Impact of diabetes and poor glycaemic control on risk of bacteraemia with haemolytic streptococci groups A, B, and G

Triple threat: how diabetes results in worsened bacterial infections

Diabetes mellitus, characterized by impaired insulin signaling, is associated with increased incidence and severity of infections. Various diabetes-related complications contribute to exacerbated bacterial infections, including hyperglycemia, innate immune cell dysfunction, and infection with antibiotic-resistant bacterial strains. One defining symptom of diabetes is hyperglycemia, resulting in elevated blood and tissue glucose concentrations. Glucose is the preferred carbon source of several bacterial pathogens, and hyperglycemia escalates bacterial growth and virulence. Hyperglycemia promotes specific mechanisms of bacterial virulence known to contribute to infection chronicity, including tissue adherence and biofilm formation. Foot infections are a significant source of morbidity in individuals with diabetes and consist of biofilm-associated polymicrobial communities. Bacteria perform complex interspecies behaviors conducive to their growth and virulence within biofilms, including metabolic cross-feeding and altered phenotypes more tolerant to antibiotic therapeutics. Moreover, the metabolic dysfunction caused by diabetes compromises immune cell function, resulting in immune suppression. Impaired insulin signaling induces aberrations in phagocytic cells, which are crucial mediators for controlling and resolving bacterial infections. These aberrancies encompass altered cytokine profiles, the migratory and chemotactic mechanisms of neutrophils, and the metabolic reprogramming required for the oxidative burst and subsequent generation of bactericidal free radicals. Furthermore, the immune suppression caused by diabetes and the polymicrobial nature of the diabetic infection microenvironment may promote the emergence of novel strains of multidrug-resistant bacterial pathogens. This review focuses on the "triple threat" linked to worsened bacterial infections in individuals with diabetes: (i) altered nutritional availability in diabetic tissues, (ii) diabetes-associated immune suppression, and (iii) antibiotic treatment failure.

Synthesis of hydrazone-based polyhydroquinoline derivatives - antibacterial activities, α-glucosidase inhibitory capability, and DFT study

In recent years, polyhydroquinolines have gained much attention due to their widespread applications in medicine, agriculture, industry, etc. Here, we synthesized a series of novel hydrazone-based polyhydroquinoline derivatives via multi-step reactions. These molecules were characterized by modern spectroscopic techniques (1H-NMR, 13C NMR, and LC-HRMS) and their antibacterial and in vitro α-glucosidase inhibitory activities were assessed. Compound 8 was found to be the most active inhibitor against Listeria monocytogenes NCTC 5348, Bacillus subtilis IM 622, Brevibacillus brevis, and Bacillus subtilis ATCC 6337 with a zone of inhibition of 15.3 ± 0.01, 13.2 ± 0.2, 13.1 ± 0.1, and 12.6 ± 0.3 mm, respectively. Likewise, compound 8 also exhibited the most potent inhibitory potential for α-glucosidase (IC50 = 5.31 ± 0.25 μM) in vitro, followed by compounds 10 (IC50 = 6.70 ± 0.38 μM), and 12 (IC50 = 6.51 ± 0.37 μM). Furthermore, molecular docking and DFT analysis of these compounds showed good agreement with experimental work and the nonlinear optical properties calculated here indicate that these compounds are good candidates for nonlinear optics.

A matched cohort study evaluating the risks of infections in people with type 1 diabetes and their associations with glycated haemoglobin

AIMS

People with type 1 diabetes (T1D) have raised infection rates compared to those without, but how these risks vary by age, sex and ethnicity, or by glycated haemoglobin (HbA1c), remain uncertain.

METHODS

33,829 patients with T1D in Clinical Practice Research Datalink on 01/01/2015 were age-sex-ethnicity matched to two non-diabetes patients. Infections were collated from primary care and linked hospitalisation records during 2015-2019, and incidence rate ratios (IRRs) were estimated versus non-diabetes. For 26,096 people with T1D, with ≥3 HbA1c measurements in 2012-2014, mean and coefficient of variation were estimated, and compared across percentiles.

RESULTS

People with T1D had increased risk for infections presenting in primary care (IRR = 1.81, 95%CI 1.77-1.85) and hospitalisations (IRR = 3.37, 3.21-3.53) compared to non-diabetes, slightly attenuated after further adjustment. Younger ages and non-White ethnicities had greater relative risks, potentially explained by higher HbA1c mean and variability amongst people with T1D within these sub-groups. Both mean HbA1c and greater variability were strongly associated with infection risks, but the greatest associations were at the highest mean levels (hospitalisations IRR = 4.09, 3.64-4.59) for >97 versus ≤53 mmol/mol.

CONCLUSIONS

Infections are a significant health burden in T1D. Improved glycaemic control may reduce infection risks, while prompter infection treatments may reduce hospital admissions.

