Fasting hyperglycemia upon hospital admission is associated with higher pneumonia complication rates among the elderly

Article (PDF Available)inInternational Archives of Medicine 3(1):16 · August 2010with50 Reads
DOI: 10.1186/1755-7682-3-16 · Source: PubMed
Abstract
Hyperglycemia is an independent predictor of adverse outcomes during hospitalization. In patients who have pneumonia, significant hyperglycemia is associated with poor outcomes. This study evaluates the interaction of the degree of hyperglycemia and complication rates stratified by age in non-critically ill patients admitted to the hospital for care of community-acquired pneumonia. Retrospective review of patient records coded for pneumonia. Analysis included 501 non-critically ill patients admitted to a tertiary care hospital in New York City. Data were stratified by diabetes status, age (less than 65 and 65 and over), and fasting blood glucose (FBG) within the first 24 hours of hospitalization. Among patients with no history of diabetes, FBG was stratified as "normal" [FBG </=100 mg/dl (5.6 mmol/l)], "mild-hyperglycemia" [101-125 mg/dl (5.7-6.9 mmol/l)], and "severe-hyperglycemia" [>/=126 mg/dl (7 mmol/l)]. The diabetic group included known diabetics regardless of FBG. The Pneumonia Severity Index (PSI) was calculated for all patients. Complications rates, hospital length of stay and mortality were compared among the groups. In patients age 65 and older, complication rates were 16.7% in normoglycemics, 27.5% in the "mild-hyperglycemia" group, 28.6% in the "severe hyperglycemia" group, and 25.5% in those with known diabetes. The mild and severe-hyperglycemics had similar complication rates (p = 0.94). Compared to the normal group, mild and severe groups had higher rates of complications, p = 0.05 and p = 0.03, respectively. PSI tended to be higher in those over the age of 65. PSI was not significantly different when the normal, mild, severe, and known diabetes groups were compared. PSI did not predict complications for new hyperglycemia (normals' mean score 87, mild 84.7, severe 93.9, diabetics 100). Hospital mortality did not differ among groups. Length of stay was longer (p = 0.05) among mild-hyperglycemics (days = 8.4 s.e. 14.3) vs. normals (days = 6.2 s.e.6.5). This study shows that FBS between 101-125 mg/dl (5.7-6.9 mmol/l) on hospital admission increases pneumonia complication rates among the elderly with no previous diagnosis of diabetes.
ORIGINAL RESEARCH Open Access
Fasting hyperglycemia upon hospital admission is
associated with higher pneumonia complication
rates among the elderly
Mario R Castellanos
1*
, Anita Szerszen
2
, Chadi Saifan
1
, Irina Zigelboym
1
, Georges Khoueiry
1
, Nidal Abi Rafeh
1
,
Robert V Wetz
1
, Morton Kleiner
1
, Nelly Aoun
1
, Kera F Weiserbs
1
, Theodore Maniatis
4
, Jeffrey Rothman
3
Abstract
Background: Hyperglycemia is an independent predictor of adverse outcomes during hospitalization. In patients
who have pneumonia, significant hyperglycemia is associ ated with poor outcomes. This study evaluates the
interaction of the degree of hyperglycemia and complication rates stratified by age in non-critically ill patients
admitted to the hospital for care of community-acquired pneumonia.
Methods: Retrospective review of patient records coded for pneumonia. Analysis included 501 non-critically ill
patients admitted to a tertiary care hospital in New York City. Data were stratified by diabetes status, age (less than
65 and 65 and over), and fasting blood glucose (FBG) within the first 24 hours of hospitalization. Among patients
with no history of diabetes, FBG was stratified as normal [FBG 100 mg/dl (5.6 mmol/l)], mild-hy perglycemia
[101-125 mg/dl (5.7-6.9 mmol/l)], and severe-hyperglycemia [126 mg/dl (7 mmol/l)]. The diabetic group included
known diabetics regardless of FBG. The Pneumonia Severity Index (PSI) was calculated for all patients.
Complications rates, hospital length of stay and mortality were compared among the groups.
