EARLY POSTOPERATIVE GLUCOSE CONTROL PREDICTS NOSOCOMIAL INFECTION-RATE IN DIABETIC-PATIENTS

Objectives: To determine the relationship between perioperative glucos e control and postoperative nosocomial infection rate in 100 consecuti ve diabetic patients undergoing elective surgery. Design and Patients: One hundred initially uninfected diabetic patients undergoing electiv e surgery were prospectively monitored for perioperative glucose contr ol and postoperative nosocomial infection rate. Glucose control was de termined by the attending surgeon or diabetologist. Setting: A large t ertiary care hospital that serves as the in-patient facility for a loc al diabetes center. Main Outcome Measures: Ail patients were screened for infection preoperatively. Only initially uninfected patients were enrolled! and all patients received perioperative antibiotic coverage. Perioperative glucose control and postoperative nosocomial infection rate were monitored prospectively. APACHE II scores were determined on all patients. Patients were stratified into two groups: those with re latively ''good'' perioperative glucose control (all values less than or equal to 220 mg/dL) and those with ''poor'' control (at least one v alue >220 mg/dL). Contingency tables were generated, comparing nosocom ial infection rates ys perioperative glucose control. Correlation coef ficients between APACHE II score and maximum and mean glucose values w ere also determined. Results: A serum glucose >220 mg/dL on postoperat ive day one (POD 1) was a sensitive (87.5%) but relatively nonspecific (33.3%) predictor of the later development of postoperative nosocomia l infection. In patients with hyperglycemia (>220 mg/dL) on POD 1, the infection rate was 2.7 times that observed (31.3% vs 11.5%) in diabet ic patients with all serum glucose values <220 mg/dL. When minor infec tion of the urinary tract was excluded, the relative risk for ''seriou s'' postoperative infection increased to 5.7 when any POD 1 blood gluc ose level was >220 mg/dL. On the basis of correlation coefficients bet ween serum glucose values and APACHE II score, only 18% of the varianc e in the highest serum glucose could be explained by disease severity alone. Conclusions: We conclude that diabetic patients undergoing majo r cardiovascular or abdominal surgery have an increased risk of infect ion that is further exacerbated by early postoperative hyperglycemia. The high rate of nosocomial infection observed in diabetic patients wi th poor glucose control suggests that hyperglycemia itself may be an i ndependent risk factor for the development of infection. Efforts to im prove perioperative glucose homeostasis in diabetic patients may reduc e the incidence of nosocomial infection and thereby improve outcome.