The influence of pre-existing diabetes mellitus on the host immune response and outcome of pneumonia: analysis of two multicentre cohort studies

Guidelines for Antibiotics Prescription in Critically Ill Patients

How to cite this article: Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, et al. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024;28(S2):S104-S216.

Association between glucose levels at admission and outcomes of pneumonia: a systematic review and meta-analysis

BACKGROUND

Elevated blood glucose at hospital admission is frequently observed and has been associated with adverse outcomes in various patient populations. This meta-analysis sought to consolidate existing evidence to assess the association between elevated blood glucose at admission and clinical outcomes amongst pneumonia patients.

METHODS

We searched PubMed, Medline, Cochrane library, Web of Science (WoS), and Scopus databases for studies, published up to 31 August 2023, and reporting on the clinical outcomes and the blood glucose levels at admission. Data were extracted by two independent reviewers. Random-effects meta-analyses were used to pool odds ratios (ORs) with 95% confidence intervals (CI) for dichotomous outcomes and weighted mean differences (WMDs) for continuous outcomes.

RESULTS

A total of 23 studies with 34,000 participants were included. Elevated blood glucose at admission was significantly associated with increased short-term (pooled OR: 2.67; 95%CI: 1.73-4.12) and long-term mortality (pooled OR: 1.70; 95%CI: 1.20-2.42). Patients with raised glucose levels were more likely to require ICU admission (pooled OR: 1.86; 95%CI: 1.31-2.64). Trends also suggested increased risks for hospital readmission and mechanical ventilation, though these were not statistically significant. Elevated blood glucose was linked with approximately 0.72 days longer duration of hospital stay.

CONCLUSION

Elevated blood glucose level at the time of hospital admission is associated with several adverse clinical outcomes, especially mortality, in patients with pneumonia. These findings underscore the importance of recognizing hyperglycemia as significant prognostic marker in pneumonia patients. Further research is needed to determine whether targeted interventions to control glucose levels can improve these outcomes.

Inflammatory and endothelial host responses in community-acquired pneumonia: exploring the relationships with HbA1c, admission plasma glucose, and glycaemic gap-a cross-sectional study

Introduction

Diabetes is associated with dysregulated immune function and impaired cytokine release, while transient acute hyperglycaemia has been shown to enhance inflammatory cytokine release in preclinical studies. Although diabetes and acute hyperglycaemia are common among patients with community-acquired pneumonia (CAP), the impact of chronic, acute, and acute-on-chronic hyperglycaemia on the host response within this population remains poorly understood. This study investigated whether chronic, acute, and acute-on- chronic hyperglycaemia are associated with distinct mediators of inflammatory, endothelial, and angiogenic host response pathways in patients with CAP.

Methods

In a cross-sectional study of 555 patients with CAP, HbA1c, admission plasma (p)-glucose, and the glycaemic gap (admission p-glucose minus HbA1c- derived average p-glucose) were employed as measures of chronic, acute, and acute-on-chronic hyperglycaemia, respectively. Linear regression was used to model the associations between the hyperglycaemia measures and 47 proteins involved in inflammation, endothelial activation, and angiogenesis measured at admission. The models were adjusted for age, sex, CAP severity, pathogen, immunosuppression, comorbidity, and body mass index. Adjustments for multiple testing were performed with a false discovery rate threshold of less than 0.05.

Results

The analyses showed that HbA1c levels were positively associated with IL-8, IL-15, IL-17A/F, IL-1RA, sFlt-1, and VEGF-C. Admission plasma glucose was also positively associated with these proteins and GM-CSF. The glycaemic gap was positively associated with IL-8, IL-15, IL-17A/F, IL-2, and VEGF-C.

Conclusion

In conclusion, chronic, acute, and acute-on-chronic hyperglycaemia were positively associated with similar host response mediators. Furthermore, acute and acute-on-chronic hyperglycaemia had unique associations with the inflammatory pathways involving GM-CSF and IL-2, respectively.

Comorbidity of patients with noncommunicable diseases in general practice. Eurasian guidelines

Создание руководства поддержано Советом по терапевтическим наукам отделения клинической медицины Российской академии наук.

ASSESSING THE CAUSAL RELATIONSHIP BETWEEN SEPSIS AND AUTOIMMUNE: A MENDELIAN RANDOMIZATION STUDY

ABSTRACT

Objective : Numerous epidemiological studies have identified a potential link between sepsis and a variety of autoimmune disorders. The primary objective of this study is to delve deeper into this connection, investigating the potential causal relationship between sepsis and autoimmune disorders through the application of Mendelian randomization (MR). Methods : To assess the potential genetic impact on sepsis risk relating to susceptibility toward immune-related outcomes, we used summary data from the largest European genome-wide association studies (GWAS) on these conditions using a two-sample MR framework. Single nucleotide polymorphisms-which had strong associations with the nine traits-were extracted from the GWAS and examined their effects in an extensive European sepsis GWAS (486,484 cases and 474,841 controls). We used inverse-variance weighted MR, weighted median, and MR Egger for analyses, supplementing these with sensitivity analyses and assessing level pleiotropy using MR methodologies. We also executed a reverse MR analysis to test sepsis' causal effects on the designated autoimmune traits. Results : With primary sclerosing cholangitis being the exception, our MR analysis suggests that susceptibility toward most autoimmune diseases does not affect sepsis risks. The reverse MR analysis did not validate any influence of sepsis susceptibility over other autoimmune diseases. Our primary inverse-variance weighted MR analysis outcomes found general confirmation through our sensitivity MR examinations. Variance in the exposures, as dictated by the single nucleotide polymorphism sets used as MR instruments, ranged between 4.88 × 10 -5 to 0.005. Conclusion : Our MR research, centered on a European population, does not validate a correlation between susceptibility to the majority of autoimmune disorders and sepsis risk. Associations discerned in epidemiological studies may owe partly to shared biological or environmental confounders. The risk susceptibility for primary sclerosing cholangitis does relate to sepsis risk, opening doors for personalized precision treatments in the future.

The alterations of innate immunity and enhanced severity of infections in diabetes mellitus

Diabetes mellitus (DM) is a metabolic inflammatory disease with a high incidence worldwide. Patients with DM are at a high risk for all types of infections. Type 1 DM is characterised with immune destruction of pancreatic β cells, while type 2 diabetes is characterised with insulin resistance and β cell dysfunction, both of which result in disorders of glucose and lipid metabolism. This metabolic disorder causes functional defects of immune cells, aberrant production of inflammatory cytokines, dysregulated immune responses, advanced pathophysiological injury of the body, and increased mortality in populations with DM upon infections. Starting with the change of natural immune system in patients with DM, this paper focused on the enhanced severity of infections in DM and the underlying innate immune alterations in preclinical and clinical studies, aiming to better understand the influence of DM on the susceptibility, pathophysiology, and clinical outcomes in infections.

Diabetes Status, c-Reactive Protein, and Insulin Resistance in Community-Acquired Pneumonia-A Prospective Cohort Study

C-reactive protein (CRP) is commonly used to guide community-acquired pneumonia (CAP) treatment. A positive association between admission glucose and CRP levels has been observed in patients with CAP. The associations between prediabetes, unknown diabetes, acute-on-chronic hyperglycaemia, and CRP levels, and between admission CRP levels and insulin resistance (IR) in CAP, remain unexplored. This study investigated the associations firstly between chronic, acute, and acute-on-chronic hyperglycaemia and CRP levels, and secondly between admission CRP levels and IR in CAP. In a prospective cohort study of adults with CAP, the associations between chronic, acute, and acute-on-chronic hyperglycaemia (admission glucose minus HbA1c-derived average glucose) and CRP levels until admission day 3 were modelled with repeated-measures linear mixed models. IR was estimated with the homeostasis model assessment of IR (HOMA-IR). The association between admission CRP levels and HOMA-IR was modelled with linear regression. In 540 patients, no association between chronic, acute, or acute-on-chronic hyperglycaemia and CRP levels was found. In 266 patients, every 50 mg/L increase in admission CRP was associated with a 7% (95% CI 1-14%) higher HOMA-IR. In conclusion, our findings imply that hyperglycaemia does not influence CRP levels in patients with CAP, although admission CRP levels were positively associated with IR.

