Glycemic Control May Reduce Infection Risk in Patients With Cirrhosis and Uncontrolled Diabetes Mellitus

Investigators evaluated the clinical impact of uncontrolled diabetes mellitus on infection and mortality in an inpatient population with advanced cirrhosis.

Although uncontrolled diabetes mellitus (DM) confers an increased risk for infection in patients with cirrhosis, glycemic control was found to reduce this risk and improve morbidity and mortality in patients with advanced cirrhosis, according to study data published in Digestive and Liver Disease.

Researchers from Cornell University used the Nationwide Inpatient Sample (NIS) database of inpatient discharges for all payers to collect patient data from 1998 and 2014. Information from 3,104,310 patients with advanced cirrhosis was analyzed for instances of bacterial infection, the study’s primary end point, and inpatient mortality, one of the evaluation’s secondary end points. Urinary tract infections (UTIs), pneumonia, spontaneous bacterial peritonitis, cellulitis or soft-tissue infection, ascending cholangitis, Clostridioides difficile infection, and sepsis or septicemia were considered qualifying bacterial infections.

Of the initial 3,104,310 patients, 906,559 with a diagnosis of DM went on to be included in the analysis. The mean patient age was 62 years (SD, 0.03); 41.5% were women, 61.3% were White. Whereas 87.9% of the DM cases were controlled DM, 12.1% were uncontrolled DM. Further, most patients (95.3%) were found to have type 2 DM

Between 1998 and 2014, the rate of DM increased from 21.3% to 38.4% (annual percent change [APC], 3.4%; 95% CI, 3.2%-3.6%) in patients who were hospitalized and had advanced cirrhosis. The investigators noted that the prevalence of uncontrolled DM decreased from 16.2% in 1998 to 9.4% in 2004, but gradually rose to 13.2% in 2014 (overall APC, 0.1%; 95% CI, 1.7%-1.4%).

Bacterial infections were reported in 29.1% of patients but were more common in those with uncontrolled DM (34.2% vs 28.4%; P <.001). Uncontrolled DM was significantly associated with an increased risk for bacterial infection (odds ratio [OR], 1.33; 95% CI, 1.29-1.37; P <.001), and the propensity for presenting with multiple infection was more common in individuals with uncontrolled DM compared with controlled DM (9.0% vs 6.3%; P <.001)

UTIs were the most prevalent type of bacterial infection diagnosed (12.7%), followed by pneumonia, cellulitis, and sepsis. All 4 of these infections were more prevalent in patients with uncontrolled DM (all P <.001). Patients with uncontrolled DM and bacterial infection were also more likely to have shock (24.1% vs 20.8%; P <.001) and respiratory failure (13.4% vs 11.3%; P <.001).  Those with uncontrolled DM and diabetic nephropathy appeared to have higher rates of acute kidney injury requiring hemodialysis (7.5% vs 6.1%; P =.03).

Findings also indicated that patients with type 1 DM had fewer bacterial infections overall (27.6%; P <.001). The prevalence of bacterial infections increased during the study period from 24.0% to 32.9% (APC, 2.4%; 95% CI, 2.0%-2.8%).

The overall inpatient mortality rate was 6.3% and did not significantly differ between patients with controlled or uncontrolled DM (6.3% vs 6.1%; P =.22). An increased mortality rate was seen in elderly (≥70 years) vs non-elderly patients (7.9% vs 5.7%; P <.001) and was highest in older patients with uncontrolled DM (8.8%; adjusted OR, 1.62; 95% CI, 1.46-1.81; P <.001).

Patients with poor glycemic control were found to have significantly longer hospital stays (7.7 vs 6.1 days; P <.001) and higher inpatient expenses ($48,869 vs $40,173; P <.001) than patients without poor control. In multivariable analyses, uncontrolled DM was associated with a significantly increased length of hospital stay (regression coefficient, 20.9%; 95% CI, 19.8%-22.1%; P <.001) and total charges (regression coefficient, 16.9%; 95% CI, 15.5%-18.3%; P <.001).

This study was potentially limited by the database’s lack of a validated algorithm to diagnose glucose control by International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes and undercoding of poor glucose control. “It is also worth noting that the treatments, diagnosis, and definitions of DM control have changed over the course of the study,” the investigators said.

The study authors concluded that patients with cirrhosis and DM were at increased risk for infections and older patients with uncontrolled DM were at increased risk for mortality. Maintaining glucose control could be a potential target for decreasing infection risk and mortality, they asserted, stating, “identifying potentially modifiable risk factors to reduce infection is vital.”

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Rosenblatt R, Atteberry P, Tafesh Z, et al. Uncontrolled diabetes mellitus increases risk of infection in patients with advanced cirrhosis. Dig Liver Dis. Published online November 2, 2020. doi: 10.1016/j.dld.2020.10.022.