Abstract
BackgroundBacterial infections are frequent triggers for diabetic ketoacidosis. In this context, delayed antibiotic treatment is associated with increased morbidity and mortality. Unnecessary administration of antimicrobial therapy might however, also negatively impact the prognosis. The usefulness of sepsis markers in diabetic ketoacidosis has not been assessed. Thus, we sought to investigate diagnostic performances of clinical and biological sepsis markers during diabetic ketoacidosis.MethodsIn this monocentric retrospective cohort study, all consecutive episodes of diabetic ketoacidosis (defined as pH ≤ 7.25, glycaemia > 300 mg/dL and presence of ketones) admitted in intensive care unit were included. A proven bacterial infection was defined as bacteriological documentation on any bacterial sample. Clinical (presence of fever: temperature > 38 °C and presence of hypothermia: temperature < 36 °C) and biological markers (whole blood count, neutrophils count, neutrophils-to-lymphocytes count ratio and procalcitonin), recorded at admission, were compared according to the presence or absence of a proven bacterial infection.ResultsBetween 2011 and 2018, among 134 episodes of diabetic ketoacidosis, 102 were included (91 patients). Twenty out of 102 were infected. At admission, procalcitonin (median: 3.58 ng/mL vs 0.52 ng/mL, p < 0.001) and presence of fever (25% vs 4%, p = 0.007) were different between episodes with and without proven bacterial infection in both univariate and multivariate analysis. Whole blood count, neutrophils count, neutrophils-to-lymphocytes count ratio and presence of hypothermia were not different between both groups. The diagnostic performance analysis for procalcitonin revealed an area under the curve of 0.87 with an optimal cutoff of 1.44 ng/mL leading to a sensitivity of 0.90 and a specificity of 0.76. Combining procalcitonin and presence of fever allowed to distinguish proven bacterial infection episodes from those without proven bacterial infection. Indeed, all patients with procalcitonin level of more than 1.44 ng/mL and fever had proven bacterial infection episodes. The presence of one of these 2 markers was associated with 46% of proven bacterial infection episodes. No afebrile patient with procalcitonin level less than 1.44 ng/mL had a proven bacterial infection.ConclusionAt admission, combining procalcitonin and presence of fever may be of value to distinguish ketoacidosis patients with and without proven bacterial infection, admitted in intensive care unit.
Highlights
Diabetic ketoacidosis (DKA) accounts for 4–9% of all hospital discharge summaries among diabetic patients [1, 2]
Type 1 diabetes was the most frequent type of diabetes (n = 60 episodes, 59%) and inaugural DKA accounted for 18% (n = 18 episodes)
On day 2 (D2), ketoacidosis was corrected as shown by a median pH of 7.41 [7.38–7.43] and glycemia 6.6 mmol/L [5.2–11.0 mmol/L]
Summary
Diabetic ketoacidosis (DKA) accounts for 4–9% of all hospital discharge summaries among diabetic patients [1, 2]. Discontinuation of insulin therapy and infections are the most frequent triggering factors [2, 5, 8]. In the context of DKA, bacterial infections are reported to increase both mortality [10] and length of stay [9]. Early detection of bacterial infections associated with adequate antibiotic treatments are key elements to improve patient outcomes. Clinical suspicion of infection can hardly be used and many patients are over-treated with antibiotics leading to inadequate treatment costs, side effects and bacteriological resistance. Bacterial infections are frequent triggers for diabetic ketoacidosis. In this context, delayed antibiotic treatment is associated with increased morbidity and mortality. We sought to investigate diagnostic performances of clinical and biological sepsis markers during diabetic ketoacidosis
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