Fighting infections difficult for diabetics

Dr. Conway McLean

Diabetics are really “up against it.” It’s not enough they have to deal with a multitude of dietary restrictions. From candy and ice cream to many drinks and juices, even soups are prepared with an excessive sugar content. To someone with diabetes, these forms of sugar all count, regardless of variation of sugar it may be. Sugar can be packaged in a tremendous variety of ways. The big food corporations have become quite skilled at making this component less obvious, dare I say even hidden? One of the most frequently encountered is the infamous high fructose corn syrup. Is this actually sugar? Don’t let the name fool you; it is sweet, and it is a sugar. How about sucrose, or even fructose? All are incarnations of sugar which are broken down by the body during the process of digestion.

Although we don’t thoroughly understand the mechanisms on a molecular level, high sugar levels in the blood affect a variety of structures. Many have heard of the kidney problems experienced by those with diabetes. Also well-known is the increased risk of stroke, as well as heart attacks. Did you know about retinopathy, in which the tiny blood vessels in the eye become diseased, resulting in impaired vision? Then there is the malfunctioning skin nerves in the extremities, producing numbness.

One aspect of diabetes which doesn’t get enough “press” is that of immunopathy. This term refers to problems with one’s immune system, the system in the body with the responsibility of fighting off bacteria and other pathogens (disease-causing organisms). The risk of suffering an amputation is a well-known complication of diabetes but, unfortunately, many don’t know why, or how to prevent this dreaded outcome. A reduction in the ability to fight off infection is nearly always a major part of the process leading to limb loss.

More than 25 million people in the United States are estimated to have diabetes mellitus, and about 20% will develop a diabetic foot ulcer during their lifetime. Over 50% of these ulcerations will become infected, resulting in high rates of hospitalization, increased morbidity and potential lower extremity amputation. The cost to the US health care system of caring for the complications of diabetes is astronomical, with diabetic foot infections accounting for 20% of all hospital admissions. Nearly one in six patients with a foot infection die within 1 year of their infection.

Although these numbers vary depending on the study, all experts agree one of the best ways to avoid infection for someone with diabetes is to keep their skin whole and intact. This is best achieved with good skin care, the use diabetic shoes, and proper medical evaluation of potential areas of ulceration. Bony prominences produce areas of pressure where calluses will develop. This seemingly innocuous build-up of dead skin often progresses to the point of ulceration. Pain is usually experienced before that, but if someone has the nerve changes of diabetes (neuropathy), the ability to experience pain accurately is impaired. They can have a full thickness ulcer, even an infected one, and have no actual pain.

Diabetic foot infections are among the most serious and frequent complications encountered in patients with diabetes mellitus. They are associated with a high rate of debilitating complications and entail many risk factors for the failure of treatment. Intact skin is an excellent barrier to the many dangerous organisms present in our environment, but that protection is lost when there is a deficit in the barrier that is the human skin, be it a blister, a crack, or bad callus.

Identifying a diabetic infection early in the process is key, and should initiate an immediate response, specifically prompt treatment. This can take many forms, depending on the type of infection. A particularly relevant phrase on this topic is as follows: the best antibiotic is cold steel. Surgery for certain kinds of infections is critical. Many bacteria trigger the formation of an abscess, which is a localized infection that has become walled-off. This growth of infected tissue inhibits the penetration of antibiotics, reducing their effectiveness. Opening up this mass surgically with a scalpel allows the body’s natural defense systems to get in there and work their magic.

How does someone with diabetes know if they have an infection if they have neuropathy and can’t feel pain appropriately? There are a variety of complaints that may be experienced. The signs of infection range from local ones, to systemic. Some examples of the former may include pain and tenderness in a localized area, redness, swelling, pus or thick drainage, or a bad odor. Whole body signs of a diabetic foot infection are not common. A recent study revealed that 82 percent of the patients admitted to a hospital for a bone infection have a normal body temp at the time of their admission.

When a diabetic infection does elicit systemic evidence of an infection it can include loss of appetite, nausea, vomiting, fever, chills, night sweats, as well as changes in mental status. Typically, regardless of whether systemic signs develop, there generally will be a worsening of blood sugar levels. If any of these systemic changes began because of a foot infection, things are not “going well” and it’s time to head to the ER.

Once the condition is diagnosed, treatment revolves around, as expected, some type of antibiotic. But there are a multitude of options, and it is part science and part fortune to choose the best in each situation. More serious infections generally require either surgery or IV antibiotics, or both. Because it’s critical to get someone started on an antibiotic quickly, familiarity with the different types of bacteria responsible is beneficial. If there is abscess formation, as mentioned, incising the mass to allow drainage is vital.

As is so often the case, an old cliché fits perfectly: an ounce of prevention is worth a pound…. and all that. Excellent skin care is recommended by all the experts, including use of a moisturizer, in creating a better, healthier barrier to all the potentially harmful things in our environment. Professionally-fit shoes can be helpful in reducing the skin irritation of poorly fitting shoes, a big problem in the world of the neuropathic.

Preventative surgery for the diabetic is common because so many of them have deformities that lead to recurrent pressure to a specific area, a hammer toe being a common example. Some type of callus will result, and eventually skin break-down. Too often, because of the absence of pain, this opening in the skin goes unrecognized for longer than optimal. Because of the immune system problems, diabetic infections can spread rapidly and invade deeper tissues. A bone infection can result, and this is ‘a whole different animal’, and much more difficult to treat. Correcting the deformity, which can often be performed through tiny incisions, does not have to be a traumatic or lengthy process.

Diabetic foot infections are one of the most common causes of hospitalization and can result in amputation, bone infection, and death. Most of them begin with a wound and once an infection occurs, these risks of worsening manifestations increase dramatically. Immunopathy is a critical factor and has been implicated in the diabetic patient’s inherent susceptibility to infection. Education is critical for the individual with diabetes, knowing what to look for and what not to do to best reduce the chance of developing an infection.

Diabetes is a multi-organ disease and living a healthy lifestyle goes a long way to reducing the consequences. As most are aware, this means eating less processed foods, minimal carbohydrates, and making healthy vegetables the foundation of your diet. Equally important is exercise which carries a multitude of beneficial effects. If you have diabetes, don’t depend on your health care provider to teach you all you need to know. Patient education is sorely missing from our health care system. In diabetic medicine, learning about your disease and all the nuances of self-care is conducive to improved health and a better quality of life. All good things to those with diabetes.

Editor’s note: Dr. Conway McLean is a physician practicing foot and ankle medicine in the Upper Peninsula, with a move of his Marquette office to the downtown area. McLean has lectured internationally on wound care and surgery, being double board certified in surgery, and also in wound care. He has a sub-specialty in foot-ankle orthotics. Dr. McLean welcomes questions or comments