using parametric and non-parametric tests, where appropriate. Univariate and multivariate analyses controlling for age, gender, and diabetes status were employed to identify any significant independent predictors of laboratory values.
Fifty-three patients met inclusion criteria (diabetics: n=24 [45.3%]; non-diabetics: n=24; unknown status: n=5). The rates of S. aureus, MRSA, and gram-negative organism identification in culture between these groups were similar (p=0.61). Mean ESR was significantly higher in diabetics compared to non-diabetics (76.19 vs. 51.33, p=0.015). Mean overall WBC, CRP did not differ significantly. Regression analysis showed that diabetics had higher odds of having increased ESR (OR=1.03/R2=0.227, p=0.013).
Among known-diabetic HIs, 13/48 infections were Proximal, and 35 were Distal. Proximal infections showed significantly higher mean CRP (136.9 vs. 50.5, p=0.001) and WBC (5.19 vs. 3.9, p=0.02); ESR did not vary significantly. Regression analysis controlling for diabetic status showed that proximal infections were more likely to have a higher CRP (OR 1.02/R2=0.329, p=0.003).
While ESR was significantly higher in diabetic patients, proximal infections had higher CRP and WBC. These findings suggest that infection location may have more profound effects on the inflammatory milieu of the hand than does diabetic status. Future assessment of the predictive utility of physical exam findings and lab findings is warranted to standardize a set of predictive criteria for HI severity. Any proposed criteria using ESR should be stratified by diabetic status. Our findings suggest if CRP is to be incorporated into predictive HI criteria, infection site must also be accounted for.
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