Antimicrobial stewardship in diabetic ketoacidosis: a single-centre experience

Identification of early predictors and model for bacterial infection in diabetic ketoacidosis patients: A retrospective study

PURPOSE

The purpose of this report was to identify effective indicators capable of predicting bacterial infection during the early stages of diabetic ketoacidosis (DKA) and to establish a diagnostic model suitable for clinical application.

METHODS

This was a retrospective cross-sectional study. Between February 2018 and May 2023, Yuhuangding Hospital admitted 101 DKA patients, of whom 45 were diagnosed with bacterial infections. A confirmed bacterial infection was defined as documented bacteriological evidence in any bacterial sample. Clinical parameters and biological markers (including cortisol, C-reactive protein (CRP), procalcitonin, etc.) were recorded during the initial DKA phase. Multivariate regression analysis was employed to construct a diagnostic model.

RESULTS

CRP (OR = 1.014, 95% CI: 1.002-1.026, p = 0.017) and cortisol (OR = 1.007, 95% CI: 1.002-1.012, p = 0.003) were found to have an independent association with bacterial infection in DKA patients. The area under the receiver operating characteristic curve (AUC) for CRP in identifying bacterial infection was 0.855 (95% CI, 0.771-0.917), with a sensitivity of 76.1% and a specificity of 83.6%. The AUC for cortisol in identifying bacterial infection was 0.847 (95% CI, 0.761-0.911), with a sensitivity of 71.7% and a specificity of 89.1%. A joint diagnostic model based on cortisol and CRP was developed through multifactor regression analysis. The AUC of this diagnostic model was 0.930 (95% CI, 0.862-0.972), resulting in a sensitivity of 93.5% and a specificity of 80.0%.

CONCLUSION

CRP and cortisol are early indicators of bacterial infection in DKA patients. Furthermore, based on their combination, the regression diagnostic model exhibits enhanced diagnostic performance.

Sepsis screening tools for predicting infection triggers and outcomes in diabetic ketoacidosis

Background: An early prediction of infection is challenging in diabetic ketoacidosis (DKA). Methods: This prospective cohort study aimed to assess effectiveness of various sepsis screening tools in predicting infections and prognosis in DKA. Results: Among 141 cases, infection (44.0%) was the commonest precipitating factor. A Sequential Organ Failure Assessment score ≥4 showed high specificity (82.28%) and high positive likelihood ratio (2.64) but limited sensitivity (46.77%). Conversely, Systemic Inflammatory Response Syndrome ≥2 exhibited good sensitivity (95.16%) but a high false-positive rate (84.28%). National Early Warning Score ≥7 and Quick Sequential Organ Failure Assessment ≥2 had low sensitivity and specificity. These sepsis tools also demonstrated low prognostic accuracy for mortality. Conclusion: Sepsis screening tools have limited predictive accuracy for infections and mortality in DKA.

Clinical Profile and Outcomes of Diabetic Ketoacidosis During COVID-19 Pandemic in North India

Although recent data have shown a declining trend in mortality in diabetic ketoacidosis (DKA), the outcomes are likely to be different during the coronavirus (COVID-19) pandemic. We conducted a prospective cohort study to evaluate the spectrum and outcomes of adult DKA during the pandemic and document differences in DKA patients with or without COVID-19. A total of 169 patients (mean age 44 years) were admitted at the Emergency Department of PGIMER, Chandigarh (India), from January 2020 to June 2021. The precipitating factors were noncompliance with antidiabetic therapy (77.5%), infections (62.7%), and noninfectious conditions (21.3%). Thirty-nine (23.1%) patients had COVID-19, including 31 with severe infection. DKA severity and resolution, ventilator requirement, hospital stay, and mortality were similar in the patients with or without COVID-19. In-hospital mortality was 39.6% (n = 67). The independent mortality predictors were ventilator requirement (p-0.000), an infection trigger (p-0.049), and hyperosmolarity (p-0.048). DKA mortality is increased significantly during the pandemic.