Results: In patients age 65 and older, complication rates were 16.7% in normoglycemics, 27.5% in the mild-
hyperglycemia group, 28.6% in the severe hyperglycemia group, and 25.5% in those with known diabetes. The
mild and severe-hyperglycemics had similar complication rates (p = 0.94). Compared to the normal gro up, mild
and severe groups had higher rates of complications, p = 0.05 and p = 0.03, respectively. PSI tended to be higher
in those over the age of 65. PSI was not significantly different when the normal, mild, severe, and known diabetes
groups were compared. PSI did not predict complications for new hyperglycemia (normals mean score 87, mild
84.7, severe 93.9, diabetics 100). Hospita l mortality did not differ among groups. Length of stay was longer
(p = 0.05) among mild-hyperglycemics (days = 8.4 s.e. 14.3) vs. normals (days = 6.2 s.e.6.5).
Conclusion: Th is study shows that FBS between 101-125 mg/dl (5.7-6.9 mmol/l) on hospital admission increases
pneumonia complication rates among the elderly with no previous diagnosis of diabetes.
Background
Pneumonia is the leading infectious cause of death in
the elderly [1]. Annually, about 5 million Americans,
mostly older adults, are diagnosed with pneumonia [2].
The presence of multiple chronic conditions, declining
cough reflex, and impaired ciliary function make older
individuals more susceptible to pneumonia and at
increased risk for its complications [1,2].
Hyperglycemia is an independent predictor of adverse
outcomes during hospitalization in multiple clinical set-
tings, including acute myocardial infarction, stroke, and
surgery [3-5]. Hospitalized individuals without a prior his-
tory of diabetes who are found to be hyperg lycemic have
increased mortality compared to kno wn di abetics and
those with normal glucose [6]. Hyperglycemic patients
(admission blood glucose 200 mg/dl [11 mmol/l]) with
community-acquired pneumonia have increased mortality
* Correspondence: mario_castellanos@siuh.edu
1
Department of Medicine, Staten Island University Hospital, 450 Seaview Ave,
Staten Island, NY 10305, USA
Full list of author information is available at the end of the article
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© 2010 Castellanos et al; licensee BioMed Central Ltd. This is an Open Ac cess article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/lic enses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided th e original work is properly cited.
and complications of pneumonia when compared to nor-
moglycemic individuals [7].
At the molecular level, hyperglycemia affects pro-
inflammatory cytokine production [8] and the function
of polymorphonuclear leukocy tes [9] and T cell s [10].
Alterations in polym orphonuclear cells have been exten-
sively studied, with demonstration of defects in adhe-
sion, chemotaxis, and phagocytosis when cells are
exposed to hyperglycemia [11], supporting clinically
observed adverse outcomes. Observational studies asso-
ciating hyperglycemia with poor patient outcome pro-
vided the basis for randomized controlled interventional
studies [12-18], which have shown that treating hyper-
glycemia with insulin protocols improves the morbidity
and mortality rates among post-operative patients in the
surgical intensive care unit (ICU) and during critical ill-
ness. As a result of these studies, contro l of hyperglyce-
mia during critical illness has become a standard of
care. Although optimal glucose targets and protocols
continue to be examined for critic ally ill patients, there
are no interventional trials evaluating goals for glucose
control in the non-intensive care setting. Observational
studies found that admission glucose above 200 mg/dl
(11 mmol/l) was a predictor of in-hospital complications
and longer l ength of stay (LOS) [ 7]. However, there are
no published studies examining whether mild hypergly-
cemia with fasting values between 100 mg/dl to 126
mg/dl (5.6-7 mmol/l) leads to ad verse outcomes in hos-
pitalized p atients outside the intensive care setting. In
this study, we evaluated patients admitted to general
medical floors for the treatm ent of community-acquired
pneumonia to determine if mild hyperglycemia affects
morbidity and mortality.
Research Design and Methods
This study was conducted at a la rge teaching hospita l.
The hospital serves a mixed urban/suburban population
of nearly half a million in a borough of New York City.
The medical records of patients admitted for the treat-
ment of pneumonia during one year were examined.
Patient s were identified by discharge diagnosis codes for
pneumonia. Eligibility criteria were: age 18 years or
older, placement on a general medical floor on admis-
sion, pneumonia diagnosed by the finding of a new infil-
trate on chest x-ray as documented by a radiology
report with clinical symptoms suggestive of a pulmonary
infection; and having an early morning fasting blood
glucose (FBG) level drawn within 24 hours of admission.
