Frequent hospital admissions for bacterial infections among aboriginal people with diabetes in central Australia

Defining the gap: a systematic review of the difference in rates of diabetes-related foot complications in Aboriginal and Torres Strait Islander Australians and non-Indigenous Australians

BACKGROUND

The Aboriginal and Torres Strait Islander community has an increased risk of developing chronic illnesses including diabetes. Among people with diabetes, foot complications are common and make a significant contribution to the morbidity and mortality associated with this disease. The aim of this review was to systematically evaluate the literature comparing the rates of diabetes related foot complications in Aboriginal and Torres Strait Islander Australians to non-Indigenous Australians.

METHODS

MEDLINE, EMBASE, The Cochrane Library; PUBMED and CINAHL were searched from inception until August 2016. Inclusion criteria were: published cross-sectional or longitudinal studies reporting the prevalence of diabetes related foot complications in both a cohort of Aboriginal and Torres Strait Islander Australians and a cohort of one other Australian population of any age with diabetes. Risk of bias was assessed using the STROBE tool.

RESULTS

Eleven studies including a total of 157,892 participants were included. Studies were set in Queensland, the Northern Territory and Western Australia, primarily in rural and remote areas. Aboriginal and Torres Strait Islander Australians experienced substantially more diabetes related foot complications with the mean age up to 14 years younger than non-Indigenous Australians. Aboriginality was associated with increased risk of peripheral neuropathy, foot ulceration and amputation. In several studies, Aboriginal and Torres Strait Islander Australians accounted for the vast majority of diabetes related foot complications (up to 91%) while comprising only a small proportion of the regional population. Reporting quality as assessed with the STROBE tool showed underreporting of: methods, sample description and potential sources of bias. There are no data available for some Australian states and for specific types of diabetes related foot complications.

CONCLUSIONS

Aboriginal and Torres Strait Islander Australians have a 3-6 fold increased likelihood of experiencing a diabetes related foot complication compared to non-Indigenous Australians. Evidence-based, culturally appropriate screening and intervention programs and improved access to effective health care services are required to prevent a widening of the gap in diabetes related foot complications between Aboriginal and Torres Strait Islander and non-Indigenous Australians.

Incidence and predictors of hospitalization for bacterial infection in community-based patients with type 2 diabetes: the fremantle diabetes study

Background

The few studies that have examined the relationship between diabetes and bacterial infections have utilized administrative databases and/or have had limited/incomplete data including recognized infection risk factors. The aim of this study was to determine the incidence and associates of bacterial infection severe enough to require hospitalization in well-characterized community-based patients with type 2 diabetes.

Methods and Findings

We studied a cohort of 1,294 patients (mean±SD age 64.1±11.3 years) from the longitudinal observational Fremantle Diabetes Study Phase I (FDS1) and 5,156 age-, gender- and zip-code-matched non-diabetic controls. The main outcome measure was incident hospitalization for bacterial infection as principal diagnosis between 1993 and 2010. We also examined differences in statin use in 52 FDS1 pairs hospitalized with pneumonia (cases) or a contemporaneous non-infection-related cause (controls). During 12.0±5.4 years of follow-up, 251 (19.4%) patients were hospitalized on 368 occasions for infection (23.7/1,000 patient-years). This was more than double the rate in matched controls (incident rate ratio (IRR) (95% CI), 2.13 (1.88–2.42), P<0.001). IRRs for pneumonia, cellulitis, and septicemia/bacteremia were 1.86 (1.55–2.21), 2.45 (1.92–3.12), and 2.08 (1.41–3.04), respectively (P<0.001). Among the diabetic patients, older age, male sex, prior recent infection-related hospitalization, obesity, albuminuria, retinopathy and Aboriginal ethnicity were baseline variables independently associated with risk of first hospitalization with any infection (P≤0.005). After adjustment for these variables, baseline statin treatment was not significant (hazard ratio (95% CI), 0.70 (0.39–1.25), P = 0.22). Statin use at hospitalization for pneumonia among the case-control pairs was similar (23.1% vs. 13.5%, P = 0.27).

Conclusions

The risk of severe infection is increased among type 2 diabetic patients and is not reduced by statin therapy. There are a number of other easily-accessible sociodemographic and clinical variables that could be used to optimize infection-related education, prevention and management in type 2 diabetes.

Streptococcus milleri Group Cutaneous Abscess Associated with Insulin Injection to Distal Lower Extremity in an Insulin-Dependent Diabetic Man

Purpose

We report a case of Streptococcus milleri group (SMG)-associated cutaneous abscess in an older diabetic man. The infection developed after subcutaneous insulin injection to the distal lower extremity. This is the first known account of SMG-associated abscess secondary to insulin administration.

