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Post Operative Infections and Diabetes

A significant cause of complications in patients undergoing surgical procedures is post-operative wound infection. The occurrence of post-operative infections depends on the complex interaction of several factors. These include 1) patient-related factors, such as the person’s immunity, nutritional status, and the presence or absence of diabetes, 2) procedure-related factors, such as placement of foreign bodies/prosthesis and severity of trauma to the patient, 3) microbial factors that contribute to the aggressiveness or invasiveness of the bacteria, and 4) the use of antibiotics before and after surgery.

Patient and procedure-related factors contribute to a higher risk for developing post-operative wound infections. Patient-related factors include extremes of age-the very young and the elderly, presence of diabetes or inadequate glucose control before and after surgery, long-time smokers, presence of ongoing or active infection, obesity, malnourishment, low albumin levels, chronic steroid use and prolonged surgical procedure.

Procedure-related factors include inadequate cleaning prior to surgery, shaving of the surgical site before surgery, improper use of antibiotics before and after surgery, inadequate operating room ventilation, increase in operating room traffic contributing to a crowded operating room during surgery, a break in the sterile technique during the procedure, poor surgical technique (i.e. inexperienced surgeon) and inadequate cleaning of the instruments used during surgery.

Why the higher risk?
Several studies have noted that patients with diabetes have a higher risk of getting postoperative wound infections compared to healthy individuals. Diabetics usually have diminished vascularization or blood supply to a particular area, leading to poor blood circulation.

People with diabetes also have abnormalities in the immune system, which lessens the ability of the body to fight infections. There is usually a dysfunction in cell-mediated immunity and phagocytic function associated with the increase in blood sugar levels. This weakens the ability of the body to attack and destroy infected cells.

High blood sugar also aids in the colonization and growth of a variety of organisms, thus making diabetic patient more susceptible to infections. Due to the above reasons, adequate blood sugar control after surgery is important for all patients who will undergo surgical procedures. This will promote good wound healing and prevent bacterial colonization of the surgical wound.

There are several steps that can help prevent the development of post-operative wound infection. The first line of defense involves steps to decrease introduction of bacteria into the wound site. These include hygienic practices such as applying antiseptics to the skin of the patient, washing and sterile gloving of the surgeon’s hand, using sterile drapes, ensuring adequate airflow inside the operating room and using gowns, caps and masks by the operating personnel.

To reduce the acquisition of resistant bacteria from the hospital environment prior to surgery, the pre-operative stay should be as short as possible. The use of antibiotics prior to surgery should also be avoided whenever possible. The impact of hair removal may also play a factor in the development of surgical site infection. Shaving using a razor may leave microabrasions around the site that may lead to colonization of bacteria. To prevent causing microabrasions, hair removal can be done by using clippers or depilatories.

Second-line measures are targeted toward improving the ability of the person to contain infection or limit its spread and the immediate elimination of bacteria that have passed through the first line of defense and have colonized the surgical wound. Most studies have emphasized that good surgical technique is the single, most important factor in preventing surgical wound infection. Gentle handling of wound tissues and prevention of blood build-up and devitalized tissues during surgery are important in maintaining an infection-free wound.

Avoidance of gaps in the wound and careful approximation of tissue planes during surgical closure also contribute in the prevention of post-surgical infection. Adequate blood sugar control and proper nourishment, particularly after surgery, also appear to decrease the incidence of wound infection.

Patients, whether diabetic or not, who will undergo surgical procedures should follow the above measures to reduce the risk of post-surgical wound infections. In diabetic patients, good blood sugar control should be strictly employed to promote good wound healing and prevent overgrowth of bacteria in the surgical wound, thereby contributing to the prevention of the development of wound infection.

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