Patients were excluded if they were being treated for a
hosp ital-acquired pneumonia, defined as either develop-
ing a new pneumonia 48 hours or more after admission
or within 2 weeks after discharge from a hospital.
Patients admitted to a critical care unit were also
excluded.
Patients who met the inclusion criteria were then
grouped according to their FBG level as follows: 1.
Known diabetic : patients known to have a previous
history of diabetes regardless of the admission FBG, 2.
Severe hyperglycemia": a group defined by FBG of 126
mg/dl (7 mmol/l) or greater and no previous history of
diabetes, 3. Mild hyperglycemia": a group defined by
FBG of 101 mg/dl to 125 mg/dl (5.7-6.9 mmol/l) and no
previous history of diabetes, 4. Normal": a group
defined by FBG of less than or equal to 100 mg/dl
(5.6 mmol/l).
Pneumonia complications were defined as a change
from the initial admission status by development of one
or more of the following during the hospitalization:
Mild complications: 1) Increase in oxygen requirement
after 24 hours of admission, 2) Incre ased antibiotic cov-
erage (defined as requiring an additional antibiotic
added to the initial treatment or a switch to more
broad-spectrum antibiotic coverage due to worsening
clinical symptoms), Severe complications: 1) Transfer
to an intensive care unit at any time during the hospita-
lization, 2) Need for mechanical ventilation, 3) Develop-
ment of sepsis (based upon clinical signs and symptoms
of having the systemic inflammatory response syn-
drome), 4) Death that occurred in the course of the hos-
pitalization was included as a severe complication. All
patients wer e managed according to pneumonia treat-
ment guidelines published by the American Thoracic
Society [19]. The three hyperglycemic groups were com-
pared to the normoglycemic g roup in terms of these
main outcome variables: frequency of pneumonia com-
plications, hospital LOS and in-hospital death rate.
Because outcomes of pneumonia are known to be
worse in the geriatric population [20], patients were
stratified by age (less than 65 years old and 65 years of
age and above).
Baseline Pneumonia Severity
The pneumonia severity index (PSI) [21-23] was used to
strati fy risk. This stratifies patients with pneumonia into
five classes for the risk of death within 30 days of pre-
sentat ion. Predictor variables are based on the presence
of co-mo rbiditi es, physical findings and selected labora-
tory tests, with points assigned for poor outcome vari-
ables. Blood glucose in this scoring system is con sidered
poor if a random value is greater than 250 mg/dl
(14 mmol/l).
Statistical analysis
The effects of mild and severe hypergly cemia on pneu-
monia outcome were determined by examining: the
frequency of pneumonia complications, LOS and in-hos-
pital death rate. The data were collected and statistical
analysis was don e to deter mine whether p atients with
Castellanos et al. International Archives of Medicine 2010, 3:16
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Page 2 of 7
any level of hyperglycemia admitted for pneumonia had
a longer hospital stay, higher rate of complications, or
an increased morta lity compared to the control patients.
The da ta was examined using The Epic Info Statistical
Package 2000. Odds ratios (OR) were calculated for
each group. Continuous data are presented as mean ±
SD and compared via ANOVA with 3 groups. Pearson
Chi Square test was used to compare the frequency of
complications within the groups. The significance level
was set at p < 0.05 for all analyses.
Results
A total of 2000 patient records were reviewed. Five hun-
dred and one cases were included; the major reason for
exclusion was the lack of a documented infiltrate on the
chest x-ray report. Patients characteristics are shown in
Table 1.