Summary

A 60-year-old Caucasian insulin-dependent diabetic male developed a severe cutaneous infection including abscess and surrounding cellulitis at the site of a self-administered insulin glargine injection on the medial portion of his right lower leg. The infection developed rapidly within 1 day following the injection. Cultures from purulent drainage were positive for SMG. The infection resolved rapidly with an antibiotic regimen including 1 dose of clindamycin followed by intravenous pipercillin/tazobactam plus vancomycin and concluded with outpatient treatment with sulfamethoxazole/trimethoprim. Organisms belonging to SMG are increasingly recognized as pyogenic pathogens responsible, most commonly, for abscess infections. SMG infections have been reported in diabetics; however, this is the first known case of SMG-associated abscess secondary to subcutaneous insulin administration.

Conclusion

A 60-year-old diabetic male experienced a severe SMG-associated abscess in the distal lower extremity after self-injection with insulin glargine. The infection resolved rapidly with intravenous and oral antibiotics. Clinicians should be aware of the potential for abscess infection from SMG at insulin injection sites.

Community-acquired pneumonia in the central desert and north-western tropics of Australia

BACKGROUND

Community-acquired pneumonia (CAP) results in significant morbidity in central and north-western Australia. However, the nature, management and outcome of CAP are poorly documented. The aim of the study was to describe CAP in the Kimberley and Central Desert regions of Australia.

METHODS

Prospective and retrospective cohort studies of inpatient management of adults with CAP at Alice Springs Hospital and six Kimberley hospitals were carried out. We documented demographic data, comorbidities, investigations, causes, CAP severity, outcome and concordance between prescribed and protocol-recommended antibiotics.

RESULTS

Two hundred and ninety-three subjects were included. Aboriginal Australians were overrepresented (relative risk 8.1). Patients were notably younger (median age 44.5 years) and disease severity lower than in urban Australian settings. Two patients died within 30 days of admission compared with expected mortality based on Pneumonia Severity Index predictions of seven deaths (chi(2), P= 0.09). Disease severity and outcome did not differ between regions. Management differences were identified, including significantly more investigations, higher rates of critical care and broader antibiotic cover in Central Australia compared with the Kimberley. Sputum culture results showed Gram-negative organisms in both regions. However, Streptococcus pneumoniae was the most frequent organism isolated in the Kimberley and Haemophilus influenzae in Central Australia.

CONCLUSION

CAP in this setting is an Aboriginal health issue. The low mortality observed and results of microbiology investigations support the use of existing antibiotic protocols. Larger studies investigating CAP aetiology are warranted. Addressing social and environmental disadvantage remains the key factors in dealing with the burden of CAP in this setting.

Community-acquired Acinetobacter infections

Acinetobacter infections have been attracting increasing attention during recent years because they have become common in hospitalized patients, especially in the intensive care unit (ICU) setting. However, the available literature suggests that the pathogen has another fearful potential; it can cause community-acquired infections. We searched PubMed and the reference lists of the initially identified articles and identified six case series regarding a total of 80 patients with community-acquired Acinetobacter baumannii infections; from these, 51 had pneumonia and 29 had bacteremia. Of these 80 patients, 45 (56%) died of the infection. In addition, we identified 26 case reports regarding 43 patients with community-acquired Acinetobacter infections; from these, 38 had pneumonia, two had meningitis, one had soft-tissue infection, one had ocular infection, and one had native valve endocarditis. Comorbidity was commonly present in patients reported in the case series as well as the case reports, mainly, chronic obstructive pulmonary disease, renal disease, and diabetes mellitus; heavy smoking and excess alcohol consumption were also common. Most of the studies originated from China, Taiwan, and tropical Australia. We also identified 12 retrospective or prospective studies (seven from the Far East, two from Oceania, one from N. Guinea, one from Palestine, and one from USA/Canada) that reported the frequency of community-acquired Acinetobacter infections; the range of isolation of Acinetobacter from patients with community-acquired pneumonia in these studies was 1.3%-25.9%. In conclusion, most community-acquired Acinetobacter infections have been reported from countries with tropical or subtropical climate, and mainly affect patients with some form of comorbidity or are associated with heavy smoking and excess alcohol consumption.