Spatio-temporal patterns of the mortality of diseases associated with malnutrition and their relationship with food establishments in Mexico

This study explores the spatio-temporal behavior of mortality due to multiple causes associated with several diseases and their relationship with the physical availability of food. We analyze data for the 2010-2020 period at the municipality level in Mexico. After collecting and standardizing national databases for each disease, we perform SATSCAN temporal and FleXScan spatial cluster analyses. We use the he Kruskal-Wallis test to analyze the differences between municipalities with high relative risk of mortality and their relationship with food retail units and food establishments. We found statistically significant relationships between clusters by disease and the physical availability of food per hundred thousand inhabitants. The main pattern is a higher average density of convenience stores, supermarkets, fast food chains and franchises, and Mexican snack restaurants in high-risk municipalities, while a higher density of grocery stores and inns, cheap kitchens, and menu restaurants exists in the municipalities with low risk. The density of convenience stores, fast food chains and franchises, and Mexican snack restaurants plays a very important role in mortality behavior, so measures must exist to regulate them and encourage and protect convenience stores, grocery stores, and local food preparation units.

Acute organ injury and long-term sequelae of severe pneumococcal infections

Streptococcus pneumoniae (Spn) is a major public health problem, as it is a main cause of otitis media, community-acquired pneumonia, bacteremia, sepsis, and meningitis. Acute episodes of pneumococcal disease have been demonstrated to cause organ damage with lingering negative consequences. Cytotoxic products released by the bacterium, biomechanical and physiological stress resulting from infection, and the corresponding inflammatory response together contribute to organ damage accrued during infection. The collective result of this damage can be acutely life-threatening, but among survivors, it also contributes to the long-lasting sequelae of pneumococcal disease. These include the development of new morbidities or exacerbation of pre-existing conditions such as COPD, heart disease, and neurological impairments. Currently, pneumonia is ranked as the 9^th leading cause of death, but this estimate only considers short-term mortality and likely underestimates the true long-term impact of disease. Herein, we review the data that indicates damage incurred during acute pneumococcal infection can result in long-term sequelae which reduces quality of life and life expectancy among pneumococcal disease survivors.

Sodium-Glucose Cotransporter 2 Inhibitors and the Risk of Pneumonia and Septic Shock

CONTEXT

Individuals with type 2 diabetes mellitus (DM) have an increased risk of pneumonia and septic shock. Traditional glucose-lowering drugs have recently been found to be associated with a higher risk of infections. It remains unclear whether sodium-glucose cotransporter 2 inhibitors (SGLT2is), which have pleiotropic/anti-inflammatory effects, may reduce the risk of pneumonia and septic shock in DM.

METHODS

MEDLINE, Embase, and ClinicalTrials.gov were searched from inception up to May 19, 2022, for randomized, placebo-controlled trials of SGLT2i that included patients with DM and reported outcomes of interest (pneumonia and/or septic shock). Study selection, data extraction, and quality assessment (using the Cochrane Risk of Bias Assessment Tool) were conducted by independent authors. A fixed-effects model was used to pool the relative risk (RRs) and 95% CI across trials.

RESULTS

Out of 4568 citations, 26 trials with a total of 59 264 patients (1.9% developed pneumonia and 0.2% developed septic shock) were included. Compared with placebo, SGLT2is significantly reduced the risk of pneumonia (pooled RR 0.87, 95% CI 0.78-0.98) and septic shock (pooled RR 0.65, 95% CI 0.44-0.95). There was no significant heterogeneity of effect size among trials. Subgroup analyses according to the type of SGLT2i used, baseline comorbidities, glycemic control, duration of DM, and trial follow-up showed consistent results without evidence of significant treatment-by-subgroup heterogeneity (all Pheterogeneity > .10).

CONCLUSION

Among DM patients, SGLT2is reduced the risk of pneumonia and septic shock compared with placebo. Our findings should be viewed as hypothesis generating, with concepts requiring validation in future studies.

Nomogram for prediction of severe community-acquired pneumonia development in diabetic patients: a multicenter study

Background

Diabetic patients with community-acquired pneumonia (CAP) have an increased risk of progressing to severe CAP. It is essential to develop predictive tools at the onset of the disease for early identification and intervention. This study aimed to develop and validate a clinical feature-based nomogram to identify diabetic patients with CAP at risk of developing severe CAP.

Method

A retrospective cohort study was conducted between January 2019 to December 2020. 1026 patients with CAP admitted in 48 hospitals in Shanghai were enrolled. All included patients were randomly divided into the training and validation samples with a ratio of 7:3. The nomogram for the prediction of severe CAP development was established based on the results of the multivariate logistic regression analysis and other predictors with clinical relevance. The nomogram was then assessed using receiver operating characteristic curves (ROC), calibration curve, and decision curve analysis (DCA).

Results

Multivariate analysis showed that chronic kidney dysfunction, malignant tumor, abnormal neutrophil count, abnormal lymphocyte count, decreased serum albumin level, and increased HbA1c level at admission was independently associated with progression to severe CAP in diabetic patients. A nomogram was established based on these above risk factors and other predictors with clinical relevance. The area under the curve (AUC) of the nomogram was 0.87 (95% CI 0.83–0.90) in the training set and 0.84 (95% CI 0.78–0.90). The calibration curve showed excellent agreement between the predicted possibility by the nomogram and the actual observation. The decision curve analysis indicated that the nomogram was applicable with a wide range of threshold probabilities due to the net benefit.

Conclusion

Our nomogram can be applied to estimate early the probabilities of severe CAP development in diabetic patients with CAP, which has good prediction accuracy and discrimination abilities. Since included biomarkers are common, our findings may be performed well in clinical practice and improve the early management of diabetic patients with CAP.

In-hospital hyperglycemia but not diabetes mellitus alone is associated with increased in-hospital mortality in community-acquired pneumonia (CAP): a systematic review and meta-analysis of observational studies prior to COVID-19

The objective of this review was to quantify the association between diabetes, hyperglycemia, and outcomes in patients hospitalized for community-acquired pneumonia (CAP) prior to the COVID-19 pandemic by conducting a systematic review and meta-analysis. Two investigators independently screened records identified in the PubMed (MEDLINE), EMBASE, CINAHL, and Web of Science databases. Cohort and case-control studies quantitatively evaluating associations between diabetes and in-hospital hyperglycemia with outcomes in adults admitted to hospital with CAP were included. Quality was assessed using the Newcastle-Ottawa Quality Assessment Scale, effect size using random-effects models, and heterogeneity using I2 statistics. Thirty-eight studies met the inclusion criteria. Hyperglycemia was associated with in-hospital mortality (adjusted OR 1.28, 95% CI 1.09 to 1.50) and intensive care unit (ICU) admission (crude OR 1.82, 95% CI 1.17 to 2.84). There was no association between diabetes status and in-hospital mortality (adjusted OR 1.04, 95% CI 0.72 to 1.51), 30-day mortality (adjusted OR 1.13, 95% CI 0.77 to 1.67), or ICU admission (crude OR 1.91, 95% CI 0.74 to 4.95). Diabetes was associated with increased mortality in all studies reporting >90-day postdischarge mortality and with longer length of stay only for studies reporting crude (OR 1.50, 95% CI 1.11 to 2.01) results. In adults hospitalized with CAP, in-hospital hyperglycemia but not diabetes alone is associated with increased in-hospital mortality and ICU admission. Diabetes status is associated with increased >90-day postdischarge mortality. Implications for management are that in-hospital hyperglycemia carries a greater risk for in-hospital morbidity and mortality than diabetes alone in patients admitted with non-COVID-19 CAP. Evaluation of strategies enabling timely and effective management of in-hospital hyperglycemia in CAP is warranted.

Clinical characteristics and risk factors associated with mortality in patients with severe community-acquired pneumonia and type 2 diabetes mellitus

BACKGROUND

The present study was performed to investigate the impacts of type 2 diabetes mellitus (T2DM) on severe community-acquired pneumonia (SCAP) and to develop a novel prediction model for mortality in SCAP patients with T2DM.

METHODS

This was a retrospective observational study conducted in consecutive adult patients with SCAP admitted to the intensive care unit (ICU) of West China Hospital, Sichuan University, China, between September 2011 and September 2019. The primary outcome was hospital mortality. A propensity score matching (PSM) analysis model with a 1:2 ratio was used for the comparisons of clinical characteristics and outcomes between T2DM and nondiabetic patients. The independent risk factors were identified via univariate and then multivariable logistic regression analysis and were then used to establish a nomogram.

