From the Guidelines
To decrease wound infection in patients with uncontrolled diabetes mellitus, controlling blood sugar pre-operatively is crucial, as it helps prevent infection and promotes wound healing. This is supported by the most recent and highest quality study, which emphasizes the importance of managing diabetes-related foot infections through a systematic and evidence-based approach 1.
The primary interventions to decrease wound infection in these patients include:
- Aggressive glycemic control, with target blood glucose levels between 140-180 mg/dL for most hospitalized patients, using insulin regimens as needed
- Proper wound care, involving regular cleansing with normal saline, debridement of necrotic tissue, and appropriate dressing selection based on wound characteristics
- Appropriate antibiotic therapy, with initial empiric therapy covering common pathogens like Staphylococcus aureus, streptococci, and gram-negative organisms
- Nutritional support, ensuring adequate protein intake (1.2-1.5 g/kg/day) and appropriate micronutrients, particularly zinc and vitamin C, which support wound healing
Other options, such as shaving, antibiotic administration within 30-60 minutes before skin incision, and increasing hypothermia, are not directly supported by the most recent evidence as the primary interventions for decreasing wound infection in patients with uncontrolled diabetes mellitus. However, antibiotic prophylaxis is a crucial aspect of preventing surgical site infections, and its administration should be guided by established protocols and guidelines 1.
In the context of wound care, controlling blood sugar pre-operatively is essential to prevent infection and promote wound healing. This approach is supported by the International Working Group of the Diabetic Foot (IWGDF) guidelines, which emphasize the importance of managing diabetes-related foot infections through a systematic and evidence-based approach 1.
Key considerations in wound care include:
- Regular cleansing with normal saline
- Debridement of necrotic tissue
- Appropriate dressing selection based on wound characteristics
- Moist wound healing principles using dressings like hydrocolloids, alginates, or foams depending on exudate levels
- Antimicrobial dressings containing silver or iodine may be beneficial for infected wounds
Systemic antibiotics are necessary for clinically infected wounds, with initial empiric therapy covering common pathogens like Staphylococcus aureus, streptococci, and gram-negative organisms. Options include amoxicillin-clavulanate 875/125 mg twice daily, cephalexin 500 mg four times daily plus metronidazole 500 mg three times daily for anaerobic coverage, or clindamycin 300-450 mg four times daily for penicillin-allergic patients. Antibiotic duration typically ranges from 7-14 days based on clinical response.
Nutritional support should ensure adequate protein intake (1.2-1.5 g/kg/day) and appropriate micronutrients, particularly zinc and vitamin C, which support wound healing. Offloading pressure from lower extremity wounds using specialized footwear, casts, or wheelchairs is essential. These interventions work together because hyperglycemia impairs neutrophil function, decreases collagen synthesis, and creates an environment favorable for bacterial growth, making infection control and wound healing particularly challenging in diabetic patients.
From the Research
Interventions to Decrease Wound Infection in Uncontrolled DM
To decrease wound infection in patients with uncontrolled Diabetes Mellitus (DM), several interventions can be considered:
- Control Blood Sugar Post-Operative: Maintaining blood glucose levels less than 200 mg/dL in the postoperative period has been shown to decrease the risk of deep wound infections in diabetic patients 2.
- Control Blood Sugar Pre-Operative: Preoperative control of blood sugar is also crucial, as hyperglycemia can impair wound healing and increase the risk of infection 3, 4.
- Antibiotic Prophylaxis: Administering antibiotics within 30 to 60 minutes before skin incision can help reduce the risk of surgical site infections, including wound infections 2.
- Other Considerations: While not directly related to blood sugar control, other factors such as nutritional status, obesity, and macrovascular and microvascular disease can also impact wound healing in diabetic patients 4, 5.
- Shaving and Hypothermia: There is no direct evidence to suggest that shaving or increasing hypothermia would be beneficial in decreasing wound infection in uncontrolled DM. In fact, shaving can potentially increase the risk of infection, and hypothermia can impair wound healing.
Key Findings
The studies suggest that controlling blood sugar levels, both preoperatively and postoperatively, is crucial in reducing the risk of wound infections in diabetic patients 2, 3, 4, 6. Additionally, maintaining good nutritional status and addressing other comorbidities can also impact wound healing outcomes 4, 5.