ABSTRACT BACKGROUND: Pneumonia is a common cause for hospital admissions and in-hospital mortality. Mortality in pneumonia is accelerated in the presence of co-morbid conditions. Diabetes mellitus being the most common co-morbid condition due to its high prevalence, we studied the effect of diabetes on the clinical profile of pneumonia in comparison with those without pneumonia. METHODS: We randomly selected 60 patients of pneumonia over a period of 1 year  among whom, 30 were diabetics and 30 were non-diabetics. A thorough clinical history and examination was carried out. Laboratory investigations including, microbiological, radiological, haematological investigations were carried out. Patients were followed up until their hospital stay (death or discharge). Results were analysed and compared between diabetic and non diabetic group with reference to age, sex, underlying concomitant disease, clinical features, complications, organisms, PSI scoring and mortality. Clinical data was compared with the observations of various other workers RESULTS: Poly-microbial etiology (20%), multi-lobe involvement (66.7%), complications, duration of hospital stay (12.30±4 vs 9.10±5.24 days) and PSI score was significantly higher among diabetics compared with non-diabetics. There was not statistical significant difference in mortality between diabetics (23.3%) and non diabetics (10%). Mortality in diabetics was more common in patients with age > 60yrs. Complications were more common in diabetic group like pleural effusion (6.7%), septic shock (20%), MODS, renal failure, VF (3.3% each) and cardiac arrest (6.7%). No relation was found with sex, duration of hospital stay, bacteremia, pleural effusion, signs of consolidation with mortality. CONCLUSION: In patients with pneumonia, Diabetes Mellitus is associated with poor prognosis, polymicrobial etiology, multilobe involvement, increased ICU admissions, increased severity in the form of high PSI score and mortality. This study suggests that this adverse outcome is more attributable to the underlying circumstances of patients than to uncommon microbiological findings. Certainly age, prior co morbidities as well as multilobe infiltrates have already been related to poor prognosis; however, in this study, diabetes also remained a significant prognostic factor of mortality in patients with pneumonia.

 

INTRODUCTION

Among the respiratory   infections,   pneumonia   is a   common   cause of hospital admissions,  although a majority are treated in out patient settings.  Pneumonia presents a challenge toPhysicians who have to decide on therapy without the benefit of a definitive etiological diagnosis, as theclinical features of pneumonia are neither sensitive nor reliable guides in permitting an etiologic diagnosis.

Underlying diseases increase the susceptibility of the patients for pneumonia; therefore, it is not surprising that epidemiologic studies have found one or more of these conditionsin a high proportion of suchepisodes1,2. It has also been reported that some co-morbidities can influence the spectrum of causative agents, facilitating unusual and more aggressive microorganisms; alternatively, habitual pathogens could show particular patterns of antimicrobial resistance3. Undoubtedly, the knowl­edge of these microbiological characteristics is criti­cal and represents the basis for empirical treatments. Moreover, serious coexisting illnesses have been identified in studies1,4 as modifyingfactors of the severity of the pneumonia; thus, these condi­tions can increase the risk of bacteremia and empyema and usually provide a poor prognosis.

On the basis of these appreciations, published guidelines on pneumonia advo­cate specific criteria for antibiotic selection and the management of patients in the presence of co morbid diseases.5 Unfortunately, the real impact of some of these underlying diseases on pneumonia has not been fully evaluated. Diabetes mellitus is a very prevalent chronicmet­abolic disorder that is present in about 5 to10% of the elderly population. Several aspects of immunity, such as polymorphonuclear leukocyte function (ie)leukocyte adherence, chemotaxis, and phagocytes and bactericidal activity of serum are depressed in patients with diabetes6,7. In consequence, some specific infections are very common in these patients, while others occur with more severity or are associated with an increased risk of complications.For patients with pneumonia, diabetes mellitus is also oneof the most common underlying diseases1, 2, 8; however, it remains uncertain as towhether pneumonia shows particular clinical manifestations, increases morbidity or mortality or involves a predisposition for more aggressive agents in patients with diabetes. In this study, we proposed to determine whether the clinical or radiological findings, the causative microorganisms, or the outcome of pneumonia are modified by the presence of diabetes mellitus as the underlying disease.

Patients with diabetes have about twice the risk of infection related mortality compared withthose without diabetes9.

