Serum glucose levels for predicting death in patients admitted to hospital for community acquired pneumonia: prospective cohort study

Philipp M Lepper, Sebastian Ott, Eveline Nüesch, Maximilian von Eynatten, Christian Schumann, Mathias W Pletz, Nicole M Mealing, Tobias Welte, Torsten T Bauer, Norbert Suttorp, Peter Jüni, Robert Bals, Gernot Rohde, German Community Acquired Pneumonia Competence Network, B Hauptmeier, H von Baum, R Marre, T Schaberg, I Hering, K Dalhoff, P Heyer, F Kunitz, H Schütte, A Tessmer, D Stolz, J Rademacher, A Gillissen, B Drewelow, J Majcher-Peszynska, S Krüger, P Martus, T Illmann, M Wallner, G Barten, L Gosman, Philipp M Lepper, Sebastian Ott, Eveline Nüesch, Maximilian von Eynatten, Christian Schumann, Mathias W Pletz, Nicole M Mealing, Tobias Welte, Torsten T Bauer, Norbert Suttorp, Peter Jüni, Robert Bals, Gernot Rohde, German Community Acquired Pneumonia Competence Network, B Hauptmeier, H von Baum, R Marre, T Schaberg, I Hering, K Dalhoff, P Heyer, F Kunitz, H Schütte, A Tessmer, D Stolz, J Rademacher, A Gillissen, B Drewelow, J Majcher-Peszynska, S Krüger, P Martus, T Illmann, M Wallner, G Barten, L Gosman

Abstract

Objective: To examine whether acute dysglycaemia predicts death in people admitted to hospital with community acquired pneumonia.

Design: Multicentre prospective cohort study.

Setting: Hospitals and private practices in Germany, Switzerland, and Austria.

Participants: 6891 patients with community acquired pneumonia included in the German community acquired pneumonia competence network (CAPNETZ) study between 2003 and 2009.

Main outcome measures: Univariable and multivariable hazard ratios adjusted for sex, age, current smoking status, severity of community acquired pneumonia using the CRB-65 score (confusion, respiratory rate >30/min, systolic blood pressure ≤ 90 mm Hg or diastolic blood pressure ≤ 60 mm Hg, and age ≥ 65 years), and various comorbidities for death at 28, 90, and 180 days according to serum glucose levels on admission.

Results: An increased serum glucose level at admission to hospital in participants with community acquired pneumonia and no pre-existing diabetes was a predictor of death at 28 and 90 days. Compared with participants with normal serum glucose levels on admission, those with mild acute hyperglycaemia (serum glucose concentration 6-10.99 mmol/L) had a significantly increased risk of death at 90 days (1.56, 95% confidence interval 1.22 to 2.01; P<0.001), and this risk increased to 2.37 (1.62 to 3.46; P<0.001) when serum glucose concentrations were ≥ 14 mmol/L. In sensitivity analyses the predictive value of serum glucose levels on admission for death was confirmed at 28 days and 90 days. Patients with pre-existing diabetes had a significantly increased overall mortality compared with those without diabetes (crude hazard ratio 2.47, 95% confidence interval 2.05 to 2.98; P<0.001). This outcome was not significantly affected by serum glucose levels on admission (P = 0.18 for interaction).

Conclusions: Serum glucose levels on admission to hospital can predict death in patients with community acquired pneumonia without pre-existing diabetes. Acute hyperglycaemia may therefore identify patients in need of intensified care to reduce the risk of death from community acquired pneumonia.

Conflict of interest statement

Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

Figures

https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4790028/bin/lepp001743.f1_default.jpg
Fig 1 Cumulative incidence of death (%) within 90 days in participants with community acquired pneumonia stratified by serum glucose levels on admission overall (n=6016) (top) and without diabetes (n=5141) (bottom). The 875 participants with missing data for serum glucose levels on admission were not included in these calculations for patients at risk
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4790028/bin/lepp001743.f2_default.jpg
Fig 2 Cumulative incidence of death (%) within 90 days in participants with community acquired pneumonia with and without pre-existing diabetes (top) and without diabetes but stratified according to high or low serum glucose levels on admission (bottom)
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/4790028/bin/lepp001743.f3_default.jpg
Fig 3 Crude and adjusted analyses of cohorts with the highest mortality. Results from all 6891 participants after multiple imputation