Pulmonary tuberculosis in spontaneously diabetic goto kakizaki rats

As a clinical association is thought to exist between diabetes and tuberculosis, this study was set up to examine whether GK/Jcl diabetic rats are more susceptible to Mycobacterium tuberculosis infection than non-diabetic rats. GK/Jcl diabetic rats were infected aerially with M. tuberculosis and their capacity to control mycobacterial growth, granuloma formation, cytokine secretion by alveolar macrophages and nitric oxide (NO) production was examined. The rats developed large granulomas but not necrotic lesions in their lungs, liver or spleen. This is consistent with a significant increase in number of colony-forming units of M. tuberculosis in the lungs (p<0.01). Expression levels of interferon-gamma, tumor necrosis factor (TNF)-alpha and interleukin (IL)-12 mRNA were lower in GK/Jcl diabetic rats than those in control Wistar rats. Alveolar macrophages from GK/Jcl rats secreted less TNF-alpha and IL-12, and produced less NO compared with those from Wistar rats. No significant difference was observed between phagocytosis of tubercle bacilli by alveolar macrophages from GK/Jcl or Wistar rats. These data show that there is a close association between experimental tuberculosis and diabetes in animals, and that alveolar macrophages from GK/Jcl diabetic rats are not fully activated by M. tuberculosis infection.

Hospital separations indicate increasing need for prevention of diabetic foot complications in central Australia

The aim of this study was to guide service provision for prevention of diabetic foot complications through the analysis of hospital separation data for those with diabetes in central Australia. We reviewed the hospital separation data for central Australia from 1992 to 1997 for adults known to be diabetic and those with diabetic foot complications. Foot complications were identified from International Classification of Diseases-9th Revision (ICD-9) codes. Additionally, we assessed the proportion of cases with diabetic foot, identified by ICD-9 coding and confirmed by record review, that were identified by Australian National-Diagnostic Related Group-Version 3 (AN-DRG-3) coding. Separations with diabetes doubled from 352 in 1992 to 796 in 1997. This represents an increase from 1232 to 2521 separations per 100,000 people over 15 years of age. Separations with foot complications increased threefold from 28 in 1992 to 90 in 1997, a rate increase from 98 to 285 per 100,000 people over 15 years of age. The proportion of diabetes separations that had foot complications remained around 10% during the 6 year period. Aboriginal people made up 89% of the individuals with foot complications and 91% of separations for diabetic foot. Foot complications were predominantly of the more acute type (90%), amenable to early intervention. The AN-DRG-3 code for diabetic foot identified only 59% (37/63 in 1997) of the separations identified by the ICD-9 codes, and admitted primarily for foot complications in Alice Springs Hospital. The known burden of hospital care for diabetes and diabetic foot complications has increased markedly in recent years. A combination of changes in prevalence, primary care utilisation, detection, hospital access or re-admission rates may underlie the observed increases. As it is very unlikely that diabetes or diabetic foot complications are being over diagnosed, or that the hospitals are over utilised, this analysis shows there is an increasingly apparent need for improved prevention of diabetic foot complications. Therefore primary health care systems should ensure that they implement evidence-based care for preventing foot complications among people with diabetes.

Diabetic foot care: developing culturally appropriate educational tools for Aboriginal and Torres Strait Islander peoples in the Northern Territory, Australia

Evidence shows that Aboriginal and Torres Strait Islander people have the highest national percentage of morbidity in relation to diabetes. Aboriginal and Torres Strait Islander people also suffer the greatest risk of amputation as a complication of diabetes. This participatory action research project sought to discover the opinions of a range of people, including registered nurses, general practitioners, Aboriginal health workers, cross-cultural liaison officers and Aboriginal and Torres Strait Islander people with diabetes. Focus groups provided valuable information regarding relevant issues of foot care education in the Northern Territory. The emergent themes included communication issues, educational resources, changing behaviour and other practical resources required for health education. The themes provided evidence of the inherent issues of foot care for Aboriginal and Torres Strait Islander people and guidance for the development of a visual educational tool. The results have lead to the development of a foot care educational tool that will be used by health-care professionals and clients in urban, community, rural and remote areas. The use of a participant action research process will ensure that the educational tool will be owned by Aboriginal and Torres Strait Islander People and health-care professionals.

Pneumococcal vaccination: an important strategy to prevent pneumonia in Aboriginal and Torres Strait Island adults

