Protein Energy Malnutrition Is Associated with Worse Outcomes in Sepsis—A Nationwide Analysis

Abstract

BackgroundProtein-energy malnutrition (PEM), resulting from depleted energy and nutrient stores, compromises the body’s defense systems and may exacerbate sepsis and its impact. However, population-based studies examining the association of PEM on the prevalence and health-care burden of sepsis are lacking. ObjectiveTo investigate the relationship between PEM and sepsis, influence of PEM on clinical outcomes of sepsis, and impact of PEM on trends in sepsis mortality. DesignThe primary study is a retrospective cohort analysis of the 2012-2014 National Inpatient Sample (NIS) patient discharge records. Secondary analyses are cross-sectional study on the 2014 NIS and trend analysis on 2007-2014 NIS. Participants/settingThe primary study included adult inpatient hospitalizations for sepsis in the United States. Main outcome measuresMortality, complicated sepsis, and 10 other metrics of clinical outcomes and health care utilization. Statistical analysisFirst, patients with sepsis (2014 NIS) were stratified into two groups: uncomplicated (without shock) and complicated (with shock). The adjusted odds ratio of having sepsis (total, uncomplicated, and complicated) was estimated with PEM as predictor using logistic regressions (binomial and multinomial). Second, among patients with sepsis (2012-2014 NIS), PEM cases were matched to cases without PEM (no-PEM) using a greedy-algorithm based propensity-matching methodology (1:1), and the outcomes were measured with conditional regression models. Finally, the trend in mortality from sepsis was calculated, stratified by PEM status, as an effect modifier, using Poisson models (2007-2014 NIS). All models accounted for the complex sampling methodology (SAS 9.4). ResultsIn 2014, PEM was associated with higher odds for sepsis (3.97 [3.89 to 4.05], P<0.0001) and complicated vs uncomplicated sepsis (1.74 [1.67 to 1.81], P<0.0001). From 2012-2014, about 18% (167,133 of 908,552) of hospitalizations for sepsis had coexisting PEM. After propensity matching, PEM was associated with higher mortality (adjusted odds ratio: 1.35 [1.32 to 1.37], P<0.0001), cost ($160,724 [159,517 to 161,940] vs $86,650 [85,931 to 87,375], P<0.0001), length of stay (14.8 [14.9 to 14.8] vs 8.5 [8.5 to 8.6] days, P<0.0001), adverse events, and resource utilization. Although mortality in sepsis has been trending down from 2007-2014 (−1.19% per year, P trend<0.0001), the decrease was less pronounced among those with PEM vs no-PEM (−0.86% per year vs −1.29% per year, P<0.0001). ConclusionsPEM is a risk factor for sepsis and associated with poorer outcomes among patients with sepsis. A concerted effort involving all health care workers in the prevention, identification, and treatment of PEM in community-dwelling people before hospitalization might mitigate against these devastating outcomes.