Major risk factors for Streptococcus dysgalactiae subsp. equisimilis bacteremia: a population-based study

BACKGROUND

Streptococcus dysgalactiae subspecies equisimilis is a human pathogen causing severe invasive infections. Detailed information on S. dysgalactiae subsp. equisimilis bacteremia and especially of predisposing factors are lacking. The purpose of the study is to investigate the risk factors of S. dysgalactiae subsp. equisimilis bacteremia compared to the general population in Finland.

METHODS

We retrospectively reviewed all patients older than 18 years with S. dysgalactiae subsp. equisimilis bacteremia in the Pirkanmaa health district from August 2015 to July 2018. The risk factors for S. dysgalactiae subsp. equisimilis bacteremia were investigated with respect to the normal population in Finland using the Finhealth study data provided by the Finnish institute for health and welfare. The study group was matched with the Finhealth study by age and sex.

RESULTS

Altogether 230 cases of S. dysgalactiae subsp. equisimilis bacteremia were detected. The medical records of 217 episodes of S. dysgalactiae subsp. equisimilis bacteremia (involving 211 patients) were available for analysis. Obesity was a statistically significant risk factor for S. dysgalactiae subsp. equisimilis bacteremia (Odds Ratio 2.96 [95% CI 2.22-3.96]). Diabetes and coronary artery disease were also associated with an increased risk of S. dysgalactiae subsp. equisimilis bacteremia (OR 4.82 [95% CI 3.62-6.42]) and (OR 3.03 [95% CI 2.18-4.19]).

CONCLUSIONS

We found obesity, diabetes, and coronary artery disease to be associated with an increased risk for S. dysgalactiae subsp. equisimilis bacteremia. These results provide an increased understanding of risk factors for S. dysgalactiae subsp. equisimilis bacteremia.

Pyogenic spondylitis due to Streptococcus agalactiae with paraspinal abscess and vertebral destruction in a diabetic patient: time course of imagings

Summary

A 76-year-old female with type 2 diabetes mellitus presented with hematuria, low back pain, and intermittent fever for 7 days. She was admitted to our hospital and diagnosed with Streptococcus agalactiae (GBS) bacteremia. CT showed an air density within the right iliopsoas muscle, and an MRI of the spine revealed hyperintensity in the right half of the L1-L2 intervertebral disk, leading to the diagnosis of a paraspinal abscess and L1-L2 pyogenic spondylitis. Antibiotic therapy was started and the clinical symptoms, as well as serologic biomarkers and radiologic images of the paraspinal abscess, were improved. The therapy was stopped on day 72 despite vertebral destruction progression. Vertebral endplate ossification was observed on day 108, and further bone formation was noted on day 177. Our case study with radiologic findings over 6 months demonstrated how bone destruction with pyogenic spondylitis, which had been treated with antibiotic therapy, improved after cessation of antibiotics.

Learning points

Although GBS is a rare cause of spondylitis, diabetic mellitus is a risk factor for the development of invasive GBS infections, especially under poor glycemic control. Bone destruction of pyogenic spondylitis can improve after discontinuation of antibiotic therapy. It may be important to decide the period of antibiotic therapy based on clinical conditions, serologic biomarkers, and soft tissue findings rather than bone findings. When elderly diabetic patients present with back pain and fever, spondylitis should be considered in the differential diagnosis to avoid potential diagnostic delays or misdiagnosis.

The association of diabetes and the prognosis of COVID-19 patients: A retrospective study

AIMS

This study evaluated the impact of previous glycemic control and in-hospital use of antidiabetic/antihypertensive drugs on the prognosis of COVID-19 patients with diabetes.

METHODS

In this retrospective cohort study, consecutive inpatients with laboratory confirmed COVID-19 were enrolled from Tongji Hospital (Wuhan, China). Patients without diabetes were matched to those with diabetes based on age, sex, and comorbidities. All patients were followed up to a clinical endpoint (discharge, worsening including transferring to ICU or immediate death). Data and outcomes were extracted from medical records and analyzed.

RESULTS

64 patients with pre-existing diabetes were included in this study, with 128 matched patients without diabetes included as a control group. Patients with diabetes had a higher rate of worsening (18.8% versus 7.8%, p = 0.025). Multivariable regression showed increased odds of worsening associated with previous glycemic control reflected by HbA1c (odds ratio 3.29, 95% CI 1.19-9.13, p = 0.022) and receiver-operating characteristics (ROC) curve identified HbA1c of 8.6% (70 mmol/mol) as the optimal cut-off value. Univariate analysis demonstrated the in-hospital use of antidiabetic/antihypertensive drugs were not associated with a higher risk of worsening.

CONCLUSIONS

COVID-19 patients with diabetes had a higher risk of worsening, especially those with poorly-controlled HbA1c, with an optimal cut-off value of 8.6%. The in-hospital use of antidiabetic/antihypertensive drugs were not associated with increased odds of worsening in patients with diabetes.