The objective of the study was to examine the appropriateness of the National Health and Medical Research Council (NHMRC) recommendations concerning pneumococcal vaccination for Aboriginal and Torres Strait Island adults. Laboratory surveillance of invasive pneumococcal disease identified 95 cases acquired by adults 15 years of age and over in Far North Queensland from 1992 to 1995. The most common diagnosis was pneumonia (77 per cent). Sixty-one cases (64 per cent) occurred in Aboriginal and Torres Strait Island adults, who acquired the disease at a younger age (mean 40 years) than did other adults (mean 50 years). Most (93 per cent) of the Aboriginal and Torres Strait Island adults had at least one of the pre-existing medical conditions in the NHMRC criteria for pneumococcal vaccination. The most common was 'alcohol abuse' (62 per cent). Fifty-three (93 per cent) of the pneumococcal isolates from the Aboriginal and Torres Strait Island adults who had pre-existing conditions were serotyped. Fifty (94 per cent) belonged to types included in the currently available pneumococcal vaccine. We conclude that the NHMRC recommendations for pneumococcal vaccination are appropriate, considering the pattern of invasive pneumococcal disease that occurs in Aboriginal and Torres Strait Island adults in Far North Queensland. Because pneumococcal vaccination can reduce the pneumonia-associated morbidity and premature mortality experienced by Aboriginal and Torres Strait Island adults, the vaccine should be offered routinely to those considered to be at risk, particularly young men who have recently begun to consume hazardous amounts of alcohol, and recently diagnosed diabetics.

Self-reported health and use of health services: a comparison of diabetic and nondiabetic persons from a national sample

Population-based epidemiological and health service utilisation information on diabetes and other noncommunicable diseases is still scarce in Australia. Such information is needed by health economists, policy makers and service providers. Data from the 1989-90 National Health Survey conducted by the Australian Bureau of Statistics have been used to obtain estimates of the prevalence of cardiovascular morbidity, life-style factors, use of hospital and medical services, and self-assessed health and happiness for Australian persons with diabetes. Prevalences are compared with those for persons without diabetes. Those with diabetes had two to three times the prevalence of most cardiovascular conditions, similar levels of exercise (except for diabetic women over 40 years of age who exercised less than their nondiabetic counterparts), lower levels of alcohol consumption (except for younger men, who had a similar frequency of heavy drinking as their nondiabetic peers), similar levels of smoking, a higher prevalence of overweight, and significantly greater frequency of hospital admissions, use of outpatient services and general practitioner consultations. About half of the people with diabetes assessed their health as good or excellent but 90 per cent stated that they were happy or very happy. No differences between diabetic people living in capital cities and other areas were found. These results have implications for education and life-style behaviour modification programs for people with diabetes. Research into the prevention and more effective management of diabetes and its complications is required in order to contain the escalating health care burden associated with diabetes in Australia.

Aborigines and tuberculosis: why they are at risk

Aborigines have higher rates of Mycobacterium tuberculosis than the rest of the community. There are insufficient contemporary data to assess how much risk tuberculosis poses to the Aboriginal community. Tuberculosis is of particular concern because of its interaction with human immuno-deficiency virus (HIV). We aimed to ascertain the available data about tuberculosis in Australian Aborigines: to determine morbidity and mortality of tuberculosis in Australian Aborigines, to ascertain the extent of known risk factors for tuberculosis in Australian Aborigines and to consider the public health implications of our findings. Sparse evidence suggests that Aborigines have higher rates of infection and of clinical tuberculosis than non-Aboriginal Australians, along with a high prevalence of known risk factors for tuberculosis. However, there is a paucity of data about specific risk factors and tuberculosis in Aborigines. In addition, Aborigines have a high prevalence of risk factors for HIV infection. The existence of concurrent risk factors for tuberculosis and HIV, in a population that already has a high rate of infection with tuberculosis is cause for grave concern. Tuberculosis control is centred on correct and rapid diagnosis and appropriate treatment, as well as efficient contact tracing. These are the most important strategies for control of tuberculosis among Aborigines, and are especially important when there is concurrence of other risk factors. Appropriate preventive therapy for infected people should also be considered.

Utilisation of health services by aboriginal Australians with diabetes

Diabetes is a major public health problem for Aboriginal Australians. We wished to determine the extent and pattern of health service utilisation by Aboriginal people with diabetes in central Australia. Medical records of all Aboriginal people known to have diabetes (n = 374), identified by a previous study, were examined for attendance to health services in central Australia. All had non-insulin-dependent diabetes. Between January 1984 and December 1986, Aboriginal adults with diabetes were admitted to hospital on 694 occasions, accounting for 10.8% of adult Aboriginal admissions. The crude admission rates were 0.78 and 0.84 per diabetes-year for men and women, respectively. The age-adjusted relative risks for admission, compared with Aboriginal non-diabetic patients, were 2.93 (95% C.I., 2.62-3.26) for men and 2.46 (95% C.I., 2.28-2.66) for women. If admission for conditions associated with diabetes are excluded, the admission rates were similar for the two groups. Infection was the most common reason for attendance to a health service, representing 41.7% and 39.8% of male and female admissions, and 21.8% and 26.3% of male and female outpatient attendances. Aboriginal patients with diagnosed diabetes suffer high morbidity and contribute disproportionately to health system costs.