References

    1. Aliberti S, Amir A, Peyrani P, Mirsaeidi M, Allen M, Moffett BK, et al. Incidence, etiology, timing, and risk factors for clinical failure in hospitalized patients with community-acquired pneumonia. Chest 2008;134:955-62.
    1. Kornum JB, Thomsen RW, Riis A, Lervang HH, Schonheyder HC, Sorensen HT. Diabetes, glycemic control, and risk of hospitalization with pneumonia: a population-based case-control study. Diabetes Care 2008;31:1541-5.
    1. Seshasai SR, Kaptoge S, Thompson A, Di AE, Gao P, Sarwar N, et al. Diabetes mellitus, fasting glucose, and risk of cause-specific death. N Engl J Med 2011;364:829-41.
    1. Shah BR, Hux JE. Quantifying the risk of infectious diseases for people with diabetes. Diabetes Care 2003;26:510-3.
    1. Abourizk NN, Vora CK, Verma PK. Inpatient diabetology. The new frontier. J Gen Intern Med 2004;19(5 Pt 1):466-71.
    1. Ramirez J, Aliberti S, Mirsaeidi M, Peyrani P, Filardo G, Amir A, et al. Acute myocardial infarction in hospitalized patients with community-acquired pneumonia. Clin Infect Dis 2008;47:182-7.
    1. Schramm TK, Gislason GH, Kober L, Rasmussen S, Rasmussen JN, Abildstrom SZ, et al. Diabetes patients requiring glucose-lowering therapy and nondiabetics with a prior myocardial infarction carry the same cardiovascular risk: a population study of 3.3 million people. Circulation 2008;117:1945-54.
    1. Spencer EA, Pirie KL, Stevens RJ, Beral V, Brown A, Liu B, et al. Diabetes and modifiable risk factors for cardiovascular disease: the prospective Million Women Study. Eur J Epidemiol 2008;23:793-9.
    1. Koziel H, Koziel MJ. Pulmonary complications of diabetes mellitus. Pneumonia. Infect Dis Clin North Am 1995;9:65-96.
    1. Kansagara D, Fu R, Freeman M, Wolf F, Helfand M. Intensive insulin therapy in hospitalized patients: a systematic review. Ann Intern Med 2011;154:268-82.
    1. Akbar DH. Bacterial pneumonia: comparison between diabetics and non-diabetics. Acta Diabetol 2001;38:77-82.
    1. Eurich DT, Gamble JM, Marrie TJ, Majumdar SR. Dysglycaemia and 90 day and 1 year risks of death or readmission in patients hospitalised for community-acquired pneumonia. Diabetologia 2010;53:497-503.
    1. Falguera M, Pifarre R, Martin A, Sheikh A, Moreno A. Etiology and outcome of community-acquired pneumonia in patients with diabetes mellitus. Chest 2005;128:3233-9.
    1. Fine MJ, Auble TE, Yealy DM, Hanusa BH, Weissfeld LA, Singer DE, et al. A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 1997;336:243-50.
    1. Kaplan V, Angus DC, Griffin MF, Clermont G, Scott WR, Linde-Zwirble WT. Hospitalized community-acquired pneumonia in the elderly: age- and sex-related patterns of care and outcome in the United States. Am J Respir Crit Care Med 2002;165:766-72.
    1. Kornum JB, Thomsen RW, Riis A, Lervang HH, Schonheyder HC, Sorensen HT. Type 2 diabetes and pneumonia outcomes: a population-based cohort study. Diabetes Care 2007;30:2251-7.
    1. McAlister FA, Majumdar SR, Blitz S, Rowe BH, Romney J, Marrie TJ. The relation between hyperglycemia and outcomes in 2,471 patients admitted to the hospital with community-acquired pneumonia. Diabetes Care 2005;28:810-5.
    1. Rueda AM, Ormond M, Gore M, Matloobi M, Giordano TP, Musher DM. Hyperglycemia in diabetics and non-diabetics: effect on the risk for and severity of pneumococcal pneumonia. J Infect 2010;60:99-105.
    1. Welte T, Suttorp N, Marre R. CAPNETZ-community-acquired pneumonia competence network. Infection 2004;32:234-8.