Based on compilation of studies from different parts of the globe, theWorld Health Organization has projected that the maximum increase in diabetes would occur in India. Considering the large population and the high prevalence of diabetes, the burden of diabetes could be enormous. With an estimated 23 million today and the numbers set to increase to 57 million by 202510.

Studies conducted in India in the last decade have highlighted that not only is the prevalence of Type-2diabetes is high, but also that it is increasing rapidly in the urban population11.

MATERIALS AND METHODS

A prospective, observational, non-interventional study was conducted by the Department of General Medicine, KIMS Hospital, Bangalore after getting the approval from the Institutional ethics committee. The period of study was 1year from march 2012 to march 2013. A total of 60 (30 diabetics and 30 non-diabetics) patients admitted in KIMS hospital for pneumonia were randomly selected after they met the inclusion criteria. Patients were randomized into diabetic and non-diabetic groups.

A detailed history was taken in all the patients with respect to presenting complaints (like fever, new or increasing sputum production, dyspnoea, chestpain), predisposing factors and accompanying illness.

A diagnosis of diabetes mellitus was based on previous clinical and /or biochemical diagnosis of diabetes mellitus and/or treatment with oral antidiabetic agents or insulin. Alternatively, diagnosis could be established during this episode of pneumonia when the fasting plasma glucose concentration was ≥ 126 mg/dl (7.0mmol/l), and/or after ingestion it was ≥ 200mg/dl (11.1mmol/l) on two or more separate occasions.

A thorough clinical examination was carried out.

Laboratory investigations like Hemoglobin, total count, differential count, erythrocyte sedimentation rate, blood urea, creatinine, random blood sugar, fasting blood sugars, post prandial blood sugars, and urine for albumin.Urine microscopy was done in all the patients on admission. The investigations were repeated as and when necessary.In all the patients chest x-ray PA view was taken on admission and 7 days after the antibiotic therapy. In few patients chest x-ray lateral view was also taken. Ultrasound of chest was also done in some of the cases. Sputum was collected for bacteriological examination after rinsing the mouth with saline before the institution of antibiotic therapy and subjected forfollowing tests.Sputum was examined macroscopically with respect to quantity, colour, odour and evidence of hemoptysis.All sputum smears were stained with gram’s stain. Based on the results of gram staining each sample was labelled as appropriate or inappropriate. Those smears which showed more than 25 polymorphs per low power field and less than 10 squamous epithelial cells per low power field was considered as appropriate sample and others as inappropriate.Sputum was also examined for AFB by ziehl nelson (z.n) stain by direct and concentration method for 3 consecutive days.

The purulent portion of the sputum was inoculated on blood agar, mac Conkey’s medium and heat blood agar. These were read after over night incubation.

Inclusion criteria:Type 2 diabetic patients and non diabetic patients who fulfill all the following criteria

  1. Fever, productive or non productive cough with or without chest pain or breathlessness.
  2. X-ray chest showing homogenous or non homogenous opacities.
  3. Sputum gram staining and culture showing pathological organisms.

Exclusion criteria:Features suggestive of viral and fungal pneumonia and culture showing
fungal growth, Patients diagnosed to have tuberculosis, Patients who are HIV positive or with other immunocompromised states,Patients with upper respiratory tract infections.

RESULTS

The present study is conducted at KIMS Hospital and research centre, from March 2012 to March 2013. A total no. of 60 pneumonia cases were studied, out of which 30 cases were pneumonia in diabetics and 30 cases were pneumonia (Study group SG) in non diabetics (control group CG).

Table 1: Comparison of age in years between two groups.

Age in years

Non-diabetic

Diabetic

No

%

No

%

40-50

11

36.7

11

36.7

51-60

9

30.0

10

33.3

61-70

6

20.0

7

23.3

>70

4

13.3

2

6.7

Total

30

100.0

30

100.0

Mean ± SD

56.90±11.83

57.93±9.71

Samples are age matched with P=0.713

 

The average age in SG was 57.93+9.71 yrs and in CG were 56.90+11.83 yrs (no significance). The age span of the patients was between 40 and 75 yrs in both groups, while most of the patients (66.7% in CG and 70% in SG) were between 40 to 60 yrs.

Table 2:comparison of sex between two groups

Sex

Non-diabetic

Diabetic

No

%

No

%

Male

23

76.7

20

66.7

Female

7

23.3

10

33.3

Total

30

100.0

30

100.0

 

Patients between two groups are sex matched with P=0.390

Most of the patients in both groups were males (76.7% in CG and 66.7% in SG). There was no statistically significant difference regarding sex in both the groups.