RESULTS

In total, 1262 SCAP patients with T2DM and 2524 matched patients without T2DM were included after PSM. Patients with T2DM had longer ICU length of stay (LOS) (13 vs. 12 days, P = 0.016) and higher 14-day mortality (15% vs. 10.8%, P < 0.001), 30-day mortality (25.7% vs. 22.7%, P = 0.046), ICU mortality (30.8% vs. 26.5%, P = 0.005), and hospital mortality (35.2% vs. 31.0%, P = 0.009) than those without T2DM. In SCAP patients with T2DM, the independent risk factors for hospital mortality were increased numbers of comorbidities and diabetes-related complications; elevated C-reactive protein (CRP), neutrophil to lymphocyte ratio (NLR), brain natriuretic peptide (BNP) and blood lactate; as well as decreased blood pressure on admission. The nomogram had a C index of 0.907 (95% CI: 0.888, 0.927) in the training set and 0.873 (95% CI: 0.836, 0.911) in the testing set, which was superior to the pneumonia severity index (PSI, AUC: 0.809, 95% CI: 0.785, 0.833). The calibration curve and decision curve analysis (DCA) also demonstrated its accuracy and applicability.

CONCLUSIONS

SCAP patients with T2DM had worse clinical outcomes than nondiabetic patients. The nomogram has good predictive performance for hospital mortality and might be generally applied after more external validations.

Admission Blood Glucose Is Associated With the 30-Days Mortality in Septic Patients: A Retrospective Cohort Study

Background: Sepsis, as one of the severe diseases, is frequently observed in critically ill patients, especially concurrent with diabetes. Whether admission blood glucose is associated with the prognosis, and outcome of septic patients is still debatable.

Methods: We retrospectively reviewed and analyzed the demographic characteristics of septic patients in the Medical Information Mart for Intensive Care III (MIMIC III, version 1.4) between June 2001 and October 2012. The Chi-square and Fisher's exact tests were used for the comparison of qualitative variables among septic patients with different glucose levels and the 30-day mortality in septic patients with diabetes or not. Univariate and stepwise multivariate Cox regression analyses were used to determine the risk factors for 30-day mortality. Kaplan-Meier analysis was conducted to reveal the different 30-day survival probabilities in each subgroup.

Results: A total of 2,948 septic patients (910 cases with diabetes, 2,038 cases without diabetes) were ultimately included in the study. The 30-day mortality was 32.4% (956/2,948 cases) in the overall population without any difference among diabetic and non-diabetic septic patients (p = 1.000). Admission blood glucose levels <70 mg/dl were only observed to be significantly associated with the 30-day mortality of septic patients without diabetes (hazard ratio (HR) = 2.48, p < 0.001). After adjusting for confounders, age >65 years (HR = 1.53, p = 0.001), the Sequential Organ Failure Assessment (SOFA) score >5 (HR = 2.26, p < 0.001), lactic acid >2 mmol/L (Lac, HR = 1.35, p = 0.024), and platelet abnormality (<100 k/ul: HR = 1.49; >300 k/ul: HR = 1.36, p < 0.001) were the independent risk factors for 30-day mortality in septic patients with diabetes. In non-diabetes population, age >65 years (HR = 1.53, p < 0.001), non-White or non-Black patients (HR = 1.30, p = 0.004), SOFA score >5 (HR = 1.56, p < 0.001), blood glucose <70 mg/dl (HR = 1.91, p = 0.003), anion gap (AG) >2 mmol/L (HR = 1.60, p < 0.001), Lac (HR = 1.61, p < 0.001), urea nitrogen >21 mg/dl (HR = 1.45, p = 0.001), alanine aminotransferase (ALT, HR = 1.31, p = 0.009), total bilirubin >1.2 mg/dl (HR = 1.20, p = 0.033), and low hemoglobin (HR = 1.34, p = 0.001) were the independent risk factors for 30-day mortality.

Conclusions: Our results indicate admission blood glucose, especially in terms of <70 mg/dl, is the key signaling in predicting the worse 30-day survival probability of septic patients without diabetes, which could help clinicians to make a more suitable and precise treatment modality in dealing with septic patients.

A New Prognostic Index PDPI for the Risk of Pneumonia Among Patients With Diabetes

Objective

Risk factors for the development of pneumonia among patients with diabetes mellitus are unclear. The aim of our study was to elucidate the potential risk factors and attempt to predict the probability of pneumonia based on the history of diabetes.

Methods

We performed a population-based, prospective multicenter cohort study of 1,043 adult patients with diabetes in China during 2017–2019. Demographic information, comorbidities, or laboratory examinations were collected.

Results

The study included 417 diabetic patients with pneumonia and 626 no-pneumonia-onset diabetic patients. The predictive risk factors were chosen on the basis of a multivariate logistic regression model to predict pneumonia among patients with diabetes including male sex [odds ratio (OR) = 1.72, 95% confidence interval (CI): 1.27–2.33, p < 0.001], age ≥ 75 years (OR = 2.31, 95% CI: 1.61–3.31, p < 0.001), body mass index < 25 (OR = 2.59, 95% CI: 1.92–3.50, p < 0.001), chronic obstructive pulmonary disease (OR = 6.58, 95% CI: 2.09–20.7, p = 0.001), hypertension (OR = 4.27, 95% CI: 3.12–5.85, p < 0.001), coronary heart disease (OR = 2.98, 95% CI: 1.61–5.52, p < 0.001), renal failure (OR = 1.82, 95% CI: 1.002–3.29, p = 0.049), cancer (OR = 3.57, 95% CI: 1.80–7.06, p < 0.001), use of insulin (OR = 2.28, 95% CI: 1.60–3.25, p < 0.001), and hemoglobin A1c ≥ 9% (OR = 2.70, 95% CI: 1.89–3.85, p < 0.001). A predictive nomogram was established. This model showed c-statistics of 0.811, and sensitivity and specificity were 0.717 and 0.780, respectively, under cut-off of 125 score.

Conclusion

We designed a clinically predictive tool for assessing the risk of pneumonia among adult patients with diabetes. This tool stratifies patients into relevant risk categories and may provide a basis for individually tailored intervention for the purpose of early prevention.

[Management of Adult Community-Acquired Pneumonia and Prevention - Update 2021 - Guideline of the German Respiratory Society (DGP), the Paul-Ehrlich-Society for Chemotherapy (PEG), the German Society for Infectious Diseases (DGI), the German Society of Medical Intensive Care and Emergency Medicine (DGIIN), the German Viological Society (DGV), the Competence Network CAPNETZ, the German College of General Practitioneers and Family Physicians (DEGAM), the German Society for Geriatric Medicine (DGG), the German Palliative Society (DGP), the Austrian Society of Pneumology Society (ÖGP), the Austrian Society for Infectious and Tropical Diseases (ÖGIT), the Swiss Respiratory Society (SGP) and the Swiss Society for Infectious Diseases Society (SSI)]

The present guideline provides a new and updated concept of the management of adult patients with community-acquired pneumonia. It replaces the previous guideline dating from 2016.The guideline was worked out and agreed on following the standards of methodology of a S3-guideline. This includes a systematic literature search and grading, a structured discussion of recommendations supported by the literature as well as the declaration and assessment of potential conflicts of interests.The guideline has a focus on specific clinical circumstances, an update on severity assessment, and includes recommendations for an individualized selection of antimicrobial treatment.The recommendations aim at the same time at a structured assessment of risk for adverse outcome as well as an early determination of treatment goals in order to reduce mortality in patients with curative treatment goal and to provide palliation for patients with treatment restrictions.

Diabetes on sepsis outcomes in non-ICU patients: A cohort study and review of the literature

AIMS

We sought to determine whether primary outcomes differ between non-ICU septic patients with and without type 2 diabetes (T2D).

METHODS

This study utilized the Hellenic Sepsis Study Group Registry, collecting nationwide data for sepsis patients since 2006, and classified patients upon presence or absence of T2D. Patients were perfectly matched for a) Sepsis 3 definition criteria (including septic shock) b) gender, c) age, d) APACHE II score and e) Charlson's comorbidity index (CCI). Independent sample t-test and chi-square t-test was used to compare prognostic indices and primary outcomes.

RESULTS

Of 4320 initially included non-ICU sepsis patients, 812 were finally analysed, following match on criteria. Baseline characteristics were age 76 [±10.3] years, 46% male, APACHE II 15.5 [±6], CCI 5.1 [±1.8], 24% infection, 63.8% sepsis and 12.2% septic shock. No significant difference was noted between two groups in qSOFA, SOFA, or suPAR1 levels (p = 0.7, 0.1 & 0.3) respectively. Primary sepsis syndrome resolved in 70.9% of cases (p = 0.9), while mortality was 24% in 28-days time. Cause of death was similar between patients with and without T2D (sepsis 17.8% vs 15.8%, heart event 3.7% vs 3.2%, CNS event 0.5% vs 0.5%, malignancy 0.7% vs 2% respectively, p = 0.6).

