Respiratory tract infections in diabetespyelonephritis & cholecystitis) Infections in diabetes....
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Transcript of Respiratory tract infections in diabetespyelonephritis & cholecystitis) Infections in diabetes....
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Respiratory tract infections in
diabetes
C. LlorPrimary Healthcare Centre Via Roma,
Barcelona
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Research Support
- I am receiving research grants from the European Commission (Sixth, Seventh Programme Frameworks and Horizon 2020)- I am receiving grants from the Instituto de Salud Carlos III (Spanish Ministry of Health)-I received grants from the Catalan Society of Family Medicine- Grant from the Fundació Jordi Gol i Gurina for a research stage at the University of Cardiff in 2013
Employee, consultant, stakeholders, speakers bureau, honoraria
None
Competing interests
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Common in diabetics
Pyelonephritis, cystitis, perinephric abscess
Periodontitis
Soft tissue infections including diabetic foot & osteomyelitis
Onychomycosis
Necrotizing fasciitis
Mucocutaneous candidiasis
Tuberculosis
Exclusively in diabetics
Invasive (malignant) otitis externa
Rhinocerebral mucormycosis
Emphysematous infections (pyelonephritis & cholecystitis)
Infections in diabetes
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Pathophysiology of infections associated with diabetes mellitus
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Infectious disease %
1 Acute pharyngotonsillitis 14.1
2 Common cold 13.2
3 Acute bronchitis 9.4
4 Acute cystitis 9.3
5 Infectious diarrhoea 6.8
6 Infectious conjunctivitis 5.4
7 Infected wound or ulcer 4.2
8 Candidal vaginitis 3.6
9 Exacerbation of CB/COPD 3.5
10 Acute sinusitis 3.5
Infectious diseases in primary care
Infectious diseases account for 33.2% of all the visits in primary care
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• Increased frequency for infections caused by Staphylococcus aureus, gram negative organisms, Mycobacterium tuberculosis
• Diabetics are 3 times more likely to colonize S. aureus in their nasopharynx. They are also colonized with gram negative bugs at times
• Diabetics with pneumococcal pneumonia might be more likely to be bacteremic or die from it (OR=1 - 1.3)
• mortality and incidence of bacterial pneumonia during epidemics of influenza
• It is recommended that diabetics receive the pneumococcal vaccine & annual flu vaccine
• Treatment regimes remain same as for non-diabetics
Pulmonary infections
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Two main objectives:
- Whether type 2 DM increases risk of death and complications following pneumonia
- Assess the prognostic value of admission hyperglycaemia
Kornum JE al. Diabetes Care 2007;30:2251–7.
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Kornum JE al. Diabetes Care 2007;30:2251–7.
Prognostic factor n Death Mort. (%)
Adjusted. MRR (95% CI)
p
30 days
No diabetes 26,877 4,098 15.1 1.0 (ref.)<0.01Type 2 diabetes 2,931 882 19.9 1.16 (1.07 – 1.27)
90 days
No diabetes 26,877 5,818 21.6 1.0 (ref.) 0.02
Type 2 diabetes 2,931 791 27.0 1.10 (1.02 – 1.18)
Adjusted mortality within 30 and 90 days among patients hospitalized for pneumonia
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Mortality curves for patients hospitalized with pneumonia, according to presence of diabetes & level of Charlson index score
Kornum JE al. Diabetes Care 2007;30:2251–7.
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Glucose level (mmol/l) n DeathMort.
(%)Adjusted MRR
(95% CI)* PType 2 diabetes patients 1,307
≤6.1 279 52 18.6 1.0 (ref.)
6.11–11.0 545 95 17.4 0.96 (0.69–1.35) 0.82
11.01–13.99 188 40 21.3 1.24 (0.82–1.88) 0.31
≥14 295 65 22.0 1.46 (1.01–2.12) 0.04
Non diabetic patients 9,107
≤6.1 4,850 675 13.9 1.0 (ref.)
6.11–11.0 3,901 808 20.7 1.43 (1.29–1.59) <0.01
11.01–13.99 195 46 23.6 1.65 (1.23–2.23) <0.01
≥14 161 42 26.1 1.91 (1.40–2.61) <0.01
Adjusted mortality within 30 days among pneumonia patients with available glucose values on admission
Kornum JE al. Diabetes Care 2007;30:2251–7.
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Outcomes among patients aged 65 or older with pneumonia
Kofteridis DP et al. JAGS 2016;64:649–51.
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Analysis of the relationship between diabetes and the occurrence of lung diseases
Adjusted for age, gender, ethnicity, smoking, BMI, education, alcohol consumption, and number of outpatient visits
Hazard ratio (95% CI) for the association between each pulmonary condition and
diabetes status
Asthma 1.08 (1.03 – 1.12)
Chronic obstructive pulmonary disease 1.22 (1.15 – 1.28)
Pulmonary fibrosis 1.54 (1.31 – 1.81)
Pneumonia 1.92 (1.84 – 1.99)
Lung cancer 1.10 (0.96–1.26)
Ehrlich SF al. Diabetes Care 2010;33:55–60.