Table 3: Comparison of Typical Clinical signs between two groups.

 

Typical presentation

Non-diabetic

Diabetic

No

%

No

%

No Consolidation

17

56.7

19

63.3

Consolidation

13

43.3

11

36.7

Total

30

100.0

30

100.0

Inference

Consolidation is equally distributed b/w groups with P=0.598

There was no statistically significant difference in typical presentation (ie) signs of consolidation and respiratory signs other than consolidation between the two groups.

Table 4: Comparison of Concomitant Underlying illness between two groups.

Concomitant Underlying illness

Non-diabetic

(n=30)

Diabetic

(n=30)

No

%

No

%

Neoplasm

1

3.3

0

CCF

1

3.3

1

3.3

Asthma

2

6.7

2

6.7

IHD

4

13.3

6

20.0

COPD

5

16.7

8

26.7

Altered sensorium

2

6.7

5

16.7

CVA

0

1

3.3

Others

4

13.3

4

13.3

Figure 4: Comparison of Concomitant Underlying illness between two groups

 

The commonly associated co morbidities in CG and SG were IHD (20% vs 13.3%), COPD (26.7% vs 16.7%) and Asthma (6.7% vs 6.7%). There was no statistically significant difference of associated co morbidities in between two groups.

 

Table 5: Comparison of Habits in years between two groups.

 

Habits

Non-diabetic

(n=30)

Diabetic

(n=30)

P value

No

%

No

%

Smoking

7

23.3

9

30.0

0.559

Alcohol

2

6.7

5

16.7

0.424

 

There was no statistically significant difference of habits (smoking and alcohol) between two groups.

 

Table 6: Comparison of RR, SBP, DBP and SPO2 between two groups

                Results are presented in Mean ± S

Parameters

Non-diabetic

(n=30)

Diabetic

(n=30)

P value

RR (bpm)

27.81±4.46

27.73±5.69

0.960

SBP (mm Hg)

124.60±26.86

133.50±41.09

0.325

DBP (mm Hg)

78.40±15.96

81.07±15.69

0.517

SPO2 , Median

(25 , 75 percentile)

90.5

(89-92)

90

(86.5-94.0)

0.870

 

Figure 6a: Comparison of HR, between two groups

 

 

There was no statistically significant difference in the vital signs (RR, BP, and SPO2) between two groups.

 

Table 7: Comparison of Investigations between Non-diabetic and diabetic

 

Investigations

Non-diabetic

(n=30)

Diabetic

(n=30)

P value

Total count , Median

(25-75th percentile)

11550

(10050-13975)

12000

(8765-15000)

0.756

Hemoglobin (gm/dl)

10.67±8.17

9.57±2.44

0.062+

BUN

16.27±8.17

25.30±16.74

0.010**

NA

136.33±8.11

137.17±7.74

0.705

There was raise in total count in both the groups with no statistically significant difference.The average Hb% in CG was 10.67+8.17 and in SG 9.57+2.44. There was significant difference between two groups, as most of the patients in SG were anemic.The BUN in CG was 16.27+8.17 and SG was 25.30+16.74 which was statistically significant. Renal failure in SG was either a consequence of sepsis or diabetic nephropathy.

 

Table 8: Comparison of Chest x-ray findings

Chest x-ray findings

Non-diabetic

Diabetic

No

%

No

%

Unilobe

18

60.0

10

33.3

Multi lobe

12

40.0

20

66.7

Total

30

100.0

30

100.0

Inference Multilobe involvement is 3.0 times more likely in Diabetic with P=0.039*

Multilobe involvement (> 2 zones involvement in chest x- ray) was more common in SG (40% in CG vs. 66.7% in SG) which is statistically significant (p=0.039). Multilobe involvement is 3 times more likely in diabetics.

Table 9: comparison of sputum gram stain between diabetics and non-diabetics

Sputum gram

Non-diabetic

(n=30)

Diabetic

(n=30)

P value

GNB

5 (16.7%)

8 (26.7%)

0.347

GPC

14 (46.7%)

5 (16.7%)

0.012*

GNC

3 (10.0%)

0.237

GBC/GNB

1 (3.3%)

0.999

GPC/GNB

2 (6.7%)

9 (30.0%)

0.020*

GPC/GPB

1 (3.3%)

3 (10.0%)

0.612

 

Figure 9: Comparison of Sputum gram between Non-diabetic and Diabetic groups

 

On Gram staining, Gram positive cocci were significantly more (p=0.012) in CG in comparison with SG (46.7% vs. 16.7%). A combination of GPC/GNB was significantly more in SG than CG (30% vs. 67%).