CONCLUSIONS

DM does not appear to negatively affect outcomes in septic patients not requiring ICU.

New thoughts on the diagnosis and treatment of patients with diabetes mellitus in relation to coronavirus disease

The coronavirus disease 2019 (COVID-19) outbreak that occurred in late 2019 has posed a huge threat to the health of all humans, especially for individuals who already have diabetes mellitus (DM). DM is one of the most serious diseases that affect human health, with high morbidity and rates of complications. Medical scientists worldwide have been working to control blood sugar levels and the complications associated with sugar level alterations, with an aim to reduce the adverse consequences of acute and chronic complications caused by DM. Patients with DM face great challenges during the pandemic owing to not only changes in the allocation of medical resources but also their abnormal autoimmune status, which reduces their resistance to infections. This increases the difficulty in treatment and the risk of mortality. This review presents, from an epidemiological viewpoint, information on the susceptibility of patients with DM to COVID-19 and the related treatment plans and strategies used in this population.

Study on metabonomics of Chinese herbal medicine in the treatment of type 2 diabetes mellitus complicated with community-acquired pneumonia

INTRODUCTION

Community-acquired pneumonia (CAP) is the main acute complication of type 2 diabetes mellitus (T2DM) and the main cause of hospitalization for infectious diseases. Unfortunately, in the treatment of type 2 diabetes mellitus complicated with community-acquired pneumonia (T2DM-CAP), modern medicine is still faced with enormous challenges because of insulin resistance and drug-resistant bacteria. In recent decades, clinical and experimental evidence shows that Chinese herbal medicine (CHM) has a certain beneficial effect on diabetes and pneumonia. Therefore, this trial aims to assess the efficacy and safety of CHM plus western medicines for the treatment of T2DM-CAP.

METHODS

We propose a double-blind, placebo-controlled, randomized superiority trial.A total of 92 participants with T2DM-CAP will be randomly allocated at a 1:1 ratio to either the experimental group, which will receive modified Ban-Xia-Xie-Xin-Decotion and basic treatment, or the control group, which will receive basic treatment only. The study duration will be 14 days. The primary outcome will be the total clinical effective rate. The secondary outcomes are traditional Chinese medicine symptom score scale, pneumonia severity index, usage time of antibiotic, time required for blood sugar to reach the required level, frequency of hypoglycemia, and chest CT. Liquid chromatograph-mass spectrometry method will be used to explore the blood metabolism profiles of the subjects, to explore the pathogenesis of T2DM-CAP and the mechanism of CHM on T2DM-CAP. Adverse events will also be evaluated.

DISCUSSION

This trial will provide evidence of the effectiveness and safety of traditional CHM in treating patients with T2DM-CAP.

TRIAL REGISTRATION NUMBER

ChiCTR2000035204.

Twelve out of 117 recovered COVID-19 patients retest positive in a single-center study of China

BACKGROUND

It has been reported that a fraction of recovered coronavirus disease 2019(COVID-19) patients have retested positive for SARS-CoV-2. Clinical characteristics and risk factors for retesting positive have not been studied extensively.

METHODS

In this retrospective, single-center cohort study, we included adult patients (≥ 18 years old) diagnosed as COVID-19 in Affiliated Yueqing Hospital, Wenzhou Medical University, Zhejiang, China. All the patients were discharged before March 31, 2020, and were re-tested for SARS-CoV-2 RNA by real-time reverse-transcriptase polymerase-chain-reaction (RT-PCR) after meeting the discharge criteria. We retrospectively analyzed this cohort of 117 discharged patients and analyzed the differences between retest positive and negative patients in terms of demographics, clinical characteristics, laboratory findings, chest computed tomography (CT) features and treatment procedures.

FINDINGS

Compared with the negative group, the positive group had a higher proportion of patients with comorbidities (Odds Ratio(OR) =2·12, 95% Confidence Interval(CI) 0·48-9·46; p = 0·029), longer hospital stay (OR=1·21, 95% CI 1·07-1·36; p = 0·008), a higher proportion of patients with lymphocytopenia (p = 0·036), a higher proportion of antibiotics treatment (p = 0·008) and glucocorticoids treatment (p = 0·003). Multivariable regression showed increasing odds of positive SARS-CoV-2 retest after discharge associated with longer hospital stay (OR=1·22, 95% CI 1·08-1·38; p = 0·001), and lymphocytopenia (OR=7·74, 95% CI 1·70-35·21; p = 0·008) on admission.

INTERPRETATION

Patients with COVID-19 who met discharge criteria could still test positive for SARS-CoV-2 RNA. Longer hospital stay and lymphopenia could be potential risk factors for positive SARS-CoV-2 retest in COVID-19 patients after hospital discharge.

FUNDING

Natural Science Foundation of Zhejiang Province, Medical Scientific Research Fund of Zhejiang Province, Wenzhou science and technology project.

Considerations for people with diabetes during the Coronavirus Disease (COVID-19) pandemic

INTRODUCTION

The severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) continues to cause havoc globally, resulting in unprecedented healthcare, societal and economic disruption. People with diabetes have been shown to be at higher risk of complications and death when exposed to pneumonia, influenza and other coronaviruses. Despite pandemic scale infection, there is currently limited understanding on the potential impact of coronavirus disease (COVID-19) on people with diabetes.

AIMS

(1) To characterise the outcomes of COVID-19 for people with diabetes and (2) add value to current recommendations for healthcare providers and people with diabetes to encourage optimal management.

METHODS

A search of PubMed, Embase and MEDLINE to March 2020 was undertaken, using search terms pertaining to diabetes, coronavirus and acute respiratory distress syndrome (ARDS). We briefly reviewed the epidemiology and pathophysiology of SARS-CoV-2 in the context of diabetes.

CONCLUSION

People with diabetes are at greater risk of severe infection and death with COVID-19. COVID-19 has significantly impacted the daily lives of individuals living with diabetes through financial implications, food and medication scarcity and its burden on mental health. In Australia, delivery of medical care has been adapted to reduce the risk of transmission, with a particular emphasis on telehealth and remote monitoring.

Influenza epidemiology and risk factors for severe acute respiratory infection in Morocco during the 2016/2017 and 2017/2018 seasons

Introduction

in order to implement an influenza vaccination program for high-risk-groups in Morocco, as recommended by the World Health Organization, an epidemiological study indicating the influenza virus effect in the development of complicated influenza for subjects with co-morbidity was required. The present study aims to evaluate the risk factors for severe acute respiratory infections caused by influenza in risk groups.

Methods

this research is based on the epidemiological and virological surveillance data of severe acute respiratory infections and influenza-like illness during the 2016/2017 and 2017/2018 seasons. It was realized using a retrospective series study with a descriptive and analytical purpose.

Results

the over-recruitment of pediatric cases with a severe acute respiratory infection has been significantly rectified because cases of severe acute respiratory infections under 15 years old in the 2017/2018 season represent only 57.9%, whereas they represented 75.9% of the total cases of severe acute respiratory infections during the 2016/2017 season. The influenza positivity rate has increased globally and specifically by age group, clinical service and co-morbidity. The risk factors considered were significantly associated with hospitalization for influenza-associated severe acute respiratory infections. The multivariate logistic regression analysis considers male sex (OR=2.1), age ≥65 years (OR=5.4), presence of influenza cases in the surroundings (OR=0.1), diabetes (OR=7.5) and chronic respiratory disease (OR=10.9) as risk factors influenza-associated severe acute respiratory infections.

Conclusion

the risk assessment of influenza-associated severe acute respiratory infections in high-risk groups revealed national epidemiological findings, particularly for diabetics and the elderly. An influenza vaccination program for these high-risk-groups becomes much recommended in Morocco.