Impact of Diabetes Mellitus Following Tonsillectomy in Adults: A National Surgical Quality Improvement Program Analysis

OBJECTIVES

To identify 30-day complication rates specific to patients with diabetes mellitus following tonsillectomy.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients undergoing tonsillectomy between 2005 and 2018. Patients were stratified into 3 cohorts: insulin-dependent diabetes mellitus (IDDM), non-insulin-dependent diabetes mellitus (NIDDM), and non-diabetes mellitus (NODM). Coarsened-exact-matching was utilized to account for baseline differences between cohorts. Outcomes studied included post-operate complications, prolonged hospitalization, and unplanned readmissions.

RESULTS

A total of 986 DM and 26 774 NODM patients were included, and the mean age of patients undergoing tonsillectomy was 29.5 ± 11.6 and 28.7 ± 11.0 years, respectively. The majority of patients were female (70.5% for both DM and NODM cohorts) and White/Caucasian (89.2% vs 89.3%). Among patients undergoing tonsillectomy, a greater proportion of DM patients experienced an operative time greater than or equal to the 75th percentile (35 minutes; 25.9% vs 22.8%, P = .024), overall morbidity (12.6% vs 5.4%, P < .001), pneumonia (0.6% vs 0.2%, P = .036), and reoperation (10.2% vs 3.5% P < .001) in comparison to NODM patients. In an analysis between IDDM (n = 379) and NIDDM (n = 211) patients, IDDM patients were at an increased risk for prolonged hospitalization (1.4% vs 0.0%, P = .045), pneumonia (5.2% vs 0.5%, P < .001), urinary tract infections (3.3% vs 0.3% P = .004), major complications (15.6% vs 7.7%, P = .002), minor complications (19.9% vs 8.2%, P < .001), and overall complications (10.0% vs 1.3%, P < .001).

CONCLUSION

DM patients are at a heightened risk for complications following tonsillectomy. Standardized protocols, careful pre-operative planning, and stringent glycemic management may help optimize patient outcomes.

Trends in Rates of Infections Requiring Hospitalization Among Adults With Versus Without Diabetes in the U.S., 2000-2015

OBJECTIVE

Vascular complications of diabetes have declined substantially over the past 20 years. However, the impact of modern medical treatments on infectious diseases in people with diabetes remains unknown.

RESEARCH DESIGN AND METHODS

We estimated rates of infections requiring hospitalizations in adults (≥18 years) with versus without diabetes, using the 2000-2015 National Inpatient Sample and the National Health Interview Surveys. Annual age-standardized and age-specific hospitalization rates in groups with and without diabetes were stratified by infection type. Trends were assessed using Joinpoint regression with the annual percentage change (Δ%/year) reported.

RESULTS

In 2015, hospitalization rates remained almost four times as high in adults with versus without diabetes (rate ratio 3.8 [95% CI 3.8-3.8]) and as much as 15.7 times as high, depending on infection type. Overall, between 2000 and 2015, rates of hospitalizations increased from 63.1 to 68.7 per 1,000 persons in adults with diabetes and from 15.5 to 16.3 in adults without diabetes. However, from 2008, rates declined 7.9% in adults without diabetes (from 17.7 to 16.3 per 1,000 persons; Δ%/year -1.5, P < 0.01), while no significant decline was noted in adults with diabetes. The lack of decline in adults with diabetes in the later period was driven by significant increases in rates of foot infections and cellulitis as well as by lack of decline for pneumonia and postoperative wound infections in young adults with diabetes.

CONCLUSIONS

Findings from this study highlight the need for greater infectious risk mitigation in adults with diabetes, especially young adults with diabetes.

Population-based risk factors for community-onset bloodstream infections

Although a number of comorbidities have been associated with development of bloodstream infection, actual risk factors have not been well defined and quantified in nonselected populations. We sought to quantify population-based risk factors for development of community-onset bloodstream infection (COBSI). Surveillance was conducted among all residents of the Western Interior of British Columbia, Canada, during 2011-2018. Risks were expressed as incidence rate ratios (IRR) with 95% confidence intervals (CI). The annual incidence was 147.1 per 100,000 and older individuals, and males were at overall higher risk. The median Charlson score was 2 (IQR, 0-3), and this was higher among those with healthcare-associated (2; IQR, 1-4) as compared to community-associated (1; IQR, 0-2; P < 0.0001) COBSI. Risk factors for development of COBSI included (IRR; 95% CI): HIV infection (8.89; 5.17-14.27), cancer (6.80; 6.13-7.54), congestive heart failure (4.68; 4.00-5.46), dementia (3.31; 2.82-3.87), diabetes mellitus (3.10; 2.80-3.42), cerebrovascular accident (2.79; 2.34-3.31), renal dysfunction (2.75; 2.33-3.22), chronic lung disease (2.03; 1.79-2.28), peripheral vascular disease (1.68; 1.39-2.01), and rheumatic disease (1.44; 1.14-1.79). Patients with multiple comorbid illnesses were older, more likely to be male, and have healthcare-associated BSI, higher rates of antimicrobial resistance, and different clinical foci of infection. A number of demographic and comorbid conditions significantly increase the risk for development of COBSI.