 

Table 10: Comparison of Sputum culture between Non-diabetic and Diabetic groups n (%)

Sputum culture

Non-diabetic

(n=30)

Diabetic

(n=30)

P value

1.E coli

1 (3.3%)

2 (6.7%)

0.999

2.Strep pneu

12 (40.0%)

7 (23.3%)

 0.592

3.Klebsiella

2 (6.7%)

5 (16.7%)

 0.424

4.Stap auerus

( MRSA/MSSA)

          6 (20.0%)

2 (6.7%)

 0.129

5.H.Influenza

1 (3.3%)

 0.999

6.Acinectobacter

3 (10.0%)

 0.237

7.Pseu aeruginosa

2 (6.7%)

3 (10.0%)

 0.999

8.Proteus mirabalis

1 (3.3%)

 0.999

9.Enterobacter

1 (3.3%)

2 (6.7%)

 0.999

10.Poly microbial

2 (6.7%)

6 (20.0%)

 0.254

11.Entrococcus

2 (6.7%)

0.492

Figure 10: Comparison of Sputum culture between Non-diabetic and Diabetic groups n (%)

 

The common organisms on sputum culture in non diabetics were Strep pneumonia (40%), Stap Auerus (205), Pseudomonas (6.7%) and Enterococcus(6.7%).

In diabetics Strep pneumonia (23.3%), Klebsiella (16.7%), Acinectobacter (10%), Polymicrobial (20%). But there was no statistical significance between the two groups.

Table 11: Comparison of Outcome between Non-diabetic and Diabetic groups

Outcome

Non-diabetic

(n=30)

Diabetic

(n=30)

P value

ICU admission, n (%)

5 (16.7%)

9 (30.0%)

0.222

Complications, n (%)

6 (20.0%)

10 (33.3%)

0.243

Mortality, n (%)

3 (10.0%)

7 (23.3%)

0.166

Duration Hospital stay

Mean ± SD

9.10±5.24

12.30±4.98

0.018*

Figure 11: Comparison of Outcome between Non-diabetic and Diabetic groups

 

There was no difference between two groups in ICU admission (or) complications.

More no. of mortalities was in SG (23.3%) in comparison with CG (10%). The duration of hospital stay was significantly more (p<0.018) in SG (12.30+4.98) in comparison with CG (9.10+5.24).

Table 12: Comparison of type of complications Non-diabetic and Diabetic groups

Type of complications

Non-diabetic

(n=30)

Diabetic

(n=30)

Pleural effusion

2 (6.7%)

2 (6.7%)

Septic shock

4 (13.3%)

6 (20.0%)

Renal failure

1 (3.3%)

MODS

1 (3.3%)

VF

1 (3.3%)

Cardiac arrest

2 (6.7%)

The complications in diabetic group were pleural effusion (6.7%), septic shock (20%), renal failure, MODS (3.3%), ventricular tachycardia (3.3%), and cardiac arrest (6.7%). In comparison with CG were pleural effusion (6.7 %), septic shock (13.3%).

Table 13: Comparison of PSI class between Non-diabetic and Diabetic group

PSI class

Non-diabetic

(n=30)

Diabetic

(n=30)

P value

Class I

15 (50.0%)

7 (23.3%)

0.032*

Class II

2 (6.7%)

2 (6.7%)

1.000

Class III

3 (10.0%)

3 (10.0%)

1.000

Class IV

5 (16.7%)

10 (33.3%)

0.036

Class V

5 (16.7%)

8 (26.7%)

0.037

Inference

Class IV and V are significantly more in Diabetic patients with P=0.038*

 

Figure 13: Comparison of PSI class between Non-diabetic and Diabetic groups

 

Patients in diabetic group were significantly more among PSI class IV and V (P =0.038), in comparison with non diabetic who were predominantly among PSI class I (P<0.032).

Table 14: Comparison of PSI between Non-diabetic and diabetic

 

PSI score

Non-diabetic

(n=30)

Diabetic

(n=30)

Range

35-170

46-194

Mean ± SD

80.27±38.14

93.43±39.31

Inference

There is higher PSI score in Diabetic group with P=0.193

PSI score was significantly more in diabetic group (93.43±38.14) in comparison with non diabetic group (80.27±38.14), (P=0.193).