CLINICAL CHARACTERISTICS OF 28 PATIENTS WITH DIABETES AND COVID-19 IN WUHAN, CHINA

Objective: Previous studies on coronavirus disease 2019 (COVID-19) were based on information from the general population. We aimed to further clarify the clinical characteristics of diabetes with COVID-19. Methods: Twenty-eight patients with diabetes and COVID-19 were enrolled from January 29, 2020, to February 10, 2020, with a final follow-up on February 22, 2020. Epidemiologic, demographic, clinical, laboratory, treatment, and outcome data were analyzed. Results: The average age of the 28 patients was 68.6 ± 9.0 years. Most (75%) patients were male. Only 39.3% of the patients had a clear exposure of COVID-19. Fever (92.9%), dry cough (82.1%), and fatigue (64.3%) were the most common symptoms, followed by dyspnea (57.1%), anorexia (57.1%), diarrhea (42.9%), expectoration (25.0%), and nausea (21.4%). Fourteen patients were admitted to the intensive care unit (ICU). The hemoglobin A1c level was similar between ICU and non-ICU patients. ICU patients had a higher respiratory rate, higher levels of random blood glucose, aspartate transaminase, bilirubin, creatine, N-terminal prohormone of brain natriuretic peptide, troponin I, D-dimers, procalcitonin, C-reactive protein, ferritin, interleukin (IL)-2R, IL-6, and IL-8 than non-ICU patients. Eleven of 14 ICU patients received noninvasive ventilation and 7 patients received invasive mechanical ventilation. Twelve patients died in the ICU group and no patients died in the non-ICU group. Conclusion: ICU cases showed higher rates of organ failure and mortality than non-ICU cases. The poor outcomes of patients with diabetes and COVID-19 indicated that more supervision is required in these patients. Abbreviations: COVID-19 = coronavirus disease 2019; ICU = intensive care unit; MERS-CoV = middle East respiratory syndrome-related coronavirus; 2019- nCoV = 2019 novel coronavirus; NT-proBNP = N-terminal prohormone of brain natriuretic peptide; SARS-CoV = severe acute respiratory syndrome-related coronavirus.

Differences between diabetic and non-diabetic patients with community-acquired pneumonia in primary care in Spain

BACKGROUND

Diabetes is one of the underlying risk factors for developing community-acquired pneumonia (CAP). The high prevalence of diabetes among population and the rising incidence of this illness, converts it as an important disease to better control and manage, to prevent its secondary consequences as CAP. The objective of this research is to describe the characteristics of the patients with diabetes and the differences with the no diabetes who have had an episode of CAP in the context of the primary care field.

METHODS

A retrospective, observational study in adult patients (> 18 years-old) who suffer from CAP and attended at primary care in Spain between 2009 and 2013 was developed using the Computerized Database for Pharmacoepidemiological Studies in Primary Care (BIFAP). We carried out a descriptive analysis of the first episodes of CAP, in patients with or without diabetes as comorbidity. Other morbidity (CVA, Anaemia, Arthritis, Asthma, Heart disease, Dementia, Depression, Dysphagia, Multiple sclerosis, Epilepsy, COPD, Liver disease, Arthrosis, Parkinson's disease, Kidney disease, HIV) and life-style factors were also included in the study.

RESULTS

A total of 51,185 patients were included in the study as they suffer from the first episode of CAP. Of these, 8012 had diabetes as comorbidity. There were differences between sex and age in patients with diabetes. Patients without diabetes were younger, and had less comorbidities including those related to lifestyles such as smoking, alcoholism, social and dental problems than patients with diabetes.

CONCLUSIONS

Patients who developed an episode of CAP with diabetes have more risk factors which could be reduced with an appropriate intervention, including vaccination to prevent successive CAP episodes and hospitalization. The burden of associated factors in these patients can produce an accumulation of risk. Health care professional should know this for treating and control these patients in order to avoid complications. Diabetes and those other risk factors associated could be reduced with an appropriate intervention, including vaccination to prevent the first and successive CAP episodes and the subsequent hospitalization in severe cases.

Graph Theoretical Analysis of Genome-Scale Data: Examination of Gene Activation Occurring in the Setting of Community-Acquired Pneumonia

INTRODUCTION

We have previously reported evidence that Black individuals appear to have a significantly higher incidence of infection-related hospitalizations compared with White individuals. It is possible that the host immune response is responsible for this vital difference. In support of such a hypothesis, the aim of this study was to determine whether Black and White individuals exhibit differential whole blood gene network activation.

METHODS

We examined whole blood network activation in a subset of patients (n = 22 pairs, propensity score matched (1:1) Black and White patients) with community-acquired pneumonia (CAP) from the Genetic and Inflammatory Markers of Sepsis study. We employed day one whole blood transcriptomic data generated from this cohort and constructed co-expression graphs for each racial group. Pearson correlation coefficients were used to weight edges. Spectral thresholding was applied to ascribe significance. Innovative graph theoretical methods were then invoked to detect densely connected gene networks and provide differential structural analysis.

RESULTS

Propensity matching was employed to reduce potential bias due to confounding variables. Although Black and White patients had similar socio- and clinical demographics, we identified novel differences in molecular network activation-dense subgraphs known as paracliques that displayed complete gene connection for both White (three paracliques) and Black patients (one paraclique). Specifically, the genes that comprised the paracliques in the White patients include circadian loop, cell adhesion, mobility, proliferation, tumor suppression, NFκB, and chemokine signaling. However, the genes that comprised the paracliques in the Black patients include DNA and messenger RNA processes, and apoptosis signaling. We investigated the distribution of Black paracliques across White paracliques. Black patients had five paracliques (with almost complete connection) comprised of genes that are critical for host immune response widely distributed across 22 parcliques in the White population. Anchoring the analysis on two critical inflammatory mediators, interleukin (IL)-6 and IL-10 identified further differential network activation among the White and Black patient populations.

CONCLUSIONS

These results demonstrate that, at the molecular level, Black and White individuals may experience different activation patterns with CAP. Further validation of the gene networks we have identified may help pinpoint genetic factors that increase host susceptibility to community-acquired pneumonia, and may lay the groundwork for personalized management of CAP.

Rapid detection and clinical spectrum of the novel influenza H1N1 strain in a diabetic pediatric population

OBJECTIVES

H1N1 infection in diabetic patients is of special concern and serious interest since the virus can place individuals, especially children, at great possible risk of subsequently developing type 1 diabetes. This work aims to describe the demographic characteristics, clinical features, and severity of illness of children with type 1 diabetes mellitus (DM), compare the incidence of pandemic H1N1 virus in children with that of the general pediatric population with influenza-like symptoms, and identify the complications of H1N1 virus infection associated with glycemic control.

METHODS

The present study included 45 children and adolescents with type 1 diabetes, who were subject to clinical and laboratory investigations. Another 30 healthy adolescents and children with a mean age of 10.43 ± 4.38 years were included as a control group. H1N1 reverse-transcriptase quantitative PCR (RT-Q PCR) was tested for H1N1 virus detection.

RESULTS

Diabetic patients positive for (H1N1) showed significantly higher random blood sugar (RBS) levels than diabetic patients negative for (H1N1). Moreover, the H1N1-positive patients had significantly higher hemoglobin (Hb) g/dL, platelet counts, total leukocyte counts (TLCs), and CRP levels. Newly diagnosed patients who were tested positive for (H1N1) and diabetic ketoacidosis (DKA) had significantly higher RBS levels and TLCs than patients who were presented with hyperglycemia.

CONCLUSION

RT-PCR is a rapid and specific method for influenza A (H1N1) virus diagnosis. In addition, early administration of oseltamivir no later than 48 hours after the infection is highly recommended in either diabetic or DKA patients suspected of having H1N1.

Guidelines for Antibiotic Prescription in Intensive Care Unit

How to cite this article: Khilnani GC, Zirpe K, Hadda V, Mehta Y, Madan K, Kulkarni A, Mohan A, Dixit S, Guleria R, Bhattacharya P. Guidelines for Antibiotic Prescription in Intensive Care Unit. Indian Journal of Critical Care Medicine 2019;23 (Suppl 1):1-63.

Healthcare utilisation and cost expenditures for pneumonia in individuals with diabetes mellitus in the USA

Pneumonia is one of the leading causes of hospitalisations among adults in the USA. Individuals with diabetes mellitus (DM) have been associated with increased risk for pneumonia and complications including death. The objectives of this study were to (1) compare the prevalence and healthcare utilisation patterns for pneumonia in individuals with and without DM, and (2) identify risk factors for pneumonia in those with DM. We performed a retrospective, cross-sectional analysis of the US adult population using Medical Expenditure Panel Surveys (MEPS) data from 2014. Overall, the data represented 24 million individuals with DM and 218 million without DM in the USA. The population-based rate for a pneumonia event was 34 per 1000 persons for individuals with DM and 19 per 1000 persons without DM. Compared to the non-DM group, individuals with DM were treated 1.8x, 2.6x and 1.4x more in the ED, hospital and outpatient, respectively. Furthermore, the average cost per pneumonia event was significantly higher among individuals with DM compared to non-DM in the inpatient setting ($11 931 vs. $7751; P < 0.001). Among individuals with DM, female sex, DM complications, smokers and administration of pneumococcal vaccines were significant factors associated with a pneumonia event.