In the under 65 years of age group the mean age w as
not significantly different among all the glucose groups
and ranged between 46.2 to 51 years. In this age set, the
mild-hyperglycemia group (N = 51) had fewer patients
with congestive heart failure (CHF). It was otherwise
comparable to the normal group (N = 56) with respect
to all other comorbidities including average PSI. The
severe hyperglycemia group (N = 44) had more patients
with chronic obstructive pulmonary disease (COPD)
compared to normals. They were otherwise similar
to the normal group with respect to all other
Table 1 Characteristics of pneumonia patients admitted to general medical floors
Admission glucose level (%)
Normal
100 mg/dl
N=56
Mild
101-125 mg/dl
N=51
Severe
>126 mg/dl
N=44
Known diabetic
N=37
Group n % n % n % n %
Average Age (se) 50.5 (10.8) - 46.7 (13.5) - 51 (10) 10.0 46.2 (10.4) -
18-64 Gender
Male 30 53.6 30 58.8 21 47.7 24 64.9
Female 26 46.4 21 41.2 23 52.3 13 35.1
History of COPD* 4 7.3 6 11.8
¶¶¶
18 40.9 7 18.9
Heart Failure 8 14.3
1 2.0 2 4.6 2 5.4
Liver disease 6 10.7 2 3.9 3 6.8 4 10.8
Cancer 5 8.9 3 5.9 4 9.1 2 5.4
Chronic renal disease 10 17.9 4 7.8 3 6.8 9 24.3
Mean PSI
61.4 (se 4.1) 61.6 (se 4.1) 61.3 (se 4.4) 74.4 (se 4.2)
N=69 N=68 N=99 N=77
n% n% n % n %
Average Age (se) 78.2 (7.3) 80.9 (9.1) 80.6(8.6) 80.0 (7.4)
65 and Above Gender
Male 36 52.2
24 35.8 48 48.5 43 55.8
Female 33 47.8 43 64.2 51 51.5 34 44.2
Living arrangement
Community 54 78.3 53 77.9 73 73.7 58 75.3
Nursing home 15 21.7 5 22.1 26 26.3 19 24.7
History of COPD
19 27.5 19 28.0 30 30.6 14 18.2
Heart Failure 18 26.1 10 14.7
13 13.1 22 28.6
Liver disease 1 1.5 3 4.4 4 4.0 2 2.6
Cancer 6 8.7 7 10.5 12 12.1 10 13.0
Chronic renal disease 24 34.8 17 25.0 22 22.2 19 24.7
PSI (mean se) * 107.8 (se = 4.5) 102.1 (se = 3.5) 108.4 (se = 3.4) 112.4 (se = 3.1)
COPD, chronic obstructive pulmonary disease
*Pneumonia Severity Index (mean and standard error), t-test compares each group with the normal group (admission glucose 99 mg/dl), *p 0.05
c
2
tests compares each group with the normal group (admission glucose 99 mg/dl)
0.01<p 0.05,
¶¶
0.001p 0.0 1,
¶¶¶
p 0.001
Note: Highlighted values were statistically different from the normal grou p; all others were not statistically significant
Castellanos et al. International Archives of Medicine 2010, 3:16
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characteristics including PSI. Finally, in the under age of
65 group, the known diabetics (N = 37) were statistically
similar to the normal controls in all baseline
characteristics.
In the older patients group, aged 65 and over, the
mean age range w as 78.2-80.9 among all the glucose
groups. In this age group, the mild-hyperglycemia group
(N = 68) had s ignificantly fewer men. It was otherwise
comp arable to the normal glucose group (N = 69) in all
aspects, including comorbidities and average PSI. The
severe hyperglycemia group ( N = 99) had significantly
fewer patients with C HF compared to the normals.
However, their other characteristics were statistically
similar to those of the normals, including PSI. Finally,
the known diabetics in the 65 and above group (N = 77)
were statistically similar to the controls in all aspects,
comorbidities and PSI.
TheaveragePSIscoresandthemorespecificPSI
classes are listed in Table 2. In both age groups, all the
hyperglycemia patients (mild, severe, and known dia-
betics) had similar numbers of patients in each PSI class
and did not differ statistically. As expected, the older
patients had higher PSI scores compared to the younger
patients.
In the younger patients, the development of pneumo-
nia complications did not differ in any of the hypergly-
cemia groups compared to the normal (Table 3).
Similarly, the number of deaths and hospital LOS in all
these groups did not differ significantly.