 

Table 15: Comparison of study characteristics in Alive and death in Diabetic patients

Study characteristics

Alive

Death

P value

Age in years, Mean ± SD

56.61±7.57

62.29±14.72

0.180

Sex; male : female

14:9

6:1

0.222

Hospital stay , Mean ± SD

(days)

10.30±4.51

5.14±5.87

0.020*

RR, Mean ± SD

25.39±3.92

35.43±3.21

<0.001**

SBP, Mean ± SD

140.30±41.16

111.14±34.49

0.101

DBP, Mean ± SD

83.56±12.76

72.86±22.15

0.105

TC, Mean ± SD

12821.0

(6119.59)

11694.29

(7094.7)

0.684

Hb, Mean ± SD

9.70±2.26

9.11±3.12

0.584

BUN, Mean ± SD

20.61±9.09

40.71±26.32

0.004**

Na, Mean ± SD

139.75±5.91

131.28±8.62

0.012*

Glucose, Mean ± SD

171.45±39.18

190.00±36.50

0.343

PSI, Mean ± SD

76.83±21.85

148.00±34.46

<0.001**

ICU admission, n (%)

2 (8.7%)

7 (100.0%)

<0.001**

Complications, n (%)

3 (13.1%)

7(100.0%)

<0.001**

 

In comparison of Alive and dead in diabetic group showed the following

  1. Duration of hospital stay was significantly more in Alive (10.30±4.51) than dead (5.14±5.87) with P = 0.020.
  2. Dead patients were tachypnic (RR =35.3±3.21) compared to Alive (25.39±3.92) with P <0.001.
  3. Renal impairment was significantly more in dead (BUN = 40.71±4.51) than in Alive (20.61±9.09) with P <0.004.
  4. Sodium levels were comparatively low in dead patients.
  5. PSI scoring was significantly more in dead (148.80±34.46) than in Alive (76.83±21.85) with P < 0.001.
  6. All dead patients were admitted to ICU (100%) in comparison to Alive patients (8.7%) with P < 0.001.
  7. All dead patients had complications (100%) compared to Alive patients (13.1%) with P < 0.001.

 

Statistical Methods:

Chi-square test and Fisher Exact test have been used to find the significance of frequency distribution of study parameters between Non-diabetic and diabetic groups. Student t test and Mann Whitney U test have been used to find the significance of mean values of study parameters between Non-diabetic and diabetic group. Odds ratio has been used to find the strength of oral manifestation between non-diabetic and diabetic.

Statistical software: The Statistical software namely SPSS 15.0, Stata 8.0, MedCalc 9.0.1 and Systat 11.0 were used for the analysis of the data and Microsoft word and Excel have been used to generate graphs, tables etc.

DISCUSSION

In the present study we have compared the following parameters like age, sex, clinical features, concomitant underlying diseases, vitals, investigations, ICU admissions, mortality, complications and PSI scoring between Diabetics and non Diabetic patients with pneumonia.

AGE:

        PRESENT STUDY                           MIQUEL et al

 

Diabetic                Non Diabetic   Diabetic                Non Diabetic

57.93±9.71yrs   56.90±11.83yrs     62yrs               54yrs

 

Diabetic        Non Diabetic       Diabetic   Non Diabetic

 

57.93±9.71yrs   56.90±11.83yrs      62yrs         54yrs

 

 

 

 

 

Miquel et al has reported that patients with diabetes were significantly older with average age of 62 yrs13.Akbar DH has also reported a higher age incidence14.In the present study average age of presentation was 57 yrs with maximum people between 40-60 yrs (70%).

SEX:

SEX            PRESENT STUDY MIQUEL et al

MALE                    66.7%                         60%

FEMALE                33.3%                         40%

 

 

 

 

Miqel et al reported that patients with diabetes were predominantly males (60%) 13.Akbar DH also reported male predominance in diabetics14.In the present study males were predominant (66.7%).

CONCOMITANT UNDERLYING DISEASE:

Present study Miquel et al

27%                      56%

 

 

 

 

Miquel et al reported that 56%of patients with diabetes had concomitant underlying disease along with diabetes13.

In the present study showed that about 27% patients had concomitant underlying disease in the form of CCF (3.3%), Asthma (6.7%), IHD (20%), COPD (26.7%), and CVA (3.3%).