Diabetes, Glycemic Control, and Risk of Infection Morbidity and Mortality: A Cohort Study

Objective

Diabetic patients have an elevated risk of infection, but the optimal level of glycemic control with the lowest infection risk remains unclear, especially among the elderly. We aimed to investigate the relation between fasting plasma glucose (FPG) level and risk of infection-related morbidity and mortality.

Method

The participants were from a community-based health screening program in northern Taiwan during 2005–2008 (n = 118 645) and were followed up until 2014. Incidence of hospitalization for infection and infection-related death was ascertained from the National Health Insurance Database and National Death Registry. Cox proportional hazards regression modelling was used to estimate the hazard ratio (HR) between FPG and risk of infection.

Results

During a median follow-up of 8.1 years, the incidence rate of hospitalization for any infection was 36.33 and 14.26 per 1000 person-years among diabetics and nondiabetics, respectively, in the total study population, but increased to 70.02 and 45.21 per 1000 person-years, respectively, in the elderly. In the Cox regression analysis, the adjusted HR comparing diabetics to nondiabetics was 1.59 (95% confidence interval [CI], 1.52–1.67) for any hospitalization for infection and 1.71 (95% CI, 1.36–2.16) for infection-related mortality. The hazard for infection morbidity and mortality was higher at both extremes (<90 and >200 mg/dl) of FPG. The excess risk associated with FPG ≤ 90 mg/dl was attenuated after controlling for multiple comorbidities.

Conclusions

Poor glycemic control (FPG > 200 mg/dl) was associated with a higher risk of infection-related morbidity and mortality, especially in the elderly population where the baseline infection risk was high.

Impact of Glycemic Control on Risk of Infections in Patients With Type 2 Diabetes: A Population-Based Cohort Study

Infections are a major clinical challenge for type 2 diabetes patients, but little is known about the impact of glycemic control. We used Cox regression analyses to examine the association between baseline and time-varying hemoglobin A1c (HbA1c) values and development of community antiinfective-agent-treated and hospital-treated infections in 69,318 patients with type 2 diabetes diagnosed between 2000 and 2012 in Northern Denmark. Incidence rates were 394/1,000 patient-years for community-treated infections and 63/1,000 patient-years for hospital-treated infections. The adjusted hazard ratios for community-treated infection at an HbA1c level of ≥10.50%, as compared with 5.50%-<6.49%, were 0.97 (95% confidence interval (CI): 0.94, 1.00) for HbA1c measured at early baseline, 1.09 (95% CI: 1.03, 1.14) for updated mean HbA1c, 1.13 (95% CI: 1.08, 1.19) for updated time-weighted mean HbA1c, and 1.19 (95% CI: 1.14, 1.26) for the latest updated HbA1c. Corresponding estimates for hospital-treated infections were 1.08 (95% CI: 1.02, 1.14) for early baseline HbA1c, 1.55 (95% CI: 1.42, 1.71) for updated mean HbA1c, 1.58 (95% CI: 1.44, 1.72) for updated time-weighted mean HbA1c, and 1.64 (95% CI: 1.51, 1.79) for the latest updated HbA1c. Our findings provide evidence for an association between current hyperglycemia and infection risk in type 2 diabetes patients.

The global diabetes epidemic: what does it mean for infectious diseases in tropical countries?

Tropical countries are experiencing a substantial rise in type 2 diabetes, which is often undiagnosed or poorly controlled. Since diabetes is a risk factor for many infectious diseases, this increase probably adds to the large infectious disease burden in tropical countries. We reviewed the literature to investigate the interface between diabetes and infections in tropical countries, including the WHO-defined neglected tropical diseases. Although solid data are sparse, patients with diabetes living in tropical countries most likely face increased risks of common and health-care-associated infections, as well as infected foot ulcers, which often lead to amputation. There is strong evidence that diabetes increases the severity of some endemic infections such as tuberculosis, melioidosis, and dengue virus infection. Some HIV and antiparasitic drugs might induce diabetes, whereas helminth infections appear to afford some protection against future diabetes. But there are no or very scarce data for most tropical infections and for possible biological mechanisms underlying associations with diabetes. The rise in diabetes and other non-communicable diseases puts a heavy toll on health systems in tropical countries. On the other hand, complications common to both diabetes and some tropical infections might provide an opportunity for shared services-for example, for eye health (trachoma and onchocerciasis), ulcer care (leprosy), or renal support (schistosomiasis). More research about the interaction of diabetes and infections in tropical countries is needed, and the infectious disease burden in these countries is another reason to step up global efforts to improve prevention and care for diabetes.

Basal insulin therapy is associated with beneficial effects on postoperative infective complications, independently from circulating glucose levels in patients admitted for cardiac surgery

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The effect of insulin per se on infective complications during cardiac surgery was evaluated.

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Eight hundred twelve patients were included.

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Insulin therapy decreased infections independently from glycemic levels.

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Basal + premeal insulin therapy is well tolerated without severe hypoglycemia cases.

Background

Although hyperglycemia is a strong predictor of postoperative infective complications (PIC), little is known about the effect of basal insulin therapy (BIT) per se on PIC.

