危重症患者中的糖尿病与社区获得性血流感染

Diabetes mellitus and community-acquired bloodstream infections in the critically ill.

作者信息

McKane Caitlin K, Marmarelis Melina, Mendu Mallika L, Moromizato Takuhiro, Gibbons Fiona K, Christopher Kenneth B

机构信息

Department of Nursing, Brigham and Women's Hospital, Boston, MA, USA.

Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.

出版信息

J Crit Care. 2014 Feb;29(1):70-6. doi: 10.1016/j.jcrc.2013.08.019. Epub 2013 Oct 3.

DOI:10.1016/j.jcrc.2013.08.019

PMID:24090695

Abstract

INTRODUCTION

Community-acquired bloodstream infections have not been studied related to diabetes mellitus in the critically ill.

HYPOTHESIS

We hypothesized that the diagnosis of diabetes mellitus and poor chronic glycemic control would increase the risk of community-acquired bloodstream infections (CA-BSIs) in the critically ill.

METHODS

We performed an observational cohort study between 1998 and 2007 in 2 teaching hospitals in Boston, Massachusetts. We studied 2551 patients 18 years or older, who received critical care within 48 hours of admission and had blood cultures obtained within 48 hours of admission. The exposure of interest was diabetes mellitus defined by International Classification of Diseases, Ninth Revision, Clinical Modification, code 250.xx in outpatient or inpatient records. The primary end point was CA-BSI (<48 hours of hospital admission). Patients with a single coagulase-negative Staphylococcus positive blood culture were not considered to have bloodstream infection. Associations between diabetes groups and bloodstream infection were estimated by bivariable and multivariable logistic regression models. Subanalyses included evaluation of the association between hemoglobin A1c (HbA1c) and bloodstream infection, diabetes and risk of sepsis, and the proportion of the association between diabetes and CA-BSI that was mediated by acute glycemic control.

RESULTS

Diabetes is a predictor of CA-BSI. After adjustment for age, sex, race, patient type (medical vs surgical), and acute organ failure, the risk of bloodstream infection was significantly higher in patients with diabetes (odds ratio [OR], 1.42; 95% confidence interval [CI], 1.10-1.82; P = .006) relative to patients without diabetes. The adjusted risk of bloodstream infection was increased in patients with HbA1c of 6.5% or higher (OR, 1.31; 95% CI, 1.04-1.65; P = .02) relative to patients with HbA1c less than 6.5%. Furthermore, the adjusted risk of sepsis was significantly higher in patients with diabetes (OR, 1.26; 95% CI, 1.04-1.54; P = .02) relative to patients without diabetes. Maximum glucose did not significantly mediate the relationship between diabetes mellitus diagnosis and CA-BSI.

CONCLUSIONS

A diagnosis of diabetes mellitus and HbA1c of 6.5% or higher is associated with the risk of CA-BSI in the critically ill.

摘要

引言

社区获得性血流感染与危重症患者的糖尿病之间的关系尚未得到研究。

假设

我们假设糖尿病的诊断以及慢性血糖控制不佳会增加危重症患者发生社区获得性血流感染（CA-BSI）的风险。

方法

1998年至2007年期间，我们在马萨诸塞州波士顿的两家教学医院进行了一项观察性队列研究。我们研究了2551名18岁及以上的患者，这些患者在入院后48小时内接受了重症监护，且在入院后48小时内进行了血培养。感兴趣的暴露因素是根据《国际疾病分类，第九次修订本，临床修订版》门诊或住院记录中的代码250.xx定义的糖尿病。主要终点是CA-BSI（入院后<48小时）。单一凝固酶阴性葡萄球菌血培养阳性的患者不被视为发生血流感染。通过双变量和多变量逻辑回归模型估计糖尿病组与血流感染之间的关联。亚分析包括评估糖化血红蛋白（HbA1c）与血流感染之间的关联、糖尿病与脓毒症风险之间的关联，以及糖尿病与CA-BSI之间关联中由急性血糖控制介导的比例。

结果

糖尿病是CA-BSI的一个预测因素。在调整年龄、性别、种族、患者类型（内科与外科）和急性器官功能衰竭后，糖尿病患者发生血流感染的风险显著高于非糖尿病患者（比值比[OR]，1.42；95%置信区间[CI]，1.10 - 1.82；P = 0.006）。与HbA1c低于6.5%的患者相比，HbA1c为6.5%或更高的患者调整后的血流感染风险增加（OR，1.31；95% CI，1.04 - 1.65；P = 0.02）。此外，与非糖尿病患者相比，糖尿病患者调整后的脓毒症风险显著更高（OR，1.26；95% CI，1.04 - 1.54；P = 0.02）。最高血糖水平并未显著介导糖尿病诊断与CA-BSI之间的关系。