TYPICAL CLINICAL SIGNS:

Miquel et al reported that typical clinical features like signs of consolidation were seen in 58% of the patients and other 42% of patients presented signs other than consolidation in diabetics13.

The present study reported 63.3% with signs of consolidation and 36.7% signs other than consolidation in diabetics.

ORGANISMS:

PRESENT STUDY                  MIQUEL et al

ORGANISMS   Diabetic       Non Diabetic      Diabetic           Non Diabetic

Strep pneu            23.3%          40.0%               31%                      35%

H influenza              –                3.33%                4%                       2%

Staph auerus          6.7%           20.0%                 3%                       2%

Gram neg org        39%             24%                   4%                       6%

Polymicrobial        20%             6.7%                  9%                       –

Atypical agents        –                    –                    30%                     35%

Unknown                  –                      –                 19%                     26%

 

 

 

 

 

 

 

 

 

 

Miquel et al has reported that there was no significant difference in microbiological results in patients with diabetes and non diabetes13.

Present study has also shown that there is no significant difference in microbiological results in between both the groups.

Spomenka et al reported that Staph auerus and Gram negative organisms such as Klebsiell, E coli, Enterobacter, Pseudomonas and Acinectobacter are common organisms in diabetes12.

Palmar DL reported that Gram positive cocci such as Strep pneu are responsible for majority of infections in diabetic patients, followed by agents such as H influenza15.

The present study has shown that among diabetes the common organisms are Strep pneu (23.3%), polymicrobial (20%), Klebsiella (16.7%), Acinectobacter (10.0%).

Miquel et al reported 9% of patients had poly microbial infections in comparision to 9% in non diabetics13.

Present study showed 20% patients had poly microbial in comparision to 6.7% in non diabetics.

ICU ADMISSION:

             PRESENT STUDY                       MIQUEL et al

Diabetic       Non Diabetic                  Diabetic          Non Diabetic

30.05%          16.7%                           14%                     9%

NOT SIGNIFICANT                             NOT SIGNIFICANT

 

 

 

 

 

 

Miquel et al reported that there was no significant difference in no of ICU admissions in between both the groups13.

Potgieter et al reported that bacterial pneumonias in diabetic individuals, especially when caused by Klebsiella and Staphlococcus is associated with more severe course of disease and more frequently need mechanical ventilation16.

The present study also showed that there is no significant difference in no. of ICU admissions in between both the groups.

COMPLICATIONS

 

 

COMPLICATIONS

 

PRESENT STUDY

 

MIQUEL et al

DIABETIC NON-DIABETIC DIABETIC NON-DIABETIC
Pleural effusion 6.7% 6.7% 33%
Septic shock 20% 20%
Renal failure 3.3%
MODS 3.3%
VF 3.3%
Cardiac arrest 6.7%

 

Koziel H et al reported that the most common complications of pneumonia in diabetics were pleural effusion, empyema and bacterimia14.

Miquel et al reported that pleural effusion was significantly more in diabetic patients and there was difference between other risk factors13.

Present study showed that there was no significant difference in complications between the two groups.

DURATION OF HOSPITAL STAY

PRESENT STUDY                          MIQUEL et al

Diabetic         Non Diabetic              Diabetic      Non Diabetic

12.30±4.98        9.10±5.24          10.2 days         9.1 days

days                   days

P = 0.018 Significant                  Not Significant

 

 

 

 

 

Miquel et al reported that duration of stay was more in diabetics in comparison with non diabetics13.

Present study has shown that duration of stay is more in non diabetics in comparison with diabetics.

PSI SCORING

                             PRESENT STUDY               MIQUEL et al

PSI class    Diabetic       Non Diabetic      Diabetic      Non Diabetic

Class I            23.3%           50.0%               4%                   25%

Class II           6.7%             6.7%                 13%                28%

Class III          10.0%            10.0%               39%               26%

Class IV          33.3%            16.7%               33%               17%

Class V           26.7%            16.7%               11%                4%

 

 

 

 

 

 

 

 

Miquel et al reported that majority of non diabetics presented with PSI class I in comparison with diabetics who in majority presented with class IV which was statistically significant13.

The present study reported that majority of non diabetics presented with PSI class I in comparison with diabetics who in majority presented with class IV and classV which was statistically.