The pneumonia complication rate varied significantly
by admission glucose in the elderly patients (age 65 and
over) (Table 4). In the elderly, the sever e hyperglycemia
group consisted of 99 patients. This group had a
significantly increased risk of developing any one com-
plication (39.4%, p = 0.0 3) and any two complications
(33.3%, p = 0.06) during the hospitalization when com-
pared to the normal group (Table 4). The mild hyper-
glycemia group consisted of 68 patients. This group had
a statistically significant risk of developing any one or
two complications compared to the normal group
(39.7%, p = 0.04 and 37.9%, p = 0.02 respectively). The
elderly patients with known diabetes (N = 77) did not
have a statistically significant increased rate of develop-
ing any one or any two complications compared to the
normal group (35.1%, p = 0.12 and 29.6%, p = 0.18
respectively).
The in-hospital mortality rate of the elderly was also
assessed and did not vary significantly among the differ-
ent groups (Table 4). The LOS or total admissio n days
among the groups, which include those with and with-
out c omplications, was not significantly diff erent. The
mean LOS for the severe hyperglycemia group was 7.7
+/- 7 .0 days; the mild hy perglycemia group had a LOS
of 6.7 +/- 4.7 days; the diabetics had a LOS of 7.3 +/-
7.3 and the control group a LOS of 6.3 +/- 6.0.
Discussion
This study compared pneumonia-related complication
rates among hospitalized, non-critically ill patients with
elevated blood glucose levels in the range o f 101 to 125
mg/dl (5.7-6.9 mmol/l) to those with overt fasting
hyperglyc emia of 126 mg/dl (7 mmol/l) as well as to
patients with known diabetes and those with normal
glucose values. We chose to study the effects of hyper-
glycemia among patients with pneumonia since pneu-
monia is a common cause for hospitalization in the
Table 2 Pneumonia severity index stratified by admission glucose level
Admission glucose level (%)
Age Pneumonia Severity Index Normal
100 mg/dl
N=56
Mild
101-125 mg/dl
N=51
Severe
>126 mg/dl
N=44
Known
diabetic
N=37
18-64 Class Points N % N % N % N %
II 70 37 66.1 35 68.6 32 72.7 19 51.4
III 71-90 8 14.3 8 15.7 8 18.2 8 21.6
IV 91-130 9 16.1 6 11.8 3 6.8 9 24.3
V >130 2 2 3.9 1 2.3 1 2.7
N=69 N=68 N=99 N=77
65+ Class Points N % N % N % N %
II 70 7 10.1 8 11.8 9 9.1 3 3.9
III 71-90 16 23.2 17 25.0 28 28.3 17 22.1
IV 91-130 32 46.4 31 45.6 33 33.3 37 48.1
V >130 14 20.3 12 17.7 29 29.3 20 26.0
*c
2
compares each group with the normal group (admission glucose 99 mg/d) * p 0.05
Note: No significant differences in PSI class among the glucose groups.
Castellanos et al. International Archives of Medicine 2010, 3:16
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Table 3 Pneumonia complications by admission glucose level among adults aged 64 and below
Admission glucose level (%)
Normal 100 mg/dl
N=56
Mild 101-125 mg/dl
N=51
Severe >126 mg/dl
N=44
Known diabetic
N=37
% % OR 95% CI p % OR 95% CI p % OR 95% CI p
Complications Types*
O
2
requirements 17.7 19.6 1.12 0.42-0.82 0.82 30 1.92 0.75-0.17 0.17 24.3 1.47 0.57-4.08 0.45
ABx coverage 23.2 17.7 0.71 0.27-1.83 0.47 25 1.03 0.44-2.77 0.8 16.2 0.64 0.21-1.87 0.41
Sepsis 12.5 5.7 1.30 0.44-3.89 0.64 13.7 1.05 0.34-3.56 0.67 18.9 1.63 0.52-5.12 0.4
Subsequent ICU use 10.9 11.8 1.09 0.33-3.62 0.9 13.7 1.29 0.39-4.32 0.67 18.9 1.91 0.58-6.21 0.4
Mechanical-vent 14.3 11.8 0.80 0.26-0.70 0.7 11.4 0.77 0.23-2.54 0.67 18.9 1.40 0.46-4.26 0.55
Deaths (N) 3.6 (2) 2(1) 0.54 0.48-0.62 0.6142 6.8(3) 1.98 0.32-12.37 0.46 0 ––0.2516
Category
No complications 80.0 80.0 –– 75.0 –––75.7 ––
Mild* 1.8 4.7 2.20 0.19-25.12 0.52 5.7 2.73 0.23-31.56 0.40 0 ––
Severe
18.8 16.3 0.88 0.32-2.45 0.80 21.4 1.23 0.45-3.36 0.69 24.3 1.44 0.52-4.00 0.47
Any one complication 52.4 19.6 1.00 0.38-2.60 1.00 25.0 1.36 0.53-3.52 0.52 24.3 1.33 0.48-3.57 0.59
Any two complications 53.3 14.6 0.96 0.32-2.88 0.94 17.5 1.19 0.39-3.61 0.75 20.0 1.43 0.46-4.30 0.54
Total admission days
(mean se)
6.0 se = 5.9 10.6 se = 21.0 7.6 se = 6.6 6.1 se = 4.5
Age (mean se) 50.5 se = 10.8 46.7 se = 3.5 51.0 se = 10.0 46.2 se = 10.4
*Mild complications: either O
2
requirements, or Antibiotic coverage
Severe complications: either subsequent ICU use , mechanical ventilation, sepsis and/or death.