Aim

To evaluate if there is an association between BIT, independent of glucose levels, and a possible improvement of PIC during the perioperative cardiosurgery period (PCP).

Methods

In 812 patients admitted for cardiac intervention and treated with a continuous intravenous insulin infusion (CIII) for hyperglycemic levels (>130 mg/dl), a retrospective analysis was performed during the PCP (January 2009–December 2011). Upon transfer to the cardiac surgery division, if fasting glucose was ≥130 mg/dl, a basal + premeal insulin therapy was initiated (121 patients, group 1); for <130 mg/dl, a premeal insulin alone was initiated (691 patients, group 2).

Findings

Compared with group 2, group 1 showed reductions in PIC (2.48% vs 7.96%, p < 0.049; odds ratio: 0.294; 95% CI: 0.110–0.780), C-Reactive Protein (p < 0.05) and white blood cell (p < 0.05) levels despite glucose levels and CIII that were higher during the first two days after surgery (179.8 ± 25.3 vs 169.5 ± 10.6 mg/dl, p < 0.01; 0.046 ± 0.008 vs 0.037 ± 0.015 U/kg/h, p < 0.05, respectively). Normal glucose levels were achieved in both groups from day 3 before the discharge. The mean length of hospital duration was 18% lower in group 1 than in group 2 (7.21 ± 05.08 vs 8.76 ± 9.08 days, p < 0.007), providing a significant impact on public health costs.

Conclusions

Basal + preprandial insulin therapy was associated with a lower frequency of PIC than preprandial insulin therapy alone, suggesting a beneficial effect of basal insulin therapy on post-surgery outcome.

INTERVAL TRAINING IS INSUFFICIENT TO ATTENUATE METABOLIC DISTURBANCES IN DIABETIC RATS

ABSTRACT Introduction: Type 1 diabetes is a metabolic disease associated to blood disturbances and disorder of the innate immune system functionality. Objective: This study investigated the effect of two weeks interval training on blood biochemistry and immunological parameters in rats with type 1 diabetes. Methods: Male Wistar rats were divided into three groups: sedentary (SE, n = 10), diabetic sedentary (DI, n = 10), diabetic interval training (DIT, n = 10). IV injection of streptozotocin (45 mg/kg) induced diabetes. Interval training consisted of swimming exercise for 30 seconds with 30 seconds of rest for 30 minutes three times a week during two weeks, with an overload of 15% of the total body mass. The evaluations performed were fasting blood glucose, triglycerides, very low-density lipoprotein cholesterol, low-density lipoprotein cholesterol, high-density lipoprotein cholesterol and total cholesterol concentrations, phagocytic capacity, cationic vesicles content, superoxide anion, and production of hydrogen peroxide of blood neutrophils and peritoneal macrophages. Results: The results showed that two weeks interval training did not attenuate the hyperglycemic state at rest and did not decrease blood lipids in the DIT group. Diabetes increased the functionality of blood neutrophils and peritoneal macrophages in the DI group. Interval training increased the content of cationic vesicles and the phagocytic capacity of blood neutrophils and peritoneal macrophages in the DIT group. Conclusion: It was found that two weeks of interval training increased the functionality parameters of innate immune cells, although this has been insufficient to attenuate the biochemical disorders caused by diabetes.

Metformin and other glucose-lowering drug initiation and rates of community-based antibiotic use and hospital-treated infections in patients with type 2 diabetes: a Danish nationwide population-based cohort study

OBJECTIVE

Data on early risk of infection in patients receiving their first treatment for type 2 diabetes are limited. We examined rates of community-based antibiotic use and hospital-treated infection in initiators of metformin and other glucose-lowering drugs (GLDs).

DESIGN

Population-based cohort study using medical databases.

SETTING

General practice and hospitals in Denmark.

PARTICIPANTS

131 949 patients with type 2 diabetes who initiated pharmacotherapy with a GLD between 2005 and 2012.

EXPOSURE

Initial GLD used for pharmacotherapy.

MAIN OUTCOME MEASURES

We computed rates and adjusted HRs of community-based antibiotic use and hospital-treated infection associated with choice of initial GLD with reference to metformin initiation, using an intention-to-treat approach.

RESULTS

The rate of community-based antibiotic use was 362 per 1000 patient-years at risk (PYAR) and that for hospital-treated infection was 51 per 1000 PYAR. Compared with metformin, the risk of hospital-treated infection was slightly higher in sulfonylurea initiators (HR 1.12, 95% CI 1.08 to 1.16) and substantially higher in insulin initiators (HR 1.63, 95% CI 1.54 to 1.72) initiators after adjustment for comorbid conditions, comedications and other confounding factors. In contrast, virtually no difference was observed for overall community-based antibiotic use (HR 1.02, 95% CI 1.01 to 1.04, for sulfonylurea initiators; and 1.04, 95% CI 1.01 to 1.07, for insulin initiators).