MORTALITY

           PRESENT STUDY                          MIQUEL et al

Diabetic       Non Diabetic             Diabetic           Non Diabetic

23.3%              10.0%                   17%                     8%

P = 0.166 Not Significant                   P = 0.002 Significant

 

 

 

 

Miquel et al reported that mortality was more common in diabetic patients which were statistically significant13.

Akbar DH reported that there was no significant difference in mortality between both the groups14.

The present study also reported that there is no difference in mortality between the two groups.

Miquel et al reported that multilobar infiltrate (P=0.003) and the simultaneous presence of co morbidities (P = 0.029) were found to be independently associated with mortality13.

 

The present study has reported that multilobar involvement, elderly (>60yrs), associated co morbidities are associated with mortality independently.

Miquel et al has shown that there was relation found with sex, length of disease, bacteremia, empyema, pleural effusion with mortality 13.

Preset study has also shown no relation between sex, length of disease, bacteremia, empyema, pleural effusion with mortality.

Koziel et al reported that Acinectobacter pneumonia has been associated with a mortality rate exceeding 60% in diabetics14.

Present study showed that there is no mortality in diabetic patients with Acinectobacter pneumonia.

 

Comparison of study characteristics in Alive and death in Diabetic patients

 

 

VARIABLES

                 PRESENT STUDY                      MIQUEL et al
DEAD ALIVE DEAD ALIVE
Age 62yrs 52yrs 71yrs 68yrs
Blood sugar at admission mg/dl 171 190 267 239
Complications 100% 13.1% 56% 37%
Hospital stay 5-14days 10days

 

Miquel et al has reported that in diabetic group mortality was significantly associated with underlying concomitant illness, multilobe involvement and no significant difference in age, sex and glucose level at entry13.The present study also showed that in diabetic group mortality was significantly associated with concomitant illness, multilobe involvement, renal impairment, high PSI score and no significant difference in age, sex and glucose level at entry.

SUMMARY

The clinical and bacteriological study of 30 cases of pneumonia in diabetics and 30 cases of pneumonia in non diabetics conducted in KIMS hospital and research centre during the period from March 2012 to March 2013. Cases were selected ramdomly and enrolled for study. Literature on histological aspects, anatomy of lung, etiopathogenesis, bacterial flora, clinical features, investigations and management of pneumonia in diabetics and non diabetics were reviewed.

Results were analysed and compared between diabetic and non diabetic group with reference to age, sex, underlying concomitant disease, clinical features, complications, organisms, PSI scoring and mortality. Clinical data was compared with the observations of various workers. The important observations made during this study are summarized as follows

  1. Males are affected more than females in both the groups with a ratio of 3:2.
  2. The average age group of patients in diabetics was 58yrs in comparison with non diabetics were 57yrs.

3.   Most of the patients were between the age group of 40-60yrs.

4. The concomitant underlying illness was neoplasm, CCF, IHD, asthma, COPD, CVA                                  out of which COPD and IHD were common in both thegroups.

There was no statistical significant difference in concomitant underlying disease      between both the groups.

5. There was no statistical significant difference in habits like smoking and alcohol                         conparison between the two groups.

6. Patients in diabetic group were anemic (Hb = 9.57±2.44gm/dl) when compared to non diabetic group (Hb = 10.67±8.17) which is statistical significant (P=0.062).

7. Renal impairment in the form of raised BUN (>25.30±16.74mg/dl) was more in diabetics when compared to non diabetics (16.27±8.170) with P=0.010.

8. On chest x-ray multilobe involvement was significantly more in diabetics (66.7%) than non diabetics (40%) with P = 0.039.( Multilobe involvement is 3 times more like in diabetes).

9. On sputum gram staining, GPC were significantly more detected in non diabetic (46.7%) with P = 0.012 when compared to diabetics where a combination of GPC/GNB were commonly detected (30%) with P = 0.020.

10. There was no statistical significant difference in the organisms detected by sputum culture in between the two groups.

But common organisms in diabetic group were Strep pneu (23.3%), Klebsiella(16.7%), Acinectobacter (10%) and Poly microbial organisms (20%) in comparison to non diabetics were Strep pneu (40%), Staph aeurus (20%).

11. There was no statistical significant difference in no. of patients admitted to ICU between the groups.

But the diabetic patients with polymicrobial etiology were majority among the ICU admission.

12. Complications were more common in diabetic group like pleural effusion (6.7%), Septic shock (20%), renal failure, MODS, VF (3.3% each) and Cardiac arrest (6.7%).