Diabetes and the solid organ transplant recipient

Solid organ transplant candidates undergo very strict screening for cardiovascular risk. Such screening has permitted significant decreases in cardiovascular morbidity and mortality over the ensuing decades of follow up. Long term follow-up has enabled us to identify an increasing incidence of pulmonary and urinary tract infections with or without sepsis as competing factors of morbidity and mortality. Indeed, all-cause mortality may now be dominated by infection-related endpoints. No population of transplant recipients is more naturally susceptible to infection as a diabetic subset, now submitted to immunosuppression. The current review details infection risk for kidney, liver, heart, and lung allograft recipients. A specific feature of this report emphasizes the enhanced risk for bacterial and fungal infection found in diabetic allograft recipients on immunosuppression therapy. The risk of repeated prescription of antibiotics in terms of evolutions of resistant strains of infectious pathogens is emphasized.

Improving Vaccination Rates in Adults With Type 2 Diabetes in a Family Practice Setting Through the Use of Evidence-Based Interventions

Background: Adults with diabetes are at increased susceptibility to infectious disease because of hyperglycemia, poor glucose control, and decreased immunity. Diabetes is the seventh leading cause of death in Texas and the United States. Objective: The purpose of this evidence-based quality improvement project was to implement processes to facilitate providers’ adherence to immunization guidelines for adults with type 2 diabetes mellitus. Method: A protocol was created for a family practice clinic using the Four Pillars Transformation Program. Interventions included immunization standing orders, vaccine needs screening, patient education, electronic medical record alerts, an appointed immunization champion, and quality improvement meetings. Results: Ten weeks post project implementation, the increased screening and education resulted in 64% of the eligible patients being vaccinated with pneumococcal polysaccharide vaccine 23, 86% pneumococcal conjugate vaccine, 89% tetanus, and 54% herpes zoster. Conclusions: The results indicate that formal printed education on diabetes and vaccines increased vaccine uptake in eligible patients by 76%. Implications for Nursing: The Four Pillars Transformation Program allows each practice the ability to modify and select interventions best suited to the practice needs, making it a feasible tool for any clinic.

Recent Advances in the Development of Vaccines for Diabetes, Hypertension, and Atherosclerosis

Vaccines are commonly used in the prevention of infectious diseases. The basic principle of vaccination is to use specific antigens, endogenous or exogenous to stimulate immunity against the specific antigens or cells producing them. Autoantigen or oligo vaccination has been used for disease animal models. More recently humanized monoclonal antibodies have been successfully used for the treatment of neoplastic disorders or familial hypercholesterolemia. Humanized monoclonal antibody therapy needs repeated injection, and the therapy is expensive. Therapeutic vaccination can lead to persistent immunized or immune tolerant against the therapeutic molecule(s) or site. However, immunization against those endogenous substances may also elicit persistent autoimmune reaction or destruction that do harm to health. Therefore, rigorous studies are needed before any clinical application. In this review, we briefly reviewed vaccines used in protection against common metabolic diseases including atherosclerosis, hypertension, and diabetes mellitus.

Progression into sepsis: an individualized process varying by the interaction of comorbidities with the underlying infection

Background

Development of sepsis is a process with significant variation among individuals. The precise elements of this variation need to be defined. This study was designed to define the way in which comorbidities contribute to sepsis development.

Methods

Three thousand five hundred nine patients with acute pyelonephritis (AP), community-acquired pneumonia (CAP), intraabdominal infections (IAI) or primary bacteremia (BSI) and at least two signs of the systemic inflammatory response syndrome were analyzed. The study primary endpoint was to define how comorbidities as expressed in the Charlson’s comorbidity index (CCI) and the underlying type of infection contribute to development of organ dysfunction. The precise comorbidities that mediate sepsis development and risk for death among 18 comorbidities recorded were the secondary study endpoints.

Results

CCI more than 2 had an odds ratio of 5.67 for sepsis progression in patients with IAI between significantly higher than AP and BSI. Forward logistic regression analysis indicated seven comorbidities that determine transition into sepsis in patients with AP, four comorbidities in CAP, six comorbidities in IAI and one in BSI. The odds ratio both for progression to sepsis and death with one comorbidity or with two and more comorbidities was greater than in the absence of comorbidities.

Conclusions

The study described how different kinds of infection vary in the degree to which they lead to sepsis. The number of comorbidities that enhances the risk of sepsis and death varies depending on the underlying infections.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-3156-z) contains supplementary material, which is available to authorized users.

Poverty as an independent risk factor for in-hospital mortality in community-acquired pneumonia: A study in a developing country population

BACKGROUND

Community-acquired pneumonia (CAP) is one of the most severe lower respiratory tract infections with a high in-hospital mortality. The aim of this study was to investigate the socioeconomic and medical risk factors affecting the prognosis of acute pneumonia. The results of this study can mention the value of socioeconomic backgrounds like poverty and illiteracy in clinical practice, even in a well-known biological phenomenon (eg acute pneumonia).

METHODS

In this cross-sectional study, all admitted patients to a tertiary teaching hospital with a diagnosis of community acquired pneumonia in a 12-month period were enrolled. Socioeconomic and demographic characteristics, underlying conditions, clinical manifestations and para-clinical test results at admission registered prospectively. A logistic regression model was conducted using in-hospital mortality as the dependent variable.

RESULTS

A total of 621 patients was included in this study. Among them, 47 patients (7.6%) died during the hospitalisation period. In multiple logistic regression analysis, pleural effusion, a higher CURB-65 score, hyponatremia, hyperglycaemia and poverty (being in the lower economic class) were identified as independent risk factors for in-hospital mortality in community-acquired pneumonia.

CONCLUSION

Numerous factors can influence the prognosis of CAP. In addition to the CURB-65 score and some other medical risk factors, socioeconomic backgrounds can also affect the early outcome in CAP. In this study, being in the lower economic class (as an indicator of poverty) is interpreted as an independent risk factor for a poor prognosis in CAP.

The impact of blood glucose on community-acquired pneumonia: a retrospective cohort study

Hyperglycaemia is common in patients with community-acquired pneumonia (CAP) and is a predictor of severe outcomes. Data are scarce regarding whether this association is affected by diabetes mellitus (DM) and also regarding its importance for severe outcomes in hospital. We determined the impact of blood glucose on severe outcomes of CAP in hospital. We studied 1318 adult CAP patients hospitalised at three Danish hospitals. The association between blood glucose and DM status and severe clinical outcome (admission to an intensive care unit (ICU) and/or in-hospital mortality) was assessed by logistic regression. Models were adjusted for CURB-65 score and comorbidities. 12% of patients had DM. In patients without DM an increase in admission blood glucose was associated with risk for ICU admittance (OR 1.25, 95% CI 1.13-1.39), but not significantly associated with in-hospital mortality (OR 1.10, 95% CI 0.99-1.23). In patients with DM an increase in admission blood glucose was not associated with ICU admittance (OR 1.05, 95% CI 1.00-1.12) or in-hospital mortality (OR 1.05, 95% CI 0.99-1.12). An increase in admission blood glucose (only in patients without DM) was associated with a higher risk for ICU admittance and a trend towards higher in-hospital mortality. DM was not associated with a more severe outcome of CAP.

Comorbidities impact on the prognosis of severe acute community-acquired pneumonia

Highlights

Abstract

Community-acquired pneumonia (CAP) is a frequent cause of admission to hospital worldwide with high mortality rates. Host comorbidities may be associated not just with a greater risk of developing the disease but also with worse outcomes. In this work, the evaluation of the impact of host comorbidities on the prognosis of severe CAP patients admitted to an Intensive Care Unit (ICU) was proposed. Severity indexes, some clinical and analytic parameters at admission in ICU as well as patient comorbidities were analyzed and statistically compared with mortality. In this study, although there was no clear link between comorbidities and mortality, factors such as smoking, obesity and previous renal disease impairment seem to have an impact on the prognosis of severe CAP.

