Callahan Devon, Keeley Jessica, Alipour Hamid, DeVirgilio Christian, Kaji Amy, Plurad David, Kim Dennis Y
Division of Trauma/Acute Care Surgery/Surgical Critical Care, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA.
Division of Trauma/Acute Care Surgery/Surgical Critical Care, Department of Surgery, Harbor-UCLA Medical Center, Torrance, CA.
Ann Vasc Surg. 2016 May;33:103-8. doi: 10.1016/j.avsg.2016.01.003. Epub 2016 Mar 8.
Diabetic foot infections (DFIs) constitute a large burden of the morbidity of diabetes, with more than 70,000 lower-extremity amputations (LEA) performed annually in the United States. A necrotizing infection signifies the most severe form of infection and is a key factor in the decision to proceed to LEA for source control. Key clinical and laboratory variables can assist in the identification of necrotizing infections; however, the effect of diabetes on these variables is unknown. Given the increased level and complexity of metabolic derangements in diabetic patients, we sought to examine characteristics predictive of necrotizing infection in patients with DFI who underwent LEA.
We performed a single-institutional retrospective analysis of diabetic patients who underwent a LEA for DFIs over an 18-month period. Patients with necrotizing infection on final pathology were compared with patients without this pathologic finding. Multivariate analysis was performed to identify independent predictors of necrotizing infection.
Of 183 patients, 57 (31%) had evidence of necrotizing infections. Factors associated with necrotizing infection on univariate analysis were the presence of bullae (11% vs. 2%; odds ratio [OR] = 4.8, P = 0.03), a higher mean admission white blood cell count (WBC; 15 vs. 12, P = 0.002), a lower mean absolute sodium (132 vs. 134, P = 0.01), a higher hemoglobin A1C (11.3 vs. 10.3, P = 0.05), hyperglycemia (289 vs. 248, P = 0.04), elevated C-reactive protein (20 vs. 11, P = 0.02), and the presence of Pseudomonas aeruginosa on final tissue culture (12.3 vs. 1.6, P = 0.004). These patients were taken to surgery more rapidly (22.5 vs. 31 hr, P = 0.04), and they had a longer postoperative stay (7 vs. 4 days, P = 0.02). On multivariate analysis, an elevated WBC was predictive of necrotizing infection (OR = 1.1, P = 0.01), whereas alcohol use was found to be protective (OR = 0.3, P = 0.04).
Clinical and laboratory variables known to be associated with necrotizing infections among the general population appear to be predictive of disease severity among patients undergoing amputation for DFIs. Identification of these abnormalities preoperatively may allow for improved operative planning, shared decision making, and resource management. Prospective validation of these findings is potentially warranted.
糖尿病足感染（DFI）是糖尿病发病的一大负担，在美国每年有超过70000例下肢截肢（LEA）手术。坏死性感染是最严重的感染形式，是决定进行LEA以控制感染源的关键因素。关键的临床和实验室变量有助于识别坏死性感染；然而，糖尿病对这些变量的影响尚不清楚。鉴于糖尿病患者代谢紊乱的程度和复杂性增加，我们试图研究接受LEA的DFI患者中预测坏死性感染的特征。
我们对18个月内因DFI接受LEA的糖尿病患者进行了单机构回顾性分析。将最终病理显示有坏死性感染的患者与无此病理发现的患者进行比较。进行多变量分析以确定坏死性感染的独立预测因素。
183例患者中，57例（31%）有坏死性感染的证据。单变量分析中与坏死性感染相关的因素包括存在大疱（11%对2%；比值比[OR]=4.8，P=0.03）、入院时平均白细胞计数（WBC）较高（15对12，P=0.002）、平均绝对钠水平较低（132对134，P=0.01）、糖化血红蛋白（HbA1C）较高（11.3对10.3，P=0.05）、高血糖（2