13. Duration of hospital stay was more in diabetics (12.30±4, 98) when compared to non diabetics (9.10±5.24) with P = 0.018.

14. Majority of non diabetics presented under PSI class I (50%) when compared to diabetics who majority of them were under PSI class IV (33.3%) and class V (26.7%).

15. There was not statistical significant difference in mortality between diabetics (23.3%) and non diabetics (10%). Mortality in diabetics was more common in patients with age >60yrs; associated concomitant illness, multilobe involvement and ploy microbial etiology and high PSI score.

16. No relation was found with sex, duration of hospital stay, bacteremia, pleural effusion, signs of consolidation with mortality.

 

CONCLUSIONS

In patients with pneumonia, Diabetes Mellitus is associated with poor prognosis, polymicrobial etiology, multilobe involvement, increased ICU admissions, increased severity in the form of high PSI score and mortality. This study suggests that this adverse outcome is more attributable to the underlying circumstances of patients than to uncommon microbiological findings. Certainly age, prior co morbidities as well as multilobe infiltrates have already been related to poor prognosis; however, in this study, diabetes also remained a significant prognostic factor of mortality in patients with pneumonia.

acKNOWLEDGE

We duly acknowledge Dr. Praveen R for taking it forward in publishing it.

 

CROSS REFERENCES

  1. Ruiz M, Ewings, Marcos MA. Etiology of community acquired pneumonia:Impact of age, co morbidity and severity. Am J Respir Crit Care Med 1999; 160:397-405.
  2. Lim WS, Macfarlane JT, Boswell TCJ. Study of implications for managementguidelines. Thorax 2001; 56:296-301.
  3. Arancibia F, Bauer TT, Ewig S. Community acquired pneumonia due to gram negative bacilli and pseudomonas aeruginosa: incidence, risk and prognosis. Arch Intern Med 2002; 162:1849-1858.
  4. Fine MJ, Smith MA,Carson CA. Prognosis and outcome of patients with community acquired pneumonia; a meta-analysis. JAMA 1995; 274:134-141.
  5. Niederman MS, Mandell LA, Anzueta. Guidelines for the management of adults with pneumonia: diagnosis, assessment of severity, antimicrobial therapy and prevention. Am J Respir Crit Care Med 2001:163; 1730-1754.
  6. Delamaire M, Maugendre D,Moreno M. Impaired functions in the diabetic patients. Diabet Med 1997; 14:29-34.
  7. Mcmahon MM, Bistrian RR. Host defences and susceptibility to infections in patients with diabetes. Infect Dis Clin North Am; 9:1-9.
  8. Ishida T, Hashimoto T, Arita M. Etiology of community acquired pneumonia  in hospitalized patients, a prospective study in japan, Chest 1998; 114:1588-1593.
  9. Shah BR, Hux JE. Quatifying the risk of infectious disease for people with diabetes, Diabetes Care. 2003; 26:510-513.
  10. King H, Aubert RE,Herman WHO. Global burden of diabetes 1995-2025; prevalence, numerical estimates and projections. Diabetes Care 1998; 21; 1414.
  11. Ramachandran A,Snehalatha C,Viswanath V. Burden of type diabetes and its complications- the Indian scenario. Current Science 2002; 83:1471.
  12. Spomenka Ljubic S, Balachandran A, Pavliae-Renar I. Pulmonary infections in diabetes mellitus. Diabetologia Croatica 2005; 4:115-124.
  13. Miquel falguera, Ricard, Antonio Martin, Anas Sheikh et al. Etiology and outcome ofCommunity acquired pneumonia in patients with diabetes mellitus. CHEST nov2005;128:3233-39.
  14. Akbar DH. Bacterial pneumonia: comparison between diabetes and non diabetes. Acta  Diabetol. 2001; 38(2):77-82.
  15. Palmar DL. Microbiology of pneumonia in the patients at risk. Am J Med.1984;74:53-59.
  16. Potgieter PD, Hammond JM. Etiology and diagnosis of pneumonia requiring ICU admission. CHEST 1992; 101:199-203.

 

SERUM ADENOSINE DEAMINASE ACTIVITY IN PULMONARY TUBERCULOSIS AND OTHER COMMON RESPIRATORY DISEASES, Veena S Rathod, Sunitha S, Huliraj N
PROFILE OF POISONING IN A TERTIARY CARE HOSPITAL - Srinivasa V,Kavya S.T,Madhumathi R, Amogh Dudhwewala