CONCLUSIONS

Rates of community-based antibiotic treatment and hospitalisation for infection were high in patients receiving their first treatment for type 2 diabetes and differed with the choice of initial GLD used for pharmacotherapy.

Diabetes mellitus and extrapulmonary tuberculosis: site distribution and risk of mortality

Scarce data exist on the relationship between diabetes and extrapulmonary tuberculosis (EPTB). We evaluated whether diabetes impacts site of TB and risk of death in patients with EPTB. We evaluated a cohort of TB cases from the state of Georgia between 2009 and 2012. Patients aged ⩾16 years were classified by diabetes status according to medical records. Site of EPTB was determined by culture and/or state TB classification. Death was defined by all-cause mortality. Of 1325 eligible reported TB cases, 369 (27·8%) had any EPTB including 258 (19·5%) with only EPTB and 111 (8·4%) with pulmonary TB and EPTB. Of all TB cases, 158 had diabetes (11·9%). In multivariable analysis, the odds of any EPTB was similar in patients with and without diabetes [adjusted odds ratio 1·04, 95% confidence interval (CI) 0·70-1·56]. The risk of death was 23·8% in patients with EPTB and diabetes vs. 9·8% in those with no diabetes (P < 0·01); after adjusting for covariates the difference was not significant (aRR 1·19, 95% CI 0·54-2·63). Diabetes was common in patients with EPTB and risk of death was high. Improved understanding of the relationship between diabetes and EPTB is critical to determine the extent that diabetes affects TB diagnosis and clinical management.

Does Celiac Disease Influence Survival in Sepsis? A Nationwide Longitudinal Study

Background

Individuals with celiac disease (CD) are at increased risk of sepsis. The aim of this study was to examine whether CD influences survival in sepsis of bacterial origin.

Methods

Nationwide longitudinal registry-based study. Through data on small intestinal biopsies from Sweden’s 28 pathology departments, we identified 29,096 individuals with CD (villous atrophy, Marsh stage III). Each individual with CD was matched with five population-based controls. Among these, 5,470 had a record of sepsis according to the Swedish Patient Register (1,432 celiac individuals and 4,038 controls). Finally we retrieved data on mortality in sepsis patients through the Swedish Cause of Death Registry.

Results

CD was associated with a 19% increase in overall mortality after sepsis (95% confidence interval (CI) = 1.09–1.29), with the highest relative risk occurring in children (adjusted hazard ratio (aHR) = 1.62; 95%CI = 0.67–3.91). However, aHR for death from sepsis was lower (aHR = 1.10) and failed to reach statistical significance (95%CI = 0.72–1.69). CD did not influence survival within 28 days after sepsis (aHR = 0.98; 95%CI = 0.80–1.19).

Conclusions

Although individuals with CD seem to be at an increased risk of overall death after sepsis, that excess risk does not differ from the general excess mortality previously seen in celiac patients in Sweden. CD as such does not seem to influence short-term or sepsis-specific survival in individuals with sepsis and therefore is not an independent risk factor for poor prognosis in sepsis.

Diabetes and infection: assessing the association with glycaemic control in population-based studies

Diabetes is a leading cause of morbidity and mortality. The global burden of diabetes is rising because of increased obesity and population ageing. Although preventive and treatment measures are well documented for macrovascular and microvascular complications, little such guidance exists for infections in people with diabetes, despite evidence suggesting greater susceptibility to infections, and worse outcomes. In particular, few studies have characterised the relation between glycaemic control and infectious disease, which we discuss in this Review. Some large population-based observational studies have reported strong associations between higher HbA1c and infection risks for both type 1 and type 2 diabetes. However, studies are contradictory, underpowered, or do not control for confounders. Evidence suggests that better glycaemic control might reduce infection risk, but further longitudinal studies with more frequent measures of HbA1c are needed. Older people (aged 70 years or older) with diabetes are at increased risk of complications, including infectious diseases. There is more uncertainty about appropriate glycaemic control targets in this age group, and evidence suggests that glycaemic control is often neglected. Robust evidence from cohorts with sufficient numbers of older people would help to develop clinically relevant guidelines and targets to reduce mortality, morbidity, and antibiotic use, and to improve quality of life.

Beta-haemolytic streptococcal endocarditis: clinical presentation, management and outcomes

BACKGROUND

Beta-haemolytic streptococcal (BHS) endocarditis is rare, but well-recognised for its high morbidity and mortality. This study sought to further characterise clinical features, management and outcomes of BHS endocarditis.

METHODS

Retrospective review of all adultpatients (≥ 18 years old) with BHS endocarditis treated at the Mayo Clinic from 1 January 2000 to 31 December 2014.