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• Relative risk of developing active disease 1-2 times that of general population. TB patients screened for DM?1,2
• Highly increased risk of multi-drug resistant tuberculosis
• Most guidelines recommends that preventive chemotherapy be given to diabetics who have a TST > 10 mm and no active disease
• DM patients had increased frequency of lung lesions confined to lower lung and more cavitary lung lesions compared with patients with TB but no DM3
• An increase in dose of sulfonylureas may be needed if rifampicin is co-administered
• Treatment is the same. Bacteriological conversion and relapse rates are same as non-diabetics
Tuberculosis and diabetes
1Ogbera AO et al. BMJ Open Diab Res 2015;3:e000112; 2Viswanathan V et al. PLoS One 2012;7:e41367.; 3Shaikh MA et al. Suadi Med J 2003;24:1073–
6.
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Patients followed from 1990 to 2012:-222,731 diabetics- 1,218,616 matched controls- The authors assumed that UK incidence rates of tuberculosis did not vary over time
Pealing L et al. BMC Med 2015;13:135.
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Tuberculosis and diabetes. Causal diagram of associations between diabetes, tuberculosis and confounders
Pealing L et al. BMC Med 2015;13:135.
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Exposure status
Number of TB cases/ 100,000 personyears at
risk
Age-adjusted rate (95%
CI)
Age-adjusted rate ratio (95% CI)
Fully adjusted
model. Rate ratio (95%
CI)
Patients without diabetes 779/57.68
13.51 (12.59–14.49)
1.00 1.00
Patients with diabetes 190/11.73
16.20(14.05–18.68)
1.20(1.02–1.40)
1.30(1.01–1.67)
Tuberculosis and diabetes. Rates and adjusted rate ratios for all types of tuberculosis by exposure to diabetes
Pealing L et al. BMC Med 2015;13:135.
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• Simple infections become untreatable or even fatal
• Many medical procedures become impossible without effective antibiotic protection, e.g.
- No heart surgery or transplantations
- No immune-modulating therapy for rheumatoid arthritis or cancers of the blood
- Limited routine operations such as hip replacements
- Reduced survival of pre-term babies
• Shortages of food due to untreatable infections in livestock
• Restrictions on trade in foodstuffs
• Restrictions on travel and migration
Antimicrobial resistance: The post-antibiotic era
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• The diagnosis of most respiratory tract infections is generally unclear and casts many doubts
• A single best treatment is not available in most respiratory tract infections
• GPs do not know the best treatments available and fail consistently to apply them
• GPs do not usually uniformly communicate the progression of the respiratory tract infections
• GPs are in the best position to evaluate trade-offs between different treatments and to make treatment decisions
• Self-consumption of antibiotics and sale of antibiotics without prescription in community pharmacies
Drawbacks in the management of respiratory tract infections in primary care
Butler CC et al. J Antimicrob Chemother 2001;48:435–40.
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Consumption Resistance
ConsumptionResistance
Drawbacks in the management of respiratory tract infectious diseases in primary care
Negative correlation between consumption & resistance and utilisation of rapid tests
No tests
CRP, Strep A, WBC, FlexiCult
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*Countries reporting only outpatient antibiotic useRomania and Spain provided reimbursement data
Total antibiotic use in 2011, expressed in number of DDD per 1,000 inhabitants per day in Europe
Versporten A et al. Lancet Infect Dis 2014;349:g5238.
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‘A 44% of UK GPs admit to have prescribed antibiotics to get a patient to leave the surgery’
Cole A. BMJ 2014;349:g5238.
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Management of the other respiratory tract infections in primary care
Condition Average duration of symptoms
When are antibiotics indicated in diabetic patients?
Acute otitis media
4 days <2 yr. always; > 2 yr if risk factors (fever,otorrhoea, severity, bilaterality, ear drum perfor.)
Acute sore throat
1 week If caused by S. pyogenes, also immunocompromised, history of rheumatic fever,
streptococcal community outbreak, severity
Influenza 1 week Refer if suspected pneumonia, severity or pulse oxymetry<92%
Common cold 1½ weeks
Acute rhinosinusitis
2½ weeks If symptoms and signs do not improve after 10 days, severe patient after the 3rd day or worsening
of symptoms after the fifth day
Acutebronchitis
3 weeks Rule out pneumonia. Consider antibiotics in severe patients
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Lack of time
Communication: Probably not his...?
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Or this...?
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More research is needed
Getting further funds?
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1 Infections caused by certain organisms, such as Staphylococcus aureus, gramnegatives, and Mycobacterium tuberculosis, occur with increased frequency in diabetic patients.
2 Infections due to common germs are associated with slightly increased morbidity, severity and mortality.
3 Risk of pneumonia is 1.1 – 1.9 times increased in diabetic patients, with increased risk of hospitalisation, and more mortality.
4 Diabetics more likely need hospitalisation during influenza epidemics. Prevention is crucial.
5 Patients with diabetes are at higher risk of contracting tuberculosis. Increased risk of multidrug resistant tuberculosis.
6 Same recommendations for other respiratory tract infections for both diabetic and non-diabetic individuals. However, more research is needed
Take-home messages
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E-mail: [email protected]