    1. Bauer TT, Ewig S, Marre R, Suttorp N, Welte T. CRB-65 predicts death from community-acquired pneumonia. J Intern Med 2006;260:93-101.
    1. Genuth S, Alberti KG, Bennett P, Buse J, Defronzo R, Kahn R, et al. Follow-up report on the diagnosis of diabetes mellitus. Diabetes Care 2003;26:3160-7.
    1. Kosiborod M, Inzucchi SE, Krumholz HM, Xiao L, Jones PG, Fiske S, et al. Glucometrics in patients hospitalized with acute myocardial infarction: defining the optimal outcomes-based measure of risk. Circulation 2008;117:1018-27.
    1. Royston P. Multiple imputation of missing values. Stata J 2004;4:227-41.
    1. Sterne JA, White IR, Carlin JB, Spratt M, Royston P, Kenward MG, et al. Multiple imputation for missing data in epidemiological and clinical research: potential and pitfalls. BMJ 2009;338:b2393.
    1. Godar DA, Kumar DR, Schmelzer KM, Talsness SR, Liang H, Schmelzer JR, et al. The impact of serum glucose on clinical outcomes in patients hospitalized with community-acquired pneumonia. WMJ 2011;110:14-20.
    1. Van den Berghe G, Wouters P, Weekers F, Verwaest C, Bruyninckx F, Schetz M, et al. Intensive insulin therapy in the critically ill patients. N Engl J Med 2001;345:1359-67.
    1. Van den Berghe G, Wilmer A, Hermans G, Meersseman W, Wouters PJ, Milants I, et al. Intensive insulin therapy in the medical ICU. N Engl J Med 2006;354:449-61.
    1. Brunkhorst FM, Engel C, Bloos F, Meier-Hellmann A, Ragaller M, Weiler N, et al. Intensive insulin therapy and pentastarch resuscitation in severe sepsis. N Engl J Med 2008;358:125-39.
    1. Marik PE, Preiser JC. Toward understanding tight glycemic control in the ICU: a systematic review and metaanalysis. Chest 2010;137:544-51.
    1. Finfer S, Chittock DR, Su SY, Blair D, Foster D, Dhingra V, et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med 2009;360:1283-97.
    1. Griesdale DE, de Souza RJ, van Dam RM, Heyland DK, Cook DJ, Malhotra A, et al. Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data. CMAJ 2009;180:821-7.
    1. Wiener RS, Wiener DC, Larson RJ. Benefits and risks of tight glucose control in critically ill adults: a meta-analysis. JAMA 2008;300:933-44.
    1. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2010;33(suppl 1):S62-9.
    1. International Expert Committee report on the role of the A1C assay in the diagnosis of diabetes. Diabetes Care 2009;32:1327-34.
    1. Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2005. Department of Health and Human Services, Centers for Disease Control and Prevention, 2005.
    1. Gornik I, Vujaklija-Brajkovic A, Renar IP, Gasparovic V. A prospective observational study of the relationship of critical illness associated hyperglycaemia in medical ICU patients and subsequent development of type 2 diabetes. Crit Care 2010;14:R130.
    1. Singanayagam A, Chalmers JD, Hill AT. Admission hypoglycaemia is associated with adverse outcome in community-acquired pneumonia. Eur Respir J 2009;34:932-9.
    1. Umpierrez GE, Isaacs SD, Bazargan N, You X, Thaler LM, Kitabchi AE. Hyperglycemia: an independent marker of in-hospital mortality in patients with undiagnosed diabetes. J Clin Endocrinol Metab 2002;87:978-82.
    1. Vanhorebeek I, Van den Berghe G. Diabetes of injury: novel insights. Endocrinol Metab Clin North Am 2006;35:859-72, x.
    1. Vanhorebeek I, Gunst J, Derde S, Derese I, Boussemaere M, Guiza F, et al. Insufficient activation of autophagy allows cellular damage to accumulate in critically ill patients. J Clin Endocrinol Metab 2011;96:E633-45.

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