Impact of Different Infection Sources on Ketoacidosis/Hyperosmolar Hyperglycemic Syndrome Hospitalizations Outcomes

Diabetic ketoacidosis (DKA) and Hyperosmolar hyperglycemic syndrome (HHS), are two acute complications of diabetes that can result in significant morbidity and mortality. Many patients present with combined features of DKA and HHS. Infection from different sources is one of the most common causes of DKA/HHS precipitations in patients with diabetes mellitus. In this study we aim to analyze the impact of different sources of infections (pneumonia, urinary tract infection, cellulitis) on DKA/HHS hospitalizations.

Methods:

Hospitalizations with DKA or HHS principal diagnosis on discharge were selected from the 2019 US National Inpatient Sample, using ICD 10 code (International Classification of Diseases, Tenth Revision, Clinical Modification) primary diagnosis on discharge. We queried the 2019 National Inpatient Sample for secondary diagnosis of pneumonia, urinary tract infection (UTI), and cellulitis using ICD 10 codes. Confounders were adjusted for using multivariable logistic analysis.

Results:

In total 205,210 adults with non-elective hospitalization with principal diagnosis of DKA or HHS, 48% female, mean age 42.2 year old, and in hospital mortality rate of 0.5%. On weighted analysis, among infection sources as a secondary diagnosis, odds of inpatient death were significantly increased for pneumonia (adjusted OR 4.49, 95% CI 2.98-6.78, p value < 0.001), mortality in patients with pneumonia 3% vs 0.4% in patients without pneumonia (p value < 0.001). However, patients with UTI or cellulitis had no significant association with in-hospital mortality compared to DKA/HHS hospitalizations without these infections (adjusted OR 0.9, 95% CI 0.5-1.5, p value = 0.7) (adjusted OR 2.9, 95% CI 0.37-23.57, p value= 0.3) respectively. Pneumonia is associated with an average increase of 2.5 days in length of hospital stay (p < 0.001, 95% CI 2.08-3.00) compared to patients without pneumonia. UTI is associated with an average increase of 1.04 day in length of hospital stay (p < 0.001, 95% CI 0.77-1.3) compared to patients without UTI. Cellulitis Is associated with an average increase of 1.74 day in the mean length of hospital stay (p = 0.002, 95% CI 0.62-2.8) compared to patients without cellulitis.

Discussion/Conclusion:

The overall in-hospital mortality in patients admitted with DKA/HHS was low (0.5%). However, our analysis showed pneumonia as a source of infection significantly associated with increased risk of in-hospital death in patients with DKA/HHS. Furthermore, in addition to pneumonia, UTI and cellulitis were associated with increase in hospital length of stay. Our study points toward the importance of identifying these sources of infection in patients with DKA/HHS with appropriate examination and investigation, followed by aggressive treatment to decrease mortality rates and hospital length of stay.