Risk factors for developing acute kidney injury in older people with diabetes and community-acquired pneumonia: a population-based UK cohort study

Background

Acute kidney injury (AKI) is being increasingly recognised in ageing populations. There are a paucity of data about AKI risk factors among older individuals with diabetes and infections, who are at particularly high risk of AKI. The objective of this study was to evaluate the risk factors for developing acute kidney injury (AKI) amongst older patients with diabetes and community-acquired pneumonia (CAP) in England, and whether the impact of underlying kidney function varied with age.

Methods

This was a population-based retrospective cohort study over 7 years (01/04/2004–31/3/2011) using electronic health records from the Clinical Practice Research Datalink linked to Hospital Episode Statistics. The study population comprised individuals with diabetes aged ≥65 years with CAP. Associations between demographic, lifestyle factors, co-morbidities and medications and development of AKI within 28 days of CAP were explored in a logistic regression model.

Results

Among 3471 patients with CAP and complete covariate data, 298 patients developed subsequent AKI. In multivariable analyses, factors found to be independently associated with AKI included: male sex (adjusted odds ratio, aOR: 1.56 95% confidence interval (CI): 1.20–2.04), hypertension (aOR1.36 95% CI 1.01–1.85), being prescribed either angiotensin-converting-enzyme inhibitors or angiotensin-II-receptor-blockers (aOR: 1.59 95% CI: 1.19–2.13), or insulin (aOR: 2.27 95% CI: 1.27–4.05), presence of proteinuria (aOR 1.27 95% CI 0.98–1.63), and low estimated glomerular filtration rate (eGFR). The odds of AKI were more graded amongst older participants aged ≥80 years compared to those of younger age: for eGFR of ≤29 mL/min/1.73m² (vs 60 ml/min/1.73m²) aOR: 5.51 95% CI 3.28–9.27 and for eGFR 30–59 mL/min/1.73m² 1.96 95% CI 1.30–2.96, whilst any eGFR < 60 ml/min/1.73m² was associated with approximately 3-fold increase in the odds of AKI amongst younger individuals (p-value for interaction = 0.007).

Conclusions

The identified risk factors should help primary care and hospital providers identify high risk patients in need of urgent management including more intensive monitoring, and prevention of AKI following pneumonia.

Influenza vaccination in older people with diabetes and their household contacts

BACKGROUND

People with diabetes are at a higher risk of influenza infections and severe complications. The vaccination of close contacts could offer indirect protection to people with diabetes; this is known as "herd immunity." The aim of this study is to investigate the vaccination rates of people with diabetes and their household contacts in Hong Kong.

RESEARCH DESIGN AND METHODS

Face-to-face interviews with 158 patients diagnosed with Type 2 diabetes and aged ⩾65years were conducted in clinics. Telephone interviews were then conducted with 281 adult household contacts.

RESULTS

Seasonal influenza vaccination rates were 54.5% and 27.4%, in people with diabetes and their contacts, respectively. The vaccination status of patients was not significantly associated with the vaccination of their household contacts (p=0.073). Among household contacts, children or the elderly, the partners or couples of patients, and those with more hours of daily contact, or with chronic conditions, were associated with higher vaccination rates. However, only age remained significant after adjusting for confounding factors in logistic regression models.

CONCLUSIONS

The low vaccination rates of people with diabetes and their close contacts highlight the need to promote vaccination in susceptible populations and to educate the public about herd immunity.

Changes in blood monocyte Toll-like receptor and serum surfactant protein A reveal a pathophysiological mechanism for community-acquired pneumonia in patients with type 2 diabetes

BACKGROUND

The lung is one of the target organs of microangiopathy in diabetes mellitus (DM); patients with type 2 diabetes mellitus (T2DM) are vulnerable to pneumonia, and a variety of pathophysiological mechanisms has been described.

AIM

This study aimed to determine the pathophysiological mechanism of community-acquired pneumonia (CAP) in T2DM patients.

METHODS

A total of 90 individuals was included in this study comprised of three groups (n = 30): healthy control, T2DM and T2DM+ CAP groups. Toll-like receptor (TLR)2 and 4 protein and messenger RNA expression in peripheral blood monocytes(PBMC) was assessed by western blot and reverse transcription-polymerase chain reaction, respectively, and surfactant protein A (SP-A) levels were examined in serum samples by enzyme-linked immunosorbent assay.

RESULTS

In T2DM and T2DM+CAP groups, levels of both TLR2/4 protein and mRNA in PBMC were decreased compared with controls (P <0.05), with lower levels observed in the T2DM+CAP group in comparison with T2DM patients (P <0.05). The serum SP-A levels in T2DM+CAP individuals were significantly higher than the values obtained for T2DM patients (P <0.05). It also showed apparent increases when compared with that in controls although no statistical significance was detected.

CONCLUSION

In T2DM patients with pneumonia, TLR2/4 levels in PBMC and serum SP-A were altered, maybe playing an important role in the susceptibility to pneumonia in T2DM patients.

Benefit of adjunct corticosteroids for community-acquired pneumonia in diabetic patients

AIMS/HYPOTHESIS

We have recently shown that adjunct prednisone shortens the time taken to reach clinical stability (time to clinical stability, TTCS) in patients with community-acquired pneumonia (CAP). Considering the hyperglycaemic effects of prednisone, there are concerns about the efficacy and safety of this therapy for diabetic patients with CAP. Our objective was to evaluate whether diabetes and/or hyperglycaemia on admission to hospital has an influence on the effect of corticosteroids on outcome in a well-defined cohort of patients with CAP.

METHODS

This is a preplanned subanalysis of a prospective randomised, double-blind placebo-controlled multicentre trial. Patients aged 18 years or older with CAP were eligible and were recruited from seven tertiary care hospitals in Switzerland within 24 h of presentation. Patients were randomised (1:1 ratio) to receive either 50 mg of prednisone daily for 7 days or placebo. Allocation was concealed with a prespecified computer-generated randomisation list. Patients, treating physicians, investigators and data assessors were masked to treatment allocation. The primary endpoint was TTCS; secondary endpoints were length of stay, mortality, duration of antibiotic treatment, CAP complications and new insulin requirement at day 30. Furthermore, we analysed whether these endpoints were influenced by a glycaemic dysregulation during the study time.

RESULTS

Of 802 patients randomised (n = 402 in the prednisone, n = 400 in the placebo group), 726 patients were treated per protocol and included in this analysis (n = 362 in the prednisone, n = 364 in the placebo group). Nineteen per cent of 726 patients had diabetes mellitus (n = 66 in the prednisone group, n = 72 in the placebo group). Adjunct prednisone shortened TTCS in diabetic and non-diabetic patients (HR 1.65 [95% CI 1.16, 2.35], p = 0.007; 1.30 [95% CI 1.10, 1.53], p = 0.002) with no evidence for effect modification by diabetes in interaction analysis (p = 0.44). No difference was found in other clinically relevant endpoints. Although adjunct prednisone was associated with glycaemic dysregulation, this did not translate into worse clinical outcomes in either group, and there was no difference in secondary endpoints.

CONCLUSIONS/INTERPRETATION

The benefit of adjunct prednisone in CAP patients is also valid for those with diabetes or hyperglycaemia on admission. Hyperglycaemia in diabetic patients or due to adjunct prednisone did not have a negative effect on outcome.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00973154 FUNDING : This study was supported by a grant from the Swiss National Foundation and by the Nora van Meeuwen Häfliger Stiftung and the Gottfried Julia Bangerter-Rhyner Stiftung.

Association of diabetes and diabetes treatment with the host response in critically ill sepsis patients

Background

Diabetes is associated with chronic inflammation and activation of the vascular endothelium and the coagulation system, which in a more acute manner are also observed in sepsis. Insulin and metformin exert immune modulatory effects. In this study, we aimed to determine the association of diabetes and preadmission insulin and metformin use with sepsis outcome and host response.

Methods

We evaluated 1104 patients with sepsis, admitted to the intensive care unit and stratified according to the presence or absence of diabetes mellitus. The host response was examined by a targeted approach (by measuring 15 plasma biomarkers reflective of pathways implicated in sepsis pathogenesis) and an unbiased approach (by analyzing whole genome expression profiles in blood leukocytes).

Results

Diabetes mellitus was not associated with differences in sepsis presentation or mortality up to 90 days after admission. Plasma biomarker measurements revealed signs of systemic inflammation, and strong endothelial and coagulation activation in patients with sepsis, none of which were altered in those with diabetes. Patients with and without diabetes mellitus, who had sepsis demonstrated similar transcriptional alterations, comprising 74 % of the expressed gene content and involving over-expression of genes associated with pro-inflammatory, anti-inflammatory, Toll-like receptor and metabolic signaling pathways and under-expression of genes associated with T cell signaling pathways. Amongst patients with diabetes mellitus and sepsis, preadmission treatment with insulin or metformin was not associated with an altered sepsis outcome or host response.