c
2
compares each glucose category with the reference group (normal 99 mg/dl).
Table 4 Pneumonia complications by admission glucose adults aged 65 and above
Admission glucose level (%)
Normal 100 mg/dl
N=69
Mild 101-125 mg/dl
N=68
Severe >126 mg/dl
N=99
Known diabetic
N=77
Complications Types* % % OR 95% CI p % OR 95% CI p % OR 95% CI p
O
2
requirements 21.7 41.2 2.52 1.19-5.32 0.014 44.4 2.88 1.44-5.78 0.002 35.1 1.94 0.92-4.07 0.075
ABx coverage 23.5 32.4 1.55 0.73-3.31 0.25 28.3 1.28 0.63-2.61 0.49 28.6 1.30 0.62-2.74 0.49
Sepsis 14.5 26.5 2.12 0.90-5.01 0.08 23.2 1.79 0.79-4.04 0.16 23.4 1.80 0.77-4.22 0.17
Subsequent ICU use 11.6 22.1 2.16 0.85-5.49 0.10 16.2 1.47 0.59-3.65 0.41 16.9 1.55 0.60-4.00 0.36
Mechanical-vent 10.1 19.1 2.09 0.78-5.62 0.1370 14.1 1.45 0.56-3.83 0.44 11.7 1.17 0.41-3.34 0.77
Deaths (N) 10.3 (7) 12 (8) 1.17 0.40-3.40 0.78 12(12) 1.22 0.45-3.27 0.69 9 (7) 0.88 0.29-2.66 0.8
Category
No complications 76.5 60.3 –– 59.8 64.9 ––
Mild* 20.9 4.4 1.94 0.31-12.15 0.47 10.3 2.73 0.24-31.36 0.40 11.4 4.77 0.98-23.16 0.03
Severe
20.6 35.3 2.22 1.02-4.81 0.04 29.9 1.83 0.88-3.82 0.11 23.4 1.36 0.31-3.03 0.45
Any one complication 23.5 39.7 2.19 1.04-4.58 0.04 40.2 2.15 1.08-4.29 0.03 35.1 1.79 0.86-3.71 0.12
Any two complications 20.0 37.9 2.49 1.13-5.45 0.02 34.1 2.04 0.96-4.31 0.06 29.6 1.71 0.78-3.79 0.18
Age (mean se) 78.2 se = 7.3 80.9 se = 9.1 80.6 se = 8.6 80.0 se = 7.4
Total admission days
(mean se)
6.3 se = 6.0 6.7 se = 4.7 7.7 se = 7.0 7.3 se = 7.3
*Mild complications: either O
2
requirements, or Antibiotic coverage
Severe complications: either subsequent ICU use , mechanical ventilation, sepsis and/or death
c
2
compares each group with the reference group (admission glucose 99 mg/dl).
Note: Highlighted values were statistically different from the normal grou p ; all others were not statistically significant
Castellanos et al. International Archives of Medicine 2010, 3:16
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elderly and the adverse effects of hyperglycemia may
potentially contribute to increased complication rates
[24].
