Discharge Recommendations for an Adult Male with Scrotal Abscess and Type 2 Diabetes on Insulin and Metformin
Resume the patient's pre-hospitalization basal-bolus insulin regimen at the doses used during hospitalization, continue metformin (unless contraindicated by renal function), complete a full course of culture-directed antibiotics, provide detailed wound-care instructions, and schedule follow-up within 1–2 weeks with both primary care and surgery. 1
Insulin Regimen at Discharge
Resume Hospital Insulin Doses
- Continue the basal-bolus insulin regimen at the same doses administered during hospitalization rather than reverting to pre-admission doses, as the hospital regimen reflects current insulin requirements during acute illness. 2, 1
- For patients with HbA1c <8%, resume previous treatment at hospital doses and arrange follow-up with the primary care provider within one month. 2, 1
- If HbA1c is 8–9%, continue the basal-bolus regimen and schedule a diabetologist consultation for therapy intensification within 1–2 weeks. 2, 1
- For HbA1c >9% or unstable blood glucose levels (>11 mmol/L or 200 mg/dL), request diabetologist advice before discharge for possible admission to a specialized diabetes service. 2, 1
Metformin Continuation
- Continue metformin at the maximum tolerated dose (up to 2,000–2,550 mg daily) unless contraindicated by renal impairment (creatinine clearance <60 mL/min for metformin). 2, 1
- Metformin reduces total insulin requirements and provides superior glycemic control when combined with insulin therapy. 2
Critical Pitfall to Avoid
- Never discharge patients on sliding-scale insulin alone without scheduled basal insulin, as this approach is condemned by major diabetes guidelines and leads to dangerous glucose fluctuations. 1, 3
Antibiotic Therapy
Culture-Directed Treatment
- Complete a full course of culture-directed antibiotics based on intraoperative cultures from the scrotal abscess. 4, 5, 6
- Scrotal abscesses in diabetic patients commonly grow Streptococcus agalactiae, Enterococcus faecalis, and occasionally Candida species, particularly in patients with uncontrolled diabetes. 4, 5
- A typical course is 2 weeks of oral antibiotics following surgical drainage, though duration should be guided by clinical response and culture results. 5, 6
Monitoring for Progression
- Educate the patient to recognize signs of Fournier's gangrene (rapidly progressive scrotal pain, erythema, crepitus, systemic toxicity), as scrotal abscesses in diabetic patients can progress to necrotizing fasciitis. 4, 6
- Instruct the patient to seek immediate emergency care if fever, worsening scrotal swelling, or systemic symptoms develop. 4, 6
Wound-Care Instructions
Daily Wound Management
- Perform twice-daily dressing changes using sterile technique with normal saline irrigation followed by dry gauze application. 5, 6
- Inspect the wound daily for signs of infection (increased erythema, purulent drainage, foul odor, worsening pain). 5, 6
- Keep the scrotal area clean and dry; avoid tight-fitting underwear that may cause maceration. 5, 6
Hygiene and Prevention
- Maintain meticulous perineal hygiene to prevent recurrent infection, particularly in the setting of glycosuria from uncontrolled diabetes. 5, 6
- Avoid sexual activity until the wound is fully healed and cleared by the surgeon. 5, 6
Follow-Up Appointments
Surgical Follow-Up
- Schedule wound check with the surgeon within 3–5 days of discharge to assess healing and remove any packing material. 5, 6
- Arrange a second surgical follow-up at 2 weeks post-discharge for wound reassessment and suture removal if applicable. 5, 6
Diabetes Follow-Up
- For HbA1c <8%, schedule primary care follow-up within 1 month to reassess glycemic control and adjust insulin doses as needed. 2, 1
- For HbA1c 8–9%, arrange diabetologist consultation within 1–2 weeks for therapy intensification. 2, 1
- For HbA1c >9%, request diabetologist evaluation before discharge to determine if specialized inpatient diabetes management is required. 2, 1
Medication Reconciliation
- Cross-check all medications at discharge to ensure no chronic medications were inadvertently stopped and verify the safety of all new prescriptions. 2, 1
- Fill prescriptions for new or changed medications and review them with the patient and family at or before discharge. 2, 1
Patient Education
Blood Glucose Monitoring
- Check pre-meal blood glucose before each meal (breakfast, lunch, dinner) and at bedtime daily. 2, 1
- Target fasting glucose is 80–130 mg/dL (4.4–7.2 mmol/L) and pre-meal glucose is 90–150 mg/dL (5.0–8.3 mmol/L). 1
- Record all glucose values and bring the log to follow-up appointments. 2, 1
Hypoglycemia Recognition and Treatment
- Recognize hypoglycemia symptoms (shakiness, sweating, confusion, rapid heartbeat) and treat immediately with 15 grams of fast-acting carbohydrate (e.g., 4 glucose tablets, 4 oz juice) if blood glucose <70 mg/dL (3.9 mmol/L). 2, 1
- Recheck glucose in 15 minutes and repeat treatment if still <70 mg/dL. 2, 1
- If hypoglycemia occurs without clear cause, reduce the implicated insulin dose by 10–20% and contact the primary care provider. 1
Insulin Injection Technique
- Review proper insulin injection technique and site rotation (abdomen, thighs, upper arms) to prevent lipohypertrophy and ensure consistent absorption. 2, 1
- Administer rapid-acting insulin 0–15 minutes before meals for optimal postprandial glucose control. 2, 1
Sick-Day Management
- Continue basal insulin even if unable to eat, as it suppresses hepatic glucose production independent of food intake. 2, 1
- Check blood glucose every 4–6 hours during illness and contact the provider if glucose remains >250 mg/dL or if nausea, vomiting, or abdominal pain develops. 2, 1
Wound-Care Education
- Provide written and verbal instructions on twice-daily dressing changes, signs of infection, and when to seek emergency care. 5, 6
Discharge Supplies and Prescriptions
Durable Medical Equipment and Supplies
- Provide the following at discharge: insulin (vials or pens), syringes or pen needles, blood glucose meter and strips, lancets and lancing device, and a glucagon emergency kit (for insulin-treated patients). 2
- Ensure prescriptions are filled and reviewed with the patient before leaving the hospital. 2, 1
Wound-Care Supplies
- Provide sterile gauze, normal saline for irrigation, medical tape, and written wound-care instructions. 5, 6
Documentation Requirements
Discharge Summary
- Include the cause of hyperglycemia (scrotal abscess with acute infection), related complications (surgical drainage, antibiotic therapy), and recommended treatments with specific insulin doses and timing. 1
- Transmit the discharge summary to the primary care provider as soon as possible after discharge to ensure continuity of care. 2, 1
- Document pending culture results and arrange for the primary care provider to receive final microbiology reports. 2, 1
Common Pitfalls to Avoid
- Never discontinue basal insulin in insulin-requiring patients, as this creates immediate risk of hyperglycemia and ketoacidosis. 1
- Never discharge patients on sliding-scale insulin alone without scheduled basal insulin, as this approach is ineffective and unsafe. 1, 3
- Do not stop metformin when resuming insulin unless contraindicated by renal impairment (creatinine clearance <60 mL/min). 1
- Do not delay follow-up appointments for patients with HbA1c >9%—arrange diabetologist consultation before discharge. 1
- Do not underestimate the risk of progression to Fournier's gangrene in diabetic patients with scrotal infections; provide clear instructions to seek emergency care for worsening symptoms. 4, 6