Conclusions

Neither diabetes mellitus nor preadmission insulin or metformin use are associated with altered disease presentation, outcome or host response in patients with sepsis requiring intensive care.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-016-1429-8) contains supplementary material, which is available to authorized users.

Risk Factors for Long-Term Mortality after Hospitalization for Community-Acquired Pneumonia: A 5-Year Prospective Follow-Up Study

BACKGROUND

Contributors to long-term mortality in patients with community-acquired pneumonia (CAP) remain unclear, with little attention paid to pneumonia etiology. We examined long-term survival, causes of death, and risk factors for long-term mortality in adult patients who had been hospitalized for CAP, with emphasis on demographic, clinical, laboratory, and microbiological characteristics.

METHODS

Two hundred and sixty-seven consecutive patients admitted in 2008-2011 to a general hospital with CAP were prospectively recruited and followed up. Patients who died during hospital stay were excluded. Demographic, clinical, and laboratory data were collected within 48 hours of admission. Extensive microbiological work-up was performed to establish the etiology of CAP in 63% of patients. Mortality data were obtained from the Norwegian Cause of Death Registry. Cox regression models were used to identify independent risk factors for all-cause mortality.

RESULTS

Of 259 hospital survivors of CAP (median age 66 years), 79 (30.5%) died over a median of 1,804 days (range 1-2,520 days). Cumulative 5-year survival rate was 72.9% (95% CI 67.4-78.4%). Standardized mortality ratio was 2.90 for men and 2.05 for women. The main causes of death were chronic obstructive pulmonary disease (COPD), vascular diseases, and malignancy. Independent risk factors for death were the following (hazard ratio, 95% CI): age (1.83 per decade, 1.47-2.28), cardiovascular disease (2.63, 1.61-4.32), COPD (2.09, 1.27-3.45), immunocompromization (1.98, 1.17-3.37), and low serum albumin level at admission (0.75 per 5 g/L higher, 0.58-0.96), whereas active smoking was protective (0.32, 0.14-0.74); active smokers were younger than non-smokers (P < 0.001). Microbial etiology did not predict mortality.

CONCLUSIONS

Results largely confirm substantial comorbidity-related 5-year mortality after hospitalization for CAP and the impact of several well-known risk factors for death, and extend previous findings on the prognostic value of serum albumin level at hospital admission. Pneumonia etiology had no prognostic value, but this remains to be substantiated by further studies using extensive diagnostic microbiological methods in the identification of causative agents of CAP.

Hospitalization for Pneumonia is Associated With Decreased 1-Year Survival in Patients With Type 2 Diabetes: Results From a Prospective Cohort Study

Diabetes mellitus is a frequent comorbid conditions among patients with pneumonia living in the community.The aim of our study is to evaluate the impact of hospitalization for pneumonia on early (30 day) and late mortality (1 year) in patients with type 2 diabetes mellitus.Prospective comparative cohort study of 203 patients with type 2 diabetes hospitalized for pneumonia versus 206 patients with diabetes hospitalized for other noninfectious causes from January 2012 to December 2013 at Policlinico Umberto I (Rome). Enrolled patients were followed up to discharge and up to 1 year after initial hospital admission or death.Overall, 203 patients with type 2 diabetes admitted to hospital for pneumonia were compared to 206 patients with type 2 diabetes admitted for other causes (39.3% decompensated diabetes, 21.4% cerebrovascular diseases, 9.2% renal failure, 8.3% acute myocardial infarction, and 21.8% other causes). Compared to control patients, those admitted for pneumonia showed a higher 30-day (10.8% vs 1%, P < 0.001) and 1-year mortality rate (30.3% vs 16.8%, P < 0.001). Compared to survivors, nonsurvivor patients with pneumonia had a higher incidence of moderate to severe chronic kidney disease, hemodialysis, and malnutrition were more likely to present with a mental status deterioration, and had a higher number of cardiovascular events during the follow-up period. Cox regression analysis found age, Charlson comorbidity index, pH < 7.35 at admission, hemodialysis, and hospitalization for pneumonia as variables independently associated with mortality.Hospitalization for pneumonia is associated with decreased 1-year survival in patients with type 2 diabetes, and appears to be a major determinant of long-term outcome in these patients.

TNF Drives Monocyte Dysfunction with Age and Results in Impaired Anti-pneumococcal Immunity

Monocyte phenotype and output changes with age, but why this occurs and how it impacts anti-bacterial immunity are not clear. We found that, in both humans and mice, circulating monocyte phenotype and function was altered with age due to increasing levels of TNF in the circulation that occur as part of the aging process. Ly6C⁺ monocytes from old (18–22 mo) mice and CD14⁺CD16⁺ intermediate/inflammatory monocytes from older adults also contributed to this “age-associated inflammation” as they produced more of the inflammatory cytokines IL6 and TNF in the steady state and when stimulated with bacterial products. Using an aged mouse model of pneumococcal colonization we found that chronic exposure to TNF with age altered the maturity of circulating monocytes, as measured by F4/80 expression, and this decrease in monocyte maturation was directly linked to susceptibility to infection. Ly6C⁺ monocytes from old mice had higher levels of CCR2 expression, which promoted premature egress from the bone marrow when challenged with Streptococcus pneumoniae. Although Ly6C⁺ monocyte recruitment and TNF levels in the blood and nasopharnyx were higher in old mice during S. pneumoniae colonization, bacterial clearance was impaired. Counterintuitively, elevated TNF and excessive monocyte recruitment in old mice contributed to impaired anti-pneumococcal immunity since bacterial clearance was improved upon pharmacological reduction of TNF or Ly6C⁺ monocytes, which were the major producers of TNF. Thus, with age TNF impairs inflammatory monocyte development, function and promotes premature egress, which contribute to systemic inflammation and is ultimately detrimental to anti-pneumococcal immunity.

As we age, levels of inflammatory cytokines in the blood and tissues increase. Although this appears to be an inevitable part of aging, it ultimately contributes to declining health. Epidemiological studies indicate that older adults with higher than age-average levels of inflammatory cytokines are at increased risk of acquiring, becoming hospitalized with and dying of Streptococcus pneumoniae pneumonia but how age-associated inflammation increased susceptibility to was not entirely clear. We demonstrate that the increase in the inflammatory cytokine TNF that occurs with age cause monocytes to leave the bone marrow prematurely and these immature monocytes produce more inflammatory cytokines when stimulated with bacterial products, thus further increasing levels of inflammatory cytokines in the blood. Furthermore, although old mice have higher levels of these inflammatory monocytes arriving at the site of S. pneumoniae, they are not able to clear the bacteria. By pharmacologically or genetically removing the inflammatory cytokine TNF or reducing the number of inflammatory monocytes we were able to restore antibacterial immunity in aged mice. Thus we demonstrate that monocytes are both influenced by and contributors to age-associated inflammation and that chronic exposure to age-associated inflammation increases susceptibility to S. pneumoniae due to altering monocyte maturity and function.

Evidence of non-linearity in the association of glycemic control with influenza/pneumonia mortality: a study of 19 000 adults from the US general population

BACKGROUND

Diabetes is a major public health problem and thought to be a risk factor for infectious diseases, but pertinent epidemiological evidence is limited. This study aimed to analyse the associations of diabetes, disease duration and glycated haemoglobin levels (HbA1c) with infectious diseases mortality in the general population, including the investigation of potential non-linear relationships.

METHODS

An observational, prospective study of 19 783 subjects included in the Third National Health and Nutrition Examination Survey, representing the adult non-institutionalized population of the United States of America, was conducted. The analysis was done by multiple Cox regression and restricted cubic spline modelling.

RESULTS

Self-reported diabetes and diabetes duration were not significantly associated with the outcomes. However, there was evidence for a non-linear association of HbA1c with mortality from influenza, pneumonia or other acute lower respiratory infections. Spline regression suggested a roughly doubled risk of mortality beyond an HbA1c of 6.5% (48 mmol/mol) in reference to 5.2% (33 mmol/mol).

CONCLUSIONS

Future studies on diabetes and infections should adequately address potential non-linearity, which may be necessary to better understand and characterize more precisely the relationship of diabetes with infectious diseases.