Patients were stratified into two distinct a ge groups
and by PSI class to identify those who may be at higher
risk for complicat ions on admission. Among our 501
patients the prevalence of diabetic range hyperglycemia
was 28.5% (in patients without a history of diabetes).
The rate of known diabetes was 22% and the range of
patients with mild hyperg lycemia on admission was
24%. In our study there were no differences in pneumo-
nia complication rates in younger patients (< 65 years)
when assessed by admission glucose. Among the elderly,
newly diagnosed fasting m ild hyperglycemia was asso-
ciated with a higher rate of pneumonia complications
compared to those with a normal glucose level on
admission.
This study demonstrates that even mild elevation of
glucose, between 101 and 125 mg/dl (5.7-6.9 mmol/l),
in an elderly group of patients with no history of dia-
betes is associated w ith an increase in the pneumonia
complication rates. The OR for developing any one
complication was 2.2 (1.04-4.58) in the elderly mild
hyperglycemia group compared to normoglycemic
patients. This was similar to patients with overt diabetic
range hyperglycemia, who had an OR of 2.15 (1.08-4.29)
(Table 4). The PSI on admission was not statistically dif-
ferent among all the groups and did not predict hospital
complications or identify those that would subsequently
require ICU admissi on. Although initially not developed
for this purpose, clinicians use PSI to risk-stratify
patients on admission. Given current evidence, a glucose
value of 250 mg/dl (14 mmol/l) as a part of the risk
assessment seems too high [7].
Neither h ospital mortality nor LOS was statistically
different among any of the grou ps, possibly due to the
relatively small sample size. To determine the sample
size to study these variables the prevalence of mild
hyperglycemia among no n-critically ill hospitalized
patients needed to be established, our study provides
this data. In addition, our results confirm evidence pro-
vided by McAlister et al [7] that admission h yperglyce-
mia in the diabetic range is associated with adverse
outcomes in elderly patients with pneumonia. In that
study, the median age of patients was 75 years. The cur-
rent study further documents that even mild hyperglyce-
mia consistent with pre-diabetes is related to higher
complication rates in patients over the age of 65.
Our findings provide the information to conduct
future research. Admission hyperglycemia,eveninthe
non-diabetic range, may be a marker of immune dys-
function and/or a pro-inflammatory state and should aid
in the identification of patients at higher risk for compli-
cation rates during hospita lization. In this study, 50% of
elderly patients who developed pneumonia had newly
diagnosed, appar ently stressed-induced, hyperglycemia.
This puts forward the need for more aggressive screen-
ing of all hospitalized patients. Our study suggests that
fasting glucose levels previously considered not to war-
rant intervention may be associated with deleterious
effects. Further studies should be conducted to evaluate
this possibility.
Author details
1
Department of Medicine, Staten Island University Hospital, 450 Seaview Ave,
Staten Island, NY 10305, USA.
2
Division of Geriatrics, Department of
Medicine, Staten Island University Hospital, 375 Seguine Ave, Staten Island,
NY 10309, USA.
3
Division of Endocrinology, Department of Medicine, Staten
Island University Hospital, 450 Seaview Ave, Staten Island, NY 10305, USA.
4
Division of Pulmonary and Critical Care Medicine, Staten Island University
Hospital, 450 Seaview Ave, Staten Island, NY 10305, USA.
Authors contributions
MC: study concept and design; data interpretation manuscript preparation,
AS: data management and interpretation, manuscript preparation, CS: data
collection and management, IZ: data collection and interpretation, GK: data
collection, NAF: data collection, RW: data interpretation, manuscript
preparation, MK: manuscript preparation, NA: data collection, KW: statystical
analysis and data interpretation, TM: study design and coordination,
manuscript review, JR: study concept and design, data interpretation,
manuscript preparation.
All authors read and approved the final manuscript.
Competing interests
The authors declare that they have no competing interests.
Received: 11 March 2010 Accepted: 2 August 2010
Published: 2 August 2010
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doi:10.1186/1755-7682-3-16
Cite this article as: Castellanos et al.: Fasting hyperglycemia upon
hospital admi ssion is associated with higher pneumonia complication
rates among the elderly. International Archives of Medicine 2010 3:16.
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