RESULTS

Forty-nine cases of BHS endocarditis were identified with a mean (± SD) age of 64 (± 14.9) years and 65% were males. The infection was community acquired in 92% of the cases, with a median (IQR) time to diagnosis from symptom onset of 6 days (5-10). Associated conditions included the presence of a prosthetic valve (41%), malignancy (33%) and diabetes mellitus (DM) (31%). Median (IQR) vegetation size was 12 mm (9-17 mm). In a univariate analysis patients with DM had larger vegetations, median (IQR) = 17 mm (10.5-26 mm) compared to non-diabetic patients, median (IQR) = 11 mm (8-15 mm) (p = 0.01). Septic brain emboli occurred in 43% of cases. Eighteen patients (37%) underwent early (within 30 days) surgery. All-cause 1 month and 6 month mortality rates were 25% and 31%, respectively.

CONCLUSION

BHS endocarditis has an acute onset and is complicated by relatively large vegetations with a high rate of systemic embolisation. DM was the second most common associated medical condition and patients with DM had larger vegetations. Despite medical and surgical advances, mortality due to BHS endocarditis remains high, particularly within 30 days of diagnosis.

The changing epidemiology of group B streptococcus bloodstream infection: a multi-national population-based assessment

BACKGROUND

Population-based studies conducted in single regions or countries have identified significant changes in the epidemiology of invasive group B streptococcus (GBS) infection. However, no studies have concurrently compared the epidemiology of GBS infections among multiple different regions and countries over time. The study objectives were to define the contemporary incidence and determinants of GBS bloodstream infection (BSI) and assess temporal changes in a multi-national population.

METHODS

Population-based surveillance for GBS BSI was conducted in nine regions in Australia, Canada, Denmark, Sweden, Finland and the UK during 2000-2010. Incidence rates were age- and gender-standardised to the EU population.

RESULTS

During 114 million patient-years of observation, 3464 cases of GBS BSI were identified for an overall annual incidence of 3.4 patients per 100,000 persons. There were marked differences in the overall (range = 1.8-4.1 per 100,000 person-year) and neonatal (range = 0.19-0.83 per 1000 live births) incidences of GBS BSI observed among the study regions. The overall incidence significantly (p = 0.05) increased. Rates of neonatal disease were stable, while the incidence in individuals older than 60 years doubled (p = 0.003). In patients with detailed data (n = 1018), the most common co-morbidity was diabetes (25%). During the study period, the proportion of cases associated with diabetes increased.

CONCLUSIONS

While marked variability in the incidence of GBS BSI was observed among these regions, it was consistently found that rates increased among older adults, especially in association with diabetes. The burden of this infection may be expected to continue to increase in ageing populations worldwide.

Excess Risk of Dying From Infectious Causes in Those With Type 1 and Type 2 Diabetes

OBJECTIVE

To investigate infection-related mortality in individuals with type 1 and type 2 diabetes.

RESEARCH DESIGN AND METHODS

A total of 1,108,982 individuals with diabetes who were registered with the Australian Diabetes register between 2000 and 2010 were linked to the National Death Index. Mortality outcomes were defined as infection-related(A-B) death (ICD codes A99-B99), pneumonia (J12-J189), septicemia (A40 and A41), and osteomyelitis (M86).

RESULTS

During a median follow-up of 6.7 years, there were 2,891, 2,158, 1,248, and 147 deaths from infection-related(A-B) causes, pneumonia, septicemia, or osteomyelitis, respectively. Crude mortality rates from infections(A-B) were 0.147 and 0.431 per 1,000 person-years in type 1 and type 2 diabetes, respectively. Standardized mortality ratios (SMRs) were higher in type 1 and type 2 diabetes for all outcomes after adjustment for age and sex. For infection-related(A-B) mortality, SMRs were 4.42 (95% CI 3.68-5.34) and 1.47 (1.42-1.53) for type 1 and type 2 diabetes (P < 0.001), respectively. For pneumonia in type 1 diabetes, SMRs were approximately 5 and 6 in males and females, respectively, while the excess risk was ∼20% for type 2 (both sexes). For septicemia, SMRs were approximately 10 and 2 for type 1 and type 2 diabetes, respectively, and similar by sex. For osteomyelitis in type 1 diabetes, SMRs were 16 and 58 in males and females, respectively, and ∼3 for type 2 diabetes (both sexes).

CONCLUSIONS

Although death owing to infection is rare, we confirm that patients with diabetes have an increased mortality from a range of infections, compared with the general population, and that the increased risk appears to be greater for type 1 than type 2 diabetes.

Bacterial infections in patients with type 1 diabetes: a 14-year follow-up study

OBJECTIVE

This study explored the annual occurrence/incidence of bacterial infections, and their association with chronic hyperglycemia and diabetic nephropathy, in patients with type 1 diabetes.

DESIGN

In a register-based follow-up study, we investigated the frequency of bacterial infections in patients with type 1 diabetes (n=4748) and age-matched and sex-matched non-diabetic control (NDC) subjects (n=12 954) using nationwide register data on antibiotic drug prescription purchases and hospital discharge diagnoses, collected between 1996 and 2009. Diabetic nephropathy was classified based on the urinary albumin excretion rate (AER).

