Objective. To evaluate whether diabetes mellitus (DM) and hemoglobin A1c (HbA1c) are risk factors for ventilator-associated pneumonia (VAP) and bloodstream infections (BSI) in critically ill patients. Methods. Prospective observational study; patients were recruited from the intensive care unit (ICU) of a general district hospital between 2010 and 2012. Inclusion criteria: ICU hospitalization >72 hours and mechanical ventilation >48 hours. HbA1c was calculated for all participants. DM, HbA1c, and other clinical and laboratory parameters were assessed as risk factors for VAP or BSI in ICU. Results. The overall ICU incidence of VAP and BSI was 26% and 30%, respectively. Enteral feeding OR (95%CI) 6.20 (1.91–20.17; ) and blood transfusion 3.33 (1.23–9.02; ) were independent risk factors for VAP. BSI in ICU ( ) and ICU mortality ( ) were significantly increased in diabetics. Independent risk factors for BSI in ICU included BSI on admission 2.45 (1.14–5.29; ) and stroke on admission2.77 (1.12–6.88; ). Sepsis 3.34 (1.47–7.58; ) and parenteral feeding 6.29 (1.59–24.83; ) were independently associated with ICU mortality. HbA1c ≥ 8.1% presented a significant diagnostic performance in diagnosing repeated BSI in ICU. Conclusion. DM and HbA1c were not associated with increased VAP or BSI frequency. HbA1c was associated with repeated BSI episodes in the ICU. 1. Introduction Ventilator-associated pneumonia (VAP) often complicates the clinical course of the critically ill patients and it may be associated with considerable morbidity and mortality [1]. VAP can be precipitated by several factors which may be associated with the underlying disease, the critical interventions that are performed in the intensive care unit (ICU), or the logical impairment that has been described in the critical illness [2, 3]. Hyperglycemia and diabetes mellitus (DM) are conditions which have been linked to alterations of immune response and are often encountered in the critical care setting [4]. However, acute hyperglycemia is usually treated in ICU and the level of alertness of physicians for the possible complications of acute hyperglycemia and DM in critically ill patients is high [5]. On the other hand, it is not known whether diabetic patients with a history of less optimum diabetic control, such as those with abnormal hemoglobin A1c (HbA1c), could be at a higher risk of ICU infections compared to diabetics with a history of well-controlled DM prior to ICU admission. Previous studies have examined the correlation between HbA1c and the outcome in diabetic patients with sepsis but the
References
[1]
M. H. Kollef, “What is ventilator-associated pneumonia and why is it important?” Respiratory Care, vol. 50, no. 6, pp. 714–721, 2005.
[2]
N. M. Joseph, S. Sistla, T. K. Dutta, A. S. Badhe, and S. C. Parija, “Ventilator-associated pneumonia: a review,” European Journal of Internal Medicine, vol. 21, no. 5, pp. 360–368, 2010.
[3]
D. Payen, V. Faivre, A. C. Lukaszewicz, and M. R. Losser, “Assessment of immunological status in the critically ill,” Minerva Anestesiologica, vol. 66, no. 5, pp. 351–357, 2000.
[4]
S. E. Geerlings and A. I. M. Hoepelman, “Immune dysfunction in patients with diabetes mellitus (DM),” FEMS Immunology and Medical Microbiology, vol. 26, no. 3-4, pp. 259–265, 1999.
[5]
American Diabetes Association, “Standards of medical care in diabetes—2011,” Diabetes Care, vol. 34, supplement 1, pp. S11–S61, 2011.
[6]
I. Gornik, O. Gornik, and V. Gasparovic, “Hemoglobin A1c predicts outcome of sepsis in patients with diabetes,” Critical Care, vol. 10, supplement 1, article P251, 2006.
[7]
I. Gornik, O. Gornik, and V. Gasparovic, “Influence of diabetes and HbA1c on the course and outcome of sepsis in the intensive care unit,” Critical Care, vol. 11, supplement 2, P124, 2007.
[8]
M. Kirby, “International expert committee recommends new role for HbA1c in diagnosing diabetes,” Primary Care Cardiovascular Journal, vol. 2, no. 3, pp. 146–148, 2009.
[9]
American Diabetes Association, “Diagnosis and classification of diabetes mellitus,” Diabetes Care, vol. 33, supplement 1, pp. S62–S69, 2010.
[10]
J. Pugin, “Clinical signs and scores for the diagnosis of ventilator-associated pneumonia,” Minerva Anestesiologica, vol. 68, no. 4, pp. 261–265, 2002.
[11]
American Thoracic Society and Infectious Diseases Society of America, “Guidelines for the Management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia,” American Journal of Respiratory Critical Care Medicine, vol. 171, no. 4, pp. 388–416, 2005.
[12]
T. C. Horan, M. Andrus, and M. A. Dudeck, “CDC/NHSN surveillance definition of health care-associated infection and criteria for specific types of infections in the acute care setting,” American Journal of Infection Control, vol. 36, no. 5, pp. 309–332, 2008.
[13]
M. M. Levy, M. P. Fink, J. C. Marshall et al., “2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference,” Intensive Care Medicine, vol. 29, no. 4, pp. 530–538, 2003.
[14]
D. R. Park, “The microbiology of ventilator-associated pneumonia,” Respiratory Care, vol. 50, no. 6, pp. 742–763, 2005.
[15]
L. J. Wheat, “Infection and diabetes mellitus,” Diabetes Care, vol. 3, no. 1, pp. 187–197, 1980.
[16]
J. D. Bagdade, R. K. Root, and R. J. Bulger, “Impaired leukocyte function in patients with poorly controlled diabetes,” Diabetes, vol. 23, no. 1, pp. 9–15, 1974.