RESULTS

The hospitalization rate due to bacterial infections was higher in patients with diabetes compared with NDCs (rate ratio (RR) 2.30 (95% CI 2.11 to 2.51)). The rate correlated with the severity of diabetic nephropathy: RR for microalbuminuria was 1.23 (0.94 to 1.60), 1.97 (1.49 to 2.61) for macroalbuminuria, 11.2 (8.1 to 15.5) for dialysis, and 6.72 (4.92 to 9.18) for kidney transplant as compared to patients with diabetes and normal AER. The annual number of antibiotic purchases was higher in patients with diabetes (1.00 (1.00 to 1.01)) as compared with NDCs (0.47 (0.46 to 0.47)), RR=1.71 (1.65 to 1.77). Annual antibiotic purchases were 1.18-fold more frequent in patients with microalbuminuria, 1.29-fold with macroalbuminuria, 2.43-fold with dialysis, and 2.74-fold with kidney transplant as compared to patients with normal AER. Each unit of increase in glycated hemoglobin was associated with a 6-10% increase in the number of annual antibiotic purchases.

CONCLUSIONS

The incidence of bacterial infections was significantly higher in patients with type 1 diabetes compared with age-matched and sex-matched NDC subjects, and correlated with the severity of diabetic nephropathy in inpatient and outpatient settings.

Global confluence of infectious and non-communicable diseases -- the case of type 2 diabetes

Globally the prevalence and public health importance of non-communicable diseases (NCD) is increasing in high-, middle-, and low-income countries alike. Concomitant to the NCD burden, control of key infectious diseases (i.e., group B Streptococcus, hepatitis C, tuberculosis, and HIV) in most regions of the world remains elusive. With new epidemiologic trends in disease burden, the allocation of resources and expertise to simultaneously control infectious diseases and NCD becomes increasingly difficult. Using the case of diabetes and three co-occurring infectious diseases, we demonstrate the importance of generating innovative strategies to attack the old (infectious diseases) and new (NCD) disease agendas together.

Incidence and predictors of hospitalization for bacterial infection in community-based patients with type 2 diabetes: the fremantle diabetes study

Background

The few studies that have examined the relationship between diabetes and bacterial infections have utilized administrative databases and/or have had limited/incomplete data including recognized infection risk factors. The aim of this study was to determine the incidence and associates of bacterial infection severe enough to require hospitalization in well-characterized community-based patients with type 2 diabetes.

Methods and Findings

We studied a cohort of 1,294 patients (mean±SD age 64.1±11.3 years) from the longitudinal observational Fremantle Diabetes Study Phase I (FDS1) and 5,156 age-, gender- and zip-code-matched non-diabetic controls. The main outcome measure was incident hospitalization for bacterial infection as principal diagnosis between 1993 and 2010. We also examined differences in statin use in 52 FDS1 pairs hospitalized with pneumonia (cases) or a contemporaneous non-infection-related cause (controls). During 12.0±5.4 years of follow-up, 251 (19.4%) patients were hospitalized on 368 occasions for infection (23.7/1,000 patient-years). This was more than double the rate in matched controls (incident rate ratio (IRR) (95% CI), 2.13 (1.88–2.42), P<0.001). IRRs for pneumonia, cellulitis, and septicemia/bacteremia were 1.86 (1.55–2.21), 2.45 (1.92–3.12), and 2.08 (1.41–3.04), respectively (P<0.001). Among the diabetic patients, older age, male sex, prior recent infection-related hospitalization, obesity, albuminuria, retinopathy and Aboriginal ethnicity were baseline variables independently associated with risk of first hospitalization with any infection (P≤0.005). After adjustment for these variables, baseline statin treatment was not significant (hazard ratio (95% CI), 0.70 (0.39–1.25), P = 0.22). Statin use at hospitalization for pneumonia among the case-control pairs was similar (23.1% vs. 13.5%, P = 0.27).

Conclusions

The risk of severe infection is increased among type 2 diabetic patients and is not reduced by statin therapy. There are a number of other easily-accessible sociodemographic and clinical variables that could be used to optimize infection-related education, prevention and management in type 2 diabetes.

Insulin modulates the inflammatory granulocyte response to streptococci via phosphatidylinositol 3-kinase

Group B streptococci (GBS; Streptococcus agalactiae) are a major cause of invasive infections in newborn infants and in patients with type 2 diabetes. Both patient groups exhibit peripheral insulin resistance and alterations in polymorphonuclear leukocyte (PML) function. In this investigation, we studied the PML response repertoire to GBS with a focus on TLR signaling and the modulation of this response by insulin in mice and humans. We found that GBS-induced, MyD88-dependent chemokine formation of PML was specifically downmodulated by insulin via insulin receptor-mediated induction of PI3K. PI3K inhibited transcription of chemokine genes on the level of NF-κB activation and binding. Insulin specifically modulated the chemokine response of PML to whole bacteria, but affected neither activation by purified TLR agonists nor antimicrobial properties, such as migration, phagocytosis, bacterial killing, and formation of reactive oxygen species. The targeted modulation of bacteria-induced chemokine formation by insulin via PI3K may form a basis for the development of novel targets of adjunctive sepsis therapy.