[17]
A. M. Corstjens, I. C. C. van der Horst, J. G. Zijlstra et al., “Hyperglycaemia in critically ill patients: marker or mediator of mortality?” Critical Care, vol. 10, no. 3, article 216, 2006.
[18]
K. Z. Vardakas, I. I. Siempos, and M. E. Falagas, “Diabetes mellitus as a risk factor for nosocomial pneumonia and associated mortality,” Diabetic Medicine, vol. 24, no. 10, pp. 1168–1171, 2007.
[19]
M. Michalia, M. Kompoti, A. Koutsikou et al., “Diabetes mellitus is an independent risk factor for ICU-acquired bloodstream infections,” Intensive Care Medicine, vol. 35, no. 3, pp. 448–454, 2009.
[20]
V. Artinian, H. Krayem, and B. DiGiovine, “Effects of early enteral feeding on the outcome of critically ill mechanically ventilated medical patients,” Chest, vol. 129, no. 4, pp. 960–967, 2006.
[21]
E. Apostolopoulou, P. Bakakos, T. Katostaras, and L. Gregorakos, “Incidence and risk factors for ventilator-associated pneumonia in 4 multidisciplinary intensive care units in Athens, Greece,” Respiratory Care, vol. 48, no. 7, pp. 681–688, 2003.
[22]
S. Nseir, F. Zerimech, C. Fournier et al., “Continuous control of tracheal cuff pressure and microaspiration of gastric contents in critically ill patients,” American Journal of Respiratory and Critical Care Medicine, vol. 184, no. 9, pp. 1041–1047, 2011.
[23]
Y. C. Chen, “Critical analysis of the factors associated with enteral feeding in preventing VAP: a systematic review,” Journal of the Chinese Medical Association, vol. 72, no. 4, pp. 171–178, 2009.
[24]
G. V. Bochicchio, L. Napolitano, M. Joshi et al., “Blood product transfusion and ventilator-associated pneumonia in trauma patients,” Surgical Infections, vol. 9, no. 4, pp. 415–422, 2008.
[25]
A. F. Shorr, M. S. Duh, K. M. Kelly, and M. H. Kollef, “Red blood cell transfusion and ventilator-associated pneumonia: a potential link?” Critical Care Medicine, vol. 32, no. 3, pp. 666–674, 2004.
[26]
M. J. Vandromme, G. McGwin Jr., and J. A. Weinberg, “Blood transfusion in the critically ill: does storage age matter?” Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, vol. 17, no. 1, article 35, 2009.
[27]
E. H. Ibrahim, L. Tracy, C. Hill, V. J. Fraser, and M. H. Kollef, “The occurrence of ventilator-associated pneumonia in a community hospital: risk factors and clinical outcomes,” Chest, vol. 120, no. 2, pp. 555–561, 2001.
[28]
A. Torres, S. Ewig, H. Lode, and J. Carlet, “Defining, treating and preventing hospital acquired pneumonia: European perspective,” Intensive Care Medicine, vol. 35, no. 1, pp. 9–29, 2009.
[29]
S. Nseir, C. Di Pompeo, E. Jozefowicz et al., “Relationship between tracheotomy and ventilator-associated pneumonia: a case-control study,” European Respiratory Journal, vol. 30, no. 2, pp. 314–320, 2007.
[30]
S. Kumar, M. H. Selim, and L. R. Caplan, “Medical complications after stroke,” The Lancet Neurology, vol. 9, no. 1, pp. 105–118, 2010.
[31]
K. Slynkova, D. M. Mannino, G. S. Martin, R. S. Morehead, and D. E. Doherty, “The role of body mass index and diabetes in the development of acute organ failure and subsequent mortality in an observational cohort,” Critical Care, vol. 10, no. 5, article R137, 2006.
[32]
D. Pittet, B. Thievent, R. P. Wenzel, N. Li, G. Gurman, and P. M. Suter, “Importance of pre-existing co-morbidities for prognosis of septicemia in critically ill patients,” Intensive Care Medicine, vol. 19, no. 5, pp. 265–272, 1993.
[33]
B. B. Graham, A. Keniston, O. Gajic, C. A. Trillo Alvarez, S. Medvedev, and I. S. Douglas, “Diabetes mellitus does not adversely affect outcomes from a critical illness,” Critical Care Medicine, vol. 38, no. 1, pp. 16–24, 2010.
[34]
S. E. Siegelaar, M. Hickmann, J. B. L. Hoekstra, F. Holleman, and J. H. DeVries, “The effect of diabetes on mortality in critically ill patients: a systematic review and meta-analysis,” Critical Care, vol. 15, no. 5, article R205, 2011.
[35]
F. J. Pasquel, D. Smiley, R. Spiegelman, E. Lin, L. Peng, and G. E. Umpierrez, “Hyperglycemia is associated with increased hospital complications and mortality during parenteral nutrition,” Hospital Practice, vol. 39, no. 2, pp. 81–88, 2011.
[36]
D. K. Heyland, S. MacDonald, L. Keefe, and J. W. Drover, “Total parenteral nutrition in the critically III patient: a meta-analysis,” Journal of the American Medical Association, vol. 280, no. 23, pp. 2013–2019, 1998.
[37]
M. P. Casaer, D. Mesotten, G. Hermans et al., “Early versus late parenteral nutrition in critically ill adults,” New England Journal of Medicine, vol. 365, no. 6, pp. 506–517, 2011.
[38]
C. M. Cely, P. Arora, A. A. Quartin, D. H. Kett, and R. M. H. Schein, “Relationship of baseline glucose homeostasis to hyperglycemia during medical critical illness,” Chest, vol. 126, no. 3, pp. 879–887, 2004